In January 2013, the
British HIV Association (BHIVA) and the Department of Health’s Expert Advisory
Group on AIDS (EAGA) published a position statement on the use of HIV treatment
by people with HIV to reduce the risk of transmission.9
The document provides UK
health professionals with a consensus statement, developed by UK experts,
which can be used to guide discussions with individuals. Clinicians,
epidemiologists, policy experts and HIV-positive people contributed to the
Key points include the following:
As effective as condoms
The statement notes that there is now conclusive randomised
clinical trial evidence, from the HPTN 052 trial, to show that transmission of
HIV through vaginal sex is significantly reduced when an HIV-positive person is
taking effective antiretroviral therapy.
“The observed reduction in HIV transmission in a clinical
trial setting demonstrates that successful ART use by the person who is HIV
positive is as effective as consistent condom use in limiting viral
transmission,” it says.
The document includes some explanatory notes, which point
out that there has never been a randomised controlled trial of the efficacy of
condom use, compared to non-use. For that reason, there are no figures that can
be directly compared. However, meta-analyses of observational studies of
serodiscordant couples who maintained 100% condom use have found the strategy
to be about 80% effective in reducing HIV infection.
The document states that the transmission risk during
vaginal intercourse will be “extremely low”, provided certain conditions are
are no sexually transmitted infections in either partner. (The document
clarifies requirements for STI screening, including following sexual
relationships outside a primary partnership.)
person with HIV has had a sustained blood plasma viral load below 50
copies/ml for more than six months, including the most recent test.
load testing occurs every three to four months (i.e. more regularly than
in standard clinical care).
In the document’s explanatory notes, it is explained that in
HPTN 052 there was a single confirmed case of HIV transmission from a person on
treatment. This individual had only recently begun treatment and would not have
met the UK
position statement’s requirement for an undetectable viral load for at least
six months. The authors say that this justifies the use of the phrase
“extremely low risk”. They clarify that this is not the same as “zero risk”.
Moreover, with the data that are available, it is not possible to give accurate
and meaningful figures for the risk of transmission during a single sexual act.
The published research was primarily done with heterosexual
couples and is assumed to relate primarily to vaginal intercourse. Data are not
available for anal intercourse, either between men, or between men and women.
“However, it is expert opinion that an extremely low risk of transmission can
also be anticipated for these practices, provided the same conditions stated
above are met,” according to the statement.
Discussion with people with HIV
Healthcare professionals should discuss the impact of treatment
on sexual transmission with all people living with HIV. For people not
currently on therapy, the possibility of starting treatment in order to reduce
transmission risk should be discussed.
Limitations of ART
The position statement notes that no single prevention
method can completely prevent HIV transmission. Moreover, antiretroviral
treatment has no effect on other sexually transmitted infections, whereas
condoms can prevent their spread.