Prevention of HIV-1 Infection with Antiretroviral Therapy

n engl j med 365;20 nejm.org november 17, 20111934
T h e n e w e ng l a nd j o u r na l o f m e dic i n e
c o r r e s p o n d e n c e
Prevention of HIV-1 Infection with Antiretroviral Therapy
To the Editor: To recommend antiretroviral
therapy (ART) as a policy to prevent transmission
of the human immunodeficiency virus type 1
(HIV-1), it is critical to understand the risk of
transmission through sex without condom use
when the plasma viral load in patients receiving
ART is fully suppressed. In addition to data re-
ported by Cohen et al. (Aug. 11 issue),1 a 2009
meta-analysis2 showed no transmissions in 291
person-years, and the Partners in Prevention
Study (ClinicalTrials.gov number, NCT00194519)3
showed one transmission in 273 person-years,
but some couples used condoms. Accounting for
the proportions of couples having sex without
the use of condoms (approximately 4%,1 75%,2
and 4%3 in these three studies, respectively), only
approximately 292 person-years of sex without
the use of condoms with viral-load suppression
have been observed over all studies combined.
Even with no transmissions, these findings are
associated with an upper 95% confidence limit
for the transmission rate of 1.3 per 100 person-
years. We think this is too high a rate on which to
base a public health prevention policy. Further,
there remain no data on men who have sex with
men, among whom transmission rates for anal sex
are likely to be different than rates for vaginal sex.
Alison Rodger, M.D.
Andrew Phillips, Ph.D.
University College London
London, United Kingdom
[e-mail]
Jens Lundgren, Ph.D.
University of Copenhagen
Copenhagen, Denmark
No potential conflict of interest relevant to this letter was re-
ported.
1. Cohen MS, Chen YQ, McCauley M, et al. Prevention of HIV-1
infection with early antiretroviral therapy. N Engl J Med 2011;
365:493-505.
2. Attia S, Egger M, Müller M, Zwahlen M, Low N. Sexual trans-
mission of HIV according to viral load and antiretroviral therapy:
systematic review and meta-analysis. AIDS 2009;23:1397-404.
3. Donnell D, Baeten JM, Kiarie J, et al. Heterosexual HIV-1
transmission after initiation of antiretroviral therapy: a prospec-
tive cohort analysis. Lancet 2010;375:2092-8.
To the Editor: Cohen et al. compared the ef-
fects of early and delayed therapy for HIV-1–
infected subjects among serodiscordant couples
and found that the first regimen more signifi-
cantly reduced the rates of sexual transmission
and the incidence of clinical events of HIV-1.
However, a comprehensive survey should be per-
formed to assess the changes in sexual behavior
among the subjects in response to ART. During
the study, although interviews regarding sexual
behavior were conducted at each visit, the chang-
es in sexual behavior before and after ART were
not compared. Reynolds et al.1 found that HIV-1
transmission was reduced among HIV-1–discor-
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