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Author Topic: Zero Transmissions through condomless sex if HIV+ Partner on suppressive ART  (Read 2885 times)

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Offline Dr.Strangelove

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Here's the first talk at CROI 2014 that got me excited:

HIV Transmission Risk Through Condomless Sex If HIV+ Partner On Suppressive ART: PARTNER Study

As far as I know the HPTN 052 study was the biggest one so far to study to what degree supressive ART minimizes the risk of HIV transmissions. In that study a single transmission occured which led to the conclusion that a successful ART reduces the risk by about 96%.
Now, unfortunately only 2% of the couples in HPTN 052 were MSM, therefore the question arose if the results of this study could be extrapolated to MSM, considering the fact that in general anal sex is known to have a higher transmission risk.
It seems like the PARTNER study (info pamphlet) may be able to close that gap. The first results of the study were presented at CROI 2014. The 10 min webcast can be watched here.

Over 1100 couples took part in the study (~66% straight, ~33% gay). Based on couple years of follow-up (CYFU) this study on condomless sex under ART is three times bigger than all previous studies combined. The results will be published shortly, a follow up study called PARTNER2 will run from 2014-2017 with a special focus on MSM.

The study looked at the transmission risks during condomless sex in serodiscordant couples where the positive partner was under suppressive ART (<200 copies/mm3). All positive partners were under ART for at least 2 years. Couples dropped out of the study if the viral load went above 200, the negative partner started PreP or did PEP or if the couple started using condoms throughout.

The estimated number of total sex acts was 44,439. Zero transmissions took place within the couples. However, some of the negative partners got infected from sex outside the relationship.
In the heterosexual couples, the estimated/expected number of transmissions (based on what we know about the usual transmission risks) within the couples, had the positive partner not been on supressive ART, was 89.

During the follow ups with the couples throughout the study it was shown that about 16% of the MSM had an STD, while 4-5% of the heterosexuals had one. Since there were zero transmissions and this is the largest study to date, apparently neither the (more risky) anal sex nor the prevalence of STDs made any difference for the transmission risk. There's still uncertainty due to the confidence intervals, which is one of the reasons to collect more data during the upcoming PARTNER2 study. But according to the given presentation, the best guess is that the risk is actually zero.

Here's the abstract:

HIV Transmission Risk Through Condomless Sex If HIV+ Partner On Suppressive ART: PARTNER Study

Background: The absolute risk of sexual HIV transmission on stable ART (HIV RNA viral load (VL) <200 c/mL) from condomless sex is unknown. Current limited data are largely focusing on vaginal sex Methodology: The international, observational multi-centre PARTNER study prospectively follows serodifferent couples (heterosexual (HT) and MSM) who had condomless penetrative anal or vaginal sex in the month prior to study entry, and where the HIV+ve partner is on ART. Every 6 months, each partner completes a sexual behaviour questionnaire and the negative partner tests for HIV. Eligibility of follow-up time in this transmission rate analysis required: continued condomless sex; not using PEP or PrEP; and latest VL <200 c/mL. For new diagnoses, phylogenetic analysis compared HIV-1 pol and env sequences by couple, after samples were anonymised. This planned analysis reports the rate of occurrence of linked transmissions.

Results: By 1st November 2013, 1110 couples were enrolled. Of 1151 couple-years of follow-up (CYFU), 894 were eligible (586 in HT and 308 in MSM). At baseline, the median duration on ART was 4.9 years (IQR: 1.9-11.4) and couples reported having condomless sex for a median 2 years (IQR: 0.5-6.3). Condomless sex with a different partner outside the partnership during follow-up was reported by 27% MSM and 2% HT HIV-negative partners. During follow-up, couples had condomless sex a median of 45 times/ year (IQR: 16-90). Although some negative partners became HIV positive during FU, no phylogenetically linked transmissions occurred, giving a rate of within-couple HIV transmission during eligible couple-years of zero (95% CI: 0-0.40/100 CYFU)(Table). The upper limit of the 95% CI for the rate of transmission was 0.96/100 CYFU for condomless anal sex (HT and MSM) and 1.97/100 CYFU for condomless receptive anal sex with or without ejaculation (MSM).

Conclusions: The overall risk of HIV transmission (in the context of previous sex without transmission) through condomless anal or vaginal sex from HIV positive people on ART with plasma VL < 200 copies/mL is extremely low, but uncertainty over the risk remains, particularly over receptive anal sex. Additional follow-up in MSM is essential to provide more precise estimates for transmission risk given the current assumptions of safety in some communities.





The Body also has an Article on that study:
Zero HIV Infections Seen Through Condomless Sex When HIV-Positive Partner Is on Effective Treatment
 
« Last Edit: March 04, 2014, 08:57:22 PM by Dr.Strangelove »


Offline mecch

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Wow, amazing result!

