Institute for Global Health, University College London, London, UK.
Institute for Global Health, University College London, London, UK.
Lancet. 2019 Jun 15;393(10189):2428-2438. doi: 10.1016/S0140-6736(19)30418-0. Epub 2019 May 2.
BACKGROUND: The level of evidence for HIV transmission risk through condomless sex in serodifferent gay couples with the HIV-positive partner taking virally suppressive antiretroviral therapy (ART) is limited compared with the evidence available for transmission risk in heterosexual couples. The aim of the second phase of the PARTNER study (PARTNER2) was to provide precise estimates of transmission risk in gay serodifferent partnerships. METHODS: The PARTNER study was a prospective observational study done at 75 sites in 14 European countries. The first phase of the study (PARTNER1; Sept 15, 2010, to May 31, 2014) recruited and followed up both heterosexual and gay serodifferent couples (HIV-positive partner taking suppressive ART) who reported condomless sex, whereas the PARTNER2 extension (to April 30, 2018) recruited and followed up gay couples only. At study visits, data collection included sexual behaviour questionnaires, HIV testing (HIV-negative partner), and HIV-1 viral load testing (HIV-positive partner). If a seroconversion occurred in the HIV-negative partner, anonymised phylogenetic analysis was done to compare HIV-1 pol and env sequences in both partners to identify linked transmissions. Couple-years of follow-up were eligible for inclusion if condomless sex was reported, use of pre-exposure prophylaxis or post-exposure prophylaxis was not reported by the HIV-negative partner, and the HIV-positive partner was virally suppressed (plasma HIV-1 RNA <200 copies per mL) at the most recent visit (within the past year). Incidence rate of HIV transmission was calculated as the number of phylogenetically linked HIV infections that occurred during eligible couple-years of follow-up divided by eligible couple-years of follow-up. Two-sided 95% CIs for the incidence rate of transmission were calculated using exact Poisson methods. FINDINGS: Between Sept 15, 2010, and July 31, 2017, 972 gay couples were enrolled, of which 782 provided 1593 eligible couple-years of follow-up with a median follow-up of 2·0 years (IQR 1·1-3·5). At baseline, median age for HIV-positive partners was 40 years (IQR 33-46) and couples reported condomless sex for a median of 1·0 years (IQR 0·4-2·9). During eligible couple-years of follow-up, couples reported condomless anal sex a total of 76 088 times. 288 (37%) of 777 HIV-negative men reported condomless sex with other partners. 15 new HIV infections occurred during eligible couple-years of follow-up, but none were phylogenetically linked within-couple transmissions, resulting in an HIV transmission rate of zero (upper 95% CI 0·23 per 100 couple-years of follow-up). INTERPRETATION: Our results provide a similar level of evidence on viral suppression and HIV transmission risk for gay men to that previously generated for heterosexual couples and suggest that the risk of HIV transmission in gay couples through condomless sex when HIV viral load is suppressed is effectively zero. Our findings support the message of the U=U (undetectable equals untransmittable) campaign, and the benefits of early testing and treatment for HIV. FUNDING: National Institute for Health Research.
背景:与异性恋伴侣相比,艾滋病毒阳性伴侣接受病毒抑制性抗逆转录病毒疗法(ART)的艾滋病毒血清学不同的男同性恋伴侣无保护性行为的艾滋病毒传播风险的证据水平有限。PARTNER 研究的第二阶段(PARTNER2)的目的是提供男同性恋血清学不同伴侣关系中传播风险的精确估计。
方法:PARTNER 研究是在欧洲 14 个国家的 75 个地点进行的前瞻性观察研究。该研究的第一阶段(PARTNER1;2010 年 9 月 15 日至 2014 年 5 月 31 日)招募并随访了报告无保护性行为的异性恋和艾滋病毒血清学不同的伴侣(艾滋病毒阳性伴侣接受抑制性 ART),而 PARTNER2 扩展(至 2018 年 4 月 30 日)仅招募并随访了男同性恋伴侣。在研究访视时,数据收集包括性行为问卷、HIV 检测(HIV 阴性伴侣)和 HIV-1 病毒载量检测(HIV 阳性伴侣)。如果 HIV 阴性伴侣发生血清转换,则对 HIV-1 pol 和 env 序列进行匿名系统发育分析,以比较双方的 HIV-1 序列,以确定关联传播。如果报告了无保护性行为、HIV 阴性伴侣未报告使用暴露前预防或暴露后预防、且 HIV 阳性伴侣最近一次就诊时病毒载量抑制(血浆 HIV-1 RNA<200 拷贝/毫升),则有资格纳入随访年。HIV 传播的发生率计算为在符合条件的随访年中发生的与系统发育相关的 HIV 感染数量除以符合条件的随访年。使用确切泊松方法计算传播发生率的双侧 95%置信区间。
结果:2010 年 9 月 15 日至 2017 年 7 月 31 日期间,共纳入 972 对男同性恋伴侣,其中 782 对提供了 1593 对符合条件的随访年,中位随访时间为 2.0 年(IQR 1.1-3.5)。在基线时,艾滋病毒阳性伴侣的中位年龄为 40 岁(IQR 33-46),伴侣报告无保护性行为的中位时间为 1.0 年(IQR 0.4-2.9)。在符合条件的随访年中,伴侣总共报告了 76088 次无保护肛交。777 名 HIV 阴性男性中有 288 名(37%)报告与其他伴侣发生无保护性行为。在符合条件的随访年中,发生了 15 例新的 HIV 感染,但无一人在夫妻内发生系统发育相关的传播,因此 HIV 传播率为零(上 95%CI 为每 100 对符合条件的随访年 0.23 例)。
解释:我们的研究结果为男同性恋者提供了与以前为异性恋伴侣提供的类似的病毒抑制和 HIV 传播风险的证据水平,并表明当 HIV 病毒载量被抑制时,通过无保护性行为在男同性恋伴侣中传播 HIV 的风险实际上为零。我们的研究结果支持 U=U(检测不到等于不传播)运动的信息,以及早期检测和治疗 HIV 的益处。
资金:英国国家卫生研究院。
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