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• W2010466976 abstract "In the majority of resource-rich countries, the most common exposure route for HIV transmission is unprotected anal intercourse among homosexual men [1,2]. HIV diagnosis rates in these settings have been increasing over the last decade [1–3], which is somewhat paradoxical considering that effective combination antiretroviral therapy (ART) has had increasing coverage. There is evidence among heterosexuals of a positive association between viral load and infectiousness [4–6], and use of ART has been shown to reduce HIV transmission risk among discordant couples [7]. Further, both a recent meta-analysis [6] and a prospective cohort study [8] calculated a remarkably similar reduction, of 92%, in HIV transmission rates from heterosexual men and women who are treated compared with those who are untreated. It might be expected that ART would also reduce HIV transmission rates among homosexual men, but the fact that the per-contact probability of HIV transmission through anal intercourse is more than 10-fold higher than by vaginal intercourse means that results may not necessarily be the same. The recent meta-analysis by Baggaley et al.[9] resulted in an estimate of the probability of HIV transmission through receptive anal intercourse of 1.4%, which aligns with our estimate from an Australian cohort of homosexual men [10]. It is surprising that these estimates of HIV transmission risk are also similar to estimates prior to the use of ART [11]. Our study is the first to differentiate the per-act probability of HIV transmission by receptive anal intercourse with or without ejaculation (1.43 and 0.65%, respectively) and insertive anal intercourse with or without circumcision (0.11 and 0.62%, respectively). We agree with Baggaley et al.[12] that it would have been useful to have more information about highly active antiretroviral therapy (HAART) coverage among HIV-infected partners of the homosexual men in our cohort to elucidate the role of antiretrovirals in reducing transmission risk among homosexual men. However, the nature of many sexual partnerships among gay and other homosexual men is that information about partners is often limited. Information about treatment status is often known among discordant regular partners and, although disclosure of HIV serostatus is becoming increasingly common among casual partners [13–16], it is still not disclosed in most partnerships, let alone discussion of the use of ART. Collection of further detail, such as level of adherence to ART among partners of men in our cohort, was also beyond the scope of feasibility. In the absence of such data, we had to make assumptions that the partners had epidemiological and clinical characteristics that were similar to those captured by Australian surveillance mechanisms. Our calculations did not directly account for the proportion of the population on ART but estimated population average transmission rates resulting from HIV-infected people with a broad distribution of viral loads. Numerous sources justify an assumption that approximately 70% of Australia's HIV-diagnosed population is on ART [17,18]. Australia's HIV Observational Database tracks a large cohort of HIV-infected people and indicates that the degree of viral suppression among HIV-treated people has increased from ∼65 in 2000 to ∼90% currently, with an average of ∼80% over the period of follow up in our cohort study [17]. However, the proportion of the HIV-infected population among Sydney homosexual men that is undiagnosed is not well known. Statistical and modeling calculations have estimated that consistently ∼10% of HIV-infected men in Sydney are undiagnosed [19], which aligns with the relatively high testing rates in this population [18]. However, a recent study conducted in Melbourne has estimated that up to 20% of HIV-infected gay men in a comparable Australian context may be undiagnosed [20]. Taken together, it is quite possible that just 45–50% (80–90 × 70 × 80%) of HIV-infected homosexual men in Sydney had undetectable viral load during our study. As this estimate shows, in a population with high rates of testing and treatment with highly effective antiretrovirals, it is likely that there are a substantial proportion of people with detectable viral load. This may go a long way toward accounting for the lack of difference in our estimates of transmission risks compared with the pre-HAART era. However, one would still expect to find a noticeable decrease in average transmission risks owing to a reduction in average community viral load [21]." @default.
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• W2010466976 date "2010-09-24" @default.
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• W2010466976 title "Infectiousness of HIV-infected men who have sex with men in the era of highly active antiretroviral therapy" @default.
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