Potent antiretroviral treatment of HIV-infection results in suppression of the seminal shedding of HIV. The Swiss HIV Cohort Study

HIV and urethritis: time required for antiretroviral therapy to suppress HIV in semen

OBJECTIVES

To examine the time required to suppress HIV in the genital tract with antiretroviral therapy (ART) in men with urethritis.

DESIGN

An observational cohort study.

METHODS

Men with HIV and urethritis not on ART were enrolled at an STI clinic in Malawi and offered to initiate ART. Blood and semen samples were collected pretreatment and at 1, 2, 4, 8, 12 and 24 weeks posturethritis treatment. Median viral loads (VLs) were calculated by ART initiation groups: 'within 1 week', 'between 1 and 4 weeks' and 'no ART before 4 weeks', based on the men's choice about whether or not to initiate ART. The presence of ART at each visit was confirmed by bioanalytical methods.

FINDINGS

Between January 2017 and November 2018, 74 men presented with urethritis and HIV and were confirmed ART naive. The median age was 32 years. Forty-one (55% of men) initiated ART within 1 week; 12 (16%) between 1 and 4 weeks; and 21 (28%) did not initiate ART by week 4. Within the 1 week group, median VL was suppressed within 4 weeks in both semen and blood. Among the 1-4 weeks group, VL was suppressed within 4 weeks in semen and 5 weeks in blood. Among the no ART before 4 weeks group, VL in semen declined within the first 4 weeks but remained unsuppressed through week 24, and there was no significant decline in blood HIV.

CONCLUSION

Treatment of urethritis and prompt initiation of ART with counseling for safer sex for at least one month is a critical measure to reduce transmission of HIV.

HIV infection

The AIDS epidemic has been a global public health issue for more than 40 years and has resulted in ~40 million deaths. AIDS is caused by the retrovirus, HIV-1, which is transmitted via body fluids and secretions. After infection, the virus invades host cells by attaching to CD4 receptors and thereafter one of two major chemokine coreceptors, CCR5 or CXCR4, destroying the host cell, most often a T lymphocyte, as it replicates. If unchecked this can lead to an immune-deficient state and demise over a period of ~2-10 years. The discovery and global roll-out of rapid diagnostics and effective antiretroviral therapy led to a large reduction in mortality and morbidity and to an expanding group of individuals requiring lifelong viral suppressive therapy. Viral suppression eliminates sexual transmission of the virus and greatly improves health outcomes. HIV infection, although still stigmatized, is now a chronic and manageable condition. Ultimate epidemic control will require prevention and treatment to be made available, affordable and accessible for all. Furthermore, the focus should be heavily oriented towards long-term well-being, care for multimorbidity and good quality of life. Intense research efforts continue for therapeutic and/or preventive vaccines, novel immunotherapies and a cure.

Rectal and seminal HIV-1 RNA decay towards virological suppression in infected MSM initiating dolutegravir/abacavir/lamivudine

BACKGROUND

The time at which the protective effect of starting ART is achieved in male rectal and genital reservoirs is not clearly established.

OBJECTIVES

To quantify HIV-1 RNA decay towards virological suppression in rectal mucosa and semen in MSM starting dolutegravir/abacavir/lamivudine (DTG/ABC/3TC).

METHODS

A longitudinal cohort study of ART-naive HIV-positive MSM was performed. HIV-1 RNA was quantified in rectal mucosa and seminal plasma samples at day 1 of ART initiation (baseline) and every 4 weeks until week 20 (w20; all participants) and week 64 (w64; 6 of 12 participants).

RESULTS

Twelve MSM, with median (IQR) age 36 (33-40) years and baseline CD4+ count 449 (411-503) cells/mm3, were included. At baseline, HIV-1 RNA was detectable in all plasma and seminal samples and 10/12 rectal samples. All participants achieved plasma virological suppression by w20, whereas HIV-1 RNA was detectable in 42% and 50% of seminal and rectal samples, respectively. At w64, HIV-1 RNA was detectable in 1/6 seminal and 1/6 rectal samples. A relationship of baseline seminal and rectal HIV-1 RNA levels with viral shedding in reservoirs (HIV-1 RNA >200 copies/mL or copies/swab) was found. In addition, a significant association of baseline plasma viral load with time to rectal HIV-1 RNA <200 copies/swab was found (P=0.025).

CONCLUSIONS

Viral decay after initiating DTG/ABC/3TC is slower in rectal mucosa and semen than in plasma. Approximately half of patients achieved undetectable HIV-1 RNA levels in rectal and genital secretions at w20 and in some patients viral shedding persisted for up to 1 year. Initial plasma viral load influences time to rectal suppression.

Effects of Urethritis on HIV in Semen: Implications for HIV Prevention and Cure

BACKGROUND

Prior to the widespread availability of antiretroviral therapy (ART), Men living with HIV with urethritis had increased concentration of HIV in semen. This study aims to better evaluate HIV shedding in men with urethritis receiving ART, and implications for the cure of HIV.

METHODS

Men living with HIV with urethritis taking ART ≥12 weeks were enrolled at a sexually transmitted infections clinic in Lilongwe, Malawi. Study follow-up included visits 1, 2, 4, 8, 12, 24, 36, and 48 weeks post urethritis diagnosis and treatment. Matched blood and semen samples were collected at all visits, and all additional episodes of urethritis were followed with extra visits 1, 2, and 4 weeks after treatment.

RESULTS

111 men enrolled in the study between January 2017 - March 2019, and 77 (69%) were suppressed in the blood (<400 copies/mL). Among the 77 men, 87 episodes of urethritis were evaluated during follow-up. Of the 87 episodes, 15 episodes (17%) had instances of seminal viral shedding ≥400 copies/mL despite viral suppression in the blood. At follow-up of non-urethritis episodes, ≤6% of men at each visit had a viral load ≥400 copies/mL in the semen while maintaining viral suppression in the blood.

CONCLUSIONS

An HIV cure requires the elimination of HIV from every body compartment, but available ART does not currently accomplish this. Our study highlights the male genital tract as a local source of HIV that can be reversibly activated. A better understanding of this phenomenon is important to advance the HIV cure field.

Treatment as Prevention: Concepts and Challenges for Reducing HIV Incidence

Four of the largest HIV prevention trials have been conducted in sub-Saharan Africa, enrolling hundreds of thousands of participants in catchment areas of millions of people. The trials have focused on community-level interventions to increase diagnosis and initiation of antiretroviral therapy (ART) to improve health and reduce HIV transmission. Universal test-and-treat strategies are deployed to achieve viral suppression thereby reducing risk to uninfected persons, known as treatment as prevention (TasP).

Genital Human Immunodeficiency Virus-1 RNA and DNA Shedding in Virologically Suppressed Individuals Switching From Triple- to Dual- or Monotherapy: Pooled Results From 2 Randomized, Controlled Trials

BACKGROUND

Increasingly, people living with human immunodeficiency virus (HIV) benefit from lower drug regimens (LDRs). Exploring viral genital shedding during LDRs is crucial to ensure their safety.

METHODS

We pooled genital sub-studies from 2 clinical trials in this area. Patients were randomized 1:1 to continue abacavir/lamivudine/dolutegravir or switch to dolutegravir (MONCAY trial), or to continue tenofovir/emtricitabine + a third agent or switch to tenofovir/emtricitabine (TRULIGHT trial). Participants whose plasma HIV-RNA remained <50 copies/mL had sperm or cervicovaginal lavage collected between Weeks 24 and 48. HIV-RNA and HIV-DNA were amplified by ultrasensitive polymerase chain reaction. The main objective was to measure the proportion of participants who had no detectable HIV in genital fluids, both according to each strategy and then in an aggregated analysis (LDR versus triple therapies).

RESULTS

There were 64 participants (35 males, 29 females) included: 16 received dual therapies and 16 received triple therapies in TRULIGHT; and 16 received monotherapies and 16 received triple therapies in MONCAY. In TRULIGHT, 13/15 (87%) of evaluable participants on dual therapy had no detectable HIV in their genital fluid, versus 14/15 (93%) under triple therapy (P = 1.0). In MONCAY, these figures were 12/15 (80%) on monotherapy versus 13/16 (81%) on triple therapy (P = 1.0). In the pooled analysis, a similar proportion of participants in the LDR and triple therapy groups had no detectable HIV: 25/30 (83%) and 27/31 (87%), respectively (P = .73).

CONCLUSIONS

There was no evidence of increased HIV-RNA and/or -DNA shedding in the genital fluids of people who maintained undetectable plasma HIV-RNA during LDRs.

