Heterosexual HIV-1 transmission after initiation of antiretroviral therapy: a prospective cohort analysis.
Heterosexual HIV-1 transmission after initiation of antiretroviral therapy: a prospective cohort analysis.
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DOI：
10.1016/s0140-6736(10)60705-2
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发表时间：
2010-06-12
期刊：
影响因子：
168.9
通讯作者：
Celum, Connie
中科院分区：
文献类型：
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作者：
Donnell, Deborah;Baeten, Jared M.;Kiarie, James;Thomas, Katherine K.;Stevens, Wendy;Cohen, Craig R.;McIntyre, James;Lingappa, Jairam R.;Celum, Connie
高血浆HIV-1 RNA浓度与HIV-1传播风险增加相关。抗逆转录病毒治疗（ART）的启动降低血浆HIV-1浓度，但很少有经验性的数据是艾滋病毒-1的传播率从接受ART的人。3381非洲异性恋HIV-1血清不一致的夫妇进行了前瞻性随访长达24个月。入组时，HIV-1感染伴侣的CD 4计数≥250个细胞/mm 3，不符合启动ART的国家指南;在随访期间，每6个月测量一次CD 4计数，并按照国家指南启动ART。未感染HIV-1的伴侣每3个月进行一次HIV-1检测。我们比较了ART启动的遗传相关HIV-1传播率。349例（10%）HIV-1感染伴侣开始ART治疗，中位CD 4计数为198个细胞/mm 3。103例HIV-1连锁传播中，只有一例来自已开始抗逆转录病毒治疗的HIV-1感染伴侣，这对应于已开始抗逆转录病毒治疗与未开始抗逆转录病毒治疗的HIV-1传播率分别为0.37/100人-年和2.24/100人-年（调整后的发病率比为0.08，95%置信区间为0.002-0.57，p=0.004）。开始抗逆转录病毒治疗后，血浆HIV-1 RNA浓度显著下降（中位数从4.88降至<2.38 log 10拷贝/mL，p<0.001），无保护性行为也是如此（抗逆转录病毒治疗前6.2%的患者就诊，开始后3.7%的患者就诊，p=0.03）。在未接受抗逆转录病毒疗法的人群中，艾滋病毒1型感染率最高（每100人年8.79例）的是CD 4细胞计数<200个/mm 3的艾滋病毒1型感染者。在HIV-1感染伴侣的CD 4 ≥200个细胞/mm 3的夫妇中，70%的传播发生在血浆HIV-1浓度超过50，000拷贝/mL时。在非洲异性恋夫妇中，ART启动后，HIV-1传播风险降低了92%，这可能是由于血浆HIV-1水平显著降低，并伴随着自我报告的避孕套使用增加。HIV-1风险最高和ART相对预防效益最大的是HIV-1感染伴侣CD 4计数<200个细胞/mm 3或血浆HIV-1 RNA浓度> 50，000拷贝/mL的夫妇。
High plasma HIV-1 RNA concentrations are associated with increased risk of HIV-1 transmission. Initiation of antiretroviral therapy (ART) reduces plasma HIV-1 concentrations, but little empiric data are available on the rate of sexual HIV-1 transmission from persons receiving ART. 3381 African heterosexual HIV-1 serodiscordant couples were followed prospectively for up to 24 months. At enrollment, HIV-1 infected partners had CD4 counts ≥250 cells/mm3 and did not meet country guidelines for ART initiation; during follow-up, CD4 counts were measured every 6 months and ART initiated following national guidelines. HIV-1 uninfected partners were tested for HIV-1 every 3 months. We compared genetically-linked HIV-1 transmission rates by ART initiation. 349 (10%) HIV-1 infected partners initiated ART, at a median CD4 count of 198 cells/mm3. Only one of 103 linked HIV-1 transmissions was observed from an HIV-1 infected partner who had initiated ART corresponding to HIV-1 transmission rates of 0.37 versus 2.24 per 100 person-years for those who had initiated versus not initiated ART, respectively (adjusted incidence rate ratio 0.08, 95% confidence interval 0.002–0.57, p=0.004). After ART initiation, plasma HIV-1 RNA concentrations decreased significantly (from median 4.88 to <2.38 log10 copies/mL, p<0.001) as did unprotected sex (6.2% of visits before to 3.7% of visits after ART initiation, p=0.03). Among those not on ART, the highest HIV-1 transmission rate (8.79 per 100 person-years) was from HIV-1 infected persons with CD4 counts <200 cells/mm3. In couples in which the HIV-1 infected partner had a CD4 ≥200 cells/mm3, 70% of transmissions occurred when plasma HIV-1 concentrations exceeded 50,000 copies/mL. Among African heterosexual couples, ART initiation was followed by a 92% reduction in HIV-1 transmission risk, likely due to significantly reduced plasma HIV-1 levels, and was accompanied by increased self-reported condom use. The highest HIV-1 risk and greatest relative prevention benefit from ART was among couples in which the HIV-1 infected partner had CD4 counts <200 cells/mm3 or plasma HIV-1 RNA concentrations >50,000 copies/mL.