https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5111303/

Research on Genotypic HIV drug resistance mutations  is published in the Indian Journal of Sexually Transmitted diseases and AIDS.  This Journal is Pub Med .This is the research done by us Dr Raj Harjani and Dr Ram Malkani. This shows that there is a primary Genomic drug resistance to HIV where after starting Anti- Retroviral Therapy (ART) we can not achieve complete viral suppression which is expected after 6 months of ART.Hence it is advisable to have Genotypic drug resistance test done in the initial visit and subsequently when treatment fails .

Investigations Required before starting Anti-Retroviral Therapy (ART)

  1. HIV Serology
  2. Plasma Viral Load
  3. CD4 Absolute count and CD4%
  4. Genotypic Drug Resistance Test (NRTI, NNRTI, PI, INSTI)
  5. HLA B5701 for ABC drug (hypersensitivity test)
  6. HIV tropism for Maraviroc drug
  7. HBV
  8. HCV
  9. VDRL
  10.  TPHA
  11. Serum Cryptococcal Antigen Test (S.CRAG)
  12. Complete Blood Count (CBC)
  13. ESR
  14. Blood Sugar (Fasting & post prandial)
  15. HbA1c
  16. Liver Function Test (LFT)
  17. Renal Function Test (RFT)
  18. Lipid Profile
  19. Thyroid Function Test (TFT)
  20. Vit D3
  21. Vit B12
  22. CT Chest and Abdomen

 

Now AIDS is chronic manageable disease like Diabetes and Hypertension.

Now AIDS is chronic manageable disease like Diabetes and Hypertension. People living with HIV/AIDS are living healthier and thinking of marrying HIV positive or HIV Negative partner (after disclosing their HIV status). Anti-Retroviral Therapy (ART) is now not only used as treatment for HIV infected patients but it is also used as a Treatment for prevention (T4P). T 4 P is Post Exposure Prophylaxis (PEP) and Pre Exposure prophylaxis (PrEP).

nam – aidsmap sys : UNDETECTABLE VIRAL LOAD MEANS NO RISK OF HIV TRANSMISSION Read here …

NAM endorses Undetectable equals Untransmittable (U=U) consensus statement

NAM aidsmap, one of the foremost sources of HIV information in the world, strongly endorses the ‘Undetectable Equals Untransmittable’ (U=U) Consensus Statement issued by the Prevention Access Campaign.

NAM’s Executive Director, Matthew Hodson, says, “The scientific evidence is clear. Someone who has undetectable levels of virus in their blood does not pose an infection risk to their sexual partners.

“In terms of HIV prevention, if condom use is safer sex, then sex with someone who has maintained an undetectable viral load is even safer sex.

“This understanding transforms the way that HIV is considered with enormous implications for what it now means to live with HIV and the best ways to prevent it. The preventative impact of effective HIV treatment underlines the importance of expanding access to treatment and of improving treatment uptake and adherence for all people living with HIV worldwide.”

Transmission risk is a major concern for people living with HIV and their sexual partners. Since the results of the PARTNER study it has been clear that the risk of HIV transmission when treatment is effective is negligible. “The fear of catching HIV from a sexual partner fuels HIV stigma, which is why it’s so important that the ‘undetectable equals untransmittable’ message is heard and understood,” says Hodson. “Condoms are not required to prevent HIV transmission when viral load is maintained at undetectable levels, although they still play an important role in preventing other STIs.”

The U=U consensus statement reads:

People living with HIV on ART [antiretroviral therapy] with an undetectable viral load in their blood have a negligible risk of sexual transmission of HIV.  Depending on the drugs employed it may take as long as six months for the viral load to become undetectable. Continued and reliable HIV suppression requires selection of appropriate agents and excellent adherence to treatment. HIV viral suppression should be monitored to assure both personal health and public health benefits.[i]

Matthew Hodson continued, “Those of us with diagnosed HIV have had to live with the idea that our bodies are dangerous. This has had a profound emotional impact on many people. Many people who live with the virus face not just sexual but also social rejection as a result. In some countries having sex without disclosing HIV status is criminalised, regardless of whether there is a risk of transmission. Ignorance about transmission risk means that people are turned away from services, such as tattooists, or even denied medical treatment. No other sexually transmitted infection carries the same power to strike fear into the hearts of the population.

“People with HIV are everywhere. We are all nationalities, all races and religions, young and old, gay, bisexual and straight. When we are undetectable we are uninfectious. This means that pretty much all the fear that HIV-negative people have of those of us living with HIV is just wasted energy.”

NAM’s mission is to support people living with HIV to live longer, healthier lives. Through providing information NAM enables people to take control of their lives and health care, understand and adhere to their HIV treatment and live longer, healthier and better quality lives.

NAM was among the first to provide accessible and accurate information about the research on the impact of treatment on transmission risk, including reports on the HPTN 052 trial and the PARTNER Study in 2011 and 2014 respectively. These stories have been some of the most popular reports on the aidsmap website. The knowledge of the impact of successful treatment on transmission risk is a powerful tool to support people living with HIV and a challenge to the stigma that people with HIV often face.