CLINICAL TRIALS REGISTRATION

NCT02302547 and NCT02596334.

Prevention of HIV transmission with sperm washing within fertile serodiscordant couples undergoing non-stimulated intrauterine insemination

The purpose of this prospective non-randomized study was to study the effectiveness of semen washing followed by intrauterine insemination (IUI) in Human Immune Deficiency Virus (HIV)-discordant couples in which the male partner was infected, in preventing HIV transmission to uninfected partner and offspring. The study was performed in a private assisted reproductive center specialized in couples with infectious diseases and enrolled sixty-nine fertile couples in which male partner tested positive for HIV, seeking for reproductive treatment. Triple sperm washing followed by viral RNA purification and real-time polymerase chain reaction was performed prior to IUI intervention. HIV transmission to female partner and newborns, and clinical pregnancy rate were the main outcome measures. A total of 180 IUI treatment cycles were performed in 69 couples. There were 16 clinical pregnancies (clinical pregnancy rate/cycle 9.0%, clinical pregnancy rate/patient 23.2%), one of which resulted in miscarriage (6.3%). No seroconversion was detected in the 69 women treated with sperm washing followed by IUI or in any of the newborns (tested at birth and at 3 months of age). Sperm washing followed by IUI is a safe and effective treatment option for serodiscordant couples wishing to conceive and to prevent HIV virus transmission to the mothers and newborns.

Modeling HIV Transmission from Sexually Active Alcohol-Consuming Men in ART Programs to Seronegative Wives

BACKGROUND

The rollout of antiviral therapy in Low and Middle Income Countries (LMICs) has reduced HIV transmission rates at the potential risk of resistant HIV transmission. We sought to predict the risk of wild type and antiviral resistance transmissions in these settings.

METHODS

A predictive model utilizing viral load, ART adherence, genital ulcer disease, condom use, and sexual event histories was developed to predict risks of HIV transmission to wives of 233 HIV+ men in 4 antiretroviral treatment centers in Maharashtra, India.

RESULTS

ARV Therapy predicted a 5.71-fold reduction in transmissions compared to a model of using condoms alone, with 79.9%, of remaining transmissions resulting in primary ART-resistance.

CONCLUSIONS

ART programs reduce transmission of HIV to susceptible partners at a substantial increased risk for transmission of resistant virus. Enhanced vigilance in monitoring adherence, use of barrier protections, and viral load may reduce risks of resistant HIV transmissions in LMIC settings.

No. 354-Canadian HIV Pregnancy Planning Guidelines

OBJECTIVE

The objective of the Canadian HIV Pregnancy Planning Guidelines is to provide clinical information and recommendations for health care providers to assist Canadians affected by HIV with their fertility, preconception, and pregnancy planning decisions. These guidelines are evidence- and community-based and flexible and take into account diverse and intersecting local/population needs based on the social determinants of health.

INTENDED OUTCOMES

EVIDENCE: Literature searches were conducted by a librarian using the Medline, Cochrane Central Register of Controlled Trials (CENTRAL), and Embase databases for published articles in English and French related to HIV and pregnancy and HIV and pregnancy planning for each section of the guidelines. The full search strategy is available upon request.

VALUES

The evidence obtained was reviewed and evaluated by the Infectious Diseases Committee of the SOGC under the leadership of the principal authors, and recommendations were made according to the guidelines developed by the Canadian Task Force on Preventive Health Care and through use of the Appraisal of Guidelines Research and Evaluation instrument for the development of clinical guidelines.

BENEFITS, HARMS, AND COSTS

Guideline implementation should assist the practitioner in developing an evidence-based approach for the prevention of unplanned pregnancy, preconception, fertility, and pregnancy planning counselling in the context of HIV infection.

VALIDATION

These guidelines have been reviewed and approved by the Infectious Disease Committee and the Executive and Council of the SOGC.

SPONSOR

Canadian Institutes of Health Research Grant Planning and Dissemination grant (Funding Reference # 137186), which funded a Development Team meeting in 2016.

RECOMMENDATIONS

HIV and SIV in Body Fluids: From Breast Milk to the Genitourinary Tract

HIV-1 is present in many secretions including oral, intestinal, genital, and breast milk. However, most people exposed to HIV-1 within these mucosal compartments do not become infected despite often frequent and repetitive exposure over prolonged periods of time. In this review, we discuss what is known about the levels of cell-free HIV RNA, cell-associated HIV DNA and cell-associated HIV RNA in external secretions. Levels of virus are usually lower than contemporaneously obtained blood, increased in settings of inflammation and infection, and decreased in response to antiretroviral therapy. Additionally, each mucosal compartment has unique innate and adaptive immune responses that affect the composition and presence of HIV-1 within each external secretion. We discuss the current state of knowledge about the types and amounts of virus present in the various excretions, touch on innate and adaptive immune responses as they affect viral levels, and highlight important areas for further study.

Histone deacetylase inhibitor chidamide promotes reactivation of latent human immunodeficiency virus by introducing histone acetylation

Highly active antiretroviral therapy can reduce the human immunodeficiency virus (HIV) viral load in the plasma to undetectable levels. However, because of the presence of latent HIV reservoirs, it is difficult to completely eradicate HIV in infected patients. Our objective was to assess the potency of chidamide, a novel histone deacetylase inhibitor recently approved for cancer treatment by the China Food and Drug Administration, to reactivate latent HIV-1 via histone acetylation. Viral reactivities of chidamide were accessed in 2 latent HIV pseudotype virus cell reporter systems (J-Lat Tat-green fluorescent protein clone A72 and TZM-bl), a latently infected full-length HIV virus cell system (U1/HIV), and resting CD4⁺ T cells from 9 HIV-infected patients under highly active antiretroviral therapy with undetectable viral load. Chidamide was able to increase HIV expression in each cell line, as evidenced by green fluorescent protein, luciferase activity, and p24, as well as to reactivate latent HIV-1 in primary CD4⁺ T cells of HIV-infected patients. Histone acetylation adjacent to the HIV promoter in A72 cells was determined by chromatin immunoprecipitation. Chidamide was able to increase histone H3 and H4 acetylation at the HIV promoter. In brief, chidamide induced the reactivation of latent HIV in pseudotype virus reporter cells, latently infected cells, and primary CD4⁺ T cells, making this compound an attractive option for future clinical trials.

After 18 months of antiretroviral therapy, total HIV DNA decreases more pronouncedly in patients infected by CRF01_AE than in those infected by subtype B and CRF07_BC

Whether the amount of HIV DNA is associated with the subtype of HIV-1 after antiretroviral therapy (ART) has not been reported. In the present study, the amount of HIV DNA and RNA and CD4+T counts in blood and semen prior to and after 18 months of ART were compared in 48 patients infected by CRF01_AE, subtype B or CRF07_BC of HIV-1. Viral RNA was suppressed and CD4 cell count recovery achieved in all patients. The level of HIV DNA were similar before ART; however, patients with CRF01_AE had less HIV DNA after ART than those with subtype B and CRF07_BC infection. According to prediction of co-receptor usage by Geno2Pheno and PSSM in combination, more than 35.6% of clones for CRF01_AE were predicted as CXCR4-using before ART, whereas less than 6% of those for subtype B and CRF07_BC were predicted as CXCR4-using. After 18 months of ART, no CXCR4-using clones were predicted in any of the subtypes. Despite more HIV RNA and fewer CD4 + T cells in patients with CRF01_AE before therapy, no significant differences (P > 0.05) in viral RNA or CD4 cell counts were observed between the subtypes after 18 months of ART. Thus, 18 months of antiretroviral therapy was more efficient in patients with CRF01_AE. Considering that successful ART dramatically reduces the viral load in both blood and semen, risks of sexual transmission of HIV were reduced, contributing to prevention of rapid spread of HIV among men who have sex with men in the region.

Belief in Treatment as Prevention and Its Relationship to HIV Status and Behavioral Risk

BACKGROUND

We evaluated attitudes toward treatment as prevention (TasP) among gay, bisexual, and other men who have sex with men (GBM) in Vancouver, Canada.

METHODS

Sexually active GBM, aged ≥16 years, were recruited between 2012 and 2015 using respondent-driven sampling. At each 6-month follow-up, participants completed a computer-administered questionnaire and nursing visit. Repeated-measures latent class analysis, grouped by self-reported serostatus, identified patterns of TasP endorsement by considering TasP-related awareness, attitudes, and behavior. Binary logistic regression identified covariates of class membership. Bivariate interactions with visit number identified factors associated with longitudinal changes in class membership.

