People living with HIV who maintain low – but still detectible – levels of the virus and adhere to their antiretroviral regimen have almost zero risk of transmitting it to their sexual partners, according to an analysis published in The Lancet. The study’s findings will be presented at an official satellite session ahead of the 12th International AIDS Society Conference on HIV Science (IAS 2023).
Findings from the systematic review indicate the risk of sexual transmission of HIV is almost zero at viral loads of less than 1,000 copies of the virus per millilitre of blood-;also commonly referred to as having a suppressed viral load. The systematic review also confirms that people living with HIV who have an undetectable viral load (not detected by the test used) have zero risk of transmitting HIV to their sexual partners.
A new policy brief from the World Health Organization (WHO), published alongside the research paper, provides updated sexual transmission prevention and viral load testing guidance to policymakers, public health professionals, and people living with HIV based on this analysis. This guidance aims to further prevent the transmission of HIV and ultimately support global efforts to achieve undetectable viral loads through antiretroviral therapy for all people living with HIV and to prevent onward transmission to their sexual partner(s) and children.
Previous research has shown people living with HIV with viral loads below 200 copies/mL have zero risk of sexually transmitting the virus. However, until now, the risk of transmission at viral loads between 200 and 1000 copies/mL was less well defined.
The authors filled this knowledge gap by searching databases for all research studies published between January 2000 and November 2022 on sexual transmission of HIV at varying viral loads. In total, eight studies were included in the systematic review, providing data on 7,762 serodiscordant couples – in which one partner was living with HIV – across 25 countries.
These findings are important as they indicate that it is extremely rare for people who maintain low levels of HIV to transmit it to their sexual partners. Crucially, this conclusion can promote the expansion of alternative viral load testing modalities that are more feasible in resource-limited settings. Improving access to routine viral load testing could ultimately help people with HIV live healthier lives and reduce transmission of the virus.”
Laura Broyles, MD, Lead Author, Global Health Impact Group (Atlanta, USA)
Taking daily medicine to treat HIV – antiretroviral therapy, or ART – lowers the amount of the virus in the body which preserves immune function and reduces morbidity and mortality associated with the virus and helps reduce HIV progression. Without ART, people living with HIV can have a viral load of 30,000 to more than 500,000 copies/mL, depending on the stage of infection.
While using lab-based plasma sample methods provides the most sensitive viral load test results, such tests are not feasible in many parts of the world. However, the new findings support the greater use of simpler testing approaches, such as using dried blood spot samples, as they are effective at categorising viral loads for necessary clinical decision-making.
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Of the 323 sexual transmissions of HIV detected across all eight studies, only two involved a partner with a viral load of less than 1000 copies/mL. In both cases, the viral load test was performed at least 50 days before transmission, suggesting individuals’ viral load may have risen in the period following the test. In studies that provided the full range of viral loads in partners with HIV, at least 80% of transmissions involved viral loads greater than 10,000 copies/mL.
Co-author Dr Lara Vojnov, of WHO, said: “The ultimate goal of antiretroviral therapy for people living with HIV is to maintain undetectable viral loads, which will improve their own health and prevent transmission to their sexual partners and children. But these new findings are also significant as they indicate that the risk of sexual transmission of HIV at low viral loads is almost zero. This provides a powerful opportunity to help destigmatise HIV, promote the benefits of adhering to antiretroviral therapy, and support people living with HIV.”
The authors acknowledge some limitations to their study. Some of the data analysed were imprecise due to variations across the studies in the definitions of ‘low viral load’, and in the timing and frequency of viral load testing and patient follow-up. Today, HIV treatment is recommended for everyone living with HIV and very large sample sizes would be needed to develop more precise estimates given the extremely low number of transmissions.
Further, the findings do not apply to HIV transmission from mother to child, as the duration and intensity of exposure – during pregnancy, childbirth, and breastfeeding – is much higher. Differences also exist in the way the virus is passed from mother to child as compared with sexual transmission. Ensuring pregnant and breastfeeding women have undetectable viral loads throughout the entire exposure period is key to preventing new childhood HIV infections.
Writing in a linked Comment, co-authors Linda-Gail Bekker, Philip Smith, and Ntobeko A B Ntusi (who were not involved in the study) said, “Laura N Broyles and colleagues’ systematic review in The Lancet further supports the almost zero risk for sexual transmission of HIV at levels less than 1000 copies per mL…This evidence is relevant for at least three important reasons. First, it highlights the need for viral load testing scale-up in all settings where people are living with HIV and taking ART…Second, as pointed out by Broyles and colleagues, these data are probably the best that we will ever have. Standard of care now requires that individuals are offered life-saving ART regardless of viral load…Third, and most importantly, this study provides strong support for the global undetectable equals untransmittable (U=U) campaign. This campaign seeks to popularise the concept that individuals with undetectable viral loads are not infectious to sexual partners, thereby reducing stigma and improving quality of life.”
