counselling can achieve reductions in viral load and HIV transmission risk
behaviour, investigators from the United States report in the online edition of
the Journal of Acquired Immune Deficiency
Syndromes. The counselling programme was associated with significant
reductions in viral load, improvements in adherence to HIV therapy and
reductions in risky sexual behaviour.
effect was most pronounced among those whose plasma HIV-1 load was not
suppressed at baseline,” comment the investigators. “This reduced viral load
and fewer sexual transmission risk behaviors seen among those undergoing the
intervention both may contribute to decreasing HIV transmission to sexual
antiretroviral therapy, many people with HIV now have a normal life
expectancy. The best outcomes are seen in individuals who adhere to their
treatment. Good adherence also has a secondary benefit, as suppression of viral
load is associated with a reduced risk of HIV transmission to sexual partners.
However, some people living with HIV have difficulty achieving and sustaining the levels of adherence
associated with the best treatment outcomes, and a significant proportion of patients with HIV have sexual behaviour that involves a risk of HIV
Seattle wanted to see if a computer-delivered intervention called Computer
Assessment and Rx Education for HIV-positive people (CARE+) improved treatment
adherence and reduced transmission risk behaviours.
designed a nine-month randomised-controlled trial involving 240 adult patients taking
The study had two
Participants in the
intervention arm had access to a computerised programme that provided
counselling about treatment adherence, HIV disclosure, safer sex, condom use,
substance abuse and the impact of adherence on viral load. Individuals in the
control arm completed computerised questionnaires, answering questions about
their treatment adherence, substance use and sexual risk behaviour.
outcomes were changes from baseline in viral load, 30-day adherence to HIV
therapy and the likelihood of reporting unprotected anal/vaginal sex or
problems with condom use.
The participants had
an average age of 45 years and approximately 90% were male. Participants reported
taking a median of 76% of their treatment doses at baseline. Sex without
condoms or condom problems were reported by approximately 30% of people on
entry to the study, and viral load was detectable in a similar proportion of
The study was
completed by 87% of the participants.
marginally significant differences in viral load changes from baseline to the
end of the study between the study arms (p = 0.053). People in the
intervention arm had an average decrease in viral load of 0.17 log10
copies/ml, compared to an average increase of 0.13 log10 copies/ml
among people in the control arm. Compared to baseline, the chances of having
an undetectable viral load at the end of the study increased significantly for
people in the CARE+ arm (p = 0.037) but fell non-significantly for people
in the assessment-only arm.
Among the study participants
who had a detectable viral load at baseline, the people receiving
computerised counselling had an average decrease in viral load of 0.60 log10
copies/ml (p = 0.004), while the control group participants had an average
non-significant increase in viral load of 0.15 log10 copies/ml. At
the end of the study, viral load was a significant 0.73 log10
copies/ml lower among people in the intervention arm (p = 0.041).
also had a significant impact on adherence. This increased by approximately 5%
(p = 0.014) among people receiving computerised counselling, but fell by a
non-significant 1.4% among people in the control arm.
Focusing on participants
with a detectable baseline viral load showed CARE+ intervention participants had an average increase in adherence of
8% (p = 0.04), whereas the control patients had a non-significant decrease of
approximately 1.5%. At the end of the study, adherence was a significant 13%
higher (p = 0.038) in people in the intervention arm compared to people in
the control arm.
associated with changes in HIV transmission risk behaviour. The odds of
behaviour involving a risk of transmission were reduced by 55% among people
in the intervention arm (p = 0.02), but increased modestly for individuals in
the control arm. At the end of follow-up, CARE+ intervention participants had
reduced odds of transmission risks compared with the controls (OR = 0.46; 95%
CI, 0.25-0.84, p = 0.12).
was highly acceptable, with 97% of participants reporting it was easy to use,
and 93% felt CARE+ sessions helped them as much, if not more, than face-to-face
“As far as we know
this is the first ART adherence and secondary transmission risk intervention to
find biological effect (viral load) and behavioral impact among persons living
with HIV,” conclude the authors. “The computer format was highly acceptable and
facilitated delivery in busy settings. Such an approach warrants further
evaluation to determine utility in improving HIV treatment outcomes and
reducing secondary HIV transmission among persons living with HIV.”