(As sidenote, how sad and ironic some of the HIV- people got infected outside their protected couple....  :(    One could ask, maybe PrEP would have been a good idea for those who like to screw bareback outside their "protected" couple...)
“From each, according to his ability; to each, according to his need” 1875 K Marx

Online Jeff G

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Dr Saag at UAB was quoted in his book as saying that ART treatment was so successful at prevention that if a transmission were to happen it rises to the level of a reportable event .

I used the word quote loosely as I cant remember the exact words but it caught my eye and I was waiting for this study to released so thanks for posting it .     

Offline AusShep

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Wow, amazing result!

(As sidenote, how sad and ironic some of the HIV- people got infected outside their protected couple....  :(    One could ask, maybe PrEP would have been a good idea for those who like to screw bareback outside their "protected" couple...)

Yeah, that's the thing that scares me with this good news.  The neg partner gets used to going condomless and doesn't take the proper precautions elsewhere, or a viral spike/treatment failure between bloodwork.  No way I'd drop condoms now, but good to know accidents may be pretty much zero risk. 

Offline Dr.Strangelove

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Yeah, that's the thing that scares me with this good news.  The neg partner gets used to going condomless and doesn't take the proper precautions elsewhere, or a viral spike/treatment failure between bloodwork.  No way I'd drop condoms now, but good to know accidents may be pretty much zero risk.
Yes, that's one interpretation. And that would not be a good 'side-effect'. But it might also be that these neg guys are the kind of hardcore barebackers that would never use a condom no matter what and they had just been lucky until now. We simply don't know why those neg guys chose not to use a condom.

Offline Growler

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“If loving someone is putting them in a straitjacket and kicking them down a flight of stairs, then yes, I have loved a few people.”

Offline buginme2

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I wanted to see if I could join this study but it's being conducted in Europe and there were no participants from the United States.  I'm positive and my partner is negative.  We have been together for several years and do not use condoms. 

In the several years we have been together we have had boat loads of unprotected sex.  Top/bottom/one of each etc.  No transmission. 

Now,a couple of qualifications.  I'm ocd about making sure I take my hiv meds.  I have pretty much 100% adherence.  Also, we both discuss the situation and are both comfortable with the risk.  I'm fact we just had the talk last week when we were sitting in the waiting room at the doctor when he was getting his latest hiv test.  He also has gone to my hiv doctor and another hiv doctor on his own to learn the facts regarding transmission risk.

As this study shows, his greatest risk of getting hiv is from someone other than me.  I'm probably the safest risk. 

What annoys me about the articles written about this study and past studies is people can't seem to look beyond what we have been taught about condoms and hiv.  Treatment as prevention works.  It's been shown to work time and time again.

Just an interesting fact about this study.  There were 44,400 sex acts cataloged in this study and not one transmission.  Had the study been testing the effectiveness of condoms there would have been a lot more transmissions.  So actually, treatment is more effective at transmissions than condoms are.  Just a observation.

Online Miss Philicia

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Treatment as prevention works IF YOU KNOW AND CAN PROVE that your partner is not only taking their medication but that it's working. Which I guess technically, if you are paranoid, means viewing their lab results every time. This can only be done with a partner, not an anonymous trick.

So for most sex, you can SEE a condom but you can't SEE someone's lab numbers. Just an observation.

As far as treatment as prevention as a general goal -- even places in Europe where healthcare and medication are free have quite sub-obtimal amounts of patients that are retained in care and/or taking their medication regularly enough to result in viral suppression. Treatment can't prevent much if you don't stick to treatment. Just an observation.
"I’ve slept with enough men to know that I’m not gay"

Offline Dr.Strangelove

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I completely agree with both of your statements.

And yes, condoms are simple in the sense that they are physical. Both partners know if a condom is used, if it was used properly and so on.
That's the hard part about treatment as prevention when you want to apply that to real world scenarios.
I mean, you could take a copy of your latest lab results with you when going to the sauna...  :D

But the important point of the study is that it does work if the meds are taken properly. So, for those of us who are responsible about taking our meds (and where the treatment works as intended -> undetectable viral load) we now know that the risk of transmission is negligible.
In my opinion the main implication for these new results are for serodiscordant couples and hopefully also for criminalization. If, as this study shows, proper treatment prevents HIV transmission even more reliably than a condom does, how can you put undetectable guys in jail, while not punish positive guys who instead use a condom?
(I know, the laws vary from country to country and state to state and in some states it's even illegal to engage in any kind of sex without prior disclosure. So, obviously there it wouldn't make a difference.)

One other thing worth mentioning is that the percentage of positive guys under treatment varies a lot among western countries. For example in some European countries it's pretty high. I don't know the numbers for Canada. But as far as I remember, in the US less of poz guys are under treatment in comparison. That's also something to consider.

