JAIDS Journal of Acquired Immune Deficiency Syndromes:
Epidemiology and Social Science
Effectiveness of Highly Active Antiretroviral Therapy in Reducing Heterosexual Transmission of HIV
Castilla, Jesús PhD*; del Romero, Jorge MD†; Hernando, Victoria MPH‡; Marincovich, Beatriz MD†; García, Soledad MD†; Rodríguez, Carmen PhD†
From the *Instituto de Salud Pública de Navarra, Pamplona, Spain; †Centro Sanitario Sandoval, Instituto Madrilen̄o de Salud, Madrid, Spain; and ‡Centro Nacional de Epidemiología, Instituto de Salud Carlos III, Madrid, Spain.
Received for publication November 15, 2004; accepted January 18, 2005.
Supported by a grant from FIPSE (foundation formed by the Spanish Ministry of Health and Consumer Affairs, Abbott Laboratories, Boehringer Ingelheim, Bristol Myers Squibb, GlaxoSmithKline, Merck Sharp and Dohme, and Roche; exp. 24324/02) and by the Spanish Networks for Research on AIDS (RIS) and Public Health (RCESP), which are funded by the Instituto de Salud Carlos III (C03/173 and G03/09).
Reprints: Jesús Castilla, Instituto de Salud Pública, Leyre 15, 31003 Pamplona, Navarre, Spain (e-mail: email@example.com).
Highly active antiretroviral therapy (HAART) has been shown to be highly effective in reducing plasma levels of HIV RNA; therefore, these treatments could diminish the risk of transmission. We analyzed 393 steady heterosexual couples, of which one partner had been previously diagnosed with HIV infection (index case) and where the nonindex partner reported his or her sexual relationship with the index case as the unique risk exposure. These couples were consecutively enrolled in the period 1991 through 2003 when the nonindex partners took their first HIV test. HIV prevalence among partners of index cases who had not received antiretroviral therapy was 8.6%, whereas no partner was infected in couples in which the index case had been treated with HAART (P = 0.0123). HIV prevalence among nonindex partners declined from 10.3% during the pre-HAART period (1991-1995) to 1.9% during the late HAART period (1999-2003; P = 0.0061). In the multivariate analysis, this decline held (odds ratio = 0.14, 95% confidence interval: 0.03-0.66) after adjusting for length of partnership, unprotected coitus, and pregnancies as well as gender, CD4+ lymphocyte count, AIDS-defining diseases, and sexually transmitted infections in the index case. When HAART became widely available, a reduction of approximately 80% in heterosexual transmission of HIV was observed, irrespective of changes in other factors that affect transmission.
HIV transmission risks in unprotected sexual relationships vary considerably according to different factors such as type of sexual practice,1 stage of HIV infection,2 presence of sexually transmitted infections,2,3 and plasma viral load in the HIV-infected partner.4-6 Highly active antiretroviral therapy (HAART) has been shown to be highly effective in reducing plasma levels of HIV RNA among infected persons7; therefore, these treatments could diminish the risk of HIV transmission.4 Reduction of infectiousness among individuals who receive antiretroviral therapy has been demonstrated in mother-to-child transmission8 but has not been fully established in sexual transmission, in spite of the important influence it could have on the course of the pandemic.9-12
In the absence of changes in other relevant factors, a reduction in the sexual transmission of HIV after the introduction of HAART would be indicative of the effectiveness of this treatment to prevent new infections. With this aim in mind, we studied first-time HIV testers whose sole risk exposure was having a steady heterosexual partner who was infected. We compared HIV prevalence among those who were recruited during the years before the introduction of HAART and those included during the period when HAART was being used.
