Patients on Suppressive ART Can Transmit HIV Infection

Summary and Comment |
September 22, 2008

Patients on Suppressive ART Can Transmit HIV Infection

  1. Salim S. Abdool Karim, MD, PhD

The documented transmission of HIV from a nonviremic patient to his partner makes a strong case for patients on successful ART to continue safer-sex practices.

  1. Salim S. Abdool Karim, MD, PhD

Earlier this year, the Swiss National AIDS Commission issued a statement suggesting that the risk for sexual HIV transmission in serodiscordant couples is negligible — and that condoms are no longer needed — if the infected person is on stable suppressive antiretroviral therapy (ART) and does not have other sexually transmitted diseases (STDs). The appropriateness of this statement was hotly debated at the International AIDS Conference in Mexico, with many expressing concerns about safety. A new case report from Germany lends credence to those concerns.

The case involved a 39-year-old HIV-infected man who started ART in 2000 with AZT/3TC and efavirenz. His plasma viral load declined to <50 copies/mL within 4 months and remained undetectable for at least the next 4 years. During this time, he reported good adherence to ART, and the treating physician confirmed the absence of other STDs. In 2002, the patient’s male partner of 2 years tested negative for HIV infection. In May 2003, the couple became less vigilant about safer-sex practices and began having unprotected anal intercourse. In July 2004, the partner seroconverted. Phylogenetic analysis ruled out the possibility that the partner had acquired the infection from a third person.

Comment

This report demonstrates that sexual transmission of HIV can occur in a serodiscordant couple, even when the initially infected partner has undetectable plasma viral loads, no other STDs, and good adherence to an antiretroviral regimen known to penetrate the genital compartment. Although compelling data demonstrate a relation between low plasma viral load and reduced risk for HIV transmission, one cannot reasonably conclude from these data that persons with undetectable viral loads pose no risk for HIV transmission. A small but real risk remains, making the promotion of safer-sex practices essential, regardless of viral load.

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