Examining the studies in relation to their year of publication shows that the magnitude of correlations did not show a consistent pattern of change over time. The 8 studies conducted before 2000, midway between the first and last studies reviewed, had a mean correlation of 0.52, whereas the 9 studies conducted 2000 and later had a mean correlation of 0.41. It is noteworthy that the outlying study that found the highest degree of concordance between BPVL and SVL had the most stringently selected sample of men in terms of treatment status and not having STIs,21 whereas the study with the lowest correlation only required being HIV-positive as the sole selection criterion.23
Studies have consistently found that HIV is less concentrated in semen than in blood plasma. However, there is considerable variability in the relative concentrations of HIV in the 2 components both between and within studies. In most cases, men whose viral load was undetectable in their semen had corresponding undetectable viral loads in their blood plasma. Studies, however, identify men with SVL that is equal to or greater than their BPVL,11,28 and studies also indicate detectable SVL among men whose BPVL was below levels of detection, with the difference often exceeding 1 log. For example, Vernazza et al.29 compared the viral loads of 28 men who had detectable BPVL and SVL and found that only 12 of the men had RNA levels in blood plasma and semen within 1 log of each other. The investigators found that 9 men demonstrated SVL 10-fold lower than their BPVL, whereas 7 men had SVL 10-fold higher than their BPVL. Also noteworthy is research conducted in Malawi, which found a consistent pattern of higher SVL among Malawian men compared with a US/Swiss sample,30–32 a difference that may be attributable to co-occurring STI.
Our review identified 4 major factors that potentially influence the relationship between BPVL and SVL: co-occurring STI, ARV treatments and adherence, HIV treatment resistance, and stage of HIV disease.
There is overwhelming evidence that co-occurring STI increase viral shedding in the genital tract and that STI significantly alter the correspondence between BPVL and SVL.33 For example, Cohen et al.30 reported that HIV shedding in semen is 8 times greater in Malawian men with urethritis when compared with men matched on CD4 cell counts and BPVL; men who had urethritis had a median SVL of 12.4 log compared with 1.5 log in the matched control group. In a case-control study, Sadiq et al.27 found a 5-fold increase in SVL among men with gonorrhea and chlamydia compared with men who were not diagnosed with an STI. It appears that asymptomatic urethritis similarly influences viral shedding. Winter et al.16 found that asymptomatic urethritis was strongly associated with increases in SVL. The increased number of HIV-infected cells in semen that accompanies genital tract inflammation is also a potential factor in sexual transmission of HIV.34 Elevated HIV shedding and increases in infected cells in semen of men who have asymptomatic urethritis is of particular concern because it is these men who are unlikely treated for urethritis and are most likely engaging in unprotected sex. Greater numbers of sex partners and higher rates of sexual intercourse may be associated with more persistent genital shedding of HIV even in the absence of STI.23 Because STI increases genital HIV shedding but not HIV shedding in blood plasma, the correlation between BPVL and SVL is suppressed by STI. In fact, studies with the lowest correlations between BPVL and SVL are those that are most likely to have included men with co-occurring STI.
ARV therapies suppress HIV replication in the genital tract to similar degrees as observed in peripheral blood.35 Although most studies have reported cross-sectional findings, Neto et al.9 reported serial correlations between BPVL and SVL taken over the course of initiating ARV therapy. In this study, the strength of the association between BPVL and SVL increased over the time men were receiving treatments. ARV therapies can markedly reduce HIV concentrations in blood plasma and semen,13 supporting the hypothesis that suppressive ARV therapies reduce the risk for HIV transmission.36 Most studies investigating the effects of ARVs on SVL show suppression of HIV replication in the genital compartment.37 HIV treatment regimens do not equally penetrate the blood plasma and genital tract compartments.22,37 Therefore, various ARV regimens differentially influence the correlation between BPVL and SVL. For example, in a study of men who had been treated with a combination ARV regimen for at least 6 months, penetration of protease inhibitors in the genital tract was variable.38 Chakraborty et al.39 showed that BPVL and SVL are not correlated when men are not treated for HIV regardless of their CD4 count and that, in contrast, the correlation between BPVL and SVL is strongest (approximately 0.40) when men are treated with ARVs and their CD4 cell counts are low (<200). Under optimal conditions, when men are treated with a highly suppressive ARV regimen, are adherent to taking their medications, and do not have co-occurring STI, one study estimates with 95% certainty that <4% of men who have an undetectable BPVL will have detectable SVL.21 Unfortunately, these optimal conditions are rarely met outside of research settings.
Failure for ARVs to achieve undetectable SVL is attributable to several factors, including drug potencies, absorption, and drug penetration.22 Nonadherence to ARV regimens is another important source of suboptimal viral suppression. Discontinuation of ARVs results in viral rebound in SVL similar to that seen in BPVL.40 In studies of treatment-naive men who initiated ARVs, significant numbers of men still have detectable SVL after months of treatment.19,41,42 This study showed that the single best predictor of persistent genital shedding of HIV was nonadherence to ARVs. Barroso and Schechter41 found a dose-response association between ARV adherence and SVL, where men who missed the fewest doses of their medications had the greatest degree of viral suppression in their semen over time.