RESULTS

A total of 774 men provided 2590 observations. Of these, 698 enrolled in the cohort, 575 had at least 1 follow-up visit. Among these, the median follow-up time was 1.98 years (Q1-Q2: 1.49-2.49 years). Repeated-measures latent class analysis identified 3 classes: "unaware" (64.2% HIV negative/unknown vs. 29.2% of HIV positive), "skeptical" (29.7% vs. 23.1%), and "believing" (6.1% vs. 47.7%). Membership in classes representing higher TasP endorsement was associated with greater odds of condomless anal sex and having more sexual partners. Age, sexual orientation, ethnicity, substance use, and social time spent with other GBM were also associated with class membership. Longitudinally, class membership was stable among HIV-positive men but shifted toward greater TasP endorsement among HIV-negative/unknown men. For HIV-negative/unknown men, increasing endorsement was positively associated with greater education, being employed, being in a relationship, and substance use and inversely associated with recent serodiscordant condomless anal sex or sexually transmitted infection diagnosis.

CONCLUSIONS

Over time, disparities in TasP diffusion by HIV status have lessened, although continue to persist across other key social strata.

A Decline in HIV Testing Among Persons Who Inject Drugs in the Seattle Area, 2004-2015

BACKGROUND

Promoting HIV testing is a key component of the public health response to HIV. Assessing HIV testing frequency among persons who inject drugs (PWID) monitors the status of these efforts and can identify unmet needs and opportunities to more effectively promote testing.

METHODS

Data were combined from 4 Seattle-area surveys of PWID from the National HIV Behavioral Surveillance (NHBS) program (2005-2015) and 6 surveys of Needle Exchange clients (2004-2015).

RESULTS

The proportion of PWID reporting an HIV test in the previous 12 months declined from 64% in 2005% to 47% in 2015 in the NHBS surveys and from 72% to 58% in the Needle Exchange surveys. These declines persisted in multivariate analyses controlling for differences in the study populations in age, race, sex, area of residence, education, current homelessness, drug most frequently injected, daily injection frequency, and combined male-to-male sex and amphetamine injection status. The proportion of NHBS participants reporting not knowing the HIV status of their last injection partner increased from 38% to 45%. The proportion not knowing the HIV status of their last sex partner increased from 27% to 38%.

CONCLUSIONS

A decrease in HIV testing was found in 2 independent Seattle-area study populations. This was complemented by increases in the proportions not knowing the HIV status of their last sex and last injection partners. Research is needed to ascertain if such declines are observed elsewhere, the reasons for the decline, and appropriate means to effectively attain optimal HIV testing frequency among PWID.

Delivering safer conception services to HIV serodiscordant couples in Kenya: perspectives from healthcare providers and HIV serodiscordant couples

Introduction: For HIV serodiscordant couples in resource-limited settings, pregnancy is common despite the risk of sexual and/or perinatal HIV transmission. Some safer conception strategies to reduce HIV transmission during pregnancy attempts are available but often not used for reasons including knowledge, accessibility, preference and others. We sought to understand Kenyan health providers’ and HIV serodiscordant couples’ perspectives and experiences with safer conception.

Methods: Between August 2015 and March 2016, we conducted key informant interviews (KIIs) with health providers from public and private HIV care and fertility clinics and in-depth interviews (IDIs) and focus group discussions (FGDs) with HIV serodiscordant couples participating in an open-label study of integrated pre-exposure prophylaxis (PrEP) and antiretroviral therapy (ART) for HIV prevention (the Partners Demonstration Project). An inductive analytic approach identified a number of themes related to experiences with and perceptions of safer conception strategies.

Results: We conducted 20 KIIs with health providers, and 21 IDIs and 4 FGDs with HIV serodiscordant couples. HIV clinic providers frequently discussed timed condomless sex and antiretroviral medications while providers at private fertility care centres were more comfortable recommending medically assisted reproduction. Couples experienced with ART and PrEP reported that they were comfortable using these strategies to reduce HIV risk when attempting pregnancy. Timed condomless sex in conjunction with ART and PrEP was a preferred strategy, often owing to them being available for free in public and research clinics, as well as most widely known; however, couples often held inaccurate knowledge of how to identify days with peak fertility in the upcoming menstrual cycle.

Conclusions: Antiretroviral-based HIV prevention is acceptable and accessible to meet the growing demand for safer conception services in Kenya, since medically assisted interventions are currently cost prohibitive. Cross-disciplinary training for health providers would expand confidence in all prevention options and foster the tailoring of counselling to couples’ preferences.

Population Pharmacokinetic Modeling of Tenofovir in the Genital Tract of Male HIV-Infected Patients

The aims of this study were to describe the blood plasma (BP) and seminal plasma (SP) pharmacokinetics of tenofovir (TFV) in HIV-1-infected men, to assess the role of genetic polymorphism in the variability of TFV transfer into the male genital tract, and to evaluate the impact of TFV SP exposure on seminal plasma HIV load (spVL). Men from the Evarist-ANRS EP 49 study treated with TFV as part of their antiretroviral therapy were included in the study. A total of 248 and 217 TFV BP and SP concentrations from 129 men were available for the analysis. For pharmacogenetic assessment, a total of 121 single nucleotide polymorphisms (SNP) were genotyped. Data were analyzed using a nonlinear mixed-effects modeling approach. TFV pharmacokinetics were best described by a two-compartment model for BP and by an effect compartment with different input and output constants for SP. TFV exposures (area under the concentration-time curve from 0 to 24 h [AUC_0-24]) were higher in SP than in BP (median AUC_0-24, 7.01 versus 2.97 mg · liter^-1 · h, respectively). The median (range) SP-to-BP AUC_0-24 ratio was 2.24 (0.53 to 34.13). After correction for multiple testing, none of the SNPs were significantly associated with the TFV transfer rate constant. The impact of the TFV SP AUC_0-24 or TFV SP-to-BP AUC_0-24 ratio on spVL was not significant (P = 0.808 and 0.768, respectively). This is the first population model describing TFV pharmacokinetics in the male genital tract. TFV SP concentrations were higher than BP concentrations. Despite TFV SP exposures being higher than BP exposures, an spVL was detectable for 12.2% of the men.

Risk Factor Associated with Negative Spouse HIV Seroconversion among Sero-Different Couples: A Nested Case-Control Retrospective Survey Study in 30 Counties in Rural China

Background

Antiretroviral therapy (ART) and condom use have been proven to reduce the risk of sexual transmission of human immunodeficiency virus (HIV) among HIV sero-different couples, but its full implementation remains a challenge. This study aims to assess HIV seroconversion rate of HIV-negative spouse and its associated risk factors among HIV sero-different couples in rural China.

Methods

An open cohort of HIV sero-different couples enrolled in 30 counties in China between October 1, 2010, and September 30, 2012, and followed-up to December 31, 2012, was constructed retrospectively. A nested case-control study of risk factors of HIV seroconversion among sero-different couples was conducted in April and May of 2013, based on the open cohort. Sero-different couples with the HIV-negative spouse seroconverting at least 3 months after the previous negative diagnosis during cohort observation period were labeled as “case couples”. The “control couples” were selected randomly from the same cohort that did not have the HIV-negative spouse seroconversion during the same period. The “case couples” and “control couples” were matched on gender, age, and region of residence. Sexual behaviors among HIV sero-different couples before and after the index spouses notifying their HIV infection status to their HIV-negative spouses were collected via face-to-face interview. Univariate and multivariate logistic regression models were used to assess factors associated with HIV seroconversion among HIV sero-different couples.

Results

Of 4481 HIV sero-different couples, a total of 53 seroconversions were observed within 5218 person-years of follow-up. The incidence rate was 1.02 (95%CI: 0.76–1.33) per 100 person-years. Forty “case couples” confirmed HIV-negative spouse seroconversions infected via marital sexual transmission, were matched to 80 “control couples”. Of the 120 couples, 81(67.5%) were receiving ART, and 70 (58.3%) reported consistently used condoms during intercourse after the index spouse was diagnosed HIV infection. Multivariate conditional logistic regression analysis showed that the desire to conceive a child (OR = 5.18, 95% CI: 1.19–22.58) significantly increased the odds of HIV seroconversion. Protective factors of spousal HIV seroconversion were currently receiving ART (OR = 0.09, 95% CI: 0.01–0.67) and consistent condom use (OR = 0.05, 95% CI: 0.01–0.28).

