Changing transmission

HIV transmission is a critical area – timing of treatment, particularly in areas not as well resourced as the Western world, is an area that needs more evidence. 

This article from NEJM talks about preventing HIV transmission by starting antiretrovirals a little earlier. As you know, previous teaching has been to commence anti-retrovirals with a CD4 count of less than 200, but recent studies have shown benefit for starting earlier. Looking at patients with a CD4 count of 350 (across four continents), the question was raised whether antiretroviral therapy would reduce transmission – and it looks like a relative reduction of about 96% (4 events in the early treatment group, vs 35 in the late treatment group [two CD4 counts below 250]). 

Interestingly, the rate of clinical events was driven greatly by the the presence of extrapulmonary tuberculosis – and early therapy reduced the rate of these events, although it is important to note that isoniazid prophylaxis was not used as prescribed. 

The Lancet has a few articles, with this first one noting that almost 40% of transmission is due to individuals with early stage infection. Although a great deal of treatment is focused on chronic infection, early treatment seems important (although much more difficult to target). They’ve also got a couple (here and here) of drug company funded studies looking at rilpivirine – which had more virological failures. There’s also this looking at the rate of partnership concurrency (which was greatly variable) and multiple partners (a mean of 6) in sub-Saharan Africa. 

To finish, have a read of this great review article on the changes happening in HIV prevention altogether. 

IMAGE Jon Rawlinson


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