Institute for Global Health, University College London, London, UK.
Denver Public Health, University of Colorado Health Sciences Center, Denver, Colorado, USA.
AIDS. 2019 Dec 1;33(15):2337-2350. doi: 10.1097/QAD.0000000000002359.
Antiretroviral treatment (ART) reduces HIV infectiousness but the effect of early ART on sexual behaviour is unclear.
We assessed, within the START randomized trial that enrolled HIV-positive adults with CD4 cell count greater than 500 cells/μl, the effect of early (immediate) versus deferred ART on: condomless sex with HIV-serodifferent partners (CLS-D); all condomless sex (CLS); HIV transmission-risk sex (CLS-D-HIV risk, defined as CLS-D and: not on ART or started ART <6 months ago or viral load greater than 200 copies/ml or no viral load in past 6 months), during 2-year follow-up. Month-12 CLS-D (2010-2014) was the primary outcome.
Among 2562 MSM, there was no difference between immediate and deferred arms in CLS-D at month 12 [12.6 versus 13.1%; difference (95% CI): -0.4% (-3.1 to 2.2%), P = 0.75] or month 24, or in CLS. Among 2010 heterosexual men and women, CLS-D at month 12 tended to be higher in the immediate versus deferred arm [10.8 versus 8.3%; difference:2.5% (-0.1 to 5.2%), P = 0.062]; the difference was greater at month 24 [9.3 versus 5.6%; difference: 3.7% (1.0 to 6.4%), P = 0.007], at which time CLS was higher in the immediate arm (20.7 versus 15.7%, P = 0.013). CLS-D-HIV risk at month 12 was substantially lower in the immediate versus deferred arm for MSM [0.2 versus 11%; difference: -10.7% (-12.5 to -8.9%), P < 0.001] and heterosexuals [0.6% versus 7.7%; difference: -7.0% (-8.8 to -5.3%), P < 0.001], because of viral suppression on ART.
A strategy of early ART had no effect on condomless sex with HIV-serodifferent partners among MSM, but resulted in modestly higher prevalence among heterosexuals. However, among MSM and heterosexuals, early ART resulted in a substantial reduction in HIV-transmission-risk sex, to a very low absolute level.
抗逆转录病毒治疗（ART）降低了 HIV 的传染性，但早期 ART 对性行为的影响尚不清楚。
我们在 START 随机试验中评估了 HIV 阳性、CD4 细胞计数大于 500 个/μl 的成年人中，早期（立即）ART 与延迟 ART 对以下方面的影响：与 HIV 血清学不同的伴侣发生无保护性行为（CLS-D）；所有无保护性行为（CLS）；HIV 传播风险性行为（CLS-D-HIV 风险，定义为 CLS-D 且：未接受 ART 或开始 ART<6 个月或病毒载量大于 200 拷贝/ml 或过去 6 个月内无病毒载量），在 2 年随访期间。12 个月时的 CLS-D（2010-2014 年）是主要结局。
在 2562 名男男性接触者中，立即和延迟组在 12 个月时的 CLS-D 没有差异[12.6%与 13.1%；差异（95%CI）：-0.4%（-3.1 至 2.2%），P=0.75]或 24 个月时，或在 CLS 中。在 2010 名异性恋男性和女性中，立即组在 12 个月时的 CLS-D 倾向于高于延迟组[10.8%与 8.3%；差异：2.5%（0.1 至 5.2%），P=0.062]；24 个月时差异更大[9.3%与 5.6%；差异：3.7%（1.0 至 6.4%），P=0.007]，此时立即组的 CLS 更高（20.7%与 15.7%，P=0.013）。立即组与延迟组相比，在 12 个月时的 CLS-D-HIV 风险显著降低[0.2%与 11%；差异：-10.7%（-12.5 至-8.9%），P<0.001]和异性恋者[0.6%与 7.7%；差异：-7.0%（-8.8 至-5.3%），P<0.001]，因为 ART 抑制了病毒。
早期 ART 策略对男男性接触者与 HIV 血清学不同的伴侣发生无保护性行为没有影响，但在异性恋者中导致流行率略有增加。然而，在男男性接触者和异性恋者中，早期 ART 导致 HIV 传播风险性行为大幅减少，降至极低的绝对水平。
