Global Health Impact Group, Atlanta, GA, USA.
WHO, Geneva, Switzerland.
Lancet. 2023 Aug 5;402(10400):464-471. doi: 10.1016/S0140-6736(23)00877-2. Epub 2023 Jul 22.
The risk of sexual transmission of HIV from individuals with low-level HIV viraemia receiving antiretroviral therapy (ART) has important public health implications, especially in resource-limited settings that use alternatives to plasma-based viral load testing. This Article summarises the evidence related to sexual transmission of HIV at varying HIV viral load levels to inform messaging for people living with HIV, their partners, their health-care providers, and the wider public.
We conducted a systematic review and searched PubMed, MEDLINE, Cochrane Central Register of Controlled Trials, Embase, Conference Proceedings Citation Index-Science, and WHO Global Index Medicus, for work published from Jan 1, 2010 to Nov 17, 2022. Studies were included if they pertained to sexual transmission between serodiscordant couples at various levels of viraemia, the science behind undetectable=untransmittable, or the public health impact of low-level viraemia. Studies were excluded if they did not specify viral load thresholds or a definition for low-level viraemia or did not provide quantitative viral load information for transmission outcomes. Reviews, non-research letters, commentaries, and editorials were excluded. Risk of bias was evaluated using the ROBINS-I framework. Data were extracted and summarised with a focus on HIV sexual transmission at varying HIV viral loads.
244 studies were identified and eight were included in the analysis, comprising 7762 serodiscordant couples across 25 countries. The certainty of evidence was moderate; the risk of bias was low. Three studies showed no HIV transmission when the partner living with HIV had a viral load less than 200 copies per mL. Across the remaining four prospective studies, there were 323 transmission events; none were in patients considered stably suppressed on ART. Among all studies there were two cases of transmission when the index patient's (ie, patient with previously diagnosed HIV infection) most recent viral load was less than 1000 copies per mL. However, interpretation of both cases was complicated by long intervals (ie, 50 days and 53 days) between the transmission date and the most recent index viral load result.
There is almost zero risk of sexual transmission of HIV with viral loads of less than 1000 copies per mL. These data provide a powerful opportunity to destigmatise HIV and promote adherence to ART through dissemination of this positive public health message. These findings can also promote access to viral load testing in resource-limited settings for all people living with HIV by facilitating uptake of alternative sample types and technologies.
Bill & Melinda Gates Foundation.
接受抗逆转录病毒疗法（ART）的低水平 HIV 病毒血症个体的 HIV 通过性传播的风险具有重要的公共卫生意义，尤其是在资源有限的环境中，这些环境使用替代基于血浆的病毒载量检测。本文总结了与不同 HIV 病毒载量水平相关的 HIV 通过性传播的证据，以为 HIV 感染者、他们的伴侣、他们的医疗保健提供者以及更广泛的公众提供信息。
我们进行了系统评价，并在 PubMed、MEDLINE、Cochrane 对照试验中心注册、Embase、会议论文引文索引-科学和世界卫生组织全球医学索引中进行了搜索，以获取 2010 年 1 月 1 日至 2022 年 11 月 17 日发表的工作。如果研究涉及血清学不一致的夫妇在不同病毒血症水平之间的性传播、不可检测即不可传播背后的科学，或低水平病毒血症的公共卫生影响，则纳入研究。如果研究没有指定病毒载量阈值或低水平病毒血症的定义，或者没有提供传播结果的定量病毒载量信息，则排除研究。排除了综述、非研究信件、评论和社论。使用 ROBINS-I 框架评估偏倚风险。使用重点关注不同 HIV 病毒载量下的 HIV 性传播的方法提取和总结数据。
确定了 244 项研究，其中 8 项被纳入分析，包括来自 25 个国家的 7762 对血清学不一致的夫妇。证据的确定性为中度；偏倚风险低。有三项研究表明，当 HIV 感染者的病毒载量小于 200 拷贝/毫升时，HIV 没有传播。在其余四项前瞻性研究中，共有 323 例传播事件；在考虑稳定抑制 ART 的患者中均未发生。在所有研究中，有两例传播发生在指数患者（即以前诊断为 HIV 感染的患者）最近的病毒载量小于 1000 拷贝/毫升时。然而，由于传播日期和最近的指数病毒载量结果之间的间隔较长（分别为 50 天和 53 天），因此对这两种情况的解释都很复杂。
病毒载量小于 1000 拷贝/毫升时，HIV 通过性传播的风险几乎为零。这些数据为消除 HIV 污名化和通过传播这一积极的公共卫生信息来促进对 ART 的坚持提供了有力的机会。这些发现还可以通过促进在资源有限的环境中对所有 HIV 感染者进行病毒载量检测，促进对替代样本类型和技术的采用，从而促进获得病毒载量检测。
比尔和梅琳达盖茨基金会。