PATIENTS AND METHODS
The study was conducted in a clinic in Madrid that launched a specific program for HIV-serodiscordant sexual couples in 1987. To each patient who was diagnosed with HIV infection, it was recommended that his or her sexual partner also visit the clinic for voluntary counseling and testing. With the informed consent of both partners, stable heterosexual couples attending this program were prospectively included in an observational study to analyze HIV sexual transmission risk, determinant factors, and needs related to prevention and reproduction aspects. Couples were recruited when the nonindex partner came to the clinic for his or her first HIV test in the period from January 1991 to December 2003. For the present analysis, 393 couples were selected with the following criteria: ongoing sexual relationship during the past 6 months, in which one of the partners (“index case”) had been diagnosed with HIV-1 with a well-identified probable route of infection and the nonindex partner had not had a previous diagnosis of HIV and where the sexual relationship with the index case was the sole known risk exposure.
Interviews and Laboratory Tests
Both members of each couple were interviewed separately during a medical visit by means of a structured questionnaire before the serologic HIV result for the nonindex partner was known. The information collected for index cases included sociodemographic characteristics, probable route of infection, date of HIV infection diagnosis, AIDS-defining diseases, last CD4+ lymphocyte count, and antiretroviral treatments. Plasma HIV RNA level (Branched-DNA; Bayer Diagnostics, France) was available since 1997. The information concerning nonindex partners contained sociodemographic data, date of the beginning of their relationship as a couple, and frequency of intercourse without a condom in the past 6 months. Women were also asked about pregnancies with their partner. For both members, the history of sexually transmitted diseases and presence of dysuria, genital discharge, ulcers, or warts were obtained through anamnesis and medical examination. Serologic study of syphilis was conducted using the reaginic test, and positive samples were confirmed by Treponema pallidum hemagglutination assay (TPHA) or the fluorescent treponemal antibody absorption test (FTA-ABS). For all participants, blood specimens were tested for HIV by an enzyme-linked immunosorbent assay, and reactive sera were confirmed by Western blot analysis.
The most complete of all antiretroviral therapies received by the index case since the beginning of the couple's relationship was considered in the analyses. For the whole of the period from 1991 through 2003, HIV prevalence among nonindex partners was compared according to index case's antiretroviral regimen (no treatment, mono- or bitherapy, 3 or more drugs).
In accordance with current international guidelines,13 HAART has been available free of charge in Spain to all patients since 1997. With this fact in mind, HIV prevalence among nonindex partners was compared for 3 calendar periods: pre-HAART (1991-1995); early HAART (1996-1998), the transition period; and late HAART (1999-2003), corresponding to the full implementation of this therapy.
A 2-sided χ2 test and the Fisher exact test were used to compare proportions. Differences in continuous variables were tested with the Wilcoxon test and Kruskal-Wallis test. The bivariate analysis was followed by a multivariate logistic regression used to identify the isolated effect of the calendar period, adjusting by confounder covariables. The association between variables was quantified by means of the prevalence odds ratio (OR) and its 95% confidence interval (CI).
Couples' Characteristics According to Enrollment Period
Table 1 shows characteristics of the 393 couples grouped according to the enrollment period. In all 3 periods, the man was the initially HIV-infected partner in most couples and most index cases were infected through risk practices related to injecting drug use, although in the late HAART period, the proportion of individuals infected by a sexual route rose to 35.8% (P = 0.0003). The mean length of the couple relationships was 2.7 years, and 8.7% of women were pregnant at the time of their first visit to the clinic, without any significant variation between periods.
The index case's CD4+ cell count at the time of inclusion in the study remained stable (P = 0.9072); nevertheless, the percentage of those diagnosed with an AIDS-defining disease rose from 9.8% to 19.8% (P = 0.0453), and the proportion of index cases with antiretroviral therapy increased from 6.5% to 49.1% (P < 0.0001). Whereas all patients who were treated during the first period underwent mono- or bitherapy, they all received combinations of 3 or more antiretroviral drugs in the last period.
Among index cases, the frequency of sexually transmitted infections decreased from 9.8% to 0.9% (P = 0.0063). None of the nonindex partners had received postexposure prophylaxis.
