April 3, 2012
Undetectable Viral Load? Not Necessarily in Semen
by Tim Horn
Undetectable viral loads in blood is not a guarantee that HIV is also undetectable in semen, according to a new study involving 101 HIV-positive men who have sex with men (MSM) conducted in Boston and published online ahead of print by the journal AIDS. Of the 83 men with undetectable virus in blood samples, roughly a quarter of them—21 MSM in total—had semen with detectable HIV.
Though the study conducted by Joseph Politch, PhD, of Boston University School of Medicine and his colleagues didn’t look at whether those with low-but-detectable levels of HIV in their semen were necessarily more likely to transmit the virus than those with undetectable seminal viral loads, the authors nevertheless caution that a risk of ongoing HIV transmission potentially remains in the absence of barrier protection during sexual activity. “Until more information on transmission risk in MSM is available,” they write, “it would be prudent to advise sexually active HIV-infected MSM to use condoms and other risk-reduction strategies throughout all stages of HIV disease regardless of HIV treatment status.”
Politch and his colleagues note that antiretroviral therapy is undoubtedly associated with a reduced risk of HIV transmission during sexual activity. In prefacing their own data, the authors reiterate the results of HPTN 052, which demonstrated that ARV therapy led to a 96 percent reduction in HIV transmission risk among HIV-discordant heterosexual couples, along with a study among MSM conducted over a decade ago concluding that HIV treatment decreases the transmission risk by roughly 60 percent.
Yet, according to the authors, “MSM have experienced a resurgent HIV epidemic in the [ARV treatment] era. Many HIV-infected MSM continue to engage in unsafe sex, and sexually transmitted infections (STIs) or other factors may promote genital HIV shedding and transmission in this population despite [ARV therapy].”
Though the “resurgent HIV epidemic” is undoubtedly multifactorial—roughly 20 percent of those living with HIV, including many MSM, are not aware they are infected and have thus not received personalized care and counseling—Politch’s group set out to explore an important factor associated with HIV transmission: the prevalence of seminal HIV shedding among HIV-positive MSM receiving ARV therapy, and how it relates to a number of clinical, behavioral and biological variables.
The study recruited HIV-positive participants from Fenway Health, a clinic catering to the health care needs of the lesbian, gay, bisexual and transgender community in Boston. Paired blood and semen samples were collected from the 101 study volunteers. Clinical and behavioral data were obtained from medical records and questionnaires. Evidence of genital herpes and genital inflammation were also assessed using laboratory tests.
The men were predominately white (74 percent), and virtually all (97 percent) identified themselves as MSM. The average age of the study volunteers was 43. Eighty percent had been on ARV therapy for more than a year; all had been on HIV treatment for at least three months.
Twenty-seven percent reported only engaging in protected sexual intercourse within the three months before study enrollment and were thus classified as low risk for acquiring a sexually transmitted infection (STI). Seventy-three percent were classified as high risk for having an STI, based on self reports of unprotected sexual intercourse in the past three months.
Nine men, all belonging to the high-risk group, tested positive for an STI within seven days before their official start in the study. Sixty-three percent of the men were positive for genital herpes, or herpes simplex virus-2, HSV-2, antibodies.
Eighteen of the 101 MSMs enrolled in the study had detectable HIV in their blood samples. The average viral load among these men was 560, but it ranged from 80 to more than 600,000. Nine (50 percent) of the men with detectable blood-based viral loads also had detectable HIV levels in their semen.
Eighty-three of the 101 MSM had undetectable levels of HIV in their blood samples. Though most also had undetectable HIV in their semen samples, 21 (25 percent) had detectable seminal viral loads.
Politch and his team note, however, that HIV levels—free-floating HIV-RNA and both HIV-RNA and HIV-DNA in cells—were significantly higher among those with detectable blood-based viral loads, compared with those with undetectable blood-based viral loads. For example, whereas the average free-floating viral load was 4,438 copies among those with detectable blood-based HIV levels, it was 51 copies among those with undetectable blood-based HIV levels.
Whether or not the free-floating virus detected in the semen samples of those with undetectable blood-based viral loads is of high enough quantity and/or quality to establish infection in a sexual partner wasn't explored by the researchers.
The authors did note, however, that the prevalence of HIV shedding among those with undetectable blood-based viral loads documented in this study proved higher than has been reported in other studies. “This is likely due to the high prevalence of STIs and genital inflammation in our sexually active MSM cohort.”
Indeed, among the three factors associated with having detectable seminal viral loads among those with undetectable blood-based levels, having an STI was associated with a 29-fold increase in the risk, compared with those who didn’t have an STI. Being positive for HSV-2 was not associated with have a detectable seminal viral load.
