Organization (WHO) guidance on the use of antiretroviral treatment (ART) for
the prevention of transmissions are likely to benefit only a “fraction” of the
targeted population, according to research published in AIDS. Investigators in Côte d’Ivoire found that only 12% of
patients with higher CD4 counts would be eligible for therapy under the present
guidance. Almost two-thirds of individuals with CD4 counts above 500 cells/mm3
would be ineligible for ART for prevention, either because they had no stable
partner or were unaware of the HIV infection status of their partner.
to patients with high CD4 cell counts who live with a seronegative partner is
an important new step to reduce HIV transmission,” comment the authors.
“However, 64% of our participants are sidelined by these recommendations, and
this has repercussions.”
With early ART patients with HIV can now have a normal life expectancy.
Long-term ART that suppresses viral load to undetectable levels also virtually
eliminates the risk of HIV transmission to sexual partners. Therefore, since
2013 WHO has recommended ART for all HIV-positive patients, irrespective of
their CD4 count, if they have an HIV-negative partner.
wanted to see how many patients would benefit from this recommendation.
Therefore they interviewed 929 adult patients about their partnership status
and the HIV infection status of their partners.
The patients were
enrolled in a larger ongoing study assessing the benefits of early ART. The
interviews were conducted in 2012.
three-quarters (78%) of patients included in the analysis were women. Median
baseline CD4 count was 491 cells/mm3 and the median age was 38
Overall, 72% of
patients said they were in a stable sexual partnership. Of the patients in a
stable partnership, 67% had declared their HIV infection status to their
partner and 59% were aware of the status of their partner. The proportion of
patients knowing the status of their partner was higher for those who had
disclosed their own status, compared to those who had not (82% vs. 10%, p <
When the study was
conducted, 49% were already on ART and 51% were not taking anti-HIV drugs. Almost
half (47%) of this latter group had a CD4 count above 500 cells/mm3
and would thus, depending on their relationship status, be possible candidates
for the initiation of ART for prevention according to WHO guidelines.
However, 30% were
not in a stable sexual partnership, 24% were in a sexual relationship with a
partner who was HIV-positive, 12% were in a relationship with a HIV-negative
partner and 34% were in a stable sexual partnership but did not know the HIV
status of their partner.
“Thus, only 12% of
adults with more than 500 CD4 cells/mm3 who participated in this
survey would be recommended to start ART, because their partner was
seronegative, according to the present WHO guidelines,” write the
investigators. They were especially concerned that almost two-thirds “could not
be given any recommendations regarding ART early initiation because they either
had no stable partnership or a stable partnership with a partner whose status
they no had knowledge.”
They recommend “steps
should be taken to encourage screening in couples, to look in detail into
factors associated with the lack of disclosure between partners, and to put in
place interventions to breakdown barriers to sharing serostatus within couples.”
They conclude there is a risk of WHO guidelines being only “marginally
implemented and reaching only a fraction of the targeted population.”