HIV Prevalence Among Nonindex Partners
For the nonindex partners, HIV prevalence declined from 10.3% in the pre-HAART period to 6.8% in the early HAART period and to 1.9% in the late HAART period (P = 0.0254). HIV prevalence among partners of index cases who had not received any antiretroviral therapy was 8.6%, whereas no partner was infected in couples in which the index case was being treated with HAART (P = 0.0123). Other variables associated with a higher HIV prevalence among nonindex partners were unprotected coital acts in past 6 months, CD4+ count less than 350 cells/μL in the index case, and pregnancy during that couple's relationship. Moreover, the presence or history of AIDS-defining diseases and high levels of HIV RNA for index cases were close to statistical significance, although this last information was only available for some couples. No association was found with gender, age, length of the relationship, time since HIV diagnosis in the index case, and presence of genital or sexually transmitted infections (Table 2).
The decrease in HIV prevalence among nonindex partners was especially pronounced when index cases had a CD4+ count less than 350 cells/μL and when they took antiretroviral drugs (Table 3). As a consequence, in the late HAART period, there was no difference in HIV prevalence between couples whose index case received HAART (0%) and those whose index case had received no treatment (3.7%; P = 0.4954).
Using logistic regression analysis, we evaluated changes in HIV prevalence between the 3 periods, which corresponded to different levels of HAART availability, adjusting them by possible confusion factors (Table 4). The results confirmed the pronounced decrease in HIV prevalence among nonindex partners recruited during the late HAART period when compared with the prevalence observed among those included during the pre-HAART period (OR = 0.14, 95% CI: 0.03-0.66; P = 0.0127). Other variables independently associated with higher HIV prevalence were CD4+ count less than 350 cells/μL, sexual intercourse without a condom in the previous 6 months, and pregnancy during that couple's relationship. In the multivariate analysis, the gender of the index cases, the length of the couples' relationships, antiretroviral therapy, and the presence or history of AIDS-defining diseases and sexually transmitted infections were not significantly associated with a higher HIV prevalence among nonindex partners. Interaction terms between calendar period and other covariables were not statistically significant.
These results demonstrate an important reduction in the heterosexual transmission of HIV and provide evidence showing that such a reduction can be attributed to HAART. On the one hand, none of the HIV-infected index cases who received HAART had transmitted HIV to his or her partner compared with 8.7% of the index cases who had not received this therapy. On the other hand, HIV prevalence among individuals with a stable heterosexual partner previously diagnosed with HIV infection is 5 times lower since HAART has been widely available than during the period before the introduction of HAART.
Comparison between calendar periods with different levels of HAART availability, once the influence of changes in other variables that affect HIV transmissibility has been excluded, enables us to evaluate the effectiveness of these therapies in reducing transmission when applied under uncontrolled conditions. Antiretroviral therapy is prescribed for patients with worse clinical, immunologic, or virologic states,13 who are thus more infectious toward their sexual partners.2-4 This could help to explain why the impact of HAART on HIV transmission has been important, although only half of the index cases underwent such therapy. With the introduction of HAART, the context in which antiretroviral therapy was prescribed was enlarged, and this could account for the fact that HIV prevalence among partners of index cases who did not receive antiretroviral drugs also decreased.
The inclusion criteria applied in our study allow us to state, with a rather high level of probability, that HIV infections detected among nonindex partners are attributable to heterosexual transmission by their index case partner. The information was collected before the nonindex partner's serologic status was known, which reduces possible biases.
The major limitation of our results is that they do not completely enable us to rule out the effect of factors other than antiretroviral therapy on the reduction of HIV prevalence among the nonindex partners. The proportion of couples who practiced unprotected coital acts decreased as well as the frequency of sexually transmitted infections, which would contribute to a lower transmission rate. In any case, the marked decrease in HIV prevalence of the nonindex partners in the HAART period was maintained after adjusting for all these changes.