Conclusions

Intention to conceive a child is the most important risk factor for HIV seroconversion among sero-different couples. Specific efforts on scientific use of ART to assist sero-different couples to achieve their wish to conceive a healthy child are needed to minimize the risk of HIV transmission.

UK guideline for the use of HIV Post-Exposure Prophylaxis Following Sexual Exposure, 2015

We present the updated British Association for Sexual Health and HIV guidelines for HIV post-exposure prophylaxis following sexual exposure (PEPSE). This document includes a review of the current data to support the use of PEPSE, considers how to calculate the risks of infection after a potential exposure, and provides recommendations on when PEPSE should and should not be considered. We also review which medications to use for PEPSE, provide a checklist for initial assessment, and make recommendations for monitoring individuals receiving PEPSE. Special scenarios, cost-effectiveness of PEPSE, and issues relating to service provision are also discussed. Throughout the document, the place of PEPSE within the broader context of other HIV prevention strategies is considered.

People living with HIV and procreation: 30 years of progress from prohibition to freedom?

The emergence of human immunodeficiency virus (HIV) infection in the 1980s drastically changed the prospects of conceiving a child for the man or woman infected with the virus. Advances in treatment then made it possible to envisage pregnancy while decreasing the risk of transmission to the child when the mother was infected. For couples where one partner was HIV-positive and who desired a child, recourse to medical help, notably medically assisted procreation, was discouraged, and very few centres offered such assistance in the 1980s and 1990s. Improved knowledge of viral excretion in the genital tracts, together with more effective treatment, made it possible to envisage medically assisted procreation for these couples, allowing them to have a child while at the same time likely reducing the risk of transmitting HIV to their partner. Several programmes have demonstrated their effectiveness in this domain. Owing to continually increasing knowledge over the past decade, natural conception can now be proposed. Couples where one or both partners are HIV-positive may opt for medically assisted procreation or natural reproduction. Specialists in reproductive medicine and HIV specialists need to provide couples with objective information allowing them to achieve near-optimal conditions that minimize HIV transmission risk. Couples will then be able to choose freely the mode of procreation most appropriate for them.

The HIV care cascade in Switzerland: reaching the UNAIDS/WHO targets for patients diagnosed with HIV

OBJECTIVES

To describe the HIV care cascade for Switzerland in the year 2012.

DESIGN/METHODS

Six levels were defined: (i) HIV-infected, (ii) HIV-diagnosed, (iii) linked to care, (iv) retained in care, (v) on antiretroviral treatment (ART), and (vi) with suppressed viral load. We used data from the Swiss HIV Cohort Study (SHCS) complemented by a nationwide survey among SHCS physicians to estimate the number of HIV-patients not registered in the cohort. We also used Swiss ART sales data to estimate the number of patients treated outside the SHCS network. Based on the number of patients retained in care, we inferred the estimates for levels (i) to (iii) from previously published data.

RESULTS

We estimate that (i) 15 200 HIV-infected individuals lived in Switzerland in 2012 (margins of uncertainty, 13 400-19 300). Of those, (ii) 12 300 (81%) were diagnosed, (iii) 12 200 (80%) linked, and (iv) 11 900 (79%) retained in care. Broadly based on SHCS network data, (v) 10 800 (71%) patients were receiving ART, and (vi) 10 400 (68%) had suppressed (<200 copies/ml) viral loads. The vast majority (95%) of patients retained in care were followed within the SHCS network, with 76% registered in the cohort.

CONCLUSION

Our estimate for HIV-infected individuals in Switzerland is substantially lower than previously reported, halving previous national HIV prevalence estimates to 0.2%. In Switzerland in 2012, 91% of patients in care were receiving ART, and 96% of patients on ART had suppressed viral load, meeting recent UNAIDS/WHO targets.

High Transmitter CD4+ T-Cell Count Shortly after the Time of Transmission in a Study of African Serodiscordant Couples

BACKGROUND

2013 WHO guidelines recommend starting ART at CD4+ T-cell counts ≤500 cells/μL. We present the T-cell counts from adult Africans with HIV shortly following transmission to their sexual partners.

METHODS

HIV-discordant couples in Zambia, Uganda and Rwanda were followed prospectively and received couples counseling and condoms. HIV uninfected partners were tested for HIV at least quarterly and HIV-infected partners received HIV care and referral for ART per national guidelines. Upon diagnosis of incident HIV infection in the previously HIV-uninfected partner, a blood sample was collected from both partners to measure CD4+ T-cells and perform viral linkage. The estimated date of infection (EDI) of the incident case was calculated based on testing history. EDI was unknown for suspected transmitting partners.

RESULTS

From 2006-2011, 4,705 HIV-discordant couples were enrolled in this cohort, and 443 cases of incident HIV infection were documented. Virus linkage analysis was performed in 374 transmission pairs, and 273 (73%) transmissions were linked genetically. CD4 counts in the transmitting partner were measured a median of 56 days after EDI (mean:90.5, min:10, max:396). The median CD4 count was 339 cells/μl (mean:386.4, min:15, max:1,434), and the proportion of partners with a CD4+ T-cell count above 500/μl was 25% (95% CI:21, 31).

CONCLUSIONS

In our cohort of discordant couples, 73% of HIV transmissions occurred within the relationship, and the transmitter CD4+ T cell count shortly after the transmission event was frequently higher than the WHO 2013 ART-initiation guidelines.

Emtricitabine seminal plasma and blood plasma population pharmacokinetics in HIV-infected men in the EVARIST ANRS-EP 49 study

We aimed to describe blood plasma (BP) and seminal plasma (SP) pharmacokinetics of emtricitabine (FTC) in HIV-1-infected men, assess its penetration in the male genital tract, and evaluate its impact on seminal plasma HIV load (spVL) detection. Men from the EVARIST ANRS EP49 study receiving combined antiretroviral therapy with FTC and with suppressed BP viral load were included in the study. A total of 236 and 209 FTC BP and SP concentrations, respectively, were available. A population pharmacokinetic model was developed with Monolix 4.1.4. The impact of FTC seminal exposure on spVL detection was explored by receiver operating characteristic (ROC) curves and mixed-effects logistic regressions. FTC BP pharmacokinetics was described by a two-compartment model. The addition of an effect compartment with different input and output constants best described FTC SP pharmacokinetics. No covariates were found to explain the variability in SP. FTC exposures (area under the concentration-time curve from 0 to 24 h [AUC0-24]) were higher in SP than in BP (median AUC0-24, 38.04 and 12.95 mg · liter(-1) · h, respectively). The median (range) SP-to-BP AUC0-24 ratio was 2.91 (0.84 to 10.08). Less than 1% of FTC AUC0-24 ratios were lower than 1. The impact of FTC SP AUC0-24 or FTC SP-to-BP AUC0-24 ratio on spVL detection was not significant (P = 0.943 or 0.893, respectively). This is the first population model describing FTC pharmacokinetics simultaneously in both BP and SP. FTC distributes well in the male genital tract with higher FTC concentrations in SP than in BP. FTC seminal plasma exposures were considered efficient in the majority of men.

Detection of Simian Immunodeficiency Virus in Semen, Urethra, and Male Reproductive Organs during Efficient Highly Active Antiretroviral Therapy

A number of men receiving prolonged suppressive highly active antiretroviral therapy (HAART) still shed human immunodeficiency virus (HIV) in semen. To investigate whether this seminal shedding may be due to poor drug penetration and/or viral production by long-lived cells within male genital tissues, we analyzed semen and reproductive tissues from macaques chronically infected with simian immunodeficiency virus mac251 (SIVmac251) who were treated for 4 months with HAART, which was intensified over the last 7 weeks with an integrase inhibitor. We showed that a subset of treated animals continued shedding SIV in semen despite efficient HAART. This shedding was not associated with low antiretroviral drug concentrations in semen or in testis, epididymis, seminal vesicles, and prostate. HAART had no significant impact on SIV RNA in the urethra, whereas it drastically reduced SIV RNA levels in the prostate and vas deferens and to a lesser extent in the epididymis and seminal vesicle. The only detectable SIV RNA-positive cells within the male genital tract after HAART were urethral macrophages. SIV DNA levels in genital tissues were not decreased by HAART, suggesting the presence throughout the male genital tract of nonproductively infected cells. In conclusion, our results demonstrate that 4 months of HAART induced variable and limited control of viral infection in the male reproductive organs, particularly in the urethra, and suggest that infected long-lived cells in the male genital tract may be involved in persistent seminal shedding during HAART. These results pave the way for further investigations of male genital organ infection in long-term-treated infected individuals.

