Portal de Periódicos da CAPES

HIV transmission under highly active antiretroviral therapy

2008; Elsevier BV; Volume: 372; Issue: 9652 Linguagem: Inglês

10.1016/s0140-6736(08)61753-5

1474-547X

Pietro Vernazza, Bernard Hirschel, Enos Bernasconi, Markus Flepp,

HIV Research and Treatment

In their model-based analysis, David Wilson and colleagues (July 26, p 314)1Wilson DP Law MG Grulich AE Cooper DA Kaldor JM Relation between HIV viral load and infectiousness: a model-based analysis.Lancet. 2008; 372: 314-320Summary Full Text Full Text PDF PubMed Scopus (274) Google Scholar predict that the risk of HIV transmission in the presence of effective treatment is low but non-zero, and that use of condoms should still be advised, contrary to advice issued in January, 2008, by the Swiss Commission on AIDS.2Vernazza P Hirschel B Bernasconi E Flepp M Les personnes seropositives ne souff rant d'aucune autre MST et suivant un traitment antiretroviral effi cie ne transmettent pas le VIH par voie sexuelle.Bull Med Suisses. 2008; 89: 165-169Google Scholar There are several flaws in the analysis by Wilson and colleagues. First, when applying their model to an untreated homosexual couple, we calculate a risk of transmission of 60% after 1 year (100 sexual contacts). That seems extraordinarily high, and contrary to published data and experience.3DeGruttola V Seage GR Mayer KH Horsburgh Jr., CR Infectiousness of HIV between male homosexual partners.J Clin Epidemiol. 1989; 42: 849-856Summary Full Text PDF PubMed Scopus (147) Google Scholar Second, Wilson and colleagues state: "Under our assumptions, the effectiveness of treatment in reducing the risk of HIV transmission per sexual act was about the same as has been reported for condoms." Therefore, even with their high estimates, Wilson and colleagues confirm the Swiss statement and even document a higher risk for condom use (without treatment) than for treatment alone. Finally, the major limitation is the neglect of the role of sexually transmitted diseases (STDs), which are well known to fuel the HIV epidemic.4Wasserheit J Epidemiological synergy: interrelationships between human immunodeficiency virus infection and other sexually transmitted diseases.Sex Transm Dis. 1992; 19: 61-77Crossref PubMed Google Scholar In the Rakai study,5Quinn TC Wawer Mj Sewankambo N et al.for the Rakai Project Study GroupViral load and heterosexual transmission of human immunodeficiency virus type 1.N Engl J Med. 2000; 342: 921-929Crossref PubMed Scopus (2484) Google Scholar genital discharge and dysuria were associated with increased risk of transmission. Thus, transmission figures in the presence of STDs overestimate the residual risk under HAART in the absence of STDs. Since the "Swiss statement" is often misinterpreted, we would like to re-emphasise the main point. The risk of sexual transmission of HIV is negligibly low if three conditions are met: (1) the HIV-infected patient is receiving antiretroviral therapy with excellent adherence; (2) blood viral load has consistently been undetectable (<40 copies per mL) for more than 6 months; and (3) no STDs are present in either of the partners. The statement also made it clear that it is up to the HIV-negative partner to decide whether he or she wants to stop using condoms with the treated partner and accept the residual risk. We declare that we have no conflict of interest. Department of ErrorWilson DP, Law MG, Grulich AE, Cooper DA, Kaldor JM. Relation between HIV viral load and infectiousness: a model-based analysis. Lancet 2008; 372: 314–20—In this Article (July 26), the start of the Methods section (p 315) should have read: "We used a mathematical expression (equation 1) derived by Smith and Blower.57 This equation is based on the results of the Rakai study of HIV transmission in heterosexual couples,2 which relate viral load to the risk of HIV transmission per unprotected penetrative sexual contact. Full-Text PDF COMET results are not stellar – Authors' replyAlthough the concerns of Michael James and Les Cleland merit consideration, their argument does contain some factual inaccuracies. Full-Text PDF HIV transmission under highly active antiretroviral therapy – Authors' replyThe authors of the "Swiss statement" assert that the risk of HIV transmission from people on effective antiretroviral therapy is negligible, despite the absence of studies large enough to provide empirical evidence. Although determination of viral titres in source partners is not typical practice, cases of transmission from effectively treated people have been reported.1 Furthermore, although HIV might be undetectable in blood, it can be present in semen or genital fluids at infectious amounts.2 Full-Text PDF