Several arguments suggest that antiretroviral therapy can reduce sexual transmission of HIV. The viral load in genital secretions seems to decline, together with the viral load in plasma, after combination therapy.14,15 A prospective study established a link between zidovudine use and a decrease in the rate of HIV transmission from infected men to their partners,16 and another more recent study suggests that homosexual men have lower infectivity after the introduction of HAART.17
As shown by other studies, the fact of having practiced unprotected coitus2,3 and the low levels of CD4+ cell counts were 2 of the major explanatory variables of HIV transmission to the sexual partner. The low levels of CD4+ cell counts can be justified mainly because of the presence of high viral load values and/or a long duration of the infection,18 and both of these circumstances could have contributed to a higher likelihood of HIV transmission. We did not find any association between the presence of sexually transmitted infections and HIV transmission to the partner,2-4 although such an association has been described in various studies.1 Nevertheless, a genital discharge was not present in any of these infections, and only 1 subject had genital ulcers.
Although not a single case of HIV transmission was found when the index case had received HAART, the existence of some risk could not be totally excluded, because the persistence of HIV in genital secretions of patients with HAART has been described.19 Some increases in risky practices have been observed for various population groups and were attributed to a slackening in preventive measures because of HAART.20-23 Other studies have revealed no change24,25 or even a decrease of risky behavior frequency that coincides with HAART introduction, however.26 A rise in risky behavior could thus cancel out or even reverse the preventive effect on sexual transmission obtained though antiretroviral therapies. This is why it is important not to forget that the main preventive measure for HIV sexual transmission remains the avoidance of risky sexual practices.
In conclusion, after the introduction of HAART, an important decrease in HIV transmission has been observed in a thoroughly studied group of steady heterosexual couples, irrespective of any changes in other factors that affect transmission. These results strongly suggest that combined antiretroviral treatments applied according to current guidelines have a great potential for preventing HIV transmission to sexual partners. The accessibility to HAART for HIV-infected people around the world, as long as it is not accompanied by a relaxation of other prevention measures, could greatly contribute to controlling the spread of HIV among similar populations.
1. Royce RA, Seña A, Cates W, et al. Sexual transmission of HIV. N Engl J Med. 1997;336:1072-1078.
2. De Vincenzi I, for the European Group on Heterosexual Transmission of HIV. A longitudinal study of human immunodeficiency virus transmission by heterosexual partners. N Engl J Med. 1994;331:341-346.
3. Saracco A, Musicco M, Nicolosi A, et al. Man-to-woman sexual transmission of HIV: longitudinal study of 343 steady partners of infected men. J Acquir Immune Defic Syndr Hum Retrovirol. 1993;6:497-502.
4. Quinn TC, Wawer MJ, Sewankambo N, et al. Viral load and heterosexual transmission of human immunodeficiency virus type 1. N Engl J Med. 2000;342:921-929.
5. Pedraza MA, del Romero J, Roldan F, et al. Heterosexual transmission of HIV-1 is associated with high plasma viral load levels and a positive viral isolation in the infected partner. J Acquir Immune Defic Syndr. 1999;21:120-125.
6. Operskalski EA, Stram DO, Busch MP, et al. Role of viral load in heterosexual transmission of human immunodeficiency virus type 1 by blood transfusion recipients. Am J Epidemiol. 1997;146:655-661.
7. Hammer SM, Squires KE, Hughes MD, et al. A controlled trial of two nucleoside analogues plus indinavir in persons with human immunodeficiency virus infection and CD4 cell counts of 200 per cubic millimeter or less. N Engl J Med. 1997;337:725-733.
8. Connor EM, Sperling RS, Gelber R, et al. Reduction of maternal-infant transmission of human immunodeficiency virus type 1 with zidovudine treatment. N Engl J Med. 1994;331:1173-1180.
9. Hosseinipour M, Cohen MS, Vernazza PL, et al. Can antiretroviral therapy be used to prevent sexual transmission of human immunodeficiency virus type 1? Clin Infect Dis. 2002;34:1291-1295.