[i] An undetectable HIV viral load only prevents HIV transmission to sexual partners. Condoms also help prevent HIV transmission as well as other STIs and pregnancy. The choice of HIV prevention method may be different depending upon a person’s sexual practices, circumstances and relationships. For instance, if someone is having sex with multiple partners or in a non-monogamous relationship, they might consider using condoms to prevent other STIs.

NAM endorses Undetectable equals Untransmittable (U=U) consensus statement

Back

Sero discordant HIV infected couples …discussion for Pre Exposure Prophylaxis (PrEP)for an uninfected partner, Anti Retroviral Therapy (ART) for infected partner or both

PrEP, ART, or Both? How I Advised a Serodiscordant Couple

John and Sally (not their real names) were married 2 years ago and were recently referred to me when John found out that he was HIV positive. He had a plasma HIV-1 RNA of 91,000 copies/mL and CD4+ cell count of 631 cells/mm3. John has been asymptomatic and Sally has been repeatedly HIV antibody negative. To their knowledge, there have been no high-risk exposures during the past 6 months, although they admit that condom use has not been 100%.

They were referred to me to address their seemingly simple questions regarding Sally’s risks of acquiring HIV from John, how they can minimize the risks, and whether they will ever be able to safely have a child together.

Starting Antiretroviral Therapy
I always start with the easy question, so I suggested latex condoms for all sexual episodes and reminded Sally to avoid contact with John’s blood. I further discussed with them the data from HPTN 052, explaining that among the serodiscordant couples in this trial, treating the infected partner with antiretrovirals in conjunction with standard safe sex practices resulted in a 96% reduction in risk of their partner becoming infected with HIV.[1] These data, along with the benefits of antiretroviral therapy for John, made it by far my preferred option among any treatment choices.

Role of PrEP
However, to provide the complete picture, I thought it important to also describe the recent US Food and Drug Administration approval and interim Centers for Disease Control and Prevention guidelines for use of tenofovir/emtricitabine for pre-exposure prophylaxis (PrEP).[2] After considering this information, they wondered whether it might be a better option to have Sally take PrEP rather than rushing John into treatment, or to have Sally take PrEP along with John taking antiretroviral therapy.

I responded that treating John is good for both of them. In addition, I explained that treating Sally with PrEP alone will reduce her acquisition risk but probably to a lesser extent than will treating John (there was a relative reduction of 75% in the overall population in the incidence of HIV infection with tenofovir/emtricitabine in the Partners PrEP trial; 66% in women).[3] In addition, PrEP will not address John’s health risks from untreated HIV and puts Sally at real risk for short-term and long-term toxicity (that could include gastrointestinal effects and fatigue[3-5] and decline in bone mineral density.[5]) Finally, I shared with them that we simply have no data to inform us how much additional protection Sally will derive from receiving PrEP if John’s viral load is suppressed on an antiretroviral regimen. In summary, I told them that my personal view is that as long as John’s viral load is well controlled on treatment, I am not convinced that the theoretical benefits of adding continuous PrEP outweigh the potential risks.

Strategies for Conception
John and Sally were also very focused on whether they would be able to have children. We discussed using donor sperm, and that was not an acceptable option for them. I also explained the concept of sperm washing with or without intracytoplasmic sperm injection, but financially these procedures were out of their reach. Finally we talked about alternative strategies that—although not as carefully studied—would likely be associated with low risk of transmission, recognizing that there may be some small but residual risk. We discussed the strategy of Sally taking PrEP and selectively discontinuing condom use during specific periods when they were trying to conceive. I explained that the risk of HIV transmission would be small if John’s viral load were suppressed on antiretroviral therapy[6] before they attempted pregnancy and perhaps further reduced if Sally were also receiving PrEP. In this scenario, the combination prevention strategy of PrEP and antiretroviral therapy might provide additional protection for Sally while limiting her exposure to PrEP to the weeks or months that they are trying to conceive. So that they could think about this at greater length and further discuss the possibilities, I reprinted the discussion on this topic that has been recently added to the Department of Health and Human Services Perinatal Guidelines.[7]

Your Thoughts?
Although I wish I had all of the answers for couples such as John and Sally, I do feel that I have a lot more data to share today than I did even 6 months ago. How would you have advised them? Do you see a role for the combination of antiretroviral therapy and PrEP in serodiscordant couples? Please share your perspectives by leaving a comment below.

Eric S. Daar, MD, is Chief, Division of HIV Medicine at Harbor-UCLA Medical Center, and Professor of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California.

Dr. Daar has disclosed that he has received funds for research support from Abbott, Gilead Sciences, Merck, Pfizer, and ViiV and consulting fees from Bristol-Myers Squibb, Gilead Sciences, Merck, and ViiV.

