Hiv Viral Load And Transmissibility Of Hiv Infection

Viral Load And Sexual Transmission Of Hiv

If you have a high viral load in your blood, then you might also have a high viral load in other body fluids, including your semen or vaginal fluid. In the first few weeks after contracting HIV, viral load is usually extremely high. People with high viral loads are more infectious and can pass HIV on more easily. On the other hand, if HIV in your blood is undetectable, it is likely to be undetectable in your semen, vagina fluid or rectum as well.

Having an undetectable viral load means that you will not pass on HIV during sex.

In 2011, a large scientific trial found that HIV treatment reduces the risk of passing on HIV to a regular heterosexual partner by 96%. The only reason it was not 100% is that one person in the trial did acquire HIV, but this happened just a few days before or after their partner started treatment.

The final results of the PARTNER 1 and PARTNER 2 studies were announced in 2016 and 2018, respectively. Between the two of them, they recruited 972 gay couples and 516 heterosexual couples in which one partner had HIV and the other did not. Over the course of the study, the gay couples had 77,000 acts of condomless penetrative sex and the heterosexual couples 36,000 acts. The PARTNER studies did not find a single HIV transmission from an HIV-positive partner who had an undetectable viral load .

Molecular Transmission Network Analysis

We used HIV-TRACE to construct a molecular transmission network. We selected the earliest pol sequence for each individual and aligned these sequences to the HXB2 pol reference sequence , calculated pairwise TN93 genetic distance among all pairs of sequences, and assembled transmission clusters by connecting pairs of sequences0.015 substitutions/site diverged . Individuals who were linked to 1 other individual were determined to be clustered in the network. This approach has previously been used for analyses of HIV surveillance data in the United States,,,. Sequences that were highly similar to the HXB2 reference sequence were filtered from the database prior to analysis.

We also constructed molecular transmission networks using more conservative genetic distance thresholds and performed additional analyses excluding people who reported injection drug use.

What Does This Mean For Me

‘Undetectable equals Untransmittable’ has been a life-changing finding for many people living with HIV. It means that if you are on effective treatment with an undetectable viral load, you do not have to worry about passing on HIV through sex, even if you do not use a condom.

Basic information on undetectable viral load

This has helped many people living with HIV have more fulfilling sex lives and less anxiety around sex.

Knowing that ‘Undetectable equals Untransmittable’ is especially useful for people wishing to have a child. Couples in which one person has undetectable HIV and the other is HIV negative can have unprotected sex in order to conceive.

However, the law on HIV may not have caught up with the science. In some countries, condomless sex without disclosing your HIV status is a criminal offence, regardless of the likelihood of HIV transmission. For information on specific countries, visit our page on criminalisation laws around the world.

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Hiv Viral Load And Transmissibility Of Hiv Infection

I’m your huckleberry. That’s just my game.

A/V SubscriberHIV Viral Load and Transmissibility of HIV InfectionJAMABox. Principles to Achieve and Maintain an Undetectable Viral Load

• In order for antiretroviral therapy to provide maximum benefit, taking medication as prescribed is essential.
• Achieving an undetectable viral load can take up to 6 months of ART. Once achieved, continued adherence is required.
• According to guidelines from the Department of Health and Human Services, viral load testing should be performed every 3-4 months after the plasma HIV-1 RNA level reaches undetectable . If viral suppression and stable immunologic status are maintained for > 2 years, the viral load testing can be extended to every 6 months thereafter.
• Stopping therapy negates the validity of assuming that U = U.