10. Gray RH, Wawer MJ, Brookmeyer R, et al. Probability of HIV-1 transmission per coital act in monogamous, heterosexual, HIV-1-discordant couples in Rakai, Uganda. Lancet. 2001;357:1149-1153.
11. Gray RH, Li X, Wawer MJ, et al. Stochastic simulation of the impact of antiretroviral therapy and HIV vaccines on HIV transmission; Rakai, Uganda. AIDS. 2003;17:1941-1951.
12. Xiridou M, Geskus R, de Wit J, et al. The contribution of steady and casual partnership to the incidence of HIV infection among homosexual men in Amsterdam. AIDS. 2003;17:1029-1038.
13. Carpenter CCJ, Fischl MA, Hammer SM, et al. Antiretroviral therapy for HIV infection in 1998. Updated recommendations of the International AIDS Society-USA panel. JAMA. 1998;280:78-86.
14. Gupta P, Mellors J, Kingsley L, et al. High viral load in semen of human immunodeficiency virus type 1-infected men at all stages of disease and its reduction by therapy with protease and non-nucleoside reverse transcriptase inhibitors. J Virol. 1997;71:6271-6275.
15. Hart CE, Lennox JL, Pratt-Palmore M, et al. Correlation of human immunodeficiency virus type 1 RNA levels in blood and the female genital tract. J Infect Dis. 1999;17:871-882.
16. Musicco M, Lazzarin A, Nocolosi A, et al. Antiretroviral treatment of men infected with human immunodeficiency virus type 1 reduces the incidence of heterosexual transmission. Arch Intern Med. 1994;154:1971-1976.
17. Porco TC, Martin JN, Page-Shafer KA, et al. Decline in HIV infectivity following the introduction of highly active antiretroviral therapy. AIDS. 2004;18:81-88.
18. Mellors JW, Muñoz A, Giorgi JV, et al. Plasma viral load and CD4+ lymphocytes as prognostic markers of HIV-1 infection. Ann Intern Med. 1997;126:946-954.
19. Sadiq ST, Taylor S, Kaye S, et al. The effects of antiretroviral therapy on HIV-1 RNA loads in seminal plasma in HIV-positive patients with and without ureteritis. AIDS. 2002;16:219-225.
20. Ostrow DE, Fox KJ, Chmiel JS, et al. Attitudes towards highly active antiretroviral therapy are associated with sexual risk taking among HIV-infected and uninfected homosexual men. AIDS. 2002;16:775-780.
21. Kartz MH, Schwarcz SK, Kellogg TA, et al. Impact of highly active antiretroviral treatment on HIV seroincidence among men who have sex with men: San Francisco. Am J Public Health. 2002;92:388-394.
22. Miller M, Meyer L, Boufassa F, et al. Sexual behavior changes and protease inhibitor therapy. SEROCO Study Group. AIDS. 2000;14 (Suppl):F33-F39.
23. Desquilbet L, Deveau C, Goujard C, et al. Increase in at-risk sexual behavior among HIV-1-infected patients followed in the French PRIMO cohort. AIDS. 2002;16:2329-2333.
24. Van der Straten A, Gomez CA, Saul J, et al. Sexual risk behaviors among heterosexual HIV serodiscordant couples in the era of post-exposure prevention and viral suppressive therapy. AIDS. 2000;14(Suppl):F47-F54.
25. Wolf K, Young J, Rickenbach M, et al. Prevalence of unsafe sexual behavior among HIV-infected individuals: the Swiss HIV Cohort Study. J Acquir Immune Defic Syndr. 2003;33:494-499.
26. Bouhnik AD, Moatti JP, Vlahov D, et al. Highly active antiretroviral treatment does not increase sexual risk behavior among French HIV infected injecting drug users. J Epidemiol Community Health. 2002;56:349-353.
