Preventing HIV Transmission in Serodiscordant Couples

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The HCPLive Peer Exchange: Optimizing Outcomes in HIV Treatment features insight and opinion on the latest developments in HIV research, diagnosis, and management from leading physician specialists.

This Peer Exchange is moderated by Paul Doghramji, MD, who is a family physician at Collegeville Family Practice in Collegeville, PA, and Medical Director of health services at Ursinus College, also in Collegeville, PA.

The panelists are:

• Alfred A. DeLuca, MD, Infectious Disease Specialist at CentraState Healthcare System in Manalapan, NJ
• Ian Frank, MD, Director of Anti-Retroviral Clinical Research and Director of Clinical Core at Penn Center for AIDS Research, and Professor of Medicine at the Hospital of the University of Pennsylvania in Philadelphia, PA
• Paul Sax, MD, Associate Professor of Medicine at Harvard Medical School and Clinical Director of the Division of Infectious Diseases and the HIV Program at Brigham and Women's Hospital, in Boston, MA

Also participating via video is Amir Qaseem, MD, Director of Clinical Policy for the American College of Physicians, based in Philadelphia, PA.

In this segment, the panelists discuss recent updates to the CDC guidelines for prevention of the spread of HIV and other sexually transmitted diseases, with an emphasis on prevention of transmission in serodiscordant couples.

Ian Frank, MD, says there are several factors to consider when determining whether pre-exposure prophylaxis (PREP) is an acceptable strategy for a particular patient. “When you’re talking about the use of antiretroviral therapy to prevent HIV transmission, the first [factor to consider] is the infected individual: is the infected individual on therapy? Nowadays, the most important factor that determines the initiation of therapy is the concept of treatment as prevention. We want to get as many people with HIV infection linked to care, on therapy with an undetectable viral load. The data suggests that those individuals are very unlikely to transmit their infection to their unaffected partners,” says Frank.

Frank notes that in multiple clinical studies that tracked tens of thousands of episodes of unprotected sex among couples there have been no cases of transmissions from a person with HIV, who’s on treatment and has an undetectable viral load, to an unaffected partner.

When it comes to counseling HIV-positive patients and their partners about PREP, Alfred DeLuca, MD, says that if the HIV-infected person in the couple is on effective treatment and has an undetectable viral load, then the sero-negative partner might want to episodically take post-exposure prophylaxis, or even pre-exposure prophylaxis.

Franks notes that pre-exposure prophylaxis with the FDA-approved once-daily combination of tenofovir and emtricitabine “is most relevant for individuals who are not in monogamous relationships.” HE also says it is vitally important that patients understand they have to take this medication every day for maximum effectiveness.

Because PREP only works to prevent HIV and not other STDs, Paul Sax, MD, notes that condom use “has to be part of the discussion” with patients. “Everybody who does HIV care, not surprisingly sees quite a bit of other infections including syphilis and, interestingly, hepatitis C, as well as gonorrhea, Chlamydia, or herpes,” he says.