IDWeek 2013: Clinical Controversies in HIV Prevention
IDWeek 2013 kicked off this week with interactive sessions and discussions of HIV care, treatment, and prevention—including a lively debate on whether doctors should counsel their patients to continue using condoms or PrEP if their HIV-positive partner is on effective HIV treatment and has an undetectable viral load.
HIV clinicians Roy Gulick and Paul Sax weighed the evidence pro and con before a packed auditorium. Gulick pointed to the continued risk of HIV transmission even with suppressed HIV—viral load can increase between medical check-ups if other sexually transmitted infections are present, for example, and the amount of virus detected in blood does not always match that found in semen and genital fluids—and observed that studies in serodiscordant couples found several new HIV infections that could not be genetically matched to the “monogamous” partner, suggesting that HIV prevention tools are still needed.
Sax countered that the risk is extremely low. Studies with serodiscordant couples found up to 96% reduction in HIV transmission risk with effective HIV treatment, and to date, only one HIV transmission has been reported from an individual with undetectable viral load, he noted. To Sax, these data suggest counseling long-term exclusive partners to keep up the condoms and PrEP is both unnecessary and unrealistic.
Members of the audience largely disagreed, however: At the close of the interactive session, 63% favored counseling individuals to continue using prevention tools.
For a summary of this and other sessions from the start of IDWeek 2013, see Liz Highleyman’s report, excerpted below and available in full at HIVandHepatitis.com.
October 3, 2013
By Liz Highleyman
…On Thursday, Roy Gulick from Weill Cornell Medical College and Paul Sax from Brigham and Women’s Hospital faced off in a “Clinical Controversies” debate about whether sexual partners of HIV positive people on fully suppressive antiretroviral therapy (ART) need to continue HIV prevention strategies with their partner.
Speaking in favor, Gulick argued that having an “undetectable” blood plasma viral load does not mean there is no virus at all in the body, and in particular in semen and cervical-vaginal fluid. There have been case reports in the literature — albeit few — of transmission despite undetectable plasma viral load.
On the con side, Sax countered that unprotected sex “is a viable option” for serodiscordant couples in long-term monogamous relationships. The groundbreaking HPTN 052 trial found that HIV transmission within heterosexual couples was reduced by 96% when the HIV positive partner started immediate ART upon HIV diagnosis regardless of CD4 T-cell count. Several other studies and a meta-analysis have reported transmission rates at or near zero when viral load is undetectable….
Stay tuned for more news from HIV-related sessions at IDWeek 2013.