Men who receive combination ARV regimens have demonstrated drug-resistant mutations in the genital tract.4,42–44 The varieties of HIV mutations observed in blood plasma and semen often differ in the 2 compartments, including among treatment-naive men.45 Multiple variants of HIV occur within an individual’s blood and semen. Even within the blood and semen compartments there are heterogeneous cell-free and cell-associated variants of HIV.46 In addition, multiple drug-resistant HIV can occur in semen without a blood plasma complement.47 Thus, differential treatment resistance in the blood and genital compartments, similar to differential drug penetration, suppresses the association between BPVL and SVL. There is considerable alarm about the potential spread of multiple drug-resistant HIV from men with resistant HIV in their semen who contract a co-occurring STI.43 Although suppressive ARV therapy can reduce viral shedding in men who have urethritis, when HIV is poorly controlled, the risk for transmitting treatment-resistant variants is particularly high.48
HIV shedding in the genital compartment occurs over the entire course of HIV disease.37 Studies that correlate SVL with CD4 cell counts show a wide range of associations. For example, Ball et al.17 found a close association between CD4 counts, the most common marker of HIV disease progression and HIV proviral DNA in both blood and semen, whereas Winter et al.16 found no association between CD4 counts and SVL. In addition, studies that report HIV symptoms as well as other markers of HIV disease progression do not find stages of HIV infection to influence the association between BPVL and SVL. For example, Vernazza et al.12 found that the association between SVL and HIV symptoms was not significant. Other studies have reported that HIV concentrations in semen are independent of HIV disease stage.49 In addition, one study compared serial samples from 5 untreated men and found very stable levels of SVL over 8 weeks,50 suggesting that SVL is relatively stable at least over a short period of time.
HIV concentrations in blood plasma and semen are correlated, with the magnitude of the associations ranging from 0.07 to over 0.60. The strength of the association between BPVL and SVL is influenced by multiple factors; co-occurring STI/urethritis weakens the association whereas ARV treatments strengthen the association. In contrast, there is limited evidence that the association between BPVL and SVL is influenced by HIV disease stage. Thus, for ARV treatments to significantly impact seminal infectivity, men must be free of co-occurring STI/urethritis and remain adherent to an HIV-suppressive treatment regimen that optimally penetrates the genital tract and to which they are not resistant in their genital compartment.
Our review was limited to studies of HIV in blood plasma and semen. However, research has investigated the correlation between HIV in female genital secretions and blood plasma with very similar results. For example, Hart et al.51 reported that BPVL correlated 0.64 with HIV RNA in vaginal secretions. The degree to which factors that influence HIV in the female genital compartment parallel the male genital tract, as well as factors that are unique to women (e.g., the menstrual cycle, changes in vaginal environment, etc.) should be the subject of review. Our literature review consisted of research from North and South America, Western Europe, and one study from Africa. Further research is therefore needed to investigate the association between BPVL and SVL in countries where HIV prevalence is greatest and ARV treatments are just becoming available.
An implication of the association between BPVL and SVL is how individual viral load test results are communicated to patients. Research shows that both HIV-infected and uninfected men who believe that having an undetectable viral load reduces the risks for HIV transmission are more likely to engage in higher-risk sexual behaviors.6 The disinhibiting effects of having an undetectable viral load on sexual risk behavior will likely offset any potential protective benefits of reductions in semen infectivity. However, semen that has an undetectable viral load remains infectious12 and knowing one’s BPVL at best only accounts for one third of the variance (the squared correlation) in knowing one’s SVL.
Individuals who engage in unprotected sex are often less adherent to their medications than those who practice safer sex,23,52,53 and they are therefore more likely to contract STI. In addition, treatment nonadherence has been associated with increased viral shedding in semen.23,41 Men who engage in unprotected sexual intercourse are also likely to use their viral load status in their sexual decision making, where having an undetectable viral load relaxes concerns about transmitting HIV.7 Therefore, those who are at greatest risk for transmitting HIV may believe that they are actually at less risk based on false assumptions of their SVL in relation to their BPVL. Also of concern is the role of cell-associated virus in HIV transmission. Seminal cells that harbor HIV proviral DNA can serve as vehicles for sexual transmission of HIV,54 particularly HIV-infected lymphocytes and macrophages.55 SVLs can be greater than BPVL,18 and men who have undetectable SVL must be considered at least somewhat infectious because the minimum quantity of HIV required for sexual transmission of the virus is unknown12 and because cell-associated virus may play a role in HIV transmission. HIV prevention messages targeted to both infected and uninfected persons should communicate the importance of condoms and other risk reduction strategies regardless of HIV treatment status and throughout all stages of HIV disease. Perhaps most critically, HIV prevention for people living with HIV/acquired immunodeficiency syndrome must include regular monitoring and aggressive treatment of co-occurring STI.
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