Antiretroviral Therapy and the Risk of Sexual Transmission of HIV

A Systematic Review and Meta-Analysis

M Davari; HB Giwa; A Nabizade; F Taheri; A Giwa

Disclosures

HIV Medicine. 2020;21(6):349-357. 

In This Article

Abstract and Introduction

Abstract

Objectives: The aim of this study was to evaluate the effect of antiretroviral therapy (ART) with or without condom use on the risk of sexual transmission of HIV.

Methods: A search of the literature was conducted in the PubMed, Web of Science, Cochrane, SCOPUS and EMBASE databases for studies dating back to 2008. The results were summarized as relative risks and incidence rates with 95% confidence intervals (CIs). The effect sizes were pooled using random-effects models and heterogeneity was evaluated using the Cochrane Q test and I 2.

Results: Of the 1424 studies retrieved in the initial search, 10 met the eligibility requirements. ART was associated with a 52% reduction in transmission risk compared to no ART, with a relative risk of 0.48 (95% CI 0.439–0.525) (Q = 0.524; I 2 = 0.0%; overall effect Z = 15.99, P < 0.0001). ART vs. no ART caused a reduction in the risk from 5.6 person-years (95% CI 3.26–9.62 person-years) (Q = 0.771; I 2 = 0.0%; overall effect Z = 6.25, P < 0.0001) in the untreated group to 0.85 person-years (95% CI 0.28–2.99 person-years) (Q = 0.038; I 2 = 76.7%; overall effect Z = 0.11, P = 0.772) in the treated group, but not significantly so, which is equivalent to an 84% reduction in the risk of sexual transmission. In accordance with the Swiss National AIDS Commission declaration, ART with suppressed viral loads was associated with a minimal risk of transmission, with a median time at risk of 0.00 person-years (95% CI 0.00–0.00 person-years) (Q = 1.00; I 2 = 0.0%; overall effect Z = 6.80, P < 0.0001).

Conclusions: ART and condom use were found to cause a significant reduction in the risk of sexual transmission of HIV in both homosexual and heterosexual populations, based on previous systematic reviews and meta-analyses.

Introduction

By the end of 2015, the World Health Organization estimated that there were 36.7 million people living with HIV/AIDS.

Antiretroviral therapy (ART) has been shown to cause a reduction in the vertical transmission of HIV and it is also used extensively for post-exposure and pre-exposure prophylaxis.[1]

Historical events have shown that the effectiveness of ART in minimizing the sexual transmission of HIV has always been uncertain[2–4] and effectiveness in reducing sexual tranmision can be determined by assessing the risk of horizontal HIV transmission between members of serodiscordant couples when the HIV-positive partner has full viral suppression with combination antiretroviral therapy (cART).[4]

Amid this uncertainty, the Swiss National AIDS Commission issued a statement in January 2008 specifying that "HIV infected individuals could be considered non-infectious if they met three conditions: adherence to cART under the care of an HIV physician, virologic suppression below the level of detection for at least 6 months, and absence of concomitant sexually transmitted infections (STIs)".[4]

The Swiss statement was controversial because some studies were later carried out showing the presence of viral particles in the genital secretions of 5–48% of patients with undetectable plasma viraemia.[5–7]

Since the Swiss statement, there has been an increase in the number of systematic reviews and meta-analyses performed that have addressed the risk of sexual transmission of HIV with ART.[8]

In this study, a systematic review was performed of all systematic reviews and meta-analyses examining the effect of ART on the risk of sexual transmission of HIV that have been carried out from 2008 (when the Swiss statement was released) to date (encompassing all recent studies). A review of secondary data was performed, as such data can provide superior evidence as to the current risk of sexual transmission of HIV and would thus be of great value to policy makers in designing, implementing and improving HIV/AIDS prevention strategies.

Objective of This Study

The aim of this study was to evaluate the effect of ART with or without condom use on the risk of sexual transmission of HIV.

Research Question

What is the effect of ART with or without condom use on the risk of sexual transmission of HIV?

Comments

3090D553-9492-4563-8681-AD288FA52ACE

processing....