This article has been cited 81 time(s).
The case for expanding access to highly active antiretroviral therapy to curb the growth of the HIV epidemic
Lancet Infectious Diseases
When to start HAART for the treatment of HIV infection
Lancet Infectious Diseases, 7(1):
West Indian Medical Journal
The 16th international AIDS conference, Toronto, 2006 working to increase the response to the growing global epidemic
West Indian Medical Journal, 56(1):
Human Reproduction UpdateContraception and HIV infection in womenHuman Reproduction Update
Netherlands Journal of Medicine
Assisted reproductive technologies to establish pregnancies in couples with an HIV-I-infected man
Netherlands Journal of Medicine, 67(8):
International Journal of AndrologyHIV infection of the male genital tract - consequences for sexual transmission and reproductionInternational Journal of Andrology
Antiviral ResearchSexual transmission of HIV-1Antiviral Research
AIDS Care-Psychological and Socio-Medical Aspects of AIDS/HivIntentions to seek and accept an HIV test among men of Mexican descent in the Midwestern USAAIDS Care-Psychological and Socio-Medical Aspects of AIDS/Hiv
Estimating sexual transmission of HIV from persons aware and unaware that they are infected with the virus in the USA
PharmacogenomicsRecent HIV-1 infection in a high-risk Ugandan cohort: implications for Phase IIB test-of-concept HIV vaccine trialsPharmacogenomics
LancetHIV prevention 2 - Biomedical interventions to prevent HIV infection: evidence, challenges, and way forwardLancet
Journal of Health Care for the Poor and Underserved
Increasing the Reach of HIV Testing to Young Latino MSM: Results of a Pilot Study Integrating Outreach and Services
Journal of Health Care for the Poor and Underserved, 20(3):
AIDS and BehaviorStrategies for Harm Reduction Among HIV-Affected Couples Who Want to ConceiveAIDS and Behavior
Current Hiv Research
HIV-1-discordant couples in sub-Saharan Africa: Explanations and implications for high rates of discordancy
Current Hiv Research, 5(4):
American Journal of Public HealthHighly active antiretroviral therapy use and HIV transmission risk behaviors among individuals who are HIV infected and were recently released from jailAmerican Journal of Public Health
EXPANDED ACCESS TO SEPs AND OTHER HARM REDUCTION MEASURES IN FRANCE
Revista Chilena De Infectologia
Clinical guide HIV/AIDS acquired immunodeficiency syndrome
Revista Chilena De Infectologia, 27(3):
International Journal of Std & AIDSCouples at risk for HIV infection in Southern India: characteristics of HIV-infected patients in concordant and discordant heterosexual relationshipsInternational Journal of Std & AIDS
Unsafe sex in regular partnerships among heterosexual persons living with HIV: evidence from a large representative sample of individuals attending outpatients services in France (ANRS-EN12-VESPA Study)
Reproductive advice in HIV discordant couples
Medicina Clinica, 129(4):
Human ReproductionIs natural conception a valid option for HIV-serodiscordant couples?Human Reproduction
Jama-Journal of the American Medical Association
The case against criminalization of HIV transmission
Jama-Journal of the American Medical Association, 300(5):
Jama-Journal of the American Medical Association
Universal Voluntary Testing and Treatment for Prevention of HIV Transmission
Jama-Journal of the American Medical Association, 301():
International Journal of Public HealthConceptualizing the integration of HIV treatment and prevention: findings from a process evaluation of a community-based, national capacity-building interventionInternational Journal of Public Health
Journal of Antimicrobial ChemotherapyReducing HIV-1 transmission through prevention strategies targeting HIV-1-seropositive individualsJournal of Antimicrobial Chemotherapy