IMPORTANCE

A substantial subset of men receiving prolonged HAART suppressing viral loads in the blood still harbor HIV in semen, and cases of sexual transmission have been reported. To understand the origin of this persistence, we analyzed the semen and male reproductive tissues from SIV-infected macaques treated with HAART. We demonstrated that persistent seminal shedding was not linked to poor drug penetration in semen or semen-producing prostate, seminal vesicle, epididymis, and testis. We revealed that HAART decreased SIV RNA to various extents in all male genital organs, with the exception of the urethra, in which SIV RNA(+) macrophages were observed despite HAART. Importantly, HAART did not impact SIV DNA levels in the male genital organs. These results suggest that infection of male genital organs, and particularly the urethra, could be involved in the release of virus in semen during HAART.

The use of Mycobacterium tuberculosis HspX and GlcB proteins to identify latent tuberculosis in rheumatoid arthritis patients

Understanding the social conditions and immunological characteristics that allow some human immunodeficiency virus (HIV)-exposed patients to remain uninfected represents an on-going challenge. In this study, the socio-demographic and sexual behaviour characteristics and immune activation profiles of uninfected individuals exposed to HIV-infected partners were investigated. A confidential and detailed questionnaire was administered and venous blood was tested using HIV-1/enzyme immunoassays, plasma HIV-1 RNA levels/bDNA and immunophenotyping/flow cytometry to determine the frequencies of CD4 and CD8 T cells expressing activation markers. The data analysis showed significant differences (p < 0.05) for immune parameters in individuals who were uninfected, albeit exposed to HIV-infected partners, compared with unexposed individuals. In particular, the exposed, uninfected individuals had a higher frequency (median, minimum-maximum) of CD4⁺HLA-DR⁺ (4.2, 1.8-6.1), CD8⁺HLA-DR⁺ (4.6, 0.9-13.7), CD4⁺CD45RO⁺ (27.5, 14.2-46.6), CD4⁺CD45RO⁺CD62L⁺ (46.7, 33.9-67.1), CD8⁺CD45RA⁺HLA-DR⁺ (12.1, 3.4-35.8) and CD8⁺CD45RO⁺HLA-DR⁺ (9.0, 3.2-14.8) cells, a decreased percentage of CD8⁺CD28⁺ cells (11.7, 4.5-24.0) and a lower cell-surface expression of Fcγ-R/CD16 on monocytes (56.5, 22.0-130.0). The plasma HIV-1 RNA levels demonstrated detectable RNA virus loads in 57% of the HIV-1⁺ female partners. These findings demonstrate an activation profile in both CD4 and CD8 peripheral T cells from HIV-1 exposed seronegative individuals of serodiscordant couples from a referral centre in Belo Horizonte, state of Minas Gerais.

Origins of HIV-infected leukocytes and virions in semen

Although semen is the principal vector of human immunodeficiency virus (HIV) dissemination worldwide, the origin of the infected leukocytes and free viral particles in this body fluid remain elusive. Here we review the accumulated evidence of the genital origin of HIV in semen from therapy naive individuals and men receiving suppressive highly active antiretroviral therapy (HAART), summarize the data on the detection and localization of HIV/SIV within the male genital tract, discuss the potential involvement of each genital tissue as a source of infected cells and virions in semen in the absence and presence of HAART, and suggest further studies. Deciphering the exact sources of HIV in semen will be crucial to improving HIV transmission prevention strategies.

Characteristics and quantities of HIV host cells in human genital tract secretions

Human immunodeficiency virus (HIV)-infected leukocytes have been detected in genital secretions from HIV-infected men and women and may play an important role in the sexual transmission of HIV. However, they have been largely overlooked in studies on mechanisms of HIV transmission and in the design and testing of HIV vaccine and microbicide candidates. This article describes the characteristics and quantities of leukocytes in male and female genital secretions under various conditions and also reviews evidence for the involvement of HIV-infected cells in both horizontal and vertical cell-associated HIV transmission. Additional research is needed in this area to better target HIV prevention strategies.

Absence of transmission from HIV-infected individuals with HAART to their heterosexual serodiscordant partners

BACKGROUND

Further studies are needed to evaluate the level of effectiveness and durability of HAART to reduce the risk of HIV sexual transmission in serodiscordant couples having unprotected sexual practices.

METHODS

A cross-sectional study was conducted with prospective cohort of heterosexual HIV serodiscordant couples where the only risk factor for HIV transmission to the uninfected partner (sexual partner) was the sexual relationship with the infected partner (index case). HIV prevalence in sexual partners at enrolment and seroconversions in follow-up were compared by antiretroviral treatment in the index partner, HIV plasma viral load in index cases and sexual risk exposures in sexual partners. In each visit, an evaluation of the risks for HIV transmission, preventive counselling and screening for genitourinary infections in the sexual partner was performed, as well as the determination of the immunological and virological situation and antiretroviral treatment in the index case.

RESULTS

At enrolment no HIV infection was detected in 202 couples where the index case was taking HAART. HIV prevalence in sexual partners was 9.6% in 491 couples where the index case was not taking antiretroviral treatment (p<0.001). During follow-up there was no HIV seroconversion among 199 partners whose index case was taking HAART, accruing 7600 risky sexual exposures and 85 natural pregnancies. Among 359 couples whose index case was not under antiretroviral treatment, over 13,000 risky sexual exposures and 5 HIV seroconversions of sexual partners were recorded. The percentage of seroconversion among couples having risky sexual intercourse was 2.5 (95% confidence interval [CI]: 1.1-5.6) when the index case did not undergo antiretroviral treatment and zero (95% CI: 0-3.2) when the index case received HAART.

CONCLUSIONS

The risk of sexual transmission of HIV from individuals with HAART to their heterosexual partners can become extremely low.

Stigmatizing attitudes towards people living with HIV/AIDS: validation of a measurement scale

BACKGROUND

Although stigmatization has long been recognized as a major obstacle to HIV prevention. The lack of a valid and reliable measurement tool for stigmatization is a major gap in the research. This study aimed to: 1) develop a scale of stigmatizing attitudes towards people living with HIV (SAT-PLWHA-S) and 2) demonstrate its reliability and validity.

METHODS

French and English-speaking experts (n = 21) from different professional communities (academics, practitioners) assessed the clarity and relevance of the proposed items. The psychometric properties of the SAT-PLWHA-S were assessed with a random digit dial population based telephone survey (n = 1,500) of respondents in Quebec, Canada. Analyses included exploratory and confirmatory factor analyses, correlations, multiple linear regressions, t-tests, hypothesis testing of factorial structure invariance, and Cronbach's alpha.

RESULTS

Confirmatory factor analysis (CFA) supported a 27-item structure with seven factors: 1) concerns about occasional encounters; 2) avoidance of personal contact; 3) responsibility and blame, 4) liberalism, 5) non-discrimination, 6) confidentiality of seropositive status, and 7) criminalization of HIV transmission. Cronbach's alphas indicate satisfactory internal consistency. An assessment of concurrent validity using Pearson's correlation and multiple linear regression shows that homophobia and HIV transmission knowledge are significant determinants of stigmatizing attitudes toward PLHIV. Discriminant validity (t-test) results suggest that the SAT-PLWHA-S can differentiate attitudes between different groups and indicates invariant factor structure across language.

CONCLUSIONS

The results of this study suggest that the SAT-PLWHA-S is a reliable and valid tool for measuring stigmatizing attitudes toward PLHIV and that it can contribute to a deeper understanding of HIV stigma.

Effectiveness of ART and condom use for prevention of sexual HIV transmission in serodiscordant couples: a systematic review and meta-analysis

BACKGROUND

Consistent and correct condom use and suppressive antiretroviral therapy for the infected partner are two of the primary strategies recommended for prevention of heterosexual HIV transmission in serodiscordant couples today. The applied effectiveness of treatment as a prevention strategy in China is still under investigation, and much less is known about its effects in the presence of other prevention strategies such as consistent condom use.

METHODS

We conducted a systematic search in PubMed and three Chinese language databases to identify relevant articles for the estimation of relative effectiveness of a) consistent condom use and b) ART use by index partners for preventing HIV transmission in serodiscordant couples. We also estimated the prevention effectiveness of ART stratified by condom use level and the prevention effectiveness of consistent condom use stratified by ART use level.

