van Sighem A, Zhang S, Reiss P, Gras L, van der Ende M, Kroon F, Prins J, de Wolf F; on Behalf of the ATHENA National Observational Cohort Study. Immunologic, Virologic, and Clinical Consequences of Episodes of Transient Viraemia During Suppressive Combination Antiretroviral Therapy. J Acquir Immune Defic Syndr. 2008 May 1;48(1):104-8.
van Sighem and colleagues aimed to investigate immunologic, virologic, and clinical consequences of episodes of transient viraemia in patients with sustained virologic suppression. From the AIDS Therapy Evaluation Project, Netherlands cohort, 4447 previously therapy-naive patients were selected who were on continuous combination antiretroviral therapy and had initial success (2 consecutive HIV RNA measurements <50 copies/mL). During episodes of viral suppression (RNA <50 copies/mL), low-level viraemia (RNA 50 to 1000 copies/mL), or high-level viraemia (RNA >1000 copies/mL) after initial success, the occurrence of therapy changes, drug resistance, and clinical events was assessed. During 11,187 person-years of follow-up, 1281 (28.8%) patients had at least 1 RNA measurement >50 copies/mL. Among 8069 episodes, there were 5989 (74.2%) episodes of suppression, 1711 (21.2%) episodes of low-level viraemia, and 369 (4.6%) episodes of high-level viraemia. Most episodes of low-level viraemia consisted of </=2 RNA measurements (93.7%), were without clinical events or therapy changes (79.6%), and were without changes in CD4 cell counts. Therapy changes (52.3% of episodes) and resistance (23.3%) were frequently observed during high-level viraemia. In conclusion, episodes of low-level viraemia are frequent and short-lasting, and the low proportion of episodes with clinical events suggests that leaving therapy unchanged is a clinically acceptable strategy. In contrast, high-level viraemia is associated with resistance and is often followed by therapy changes.
Editors´note: Although the focus here is on whether viraemia should be an indication for a change in therapy, viraemia in previously naive patients on treatment has potential relevance for transmission risk. A high proportion of patients were viraemic during winter when influenza and the common cold are more prevalent, suggesting that antigenic stimulation due to other infections may play a role. Thus, although effective antiretroviral treatment reduces viral load, blips can still occur – 28.8% of continuously treated patients in this large-cohort experienced at least one transient episode of viraemia.
Kwara A, Delong A, Rezk N, Hogan J, Burtwell H, Chapman S, Moreira CC, Kurpewski J, Ingersoll J, Caliendo AM, Kashuba A, Cu-Uvin S. Antiretroviral drug concentrations and HIV RNA in the genital tract of HIV-infected women receiving long-term highly active antiretroviral therapy. Clin Infect Dis. 2008;46(5):719-25.
Kwara and colleagues aimed to determine antiretroviral drug concentrations and human immunodeficiency virus (HIV) RNA rebound in cervicovaginal fluid in relation to blood plasma in women receiving suppressive highly active antiretroviral therapy. Thirty-four HIV-infected women who had plasma HIV RNA levels < or =80 copies/mL for at least 6 months were enrolled. Sixty-eight paired cervicovaginal fluid and blood plasma drug concentrations and HIV RNA levels were determined before and 3-4 h after drug administration. For each woman and antiretroviral drug, the cervicovaginal fluid:blood plasma drug concentration ratios before and after drug administration were calculated. The nonparametric Wilcoxon rank sum test was used to determine if these ratios were different from 1.0. Lamivudine (administered to 20 patients) and tenofovir (administered to 16) had significantly higher concentrations in cervicovaginal fluid than in blood plasma before drug administration, with mean cervicovaginal fluid:blood plasma concentration ratios of 3.19 (95% confidence interval, 1.2-8.5) and 5.2 (95% confidence interval, 1.2-22.6), respectively. Efavirenz (administered to 13 patients) and lopinavir (administered to 6) had significantly lower concentrations in cervicovaginal fluid, with mean cervicovaginal fluid:blood plasma concentration ratios of 0.01 (95% confidence interval, 0.00-0.03) and 0.03 (0.01-0.11), respectively. During the study visit (median time after enrolment, 6 months), blood plasma and cervicovaginal fluid detectable HIV RNA levels were observed 7 patients (20.6%) and 1 patient (2.9%), respectively. Despite lower cervicovaginal fluid concentrations of key antiretroviral therapy components, such as efavirenz and lopinavir, virologic rebound was rare. The high concentrations of tenofovir and lamivudine in cervicovaginal fluid may have implications for the prevention of sexual transmission during antiretroviral therapy and for pre-exposure or post-exposure prophylaxis.
Editors´note: Both non-nucleoside reverse transcriptase inhibitors and protease inhibitors penetrate poorly into the genital tract achieving concentrations from 3 to 33% of their concentrations in paired blood plasma. Whether this creates the equivalent of local suboptimal therapy which could lead to genital tract viral drug resistance is not known. The good news is that the nucleoside reverse transcriptase inhibitors that form the backbone of combination therapy not only accumulate but actually concentrate in cervicovaginal fluid, which could have implications for prevention of onward HIV transmission.
Belza MJ, de la Fuente L, Suárez M, Vallejo F, García M, López M, Barrio G, Bolea A; Health And Sexual Behaviour Survey Group. Men who pay for sex in Spain and condom use: prevalence and correlates in a representative sample of the general population. Sex Transm Infect. 2008;84:207–211.
Belza and colleagues aimed to estimate the percentage of men who have paid for heterosexual sex in Spain and the percentage who used condoms. They aimed to identify the main factors associated with these behaviours and to describe opinions about condoms. Sexual behaviour probability sample survey in men aged 18–49 years resident in Spain in 2003 (n=5153). Computer-assisted face to face and self interview was used. Bivariate and multivariate logistic regression analyses were performed. 25.4% (n=1306) of the men had paid for heterosexual sex at some time in their lives; 13.3% (n=687) in the last 5 years and 5.7% (n=295) in the last 12 months. In the logistic analysis this behaviour was associated with older age, lower education, being unmarried, foreign birth, being a practicing member of a religious group, unsatisfactory communication with parents about sex, age under 16 years at first sexual intercourse and having been drunk in the last 30 days. Of the men who had paid for sex in the previous 5 years, 95% (n=653) had used a condom in the most recent paid contact. In the multivariate analysis, not using a condom was associated with age over 30 years and first sexual intercourse before age 16 years. Men who did not use condoms in the last commercial intercourse had more negative opinions about condoms. In conclusion, the prevalence of paying for heterosexual sex among Spanish men is the highest ever described in developed countries. The many variables associated with paying for sex and condom use permit the characterisation of male clients of prostitution and should facilitate targeting HIV prevention policies.
Editors´note: There have been many studies of female sex workers but little research on the prevalence of paying for sex in the general male population. This study is intriguing not only because condom use in these encounters is so high but because a quarter of men have paid for sex at some point in their lives. Aside from a number of expected associations, logistical regression found that practicing members of a religious group (94.4% of whom were Catholic) – defined as attending religious services once a week or more - had a higher prevalence of commercial sex relations and were less likely to use condoms in these encounters.