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Undetectable = Uninfectious: Revolutionary Findings on HIV Transmission Risk

Explore groundbreaking studies showing no transmission risk when viral load is undetectable, impacting men, women, and mother-to-child transmission. Learn about the effects of HAART on transmission rates and the potential for HAART to surpass condom efficacy. Discover projections on HIV infections and cost savings with HAART treatment. Get insights on ongoing trials and unanswered questions in controlling the epidemic.

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Undetectable = Uninfectious: Revolutionary Findings on HIV Transmission Risk

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  1. Undetectable = Uninfectious ? Treatment as Prevention

  2. All Men-Women Women-Men No transmission if VL « undetectable » « Rakai » Study: Transmission risk as a function of viral load Quinn et al. N Engl J Med 2000;342:921-9

  3. N Engl J Med 1999;341:394-402 Maternal levels of plasma HIV RNA and the risk of perinatal transmission • Mother’s viremia of a non infected newborn • Mother’s viremia of an infected newborn No transmission if maternal viremia < 1000/ml

  4. Mother to Child Transmission AZT HAART % ofinfected children

  5. Effect of HAART on MTCT • 2202 babies born to HIV+ mothers with undetectable viral load at the time of confinement • 3 neonatal infections Claire Townsend et al. 15th CROI, Poster 653

  6. Transmission by breast milk Mothers on NVP/3-TC/AZT, 2 studies in Kenya and Uganda, 441 and 172 pregnancies, one infection % infected children IAS Conference Syndney, Abstracts TUAX 101 and 102

  7. Effects of HAART on heterosexual transmission • Prospective studies of 393 heterosexual couples in Madrid • The index patients were HIV positive, and consulted between 1991-2003 • Partners’ only HIV risk was exposure to the index patients • All partners had repeated HIV tests to investigate HIV infection in partners Castilla, et al. JAIDS 2005; 40:96-101

  8. Prevalence of HIV infection in the partners Pre-HAART HAART Pourcent des partenaires infecté(e)s

  9. « HAART versus condoms »Infection rates in sex partners Unsafe sex Ttmt of the index pt No ttmt Mono- oubitherapy >1/month <1/mo Never HAART % % 12 10 9 10 8 8 7 6 6 5 4 4 3 2 2 1 0 0 Castilla, et al. JAIDS 2005; 40:96-101

  10. Condoms plus HAART in comparison to condoms alone: 2 African studies • What they had in common: • Transmission in Uganda • Sero-discordant Couples • Condom Promotion • How they differed: • Study A*, without HAART, evaluated the effect of circumcision on male-to-female transmission • Study B**, with HAART, evaluated transmission both ways * Wawer M et al. Abstract 33 LB, 15th CROI, Boston 2008 **Bunnell R et al. Abstract 29, 15th CROI, Boston 2008

  11. Results Study A* Study B** Condoms HAART -  N infections observed 12% ppy 0.5 % ppy 95% CI 9 – 15 0.01-3.0 * Wawer M et al. Abstract 33 LB, 15th CROI, Boston 2008 **Bunnell R et al. Abstract 29, 15th CROI, Boston 2008, AIDS 2006

  12. Rwanda • Follow-up of 1034 sero-discordant couples; in 248 the infected partner was on HAART • In spite of condom promotion, 42 incident infections were observed HAART No HAART N total 248 786 Seroconversions 2 40 Per cent 0.8 5.1 * Kayitenkore K et al. 14th International AIDS ConferenceToronto 2006, abstract no. MOKC101

  13. In conclusion • HAART lowers MTCT • HAART lowers heterosexual transmission (no data on male homosexual transmission) • In Africa and in Europe, HAART appears more efficacious than condoms, in sero-discordant heterosexual couples

  14. Effects of HAART on the AIDS Epidemic Projections for British Columbia

  15. 10 9 8 7 6 5 4 3 2 1 0 2006 2010 2014 2018 2022 2026 2030 2034 2038 Treat 30% HIV infections per 1000 population Treat all 2006 10 14 18 22 26 30 34 38 42 2050 Hogg et al. Unpublished, 2006

  16. Costs of treatment 109 $ Treat all Treat 30% 2006 10 14 18 22 26 30 34 38 42 2050 Hogg et al. Unpublished, 2006

  17. Costs of HAART Billions de $ Great savings Small investment 2006 10 14 18 22 26 30 34 38 42 2050 • Lima VD et al. Expanded Access to Highly Active Antiretroviral Therapy: A Powerful Strategy to Curb the HIV Epidemic; JID 2008; volume 198, July 1. • Hogg et al. Unpublished, 2006

  18. Next on the Agenda • Controlled trials • In sero-discordant couples (HPTN 052 study already underway) • In the general population (planned) • Important unsolved questions • Efficacy • Acceptability • Compliance • Sustainability

  19. Undetectable = Uninfectious • In Medicine, never say never… • Biologically plausible • Observational data with limits • Heterosexual couples • Low number = high upper limits of CIs • How to position yourself when faced with small risks

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