RESULTS

Pooled results from the eleven eligible studies found a pooled HIV seroconversion incidence of 0.92 cases per 100 person years (PY) among HIV-negative spouses whose index partners were taking ART versus 2.45 cases per 100 PY in untreated couples. The IRR comparing seroconversion in couples where the index-partner was on ART versus not on ART was 0.47 (95%CI: 0.43, 0.52), while stratified by condom use, the IRR was 0.33(0.17,0.64). The IRR comparing incidence in couples reporting "consistent condom use" versus those reporting otherwise was 0.02(95%CI:0.01,0.04), after stratified by ART use level, the IRR was 0.01(95%CI: 0.00, 0.06).

CONCLUSIONS

ART use by index partners could reduce HIV transmission in serodiscordant couples, and the effectiveness of this prevention strategy could be further increased with consistent condom use.

Pharmacokinetics of antiretrovirals in genital secretions and anatomic sites of HIV transmission: implications for HIV prevention

The incidence of HIV remains alarmingly high in many parts of the world. Prophylactic use of antiretrovirals, capable of concentrating in the anatomical sites of transmission, may reduce the risk of infection after an unprotected sexual exposure. To date, orally and topically administered antiretrovirals have exhibited variable success in preventing HIV transmission in large-scale clinical trials. Antiretroviral mucosal pharmacokinetics may help explain the outcomes of these investigations. Penetration and accumulation of antiretrovirals into sites of transmission can influence dosing strategies and pre-exposure prophylaxis clinical trial design. Antiretroviral tissue distribution varies widely within and between drug classes, attributed in part to their physicochemical properties and tissue-specific drug transporter expression. Nucleoside(-tide) reverse transcriptase inhibitors, the CCR5 antagonist maraviroc, and the integrase inhibitor raltegravir demonstrate the highest penetration into the male and female reproductive tracts and colorectal tissue relative to blood. This review describes antiretroviral exposure in anatomic sites of transmission, and places these findings in context with the prevention of HIV and the efficacy of pre-exposure prophylactic strategies.

Elevated urinary leukocyte esterase as a potential surrogate marker for HIV sexual transmission risks in men receiving antiretroviral therapy

Local genital tract inflammation stimulates leukocyte activity and causes HIV shedding, potentially increasing HIV sexual infectiousness. Although there are available clinical markers for genital tract inflammation, such as urinary leukocyte esterase, none have yet been examined in relation to HIV sexual risk behaviours. We sought to examine the association between urinary leukocyte esterase and sexual practices. Sexually active men living with HIV and receiving antiretroviral therapy (ART, N = 290) provided urine specimens and completed behavioural health assessments. HIV RNA tests and CD4 cell counts were abstracted from medical records. Urine specimens were analysed for leukocyte esterase using a standard point-of-care dipstick test. Thirty-one (10.6%) participants tested positive for leukocyte esterase. Logistic regression models did not indicate differences between men with elevated and un-elevated leukocyte activity on demographic, health, recent sexually transmitted infection symptoms and diagnoses or substance use. However, men with elevated leukocyte activity indicated significantly greater sexual behaviour in the previous three months, including more recent unprotected sexual intercourse. A simple over-the-counter urine test may serve as an indicator of sexual HIV infectiousness to inform further evaluation and treatment of genital tract inflammation, as well as condom use decisions during times of increased genital tract inflammation.

High burden of STIs among HIV-infected adults prior to initiation of ART in South Africa: a retrospective cohort study

OBJECTIVES

To assess the burden of sexually transmitted infections (STIs) among HIV-positive South Africans in the period prior to antiretroviral therapy (ART) initiation compared with the period once on ART.

METHODS

We linked the clinic records of 1465 patients currently on ART to the electronic database which records all visits to city clinics. We used a mixed effects Poisson model to assess the relative rates of occurrence of treatment seeking for an STI in the periods prior to initiation of ART and while on ART.

RESULTS

We accumulated 4214 person-years of follow-up, divided nearly equally between the pre-ART and on-ART periods. The rate of treatment seeking for new STIs was 5.50 (95% CI 5.43 to 5.78) per 100 person-years, and individuals had on average a sevenfold higher rate of seeking treatment for STIs in the period prior to initiating ART (9.57 per 100 person-years) compared with the period once on ART (5.5 per 100 person-years) (adjusted rate ratio (RR) 7.01, 95% CI 4.64 to 10.59). Being male (RR 1.73, 95% CI 1.18 to 2.55) or younger (age <25) (RR 2.67, 95% CI 1.53 to 4.65) was associated with higher incidence of clinic visits for STI treatment, while advanced stage of HIV disease (WHO stage 4) (RR 0.33, 95% CI 0.15 to 0.69) was associated with lower incidence.

CONCLUSIONS

The period prior to the initiation of ART is a critical period where increased attention should be focused on the detection and treatment of STIs. A successful effort to treat STIs in this period will likely reduce further HIV transmission and fits within a test-and-treat approach.

Timing of intermittent seminal HIV-1 RNA shedding in patients with undetectable plasma viral load under combination antiretroviral therapy

It was demonstrated that combination antiretroviral therapy (cART) reduces the HIV-1 viral load (VL) in the blood and the seminal compartment. Some studies have reported that the seminal HIV-1 VL is undetectable in individuals with an undetectable blood plasma viral load (bpVL) under cART. However, some recent studies have demonstrated that seminal HIV-1 RNA may still be detected, and potentially infectious, even in the case of an undetectable bpVL. The aim of this retrospective study was to determine the detection rate of a seminal VL and whether shedding could be intermittent over a very short time.

From January 2006 to December 2011, 88 HIV-1 infected men, enrolled in an Assisted Reproduction program, provided 306 semen samples, corresponding to 177 frozen sperm samples (two samples delivered at a one-hour interval (n = 129) or one sample (n = 48)). All enrolled men were under cART, with an undetectable bpVL for more than 6 months. HIV-1 RNA was quantified in seminal plasma using a Roche COBAS Ampliprep COBAS TaqMan HIV-1 test.

Seminal HIV-1 RNA was detected in 23 samples (7.5%) from 17 patients (19.3%). This detection rate was stable over years. With regards to the freezing of two samples delivered at a one-hour interval, the proportion of discordance between the first and second samples was 9.3% (12/129).

Our results confirm the intermittent shedding of HIV-1 in semen. While this finding has been shown by studies examining longer time intervals, to our knowledge, this has never been demonstrated over such a short time interval.

Use of observational data in evaluating treatments: antiretroviral therapy and HIV

Observational data are increasingly used in various therapeutic areas to evaluate the use, effectiveness and side effects of new treatments. Whilst randomized clinical trials remain the gold standard for evaluating the efficacy of new agents, they have a number of limitations for HIV, including the limited number of combinations that are compared and the costs of long-term follow-up. Observational data from seroconverter and clinical cohorts have been used to compare the short- and longer-term effectiveness of different therapy combinations and to evaluate the longer-term risks associated with antiretroviral therapy. Furthermore, they provide the opportunity to evaluate the relative success of more complex patterns of therapy, such as sequencing of different regimens over time. However, because of the nature of these data, a number of potential biases may arise which can influence interpretation.

Initiation of antiretroviral therapy

With the widespread availability of antiretroviral therapy, there is a dramatic decline in HIV related morbidity and mortality in both developed and developing countries. Further, the current antiretroviral drug combinations are safer and the availability of newer monitoring assays and guidelines has vastly improved the patient management. The clinician needs to evaluate several key issues prior to institution of antiretroviral regimen including the correct stage of starting the treatment and the kind of regimen to initiate. In addition to various disease related factors, it is also critical to assess the patient's general condition including nutritional status, presence of co-morbidities and mental preparedness prior to starting the therapy. The patients need to develop an overall understanding of the treatment and its benefits and the importance of lifelong adherence to the drugs. The presence of special situations like pediatric age, older patients, pregnancy, lactation and presence of opportunistic infections also require modification of the therapy. This review briefly summarizes issues relevant to the clinician prior to the initiation of antiretroviral therapy.