References

1. Cohen MS, Chen YQ, McCauley M, et al. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med. 2011;365:493-505.

2. Centers for Disease Control and Prevention. Interim guidance for clinicians considering the use of preexposure prophylaxis for the prevention of HIV infection in heterosexually active adults. MMWR Morb Mortal Wkly Rep. 2012;61:586-589

3. Baeten JM, Donnell D, Ndase P, et al. Antiretroviral prophylaxis for HIV prevention in heterosexual men and women. N Engl J Med. 2012;367:399-410.

4. Grant RM, Lama JR, Anderson PL, et al. Preexposure chemoprophylaxis for HIV prevention. N Engl J Med. 2011;364:1373.

5. Thigpen MC, Kebaabetswe PM, Paxton LA, et al. Antiretroviral preexposure prophylaxis for heterosexual HIV transmission in Botswana. N Engl J Med. 2012;367:423-434.

6. Quinn TC, Wawer JW, Sewankambo N, et al. Viral load and heterosexual transmission of human immunodeficiency virus type 1. N Engl J Med. 2000;342:921-929.

7. Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission. Recommendations for use of antiretroviral drugs in pregnant HIV-1- infected women for maternal health and interventions to reduce perinatal HIV transmission in the United States. Available at: http://aidsinfo.nih.gov/contentfiles/lvguidelines/PerinatalGL.pdf. Accessed September 24, 2012.

 

I take 6 months approximately to treat male HIV-positive man with ART. And once he is investigated and treated for other sexually transmitted diseases, I prescribe TDF + FTC combination pill before and after Intra Uterine Insemination (IUI) to uninfected partner. Results are promising after 3 IUI.
Dr Raj Harjani Mumbai INDIA – 2/3/2013 
Responses (1)

 

Cool. Did we get the confimation levels of viral loads before IUI?
Dr Adegboye, NIGERIA – 2/17/2013 
Responses (1)

 

We confirm with plasma viral load. once undetectable for at least 2 months, then we consider person fit for sperm wash. Generally all male serodiscordant couples achieve undetectable levels by 4 months.
Dr Raj Harjani Mumbai INDIA – 2/25/2013

 

In my practice, I have several times come across discordant couples. But the difference with John and Sally’s case is that over 90% of my cases have been HIV advanced with children and irregularly practicing protected sex. We are living in a gender inequality culture where sex practice is male initiative, while woman, regardless her HIV status has no power to oppose her partners choice in term of safer sex practice. In our experience, women are more adherent to treatment than men. At our ARTClinic, discordant couples coming together for review can be estimated as less than 5%, among them those preoccupied about having safely children. We attempt to encourage them to report for routine review visits at ART clinic as a couple for proper IEC (information, education and communication) more especially for discordant couples. The concept of PrEP for uninfected HIV partner is not yet in practice in our ART clinic. We need to start now this important program targeting the concerned couples.
muhemedi – 1/17/2013 

 

I love Joels categorization of the 3 approaches and will quote it widely.
David A. Wohl, MD – 11/11/2012 

 

This question just came up with a male patient of mine who is suppressed and wants to have a child with his HIV-negative wife. They have been scrupulous about using condoms. I described 3 approaches, which I called “safe,” “extremely safe,” and “ridiculously safe.” The “safe” approach is to have unprotected intercourse during times of maximum fertility (determined by home ovulation monitoring), based on the fact that suppressive ART was 96% effective in HPTN 052 (and having an undetectable viral load was 100% effective, something that is less often mentioned). The “extremely safe” approach is to add courses of PrEP for his wife during times of attempted conception. The “ridiculously safe” approach is to use sperm washing. My patient and his wife are inclined to take the middle approach, which seems like a good choice to me. Some have also suggested conceiving by home artificial insemination with a syringe rather than actual intercourse to reduce vaginal trauma, though this seems unnecessary if you’re combining ART and PrEP.
Joel E. Gallant, MD, MPH – 10/29/2012 

 

This is an interesting clinical scenario encountered frequently, and providing concrete answers through data support and clinical trials will definitely help couples to make decisions, and help consulting and treating physicians to provide more precise data for that purpose.
Doctor “T” – 10/24/2012 
Responses (1)

 

I agree with Dr T. One question is whether the belt and suspenders approach of ART for him and PrEP for her would offer anything more than ART for John alone? The calculus gets more complex when adding in potential toxicity of tenofovir in Sally (reduced BMD, for instance) and financial cost of PrEP. Short term use during attempts at conception may be more feasible. For the couples I have seen (most often an HIV+ patient of mine and his uninfected partner), the major issue has been access as these folks have no insurance.
David A. Wohl, MD – 10/28/2012 

 

Leave a comment

Comment:

Comments are allowed only from healthcare professionals who are registered members of Clinical Care Options. Comments are subject to approval by the ClinicalThought moderator. CCO reserves the right to not publish submitted comments.
Poll
Which of the following best summarizes your personal experience prescribing oral tenofovir/emtricitabine for PrEP?
Poll Results