Journal reference:
Broyles, L. N., et al. (2023) The risk of sexual transmission of HIV in individuals with low-level HIV viraemia: a systematic review.The Lancet. doi.org/10.1016/S0140-6736(23)00877-2.
Some Ontario doctors have started offering a free shot that can protect babies from respiratory syncytial virus while Quebec will begin its immunization program next month.
The new shot called Nirsevimab gives babies antibodies that provide passive immunity to RSV, a major cause of serious lower respiratory tract infections for infants and seniors, which can cause bronchiolitis or pneumonia.
Ontario’s ministry of health says the shot is already available at some doctor’s offices in Ontario with the province’s remaining supply set to arrive by the end of the month.
Quebec will begin administering the shots on Nov. 4 to babies born in hospitals and delivery centers.
Parents in Quebec with babies under six months or those who are older but more vulnerable to infection can also book immunization appointments online.
The injection will be available in Nunavut and Yukon this fall and winter, though administration start dates have not yet been announced.
This report by The Canadian Press was first published Oct. 21, 2024.
-With files from Nicole Ireland
Canadian Press health coverage receives support through a partnership with the Canadian Medical Association. CP is solely responsible for this content.
ISLAMABAD (AP) — Polio cases are rising ahead of a new vaccination campaign in Pakistan, where violence targeting health workers and the police protecting them has hampered years of efforts toward making the country polio-free.
Since January, health officials have confirmed 39 new polio cases in Pakistan, compared to only six last year, said Anwarul Haq of the National Emergency Operation Center for Polio Eradication.
The new nationwide drive starts Oct. 28 with the aim to vaccinate at least 32 million children. “The whole purpose of these campaigns is to achieve the target of making Pakistan a polio-free state,” he said.
Pakistan regularly launches campaigns against polio despite attacks on the workers and police assigned to the inoculation drives. Militants falsely claim the vaccination campaigns are a Western conspiracy to sterilize children.
Most of the new polio cases were reported in the southwestern Balochistan and southern Sindh province, following by Khyber Pakhtunkhwa province and eastern Punjab province.
The locations are worrying authorities since previous cases were from the restive northwest bordering Afghanistan, where the Taliban government in September suddenly stopped a door-to-door vaccination campaign.
Afghanistan and Pakistan are the two countries in which the spread of the potentially fatal, paralyzing disease has never been stopped. Authorities in Pakistan have said that the Taliban’s decision will have major repercussions beyond the Afghan border, as people from both sides frequently travel to each other’s country.
The World Health Organization has confirmed 18 polio cases in Afghanistan this year, all but two in the south of the country. That’s up from six cases in 2023. Afghanistan used a house-to-house vaccination strategy this June for the first time in five years, a tactic that helped to reach the majority of children targeted, according to WHO.
Health officials in Pakistan say they want the both sides to conduct anti-polio drives simultaneously.
WASHINGTON (AP) — Millions of people with private health insurance would be able to pick up over-the-counter methods like condoms, the “morning after” pill and birth control pills for free under a new rule the White House proposed on Monday.
Right now, health insurers must cover the cost of prescribed contraception, including prescription birth control or even condoms that doctors have issued a prescription for. But the new rule would expand that coverage, allowing millions of people on private health insurance to pick up free condoms, birth control pills, or “morning after” pills from local storefronts without a prescription.
The proposal comes days before Election Day, as Vice President Kamala Harris affixes her presidential campaign to a promise of expanding women’s health care access in the wake of the U.S. Supreme Court’s decision to undo nationwide abortion rights two years ago. Harris has sought to craft a distinct contrast from her Republican challenger, Donald Trump, who appointed some of the judges who issued that ruling.
“The proposed rule we announce today would expand access to birth control at no additional cost for millions of consumers,” Health and Human Services Secretary Xavier Becerra said in a statement. “Bottom line: women should have control over their personal health care decisions. And issuers and providers have an obligation to comply with the law.”
The emergency contraceptives that people on private insurance would be able to access without costs include levonorgestrel, a pill that needs to be taken immediately after sex to prevent pregnancy and is more commonly known by the brand name “Plan B.”
Without a doctor’s prescription, women may pay as much as $50 for a pack of the pills. And women who delay buying the medication in order to get a doctor’s prescription could jeopardize the pill’s effectiveness, since it is most likely to prevent a pregnancy within 72 hours after sex.
If implemented, the new rule would also require insurers to fully bear the cost of the once-a-day Opill, a new over-the-counter birth control pill that the U.S. Food and Drug Administration approved last year. A one-month supply of the pills costs $20.
Federal mandates for private health insurance to cover contraceptive care were first introduced with the Affordable Care Act, which required plans to pick up the cost of FDA-approved birth control that had been prescribed by a doctor as a preventative service.
The proposed rule would not impact those on Medicaid, the insurance program for the poorest Americans. States are largely left to design their own rules around Medicaid coverage for contraception, and few cover over-the-counter methods like Plan B or condoms.