Annals of EpidemiologyPlausible and implausible parameters for mathematical modeling of nominal heterosexual HIV transmissionAnnals of Epidemiology
M S-Medecine Sciences
HIV-positive women: sexual life and prevention
M S-Medecine Sciences, 24():
AIDSDeterminants of HIV-1 transmission in men who have sex with men: a combined clinical, epidemiological and phylogenetic approachAIDS
Safety and efficacy of sperm washing in HIV-1-serodiscordant couples where the male is infected: results from the European CREAThE network
Annals of Internal Medicine
Narrative review: Antiretroviral therapy to prevent the sexual transmission of HIV-1
Annals of Internal Medicine, 146(8):
AIDS Care-Psychological and Socio-Medical Aspects of AIDS/HivThe impact of HIV treatment on risk behaviour in developing countries: A systematic reviewAIDS Care-Psychological and Socio-Medical Aspects of AIDS/Hiv
Hiv MedicineBritish HIV Association, BASHH and FSRH guidelines for the management of the sexual and reproductive health of people living with HIV infection 2008Hiv Medicine
Plos OneThe Impact of Pre-Exposure Prophylaxis (PrEP) on HIV Epidemics in Africa and India: A Simulation StudyPlos One
Journal of Clinical MicrobiologyDetermining Seminal Plasma Human Immunodeficiency Virus Type 1 Load in the Context of Efficient Highly Active Antiretroviral TherapyJournal of Clinical Microbiology
Commentary on Uhlmann et al. (2010): Managing HIV in drug users - the huge gap remaining between evidence and international policy and practice
ThoraxHIV prevalence and testing practices among tuberculosis cases in London: a missed opportunity for HIV diagnosis?Thorax
Clinical Infectious DiseasesAddressing Research Priorities for Prevention of HIV Infection in the United StatesClinical Infectious Diseases
Reproductive Health MattersSexual health for people living with HIVReproductive Health Matters
Developing World Bioethics
Exploring disparities between global HIV/aids funding and recent tsunami relief efforts: An ethical analysis
Developing World Bioethics, 7(1):
Journal of Infectious DiseasesMaking universal access a reality - What more do we need to know?Journal of Infectious Diseases
British Medical JournalCombined antiretroviral treatment and heterosexual transmission of HIV-1: cross sectional and prospective cohort studyBritish Medical Journal
M S-Medecine Sciences
Clinic and transmission of HIV in women: literature review
M S-Medecine Sciences, 24():
Hiv MedicineBritish HIV Association and Children's HIV Association guidelines for the management of HIV infection in pregnant women 2008Hiv Medicine
AIDS Patient Care and StdsSafer sexual behaviors after 12 months of antiretroviral treatment in Mombasa, Kenya: A prospective cohortAIDS Patient Care and Stds
Plos OneExpanding HAART Treatment to All Currently Eligible Individuals under the 2008 IAS-USA Guidelines in British Columbia, CanadaPlos One
Reproductive options for HIV-serodiscordant couples
AIDS Reviews, 8(3):
AIDS Care-Psychological and Socio-Medical Aspects of AIDS/HivLate HIV diagnosis and delay in CD4 count measurement among HIV-infected patients in Southern ThailandAIDS Care-Psychological and Socio-Medical Aspects of AIDS/Hiv
Gynecologie Obstetrique & FertiliteAssisted reproductive care in serodiscordant couples whose man is infected with HIVGynecologie Obstetrique & Fertilite
Canadian Medical Association JournalThe use of highly active retroviral therapy to reduce HIV incidence at the population levelCanadian Medical Association Journal
HIV testing for whole populations
Jama-Journal of the American Medical Association
HIV prevention for a threatened continent - Implementing positive prevention in Africa
Jama-Journal of the American Medical Association, 296(7):
European Journal of PediatricsCharacteristics of HIV-infected children recently diagnosed in Paris, FranceEuropean Journal of Pediatrics
