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ART use doesn't increase sexual risk among people with HIV in the UK
Michael Carter, 2016-04-28 08:50:00
antiretroviral therapy (ART) is not associated with an increased risk of
condomless sex with HIV-negative/unknown status partners – sex that potentially
involves a risk of transmission – investigators from the UK report in the online
edition of AIDS. Moreover, ART was
associated with a significant reduction in the prevalence of sex involving a risk
of HIV transmission.
“In this large
multicentre study of people attending HIV clinics in the UK in 2011/12, use of
ART was not associated with higher prevalence of CLS-D [condomless discordant
sex],” comment the authors.
rates in the UK continue to be high, especially among men who have sex with men (MSM). Although it has been
estimated that most new HIV infections have their source in individuals who are
unaware they have HIV, a significant proportion – up to 20% in MSM – arise from
people who are already diagnosed.
There is now
convincing evidence that people taking ART who have an undetectable viral load are extremely unlikely to pass HIV on to their sexual partners. The health
benefits of prompt ART have also been established, and most treatment
guidelines therefore now recommend the early initiation of HIV therapy.
It is uncertain if
taking ART influences sexual behaviour, especially when viral load is
suppressed. Investigators from the UK therefore designed the ASTRA (Antiretovirals,
Sexual Transmission Risk and Attitudes) study to see if ART and perceived viral
load status had an impact on sexual behaviour, especially condomless sex with a
partner who was HIV-negative or of unknown HIV status.
Eight hospital HIV
outpatient clinics across the UK participated in the study, recruiting 3178
adult patients (of which 88% were taking antiretroviral therapy), all of whom had diagnosed HIV infection for at least three
asked to complete a questionnaire about their demographic background, use of
ART, perceived viral load and sexual behaviour in the previous three months. In
particular, participants were asked whether they had had condomless anal or vaginal sex
with a partner who was HIV-negative/unknown status. MSM were asked if they were
receptive, insertive, or both, and if insertive, if they ejaculated in their
Participants were also
asked whether they believed that an undetectable viral load made someone less
infectious, and whether people with an undetectable viral load needed to use condoms
to prevent HIV transmission.
population comprised 2189 MSM, 360 heterosexual men and 629 women. The vast
majority reported being on ART, including 87% of MSM, 93% of heterosexual men
and 89% of heterosexual women, of whom 84%, 62% and 71%, respectively, had an
undetectable viral load.
Analysis of the
sexual behaviour of MSM showed that 38% reported condomless sex, with 15%
reporting condomless sex with an HIV-negative/unknown partner. Of men in the
latter category, less than a third reporting insertive sex ejaculated in their
partner and 40% said they only had receptive anal sex. MSM reporting condomless
sex with HIV-negative/unknown partners were more likely than other MSM to
report sexually transmitted infections (22 vs 9%) and group sex (45 vs 16%).
Overall MSM on ART
were less likely to report condomless sex with HIV-negative/unknown partners
than men who were not on ART (14 vs 19%, p < 0.05). Those on ART were also
less likely to report sexually transmitted infections (10 vs 17%), group sex (20 vs 29%) and ten or
more partners in the past year (25 vs 36%) – all p < 0.001.
Among MSM on ART,
prevalence of condomless sex with HIV-negative/unknown partners was higher
among those reporting an undetectable viral load than those reporting a viral
load above 50 copies/ml (15 vs 10%, p = 0.014). However, prevalence of
condomless sex with a possible risk of HIV transmission was higher among MSM
not on ART (19%) than in both ART groups.
After taking into
account demographic and HIV-related factors, compared to MSM on ART reporting
an undetectable viral load, those on ART without an undetectable viral load has
a significantly lower prevalence of condomless sex with HIV-negative/unknown
partners (adjusted PR = 0.67; 95% CI, 0.46-0.96).
by heterosexual men and women showed that 6% and 11%, respectively, reported
condomless anal/vaginal sex with HIV-negative/unknown partners.
men, prevalence of condomless anal/vaginal sex with HIV-negative/unknown
partners did not differ significantly between those on ART and those not on ART
(6 vs 4%), a finding replicated in heterosexual women (11 vs 9%).
The majority of
participants believed that condoms were needed to prevent HIV transmission,
even in the context of an undetectable viral load. However, just over a third
(38%) of participants reporting condomless sex with HIV-negative/unknown partners
gave “belief that transmission risk is very low” as one reason for not using a
condom. The percentage was 42% for those reporting an undetectable viral load,
23% for people on ART with a detectable viral load and 28% for people not
A check of clinic
records showed that 97% of participants reporting an undetectable viral load did in
fact have a viral load below 50 copies/ml.
highlight the importance, as ART use expands, of promoting sustained high
adherence, regular viral load testing, and ongoing awareness of personal viral
load,” comment the researchers.
Prevalence of risk
of HIV transmission was 3% overall: 16% among those not on ART, 3% for patients
on ART with a detectable viral load, and 0.6% for ART-treated patients with
“Among people with
HIV in the UK, use of ART was not associated with increased prevalence of CLS
[condomless sex] or CLS-D [condomless discordant sex], and was associated with
greatly reduced prevalence of [HIV transmission] risk,” conclude the
researchers. “These results support the prevention role of ART offered to all
people with HIV, and emphasise the need to focus on HIV/STI prevention among
those not wishing to start ART.”