Sexual Transmission under HAART The Statement

Sexual Transmission under HAART The Statement Pietro Vernazza President EKAF-Swiss Commissionon AIDS Related Issues The Swiss Commission on AIDS related issues (EKAF) Clinical Sciences Social Sciences Diagnostic Laboratory HIV/STD Prevention Legal Aspects FB Infektiologie / Spitalhygiene Physician‘s association Community members Political Sciences NGOs Diagnostic Expert group Clinical Expert group The development of the EKAF statement Why a statement • Criminal prosecution (CH > 30 cases!) • Couples willing to conceive a child • Discrepancy public/ private information – Problems of inconsistancy of information – Risk of uncontrolled diffusion FB Infektiologie / Spitalhygiene HIV-Transmission risk over time PHI Infectiousness (arbritrary scale) STDs Weeks Vernazza, AIDS 1999;13:155–166 (adapted) Months / Years FB Infektiologie / Spitalhygiene The development of the EKAF statement Evaluation by Expert Group (FKT) • High Risk Relevant for Public Health  Relevant fortheindividual • NegligibleRisk:  Similar to risks of daily life FB Infektiologie / Spitalhygiene • IntermediateRisk: Daily risk: Passive Smoking •Poll Newzealand 1996Mortality registry 1996-99 • 150‘000 men, Non-Smoker / 45-75-yo (80% below 65) •Excess mortality if smoker living in same household (≈ 14%) + 170/1051:600 per year FB Infektiologie / Spitalhygiene Hill et al, Am J Epid, 2006 Mountain climbing et al. 200‘000 alpinists in Swiss alps ~10 deaths in avalanches yearly 1:20‘000 FB Infektiologie / Spitalhygiene HIV transmission household Swiss recommendation1986 • Evaluation of risk – No documented individual case – Biological factors poorly known – Few retrospective studies Author Kaplan 1985 Jason 1986 Journal Contactstested PID JAMA 12 31 101 Friedland, 1986 NEJM Bieberfeld, 1986 ScandJID Friedland, 1990 AIDS 56 206 (38months) Total < 300 Contacts! BAG-Bulletin 1986 95% CI: 0 - 0.01 FB Infektiologie / Spitalhygiene HIV transmission household Swiss recommendation 1986 • Evaluation of risk – No documented individual case – Few retrospective studies – Biological factors poorly known • Recommendation 1986: – Household contacts: no risk – Exclusion sexual contacts BAG-Bulletin, 1986 FB Infektiologie / Spitalhygiene Friedland , AIDS 1990: casual Friedland, AIDS, 1990, July FB Infektiologie / Spitalhygiene Transmission risk by oral sex Swiss Recommendation 29.1.1996 • Evaluation of risk – No prospective studies available – > 40 documented individual cases – Biological factors supporting low risk • Recommendation: – Oral sex considered as „safer sex“ – Exclude ejaculation in mouth EKAF, BAG-Bulletin 3/96, 29.1.1996, p8-10 FB Infektiologie / Spitalhygiene Other risks of HIV-transmission • Receptive oral Sex (MSM): 0.0004 / act Vittinghoff, 1999, Am J. Epid 1:2‘500  0.9 / 100 py for always users Davis, 1999, Fam Plan Perspectives FB Infektiologie / Spitalhygiene • Condom-protected vaginal Sex: Transmissionriskunder ART Risk estimation • Published partner studies – N<500, no Trsm 95%-CI: < 1:160 • Extrapolation Chakraborty et al FB Infektiologie / Spitalhygiene – Risk extrapolation: < 1:100‘000 Transmission risk and seminal VL 1:100‘000 Chakraborty et al. AIDS 2001,15: 621-7 FB Infektiologie / Spitalhygiene Transmission risk under ART Risk estimation • Published partner studies – N<600, no Trsm 95%-CI: < 1:200 • Extrapolation Chakraborty et al • Absence of observed cases – What is the denominator? • SHCS*: 20% practice unsafe sex • Europe:>300’000 ART  30 x sex/year • Detection rate 1%  1:100‘000 *Panozzo et al, 2003, SMW FB Infektiologie / Spitalhygiene – Risk extrapolation: < 1:100‘000 Activity of ART for Prevention ART is comparable to condom use Sex w/o Condom Infection rate partners (%) >1/Mt. <1/Mt. Always with condom Partner under HAART None Mono- / BiTherapy Tripletherapy Castilla, et al. JAIDS 2005; 40:96-101 FB Infektiologie / Spitalhygiene Consider biology... • STDs: epidemiologic synergy – STDs increase genital viral load – STDs increase susceptibility to HIV FB Infektiologie / Spitalhygiene • Genital viral load may take some more time to get below <40 cp/ml •  Communication about safety under HAART should be targeted The EKAF statement What the statement described • It‘s ok. to talk about risk estimates • Under optimal conditions, risk is in the range of daily life („negligible“) FB Infektiologie / Spitalhygiene – Long term maximal suppression – Perfect adherence, regular checks – Absence of STDs • Informed partner to decide on condom use HIV transmission risks are dizzy Oral sex3 Ejac Sex under ART FB Infektiologie / Spitalhygiene STD Condom Use2 Vaginal sex1 Anal sex1 10-4 10-3 Risk per act 0.01 1999 10-6 1Royce 10-5 et al, NEJM, 1997 0.1 2Davis 1999 3Vittinghoff, The EKAF statement What the statement did not say • No advice against using condoms • No change in prevention messages FB Infektiologie / Spitalhygiene partly Swiss statement confirmed receptive penile-anal insertive penile-vaginal Wilson et al, The Lancet, 27.7.2008, p314-20 FB Infektiologie / Spitalhygiene Effect of treatment vs. Condom (based on math. Model by Wilson et al.) In serodiscordant male couple after 100 anal contacts Garnett & Gazzard, The Lancet, 27.7.2008, editorial comment FB Infektiologie / Spitalhygiene Risk of airline crashes 2006 Worldwide Russia/GUS Africa Central America Asia / Pacific… Northamerica Europe 0 0.67 0.49 0.32 5 Total losses per mio of starts NZZ 18.4.2007 (Quelle: IATA) 0.65  1:1.6 Mio 8.6 4.31 1.8 FB Infektiologie / Spitalhygiene 10