Journal of Infectious DiseasesExpanded access to highly active antiretroviral therapy: A potentially powerful strategy to curb the growth of the HIV epidemicJournal of Infectious Diseases
Declining prevalence of HIV-infected individuals at risk of transmitting drug-resistant HIV in Denmark during 1997-2004
Antiviral Therapy, 11(5):
Jaids-Journal of Acquired Immune Deficiency Syndromes
Late diagnosis of HIV infection: Epidemiological features, consequences and strategies to encourage earlier testing
Jaids-Journal of Acquired Immune Deficiency Syndromes, 46():
Jama-Journal of the American Medical Association
Antiretroviral treatment of adult HIV infection - 2008 recommendations of the International AIDS Society USA panel
Jama-Journal of the American Medical Association, 300(5):
Journal of Community HealthHIV Testing Practices and Attitudes on Prevention Efforts in Six Diverse Chicago CommunitiesJournal of Community Health
Bmc Medical GenomicsHost sequence motifs shared by HIV predict response to antiretroviral therapyBmc Medical Genomics
Medicina ClinicaHIV sexual transmission. Should we review the risk among individuals with long-term viral supression?Medicina Clinica
Clinical Infectious DiseasesTreatment to Prevent Transmission of HIV-1Clinical Infectious Diseases
Revista Da Associacao Medica Brasileira
Hiv vaginal viral load in Brazilian HIV-infected women
Revista Da Associacao Medica Brasileira, 54(1):
Relation between HIV viral load and infectiousness: a model-based analysis
Clinical Infectious DiseasesWhen to Start Antiretroviral Therapy?Clinical Infectious Diseases
LancetCan antiretroviral therapy eliminate HIV transmission?Lancet
Social Science & MedicineMajor reduction in AIDS-mortality inequalities after HAART: The importance of absolute differences in evaluating interventionsSocial Science & Medicine
Tropical Medicine & International HealthWhat is new in HIV/AIDS research in developing countries?Tropical Medicine & International Health
Biological, Psychosocial, Therapeutic and Quality of Life Inequalities between HIV-Positive Men and Women - A Review from a Gender Perspective
AIDS Reviews, 12(2):
Current Opinion in Infectious DiseasesPreexposure prophylaxis for HIV infection: it's not as easy as ABCCurrent Opinion in Infectious Diseases
Current Opinion in Infectious DiseasesLate diagnosis of HIV infection: major consequences and missed opportunitiesCurrent Opinion in Infectious Diseases
JAIDS Journal of Acquired Immune Deficiency SyndromesPotential Impact of Antiretroviral Therapy on HIV-1 Transmission and AIDS Mortality in Resource-Limited SettingsJAIDS Journal of Acquired Immune Deficiency Syndromes
JAIDS Journal of Acquired Immune Deficiency SyndromesMaraviroc Concentrates in the Cervicovaginal Fluid and Vaginal Tissue of HIV-Negative WomenJAIDS Journal of Acquired Immune Deficiency Syndromes
JAIDS Journal of Acquired Immune Deficiency SyndromesCost-Effectiveness of Alternative Strategies for Initiating and Monitoring Highly Active Antiretroviral Therapy in the Developing WorldJAIDS Journal of Acquired Immune Deficiency Syndromes
JAIDS Journal of Acquired Immune Deficiency SyndromesLate-Disease Stage at Presentation to an HIV Clinic in the Era of Free Antiretroviral Therapy in Sub-Saharan AfricaJAIDS Journal of Acquired Immune Deficiency Syndromes
JAIDS Journal of Acquired Immune Deficiency SyndromesNatural Pregnancies in HIV-Serodiscordant Couples Receiving Successful Antiretroviral TherapyJAIDS Journal of Acquired Immune Deficiency Syndromes
Sexually Transmitted DiseasesSexual Transmission of HIV-1 Among Serodiscordant Couples in Porto Alegre, Southern BrazilSexually Transmitted Diseases
HIV infection; HIV transmission; heterosexual transmission; antiretroviral therapy
© 2005 Lippincott Williams & Wilkins, Inc.
Highlight selected keywords in the article text.