Plhiv Who Are Diagnosed But Not Virally Suppressed

A substantial proportion of individuals who have previously received an HIV diagnosis have either not yet initiated ART or have not achieved viral suppression. Individuals in this group can be further divided into 3 categories: those who have never been linked to ART those who have initiated ART but have not yet achieved viral suppression or have been lost to follow-up and stopped ART and, those who are sustained on treatment but are showing signs of breakthrough viremia or treatment failure. For individuals who have never initiated treatment or been lost to follow-up, programs can initiate outreach campaigns through clinical or community staff to engage or reengage previously diagnosed individuals. These campaigns can promote U=U messaging, the benefits of new dolutegravir-based treatment regimens, and convenient and confidential options for PLHIV to access same-day HIV treatment. For individuals who are receiving treatment but have not achieved viral suppression, providers can offer additional personalized adherence counseling and support. Immediate support should be provided to individuals with a viral load test indicating an unsuppressed viral load to help to identify and address root causes of adherence or treatment failure that require regimen switching.

Immediate support should be provided to PLHIV who are diagnosed but not virally suppressed to help address root causes of adherence or treatment failure.

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Managing Transient Viremia Or Blips

Highly adherent patients may experience intermittent or transient viremia, commonly termed viral blips. Blips are defined in the context of effective treatment as a single, measurable HIV RNA level, typically < 200 copies/mL, that is followed by a return to a viral load below the limit of detection or quantification. With contemporary ART regimens, about 10% of persons per year who are adherent to ART may experience a blip.33-35 Most blips likely represent normal biological fluctuation or laboratory artifact and not inadequate adherence.36-38 Persistent viremia 200 copies/mL has been associated with increasing risk of virologic failure33,39 that, in the context of TasP, can lead to increased risk of sexual transmission.10 The PARTNER studies and Opposites Attract excluded observation time when the viral load of the participant with HIV was 200 copies/mL. The frequency of blips < 200 copies/mL was not reported in Opposites Attract however, in PARTNER 1 and PARTNER 2, transient elevations in viral loads above the limit of detection but < 200 copies/ml were observed for 6% and 4% of the total follow-up time, respectively, during which time no phylogenetically linked infections were observed.

Does U=u Apply To The Non

This page is about HIV transmission during sex.

But an undetectable viral load is also crucial for conception, pregnancy and birth. If you maintain an undetectable viral load during pregnancy, the risk of HIV being passed on to your baby is just 0.1%, or one in a thousand.

During breastfeeding, an undetectable viral load greatly reduces the risk of passing HIV on, although it does not completely eliminate this possibility. In the UK and other countries where clean water and sterilising equipment are available, bottle feeding with formula milk is the safest way to feed your baby.

If you use injection drugs and or other equipment, taking HIV treatment and having an undetectable viral load greatly reduces the risk of passing HIV on, but we dont know by how much.

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How Is Hiv Not Spread

HIV is not spread by:

• Air or water
• Mosquitoes, ticks, or other insects
• Saliva, tears, sweat, feces, or urine that is not mixed with the blood of a person with HIV
• Shaking hands hugging sharing toilets sharing dishes, silverware, or drinking glasses or engaging in closed-mouth or social kissing with a person with HIV
• Drinking fountains
• Other sexual activities that dont involve the exchange of body fluids .
• Donating blood

How Is Hiv Spread From Person To Person

HIV can only be spread through specific activities. In the United States, the most common ways are:

• Having vaginal or anal sex with someone who has HIV without using a condom the right way every time or taking medicines to prevent or treat HIV. Anal sex is riskier than vaginal sex for HIV transmission. Learn more about the HIV risk associated with specific sexual activities.
• Sharing injection drug equipment, such as needles,syringes, or other drug injection equipment with someone who has HIV because these items may have blood in them, and blood can carry HIV. People who inject hormones, silicone, or steroids can also get or transmit HIV by sharing needles, syringes, or other injection equipment. Learn more about HIV and injection drug use.

Less common ways are:

• An HIV-positive person transmitting HIV to their baby during pregnancy, birth, or breastfeeding. However, the use of HIV medicines and other strategies have helped lower the risk of perinatal transmission of HIV to less than 1% in the United States. Learn more.
• Being exposed to HIV through a needlestick or sharps injury. This is a risk mainly for health care workers. The risk is very low.