As for the other two factors, genital inflammation—notably an increase in tumor necrosis factor-alpha, an inflammatory marker—was associated with a 14-fold increase in the risk, whereas unprotected insertive anal sex with an HIV-positive person—“topping” a positive partner without a condom—was associated with a sevenfold increase in the risk of having detectable HIV in semen even when HIV is undetectable in blood samples.
“In light of recent evidence that even low amounts of HIV in semen could pose a transmission risk in MSM, who are more vulnerable to HIV infection than heterosexual men, this information has potential clinical significance for the HIV epidemic in MSM,” the authors conclude. “HIV-infected men who engage in unprotected intercourse may use [ARV therapy] and viral load status in their sexual decision-making, and being on [ARV therapy] or having an undetectable blood viral load may relax concerns about transmitting HIV. Therefore, MSM at risk for transmitting HIV may believe that they have a low risk based on incorrect assumptions that [ARV therapy] eliminates HIV from semen.”
Of particular concern to the study investigators is that ongoing replication of the virus in the genital tract, in the presence of ARV therapy, can lead to the accumulation of drug-resistance mutations and the possible spread of treatment-resistant virus. This, they point out, "may contribute to the high prevalence of antiretroviral drug-resistant HIV in HIV-infected individuals in the United States [who have not yet started ARV therapy]."
In addition to the suggestion that condom use continue to be promoted as a harm-reduction strategy among HIV-positive MSM who are otherwise responding well to ARV treatment, the authors also note the need to “promote the aggressive diagnosis and treatment of STIs.”
Search: hiv, semen, genital, viral load, transmission, prevention, gay, men who have sex with men, msm, fenway, boston
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comments 15 - 22 (of 22 total)
Jalke, New York, 2012-04-06 08:00:36
I would agree with most other comments that this is just more hysterics designed to intimidate people into using condoms. Anytime a study concludes there a minimal risk of transmission, as several other studies have, someone has to go and point at conjectures and "possible risks" to keep the fear out there. Also, by continuing to call it "unsafe" sex vs. "unprotected" sex they stir up panic. Spend the money to find a freaking cure instead!
Andy, , 2012-04-05 09:44:08
So the study implies, but does not establish, that poz men are dangerous. Then, we're admonished to stop putting others at risk, ignoring the fact that it takes two for sex. So this is basically serophobia masquerading as "prevention science". Looks like another low point for "prevention".
jjbearphx, Phoenix, 2012-04-05 04:01:04
It was established early into the fight against HIV and how it was spread, that the virus was not always present in ejaculate. In some men it was never present in some it was present one test and not there the next. How many men know that a condom is only a maze for the virus as the virus is smaller than the pores in the latex. Give us credible risk reduction information when we play with sero discordant partners, and we will use it. Risk reduction ratings went by by when GW2 took ofice
Unbeliever2012, New York, 2012-04-05 03:32:44
I find it concerning that the term shedding is undefined in its truest sense. The study omits if the detectable HIV in any semen was infectious. Discovery of HIV RNA or DNA in semen or vaginal fluids is meaningless without the disclosure of factual evidence that the detected material is of an infectious class or not. Especially in light of many other studies which have had similar findings but quantified the lack of any kind of infectious HIV cells in subjects expressing HIV "shedding".
Marc, , 2012-04-04 17:13:58
I thought this was well established, just as I thought it was irrellevant since "undetectable" has never meant "nonexistent". The better question is why we're talking about "detectable viral load", as opposed to "infectious viral load"? The latter issue is the one that matters. I guess since questions about "infectiousness" dont easily support finger pointing and hand wringing guilt about pozzies who dare to engage in serodiscordant sex, it doesn't get funded.
musicmuse4u2, Austin, TX, 2012-04-04 15:16:57
Nobody seems to address the issue of the chances of an "undetectable" (fewer than 48 copies) POZ bottom passing HIV to an unprotected top.
Also, why not HPV for bottoms???
Joe D, Charlotte, NC, 2012-04-04 14:21:20
This is an interesting study that seems to have a serious flaw that would bring the posted conclusion into question. If only 50% of those with a DEtectable blood viral load also had a detectable VL in their semen, how can the validity of the seminal samples be trusted? I would feel better if there was an established control group where all those with detectable blood VL also had a detectable semen VL. It seems the study only supports the idea that protected sex is better than unprotected.
jjbearphx, Phoenix, 2012-04-04 13:37:52
comments 15 - 22 (of 22 total)
Ok so they fired a shotgun and hit the target, this study has to many variables to be significant, It is well known that STI's and cankers cause shedding of Virus. A more focused study of a clean study group is needed to make a definitive analysis. Only undetectable viral load without the other factors thrown in. Including men with active or freshly treated STI's is going to skew the results. Granted this is a more realistic portion of the population. POZ men serosort with POZ POZ partners.
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