Approximately 40% of HIV-positive people
in a stable relationship with an HIV-negative person in Kenya have reservations
about starting antiretroviral therapy early for the purposes of prevention,
investigators report in the online edition of the Journal of Acquired Immune Deficiency Syndromes.
Willingness to use pre-exposure prophylaxis
(PrEP) was high among the HIV-negative partners. However, this finding is likely to
have been influenced by the fact that the study involved couples involved in a PrEP study.
The investigators believe that their
findings could have implications for the use of HIV treatment in prevention.
“A possible HIV-1 prevention strategy for
serodiscordant couples that will utilize both ART [antiretroviral therapy] and
PrEP is for the HIV-1-uninfected partner to use PrEP until the HIV-1 infected
partner is willing and able to initiate ART,” suggest the authors. “Such a
strategy would be cost-effective, provide HIV-1 infected partners an
opportunity to decide when to start ART, and may allow a ‘bridge period’ for a few
months after the infected partner starts ART, when transmission may still be
high because viral load is not yet suppressed.”
Antiretroviral-based strategies are among
the most promising new approaches to HIV prevention.
Research involving serodiscordant heterosexual
couples showed that early antiretroviral therapy reduced the risk of
transmission of the virus by 96%.
Some research has also shown that antiretroviral drugs taken by HIV-negative people (PrEP) can reduce their risk of
Serodiscordant couples are a priority
population for the use of HIV treatment. But, before strategies for its use are
developed, it is important to understand the couples’ preferences for and
concerns about the use of antiretrovirals for this purpose.
Investigators therefore recruited 181
serodiscordant couples in Kenya, enrolled in the Partners PrEP study, to a substudy
enquiring about their willingness to use HIV treatment as prevention.
The HIV-positive partners all had a CD4
cell count above 350 cells/mm3 and were therefore ineligible for
antiretroviral therapy according to Kenyan national guidelines. The study was
conducted between March and July 2011, before the publication of research
showing the efficacy of PrEP in heterosexual couples and of the results from the HTPN 052 study, which
showed that early HIV therapy reduced HIV risk by 96% in serodiscordant
Both the HIV-negative and HIV-positive
partners completed questionnaires.
HIV-negative individuals were asked: “If we
find that PrEP works to keep people free from HIV, would you be willing to take
PrEP tablets every day for the next five years?”
HIV-infected partners were asked: “Would
you be willing to start antiretrovirals before your CD4 count reaches 350 if it
would lower your chances of giving HIV to your partner?”
Participants were asked to describe
their main concerns about early HIV treatment or PrEP. They were also asked to
say which of these strategies they preferred.
Some 69% of HIV-positive men and 58% of
HIV-positive woman said that they would be willing to take early treatment for
the purposes of prevention.
An overwhelming majority of HIV-negative
people (94% of men and 86% of women) expressed a willingness to take PrEP.
When asked to state a preference between
the two approaches, 61% of HIV-positive men and 50% of HIV-negative women said
they would prefer early HIV therapy.
A majority of HIV-negative participants expressed a preference for PrEP (57% of men and 56% of women).
In just over a quarter of couples (26%),
both members preferred to have the HIV-negative partner take PrEP and in 22% of
couples both members preferred early antiretroviral therapy for the infected
Among HIV-positive participants, the primary
concerns about early treatment for prevention were side-effects (51%), stigma
(21%), pill burden (19%) and fears about resistance (18%).
A total of 14 HIV-negative people were
unwilling to use PrEP. Their primary concerns were the duration of treatment
(6/14), taking treatment when they were not sick (3/14), and side-effects
“In our study, not all couples would be
willing to use ART prior to the HIV-1 infected partner having clinical symptoms
and a perceived need for initiation; PrEP could be a suitable alterative for
these couples,” conclude the authors. “As antiretroviral-based HIV-1 prevention
strategies are incorporated into prevention policies and programs, it will be
important to understand and accommodate couples’ preferences and willingness to
use antiretroviral-based HIV-1 prevention.”