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CDC Consultation on the Effect of Antiretroviral Therapy (ART) on Risk of Sexual Transmission of HIV

By Julie Davids

If a person has HIV but the level of virus in their blood is so low that it is undetectable, is it all but impossible that they will transmit HIV to their sex partners?

Early this year, the Swiss Federal AIDS Commission published a strong statement giving a thumbs-up to this notion, entitled " HIV-positive individuals without additional sexually transmitted diseases (STD) and on effective anti-retroviral therapy are sexually non-infectious." The statement, intended in part to fend off criminal charges against people with HIV for sexual conduct, sparked much discussion and debate worldwide.

In the wake of the announcement, CDC issued a short statement re-affirming their recommendation that people living with HIV who are sexually active use condoms consistently and correctly with all sex partners, and stressing that the Swiss Commission acknowledged that "there are no scientific data that the risk of transmission in these circumstances is zero."

But the provocative question of treatment-as-prevention is not going away, and was under scrutiny this October as CDC pulled together staff and outside researchers and advocates for a Consultation on the Effect of Antiretroviral Therapy (ART) on Risk of Sexual Transmission of HIV.

Representatives of CHAMP's Prevention Research Advocacy Working Group (PRAWG), including board chair Walt Senterfitt and PRAWG leader Mark Hubbard of Nashville, TN, were on hand to hear the data and dive into the debate.

The use of antiretrovirals as HIV prevention is a hot issue right now, with topics ranging from:
  • the potential role of effective therapy in HIV positive people reducing (or even eliminating) the risk of transmission to others, and if treatment guidelines should reflect this role;
  • ongoing trials looking at ARVs as preventive therapy in HIV negative people (Pre-Exposure Prophylaxis, or PrEP); and
  • the failure to extend the reach of ARVs to pregnant women around the world to drastically reduce transmission of HIV from mothers to infants, and to then keep mothers healthy to raise their children.
Like so many things in HIV prevention, there's nothing simple about the realities of considering ARVs as prevention, and the questions swirling around treatment-as-prevention are complicated:
  • Is sex-on-ARVs the new oral sex (that is to say, a common practice where it is now believed there is very low risk of HIV transmission but a lack of definitive data to prove it)?
  • How common is superinfection (when an HIV positive person is infected with an additional strain or strains from unsafe sex with another HIV positive person), and does it alter the impact of HIV in the body?
  • Should doctors offer treatment to people with HIV at higher CD4 counts than current guidelines recommend, allowing individuals to decide if they want to have an additional possible defense against transmission to others?
  • Who would pay for the additional cost of ARVs if people choose earlier treatment in an era of less toxic therapies and more discussion of possible prevention benefits?
  • And should couples with a positive male and negative female be offered a package of ARVs for him and PrEP for her plus top-notch conception counseling, if they want to set condoms aside in order to make a baby?
There's a compelling need for answers. Several participants noted that the apparent rise of other STDs without a drastic increase in HIV infection in some gay communities with low rates of condom use in the past decade points to a protective effect of treatment – while others point to mathematical models suggesting that increases in risky sex would override a partial protective effect.

At the consultation, CHAMP urged CDC to prepare clear information on what is currently known about treatment-as-prevention, what remains to be learned, and to distribute this information through their website, prevention programs and the media.

As one participant said, "There's never been a randomized controlled trial of parachutes, but we know if we jump out of an airplane, we surely want one."

CHAMP is working with our allies to prepare briefing materials and analysis on these issues, and encourages all who are interested to join the PRAWG to help move our efforts forward.

Click here to download the Swiss Statement and background reading materials on the Consultation.