HIV is spread only in extremely rare cases by:

Learn more about how HIV is passed from one person to another.

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Counseling Individuals With Hiv About U=u

Lead authors: Oni Blackstock, MD, MHS Julie Myers, MD, MPH Paul Kobrak, PhD and Demetre Daskalakis, MD, MPH in collaboration with the Medical Care Criteria Committee, June 2019 updated December 2020

Care providers should inform all patients of the following: People who keep their HIV viral load at an undetectable level by consistently taking HIV medications will not pass HIV to others through sex.

Sharing this message with all patients can help accomplish the following:

• Diminish stigma associated with having HIV.
• Reduce barriers to HIV testing and treatment.
• Increase interest in starting and staying on antiretroviral therapy .
• Improve self-esteem by removing the fear of being contagious.
• Support healthy sexuality regardless of HIV status.
• Reduce sex partners concerns.

Providing this message is important regardless of the patients current sexual activity, as many people living with HIV maintain celibacy because of the fear and anticipatory guilt of potentially transmitting HIV.

Encourage patients newly diagnosed with HIV and those previously diagnosed but not taking ART to immediately start treatment.

Explain that doing so will help them avoid damage to their body and immune system and will prevent transmission of HIV to their sex partners.

Provide the following information about U=U to patients :

Counsel patients to share information about the research on U=U as follows :

Reference

Treatment As Prevention Applies Only To Sexual Transmission Of Hiv

Available clinical data only support the use of TasP to prevent sexual HIV transmission in patients with viral loads < 200 copies/mL. The effectiveness of this strategy to prevent transmission from blood exposure has not been determined. In addition, while suppression of maternal viral load substantially reduces the risk of perinatal transmission and transmission through breastfeeding, it does not eliminate these risks, and transmission has occurred via breastfeeding despite continuous viral suppression .

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Putting A Number On It: The Risk From An Exposure To Hiv

This information was provided by CATIE . For more information, contact CATIE at 1-800-263-1638.

Author: James Wilton

Service providers working in HIV prevention are often asked by their patients and clients about the risk of HIV transmission from an exposure to HIV through sex. What do the latest studies tell us about this risk? And how should we interpret and communicate the results?

Molecular Transmission Network Permutations

We assessed the relationship between viral load and clustering through 10,000 random permutations of viral loads across the molecular transmission network. For each permuted network, we calculated the ratio of median viral loads in clustered and nonclustered individuals with wild-type virus, stratified by stage of infection at diagnosis. These permutations were used to generate a null expectation against which we compared these ratios from the observed network.

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The Challenge Of Acute Hiv Infection

The proposed micro-epidemic control approach emphasizes diagnosis of and intervention during AHI in light of the substantial role that AHI plays in epidemic transmission of HIV. Most current national HIV testing algorithms rely on antibody-based serological testing that cannot detect AHI. As a result, these approaches misdiagnose potential core transmitters as HIV-uninfected and miss critical opportunities to maximize the prevention benefits of HIV treatment. Affordable, accurate, and scalable solutions to diagnose AHI have remained elusive.

The brief duration of AHI poses a major challenge to diagnosis., Detection of AHI depends on infected individuals having a blood test during the short AHI period and then establishing the presence of HIV RNA or p24 antigen . Individuals facing high infection risks would need to seek HIV testing with HIV RNA or p24 technologies on a frequent basis to increase the likelihood of detecting an infection during the acute period.

The Natural History of HIV Disease Progression in the Absence of Antiretroviral Therapy, Variable Transmission Probabilities Associated With Viral Burden, and Capacities for Detection of HIV Infection Through Different Diagnostics

Abbreviations: Ag, antigen Ab, antibody PCR, polymerase chain reaction.

The brief duration of acute infection and cost of testing poses barriers to diagnosis.