Attitudes towards and Beliefs about HIV Testing among Latino Immigrant MSM: A Comparison of Testers and Nontesters

Latino immigrant men who have sex with men (MSM) are at risk for HIV and delayed diagnosis. An exploratory study using qualitative interviews that assess the beliefs and attitudes of 54 Latino immigrant MSM in Seattle, Washington, is presented. The goal of this research is to determine whether attitudinal differences exist between participants who had and had not been tested and to use any insight into the development of a media campaign to promote testing. Over one-third of the men have never been tested for HIV. Nontesters are more likely to be men who have sex with men and women, have less knowledge about HIV risks, perceive their sexual behaviors as less risky, and deflect HIV-related stigma. Testers are more likely to be self-identified as being gays. Both groups believe that fear of a positive result is the main barrier to testing. Both groups believe that family members have negative attitudes towards HIV testing and that having Latino staff at HIV testing sites hinders confidentiality. Financial concerns with regard to the cost of testing were also expressed by both groups. Based on these insights, recommended strategies for the development of HIV prevention and testing campaigns are made.

Semen CD4+ T cells and macrophages are productively infected at all stages of SIV infection in macaques

The mucosal events of HIV transmission have been extensively studied, but the role of infected cells present in the genital and rectal secretions, and in the semen, in particular, remains a matter of debate. As a prerequisite to a thorough in vivo investigation of the early transmission events through infected cells, we characterized in detail by multi-parameter flow cytometry the changes in macaque seminal leukocytes during SIVmac251 infection, focusing on T cells, macrophages and dendritic cells. Using immunocytofluorescence targeting SIV proteins and real-time quantitative PCR targeting SIV DNA, we investigated the nature of the infected cells on sorted semen leukocytes from macaques at different stages of infection. Finally, we cocultured semen CD4⁺ T cells and macrophages with a cell line permissive to SIV infection to assess their infectivity in vitro. We found that primary infection induced strong local inflammation, which was associated with an increase in the number of leukocytes in semen, both factors having the potential to favor cell-associated virus transmission. Semen CD4⁺ T cells and macrophages were productively infected at all stages of infection and were infectious in vitro. Lymphocytes had a mucosal phenotype and expressed activation (CD69 & HLA-DR) and migration (CCR5, CXCR4, LFA-1) markers. CD69 expression was increased in semen T cells by SIV infection, at all stages of infection. Macrophages predominated at all stages and expressed CD4, CCR5, MAC-1 and LFA-1. Altogether, we demonstrated that semen contains the two major SIV-target cells (CD4+ T cells and macrophages). Both cell types can be productively infected at all stages of SIV infection and are endowed with markers that may facilitate transmission of infection during sexual exposure.

Human Immunodeficiency Virus infection is predominantly transmitted by mucosal exposure, after sexual intercourse. Although substantial progresses have been recently achieved in our understanding of the mechanisms of HIV mucosal transmission, many questions remain. Semen is one of the major sources for HIV which contains both cell-free viral particles and viral infected cells. However, today, the role of cell-associated virus has been largely understudied. We provide here a detailed characterization of the semen leukocyte populations in the highly relevant experiment model of SIV infection of macaques. We demonstrate that the major target cells for the virus, CD4⁺ T cells and macrophages, are present in macaques semen at all stages of infection. Both cell types are productively infected in vivo and are endowed with adhesion and migration markers that may facilitate virus transmission during sexual exposure. The acute phase of infection is associated with a strong seminal inflammation that may increase semen leukocytes infectivity. This work supports for a role of cell-associated virus in HIV transmission which needs to be considered for the design of prevention strategies.

Dolutegravir pharmacokinetics in the genital tract and colorectum of HIV-negative men after single and multiple dosing

OBJECTIVES

To describe first-dose and steady state pharmacokinetics (PKs) of dolutegravir (DTG) in blood plasma (BP), seminal fluid (SF), colorectal tissue (RT), and rectal mucosal fluid (RF) of healthy HIV-negative men.

DESIGN

A phase 1, open-label, PK study that enrolled 12 healthy men taking 50 mg DTG daily for 8 days.

METHODS

Eleven paired BP samples and 3 SF and RF samples were collected over 24 hours after first (PK1) and multiple (PK2) dosing. RT biopsies were collected at 1 of 6 time points at PK1 and PK2 to generate composite PK profiles. DTG concentrations were analyzed by validated liquid chromatography-tandem mass spectrometry (LC-MS/MS). Noncompartmental PK analysis was conducted with Phoenix WinNonlin v6.3, and Spearman rank correlations were determined using SAS v9.3.

RESULTS

BP area under the concentration-time curves (AUCs) were similar to previous reports, and concentrations at 24 hours (C24 h) were 6- to 34-fold greater than the protein-adjusted concentration required for 90% viral inhibition (PA-IC90) of 64 ng/mL. SF exposures were <7% of BP and below the PA-IC90. RT exposures were 17% of BP and ∼2-fold greater than the PA-IC90. RF AUCs were ∼2%-5% of RT and did not correlate with RT (rho = 0.43, P = 0.17). Accumulation of DTG with multiple dosing was observed in BP, SF, and RT.

CONCLUSIONS

DTG BP PKs were consistent with previously published values. SF concentrations were <7% BP, with SF C24 h below the PA-IC90. However, SF protein binding was not measured. Although the AUC of DTG in RT was <20% BP, RT C24 h remained ∼2-fold higher than the PA-IC90. RF was not a strong surrogate for RT concentrations.

HIV-1 transmission during early antiretroviral therapy: evaluation of two HIV-1 transmission events in the HPTN 052 prevention study

In the HPTN 052 study, transmission between HIV-discordant couples was reduced by 96% when the HIV-infected partner received suppressive antiretroviral therapy (ART). We examined two transmission events where the newly infected partner was diagnosed after the HIV-infected partner (index) initiated therapy. We evaluated the sequence complexity of the viral populations and antibody reactivity in the newly infected partner to estimate the dates of transmission to the newly infected partners. In both cases, transmission most likely occurred significantly before HIV-1 diagnosis of the newly infected partner, and either just before the initiation of therapy or before viral replication was adequately suppressed by therapy of the index. This study further strengthens the conclusion about the efficacy of blocking transmission by treating the infected partner of discordant couples. However, this study does not rule out the potential for HIV-1 transmission to occur shortly after initiation of ART, and this should be recognized when antiretroviral therapy is used for HIV-1 prevention.

Overcoming biological, behavioral, and structural vulnerabilities: new directions in research to decrease HIV transmission in men who have sex with men

Men who have sex with men (MSM), including transgender women, comprise a heterogeneous group of individuals whose sexual behaviors and gender identities may vary widely between cultures and among individuals. Their sources of increased vulnerability to HIV are diverse, including the increased efficiency of HIV transmission via unprotected anal intercourse, sexual role versatility, asymptomatic sexually transmitted infections, and behavioral factors that may be associated with condomless sex with multiple partners. Societal stigmatization of homosexual behavior and gender nonconformity may result in internalized negative feelings that lead to depression, other affective disorders, and substance use, which in turn are associated with increased risk-taking behaviors. Social stigma and punitive civil environments may lead to delays in seeking HIV and sexually transmitted disease screening, and later initiation of antiretroviral therapy. The iPrEX study demonstrated that chemoprophylaxis can decrease HIV acquisition in MSM, and the HIV prevention trials network 052 study established the biological plausibility that earlier initiation of highly active antiretroviral therapy can decrease HIV transmission to uninfected partners. Despite these advances, MSM remain among the most significantly HIV-affected population in resource-rich and limited settings. New studies will integrate enhanced understanding of the biology of enhanced rectal transmission of HIV and the focused use of antiretrovirals for prevention with culturally tailored approaches that address the potentiating social and behavioral factors associated with enhanced HIV spread among MSM.

Antiretroviral pharmacology in mucosal tissues

Strategies to prevent HIV infection using preexposure prophylaxis are required to curtail the HIV pandemic. The mucosal tissues of the genital and rectal tracts play a critical role in HIV acquisition, but antiretroviral (ARV) disposition and correlates of efficacy within these tissues are not well understood. Preclinical and clinical strategies to describe ARV pharmacokinetic-pharmacodynamic relationships within mucosal tissues are currently being investigated. In this review, we summarize the physicochemical and biologic factors influencing ARV tissue exposure. Furthermore, we discuss the necessary steps to generate relevant pharmacokinetic-pharmacodynamic data and the challenges associated with this process. Finally, we suggest how preclinical and clinical data might be practically translated into optimal preexposure prophylaxis dosing strategies for clinical trials testing using mathematical modeling and simulation.

