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Intervention Review

Antiretroviral therapy for prevention of HIV transmission in HIV-discordant couples

  1. Andrew Anglemyer1,
  2. George W Rutherford1,*,
  3. Matthias Egger2,
  4. Nandi Siegfried3

Editorial Group: Cochrane HIV/AIDS Group

Published Online: 11 MAY 2011

Assessed as up-to-date: 2 APR 2011

DOI: 10.1002/14651858.CD009153


How to Cite

Anglemyer A, Rutherford GW, Egger M, Siegfried N. Antiretroviral therapy for prevention of HIV transmission in HIV-discordant couples. Cochrane Database of Systematic Reviews 2011, Issue 5. Art. No.: CD009153. DOI: 10.1002/14651858.CD009153.

Author Information

  1. 1

    University of California, San Francisco, Global Health Sciences, San Francisco, California, USA

  2. 2

    Institute of Social and Preventive Medicine, Institute of Social Medicine, Bern, Switzerland

  3. 3

    University of Cape Town, Department of Public Health and Primary Health Care, Cape Town, South Africa

*George W Rutherford, Global Health Sciences, University of California, San Francisco, 50 Beale Street, Suite 1200, San Francisco, California, 94105, USA. GRutherford@psg.ucsf.edu.

Publication History

  1. Publication Status: New
  2. Published Online: 11 MAY 2011

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Abstract

  1. Top of page
  2. Abstract
  3. Plain language summary

Background

Antiretroviral drugs have been shown to reduce risk of mother-to-child transmission of human immunodeficiency virus (HIV) and are also widely used for post-exposure prophylaxis for parenteral and sexual exposures. Observational data, ecological studies and models suggest that sexual transmission may be lower in couples in which one partner is infected with HIV and the other is not and the infected partner is on antiretroviral therapy (ART).

Objectives

To determine if ART use in an HIV-infected member of an HIV-discordant couple is associated with lower risk of HIV transmission to the uninfected partner compared to untreated discordant couples.

Search strategy

We used standard Cochrane methods to search electronic databases and conference proceedings with relevant search terms without limits to language.

Selection criteria

Randomised controlled trials, cohort studies and case-control studies of HIV-discordant couples in which the HIV-infected member of the couple was being treated or not treated with ART

Data collection and analysis

Abstracts of all trials identified by electronic or bibliographic scanning were examined independently by two authors. We initially identified 1814 references and examined 23 in detail for study eligibility. Data were abstracted independently using a standardised abstraction form.

Main results

Seven observational studies and no randomised controlled trials were included in the review. These seven studies identified 436 episodes of HIV transmisison, 71 among treated couples and 365 among untreated couples. The summary rate ratio for all seven studies was 0.34 [95% CI 0.13, 0.92], with substantial heterogeneity (I2=73%). After excluding two studies with inadequate person-time data, we found a summary rate ratio of 0.16 [95% CI 0.07, 0.35] with no noted heterogeneity (I2=0%). We also performed subgroup analyses to see if the effect of ART on prevention of HIV differed by the index partner's CD4 cell count. Among couples in which the infected partner had >350 CD4 cells/µL, we estimated a rate ratio of 0.02 [95% CI 0.00, 2.87]. In this subgroup, there were 61 transmissions in untreated couples and none in treated couples.

Authors' conclusions

ART appears to be a potent intervention for prevention of HIV in discordant couples. However, the most important question from a clinical standpoint is whether being in a serodiscordant sexual relationship and having >350 CD4 cells/µL should be an indication for ART. In our analysis, there were broad confidence intervals in this subgroup, overlapping the null hypothesis of no effect. There is currently one large randomised controlled trial in the field, whose results are scheduled to be ready in 2015. Significant questions remain about durability of protection, when to start treating an infected partner (for instance, at diagnosis or at a specific CD4 level) and transmission of ART-resistant strains to partners.

 

Plain language summary

  1. Top of page
  2. Abstract
  3. Plain language summary

Antiretroviral therapy for prevention of HIV transmission in HIV-discordant couples

Antiretroviral drugs may prevent transmission of HIV from an infected sexual partner to an uninfected one by suppressing viral replication. We found seven observational studies that had examined this question. Overall we found that in couples in which the infected partner was being treated with antiretroviral drugs the uninfected partners had more than 5-times lower risk of being infected than in couples where the infected partner was not receiving treatment. Since WHO already recommends antiretroviral treatment for all persons with ≤350 CD4 cells/µL, we also examined studies that had looked at partners with CD4 counts higher than this level. We found that there was inconclusive evidence that in this group HIV was less likely to be transmitted. A large randomised trial is currently being conducted, and a more definitive answer should be available by 2015.