Pooled Pcr To Facilitate Detection Of And Intervention During Ahi

The gold standard for detection of AHI is molecular testing, specifically HIV-1 RNA PCR. This approach is considered the standard of care to facilitate early infant diagnosis among children born to HIV-infected mothers. However, PCR is relatively expensive. To extend PCR testing efficiently to all individuals facing elevated HIV infection risks but who have nonreactive serological testing results as part of a targeted HIV testing strategy, samples can be pooled such that qualitative PCR is run on a batch that combines like sample types sourced from different individuals. Individual results are confirmed as negative for negative pools. For reactive pools, each sample in the pool is then tested with quantitative PCR viral load independently to identify and rapidly intervene with individuals with reactive results. The Thai Red Cross AIDS Research Center has been applying a pooling approach with plasma samples as a cost-efficient strategy to identify and treat individuals with AHI who might otherwise not receive a diagnosis using serological testing. Nevertheless, separation, storing, and transfer of plasma can pose logistical challenges in resource-limited settings and incur additional costs. Pooled PCR testing may also be possible on point-of-care viral load platforms as these become more affordable and widely available, realizing additional benefits in terms of efficiency, convenience, and early detection and intervention.

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Effect Of Sexually Transmitted Infections On Treatment As Prevention

The presence of STIs in a person with HIV does not appear to meaningfully alter the risk of sexual transmission when the persons viral load is < 200 copies/mL. The PARTNER studies and the Opposites Attract study regularly assessed participants for STIs, which were diagnosed in 6% of heterosexual participants and 13% to 27% of men who have sex with men. Although the authors of the studies noted that their findings could not rule out the possibility that STIs in participants with viral loads < 200 copies/mL might affect the risk of HIV transmission, when viewed collectively, these data suggest that any effect is very small, since STIs were common and no linked infections were observed. The Panel recommends that patients using TasP be informed that maintaining a viral load of < 200 copies/mL does not prevent acquisition or transmission of other STIs, and that it is not substitute for condoms or behavioral modifications . Providers should also routinely screen all sexually active persons with HIV for STIs, both for their own health and to prevent transmission of STIs to others . Refer to CDCs Sexually Transmitted Diseases Treatment Guidelines for details.

Why It Is Good To Have An Undetectable Viral Load

Having an undetectable viral load is important for a number of reasons.

First of all, because your immune system is able to recover and become stronger, it means that you have a very low risk of becoming ill because of HIV. It also reduces your risk of developing some other serious illnesses as well. There is some evidence that the presence of HIV can increase the risk of cardiovascular disease .

Secondly, having an undetectable viral load means that the risk of HIV becoming resistant to the anti-HIV drugs you are taking is very small.

Finally, having an undetectable viral load means that you will not pass HIV on during sex.

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Combining Ahi Screening With Recency Testing To Facilitate Earlier Hiv Diagnosis And Intervention

Rapid HIV recency assays, such as the Asanté HIV-1 Rapid Recency® Assay and the Maxim Swift HIV Recent Infection Assay , were developed to help identify individuals who have become HIV infected within the past yearon average in the past 6 monthsto help estimate HIV incidence and improve the focus of programming in settings, populations, and networks in which incident infections continue to occur. Rapid recency point-of-care antibody-based assays differentiate between recent HIV infectionwhen the antibody response is immature, as reflected by low avidity or binding strength of the antibodyand long-term infections in which a mature antibody response is measured by strong antibody avidity., The assays can yield false-recent results among individuals who naturally control HIV well or are receiving ART, so a recent infection result is usually confirmed using a recent infection testing algorithm in which a viral load test is conducted with results of 1,000 copies/mL confirming recent infection.,,

Testing the contacts of recently infected individuals could improve a programs capacity to detect and treat undiagnosed individuals.

An Illustrative Workflow for Acute HIV Infection Screening, Additionally Applying Recency Testing Data to Help Improve Focus

Abbreviations: Ab+, antibody positive Ab, antibody negative AHI, acute HIV infection Ag+, antigen positive Ag, antigen negative ART, antiretroviral therapy HIV+, HIV-positive PLHIV, people living with HIV.