A pandemic of the poor: social disadvantage and the U.S. HIV epidemic

The U.S. HIV/AIDS epidemic has evolved over the past 30 years and is now concentrated in socially marginalized and disenfranchised communities. The health disparities in this epidemic are striking, with most HIV infections occurring in sexual minorities and communities of color. While widely recognized, the health disparities in HIV and AIDS are not often discussed. In this article, we examine the factors underlying health disparities in the U.S. HIV epidemic. We first discuss the interlocking relationships between biological, social, and behavioral factors that drive HIV/AIDS epidemics. Guided by a well-established conceptual model of health disparities, we then describe the social positions of those most affected by HIV and AIDS, particularly racial and gender groups. Structural and economic conditions-including environmental resources, constraints, access to care, and psychosocial influences-are examined in relation to HIV disease trajectories. Greater attention to contextual factors and comorbidities is needed to reduce the health disparities in HIV/AIDS.

Missed connections: HIV-infected people never in care

OBJECTIVE

Clinical interventions that lengthen life after HIV infection and significantly reduce transmission could have greater impact if more HIV-diagnosed people received HIV care. We tested a surveillance-based approach to investigating reasons for delayed entry to care.

METHODS

Health department staff in three states and two cities contacted eligible adults diagnosed with HIV four to 24 months previously who had no reported CD4+ lymphocyte (CD4) or viral load (VL) tests. The staff conducted interviews, performed CD4 and VL testing, and provided referrals to HIV medical care. Reported CD4 and VL tests were prospectively monitored to determine if respondents had entered care after the interview.

RESULTS

Surveillance-based follow-up uncovered problems with reporting CD4 and VL tests, resulting in surveillance improvements. However, reporting problems led to misspent effort locating people who were already in care. Follow-up proved difficult because contact information in surveillance case records was often outdated or incorrect. Of those reached, 37% were in care and 29% refused participation. Information from 132 people interviewed generated ideas for service improvements, such as emphasizing the benefits of early initiation of HIV care, providing coverage eligibility information soon after diagnosis, and leveraging other medical appointments to provide assistance with linkage to HIV care.

CONCLUSIONS

Surveillance-based follow-up of HIV-diagnosed individuals not linked to care provided information to improve both surveillance and linkage services, but was inefficient because of difficulties identifying, locating, and recruiting eligible people. Inefficiencies attributable to missing, incomplete, or inaccurate surveillance records are likely to diminish as data quality is improved through ongoing use.

Short communication: human immunodeficiency virus rebound in blood and seminal plasma following discontinuation of antiretroviral therapy

Although there is discordance between human immunodeficiency virus (HIV) blood plasma and seminal plasma viral loads (VL), little is known about the dynamics of VL rebound in these compartments upon discontinuation of highly active antiretroviral therapy (HAART). Therefore, we sought to examine the relationship between blood and semen VL rebound after discontinuation of HAART. Participants in this substudy were men enrolled from two centers of a multicenter, placebo-controlled randomized trial of HIV therapeutic vaccination using ALVAC with or without Remune. With at least 2 years of sustained virologic suppression and following a 20-week vaccination course, subjects underwent structured HAART interruption. Fourteen men provided semen samples. Seven to 12 weeks after HAART interruption, all 14 men had detectable blood VLs whereas 8 of 14 had detectable seminal VLs. There was a significant correlation between blood and seminal VLs (Spearman r=0.58, p=0.03) at the time of semen collection. An earlier time to detectable blood VL after HAART interruption was associated with higher seminal VL (Spearman r=-0.64, p=0.02). These findings support the compartmentalization of HIV and underscore the importance of understanding the genital tract as an HIV reservoir in the quest to minimize HIV transmission.

Acute HIV-1 infection in the Southeastern United States: a cohort study

In 1998 a collaboration between Duke University and the University of North Carolina, Chapel Hill (UNC) was founded to enhance identification of persons with acute HIV-1 infection (AHI). The Duke-UNC AHI Research Consortium Cohort consists of patients ≥18 years old with a positive nucleic acid amplification test (NAAT) and either a negative enzyme immunoassay (EIA) test or a positive EIA with a negative/indeterminate Western blot. Patients were referred to the cohort from acute care settings and state-funded HIV testing sites that use NAAT testing on pooled HIV-1 antibody-negative samples. Between 1998 and 2010, 155 patients with AHI were enrolled: 81 (52%) African-Americans, 63 (41%) white, non-Hispanics, 137 (88%) males, 108 (70%) men who have sex with men (MSM), and 18 (12%) females. The median age was 27 years (IQR 22-38). Most (n=138/155) reported symptoms with a median duration of 17.5 days. The median nadir CD4 count was 408 cells/mm(3) (IQR 289-563); the median observed peak HIV-1 level was 726,859 copies/ml (IQR 167,585-3,565,728). The emergency department was the most frequent site of initial presentation (n=55/152; 3 missing data). AHI diagnosis was made at time of first contact in 62/137 (45%; 18 missing data) patients. This prospectively enrolled cohort is the largest group of patients with AHI reported from the Southeastern United States. The demographics reflect the epidemic of this geographic area with a high proportion of African-Americans, including young black MSM. Highlighting the challenges of diagnosing AHI, less than half of the patients were diagnosed at the first healthcare visit. Women made up a small proportion despite increasing numbers in our clinics.

Trends and determining factors associated with adherence to antiretroviral therapy (ART) in Cameroon: a systematic review and analysis of the CAMPS trial

BACKGROUND

The benefits of antiretroviral therapy (ART) cannot be experienced if they are not taken as prescribed. Yet, not all causes of non-adherence are dependent on the patient. Having to pay for medication reduces adherence rates. Non- adherence has severe public health implications which must be addressed locally and globally. This paper seeks to describe the trends in adherence rates reported in Cameroon and to investigate the determinants of adherence to ART in the Cameroon Mobile Phone SMS (CAMPS) trial.

METHODS

We conducted a systematic review of electronic databases (PubMed, Google Scholar, Web of Science, CINAHL, EMBASE and PSYCINFO) for publications on adherence to ART in Cameroon (from January 1999 to May 2012) and described the trend in reported adherence rates and the factors associated with adherence. Data were extracted in duplicate. We used multivariable analyses on the baseline data for 200 participants in the CAMPS trial to determine the factors associated with adherence in four models using different measures of adherence (more than 90% or 95% on the visual analogue scale, no missed doses and a composite measure: 100% on the visual analogue scale, no missed doses and all pills taken on time).

RESULTS

We identified nine studies meeting our inclusion criteria. Adherence to ART in Cameroon has risen steadily between 2000 and 2010, corresponding to reductions in the cost of medication. The factors associated with adherence to ART in Cameroon are grouped into patient, medication and disease related factors. We also identified factors related to the health system and the patient-provider relationship. In the CAMPS trial, education, side effects experienced and number of reminder methods were found to improve adherence, but only using multiple reminder methods was associated with better adherence in all the regression models (Adjusted Odds Ratio [AOR] 4.11, 95% Confidence Interval [CI] 1.89, 8.93; p<0.001; model IV).

CONCLUSIONS

Reducing the cost of ART is an important aspect of ensuring adequate adherence rates. Using multiple reminder methods may have a cumulative effect on adherence to ART, but should be investigated further.

Reproductive assistance in HIV serodiscordant couples

BACKGROUND

Three quarters of individuals infected with human immunodeficiency virus (HIV) are in their reproductive years and may consider pregnancy planning. Techniques have been developed which can minimize the risk of HIV transmission in these couples, and the current literature on this topic is reviewed here.

METHODS

We reviewed the literature for the following topics: risk of HIV transmission, effects of HIV infection on fertility, reproductive assistance in industrialized and low-income countries, pre-exposure chemoprophylaxis (PrEP) and timed intercourse in HIV-discordant couples for both male and female positivity. Relevant publications were identified through searches of the EMBASE Medline and PubMed databases, the Google-indexed scientific literature and periodic specialized magazines from the on-line Library Service of the University of Milan, Italy.

RESULTS

In serodiscordant couples in which the man is positive, the primary method used to prevent HIV transmission is 'sperm washing', followed by IUI or IVF. Data show that sperm washing in HIV-positive men has not produced seroconversion in women or their offspring; however, the evidence is limited. Recently, increasing evidence describing PrEP for HIV prevention has been published and PrEP could be an alternative to ART for fertile couples. Usually HIV-infected women undergo self-insemination around the time of ovulation. Few studies have been published on IVF outcome in HIV-infected women.

CONCLUSIONS

Assisted reproduction programmes should be integrated into global public health services against HIV. For HIV serodiscordant couples with infected men, sperm washing should be the first choice. However, timed intercourse and PrEP for HIV prevention has been reported. Recent data highlight the possible impairment of fertility in HIV-infected women. Efforts to design a multicentric study should be strengthened.