Offline buginme2

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No one, including myself is advocating taking a strangers word that they are adherent to their meds or are undetectable.  Besides if your having sex with a stranger you should still be using condoms and other safer sex practices as HIV is not the only game in town. 

However, even with that TaP has demonstrated a reduction in new HIV cases.  Vancouver BC was one of the first places that aggressively started a treatment as prevention program and it has worked very well.  New HIV cases have dropped by more than 40%. 

http://www.aidsmap.com/HIV-treatment-as-prevention-the-experience-in-British-Columbia/page/2827633

The thing I find interesting and was making a point of in my post is that whenever these studies are published that show just how effective treatment is at preventing new infections there is always a chorus of "but wait what about...." 

The HIV community is very tied to condoms as the only means of prevention.  All I'm saying is, for some, it's not the only game in town.


Offline buginme2

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The same arguments are being made against PreP and much of the push back has come from the hiv and gay.  There has been a negative tone against men who use prep to prevent them from becoming hiv positive.

Why can't we use more than one prevention strategy?

Online leatherman

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The HIV community is very tied to condoms as the only means of prevention.  All I'm saying is, for some, it's not the only game in town.
they are not the only means of prevention at all ;) however when the HIV education/prevention community also considers pregnancies, syphilis and gonorrhea, they know that promoting condoms is promoting the one-size-fits-nearly-all solution. Getting the best bang outta the prevention dollar buck, the HIV-STD-pregnancy prevention community gets the most positive results by promoting condoms.

of course, we need to use every strategy; but, hands down, condoms do more good for less $$$ against every other strategy.

but this is all for a different thread  ;)
to me the zero transmission thing also shoots down the old super-infection scare about pozzies doing it together sans condom. ;0 what's that new phrase? as yes, "condom-less sex"  8)
leatherman (aka mIkIE)


chart from 1992-2013; updated 2/09/13  Reyataz/Norvir/Truvada

Offline buginme2

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to me the zero transmission thing also shoots down the old super-infection scare about pozzies doing it together sans condom. ;0 what's that new phrase? as yes, "condom-less sex"  8)

Good point.  I hadn't thought of that. Hopefully we can put that boogie man to bed.  After all that was really a made up scare tactic.


Offline tednlou2

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Just read this article.  We've discussed this here several times.  I'm just not sure you could convince many a barebacker that they would be less likely to be infected from a poz, UD guy-- over some dude telling you he's neg and gets tested every 3 months.


http://www.thebody.com/content/73880/fuck-poz-guys.html

Offline AusShep

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I have a question about virologic failure.

Of those dropped from the study, 18% was because they had a VL rebound above 200.  They had all been UD for 2+ years prior.  Even those with 100% compliance can have virologic failure from studies I've read (they're several years old though).

Does this tend to happen slowly, with a blip beforehand that could be monitored more closely, or do people go from UD to thousands very quickly?  3 month testing would obviously be better than 6 months, like I, and I assume many of us are doing with UD levels.  People can go from 100k to UD in 3 months, is the reverse also possible/at all likely?


Offline OneTampa

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The local radio shows are running several news casts about this.  I heard Dr. Fauci on one of the shows. Encouraging reports flavored still with caution.
"He is my oldest child. The shy and retiring one over there with the Haitian headdress serving pescaíto frito."

Offline RapidRod

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Good point.  I hadn't thought of that. Hopefully we can put that boogie man to bed.  After all that was really a made up scare tactic.
Prep instructions says to be used in conjunction with other methods of protection. Not to replace the use of condoms which are known when used correctly and consistently protect against HIV and most other STDs.

Online leatherman

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Prep instructions says to be used in conjunction with other methods of protection. Not to replace the use of condoms which are known when used correctly and consistently protect against HIV and most other STDs.
except when you're already infected with HIV, you don't need PrEP or condoms to protect against HIV. ;)

I will grant you (because I'm pro-condom and ambivalent about Truvada-PrEP) that condoms will also protect against other STDs or pregnancy, and most people SHOULD use condoms regardless of their HIV status to fully protect themselves.

However, previous studies have show that poz-to-poz HIV retransmission/reinfection only happens to people who are not on successful therapy. the results of this study clearly confirms that UD HIV positive people will not transmit HIV to their partners and cause some sort of super infection.
leatherman (aka mIkIE)


chart from 1992-2013; updated 2/09/13  Reyataz/Norvir/Truvada

Offline buginme2

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Prep instructions says to be used in conjunction with other methods of protection. Not to replace the use of condoms which are known when used correctly and consistently protect against HIV and most other STDs.

What does prep have to do with so called superinfection or this thread for that matter?

 


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