Letter to the Editor
To the Editors
HIV transmission is rare at viral loads (VL) up to several thousand copies.1 However, persons with low VL are at risk for sexually transmitted disease (STD) if they engage in unprotected sex, which may be related to beliefs about lower HIV infectiousness.2 Among persons with HIV, coinfection with another STD is common3 but has not been studied in a population-based group that is generally assumed unlikely to transmit HIV.4 We investigated STD prevalence among persons with different HIV VL levels, focusing on the subpopulation with low VL, by matching HIV and STD registry data.
The New York City (NYC) HIV/AIDS surveillance registry contains data on New Yorkers diagnosed as having AIDS since 1981 and HIV infection or disease since 2000. Since 2005, it has received HIV-related laboratory results on persons living with HIV/AIDS (PLWHA) in NYC. The NYC STD surveillance registry contains data on New Yorkers diagnosed and reported to have any of 7 notifiable STD. A cross-registry match included 138,235 PLWHA as of March 30, 2011, excluding persons who died before January 1, 2000, and STD cases diagnosed January 1, 2000 to June 30, 2010. Viral load test dates and results were obtained from the HIV registry as of June 30, 2011. Among 69,418 PLWHA in 2009 who had 1 or more VL tests in 2009 and survived 31 days or longer after VL measurement (62.8% of all 2009 PLWHA), we calculated the proportion of those with a diagnosis of early syphilis, gonorrhea, chlamydia, or lymphogranuloma venereum within 31 days before or after the last VL in 2009 and characterized demographic and clinical characteristics and coinfection rates of PLWHA whose last VL was low (defined as 0–3499 copies/mL).1
Last VL was 0 to 3499 for 55,558 persons, 80.0% of PLWHA in the analysis, among whom last VL was less than 1000 copies/mL for 92.9% and less than 400 copies/mL for 87.3%. Of the 55,558, 478 (0.9%) had an STD diagnosis within 31 days of their low VL, with the highest prevalence among persons aged 20 to 29 years (3.1%) and 30 to 39 years (1.9%) and men who have sex with men (MSM; 1.8%) (Table 1). Early syphilis (43.1%) and chlamydia (36.3%) were the most frequent STD among PLWHA with low VL, followed by gonorrhea (19.7%) and lymphogranuloma venereum (0.8%). Most persons with STD and low VL were male (91.4%) and, specifically, MSM (73.8%). Sexually transmitted disease prevalence was higher among PLWHA with higher last VL (1.9% among 3500–9999; 2.0% among 10,000–99,999; and 2.2% among ≥100,000 [P trend <0.0001]).
Overall, bacterial STD was rare (<1%) among PLWHA who, on the basis of their low VL, are assumed unlikely to transmit HIV. Still, these STD prevalence data suggest ongoing risk behavior (unprotected sex) among some persons with low VL and reinforce the value of STD screening and risk reduction services, even for persons with low HIV VL. Subgroups such as young adults and MSM had a higher STD prevalence that would be even higher if the highly prevalent genital herpes simplex virus were reportable also. Previous studies have found disproportionate STD rates among MSM PLWHA locally5,6 and nationally,7 and a recent mathematical model suggested that increased unprotected sex among MSM has diminished the population-level benefits of antiretroviral treatment for HIV prevention.8 Our findings reinforce the value of STD screening and risk reduction counseling among persons with low HIV VL.
Ellen W. Wiewel, MHS
Sarah L. Braunstein, PhD, MPH
Preeti Pathela, DrPH, MPH
Qiang Xia, MD, MPH
Lucia V. Torian, PhD
New York City Department of Health
and Mental Hygiene
New York, NY
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2. Kalichman SC, Cherry C, Amaral CM, et al. Adherence to antiretroviral therapy and HIV transmission risks: Implications for test-and-treat approaches to HIV prevention. AIDS Patient Care STDS 2010; 24: 271–277.
3. Wasserheit JN. Epidemiological synergy. Interrelationships between human immunodeficiency virus infection and other sexually transmitted diseases. Sex Transm Dis 1992; 19: 61–77.
4. Kalichman SC, Eaton L, Cherry C. Sexually transmitted infections and infectiousness beliefs among people living with HIV/AIDS: Implications for HIV treatment as prevention. HIV Med 2010; 11: 502–509.
5. Manning SE, Pfeiffer MR, Nash D, et al. Incident sexually transmitted infections among persons living with diagnosed HIV/AIDS in New York City, 2001–2002: A population-based assessment. Sex Transm Dis 2007; 34: 1008–1015 1010.1097/OLQ.1000b1013e3180eaa1243.
6. Pathela P, Braunstein SL, Schillinger JA, et al. Men who have sex with men have a 140-fold higher risk for newly diagnosed HIV and syphilis compared with heterosexual men in New York City. J Acquir Immune Defic Syndr 2011; 58: 408–416.
7. Heffelfinger JD, Swint EB, Berman SM, et al. Trends in primary and secondary syphilis among men who have sex with men in the United States. Am J Public Health 2007; 97: 1076–1083.
8. Phillips AN, Cambiano V, Nakagawa F, et al. Increased HIV incidence in men who have sex with men despite high levels of ART-induced viral suppression: analysis of an extensively documented epidemic. PLoS One 2013; 8: e55312.