ArticlesAntiretroviral therapy to prevent HIV transmission in serodiscordant couples in China (2003–11): a national observational cohort study
Introduction
The beneficial role of antiretroviral therapy in reduction of mortality in people infected with HIV has been clearly shown.1, 2, 3, 4, 5 The additional role of antiretroviral therapy in reduction of HIV viral load and thereby prevention of transmission of HIV6, 7 in serodiscordant couples (in which one partner is HIV-positive and the other HIV-negative) was suggested by investigators of several observational studies8, 9, 10 and in 2011 was lent support by the results of the prospective, randomised clinical trial HPTN 052.11 Because of the strength of these studies, but despite the absence of evidence to show the feasibility and durability of such a public health approach on a national scale, WHO has issued guidelines recommending that antiretroviral therapy be offered to the HIV-positive partner from all serodiscordant couples, irrespective of CD4 cell count, to reduce the risk of HIV transmission.12
By the end of 2011, China had an estimated 780 000 people infected with HIV. Since the beginning of the national treatment programme in 2003, a cumulative total of 157 050 individuals have received antiretroviral therapy.13 One meta-analysis of studies in HIV serodiscordant couples from China reported an overall rate of 1·2 infections per 100 person-years (95% CI 0·9–1·7).14 However, these individual studies did not measure the effect of antiretroviral treatment on transmission, so the meta-analysis was also unable to analyse the effect of treatment. The investigators did, however, suggest that treatment was beneficial on the basis of a subanalysis that showed a decrease in rates of infection in the years after the scale-up of treatment (2005–11), compared with the years before treatment was available (1994–2004). In this study, our aim was to measure the effect of antiretroviral therapy on the transmission of HIV in serodiscordant couples across China, and thereby assess the feasibility and durability of such a treatment-as-prevention approach on a national scale in a developing country context.
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Study design and procedures
All individuals in China who test HIV-positive are reported to the National Center for AIDS/STD Control and Prevention at the Chinese Center for Disease Control and Prevention (China CDC). Baseline data from these individuals, including demographic characteristics, route of infection, and CD4 cell count, are captured in the national HIV epidemiology database. The local CDC follows up individuals who report a spouse or regular sex partner with whom they cohabit, and tests them for HIV, with
Results
As of Dec 31, 2011, 444 712 HIV-positive individuals were recorded in China's national HIV epidemiology database. 56 726 of these individuals were identified as having an HIV serodiscordant spouse or cohabiting partner of the opposite sex at their baseline visit. 2607 couples were excluded because their epidemiology and treatment database records could not be matched, and a further 2883 couples were excluded because they had previously received treatment. Of the remaining couples, 26 180 had
Discussion
In this retrospective analysis of China's national HIV epidemiology and treatment databases from 2003 to 2011, which included 38 862 treatment-naive and treated HIV serodiscordant couples, we noted a 26% relative reduction in HIV infection in couples in which the index patient was treated for HIV (panel). The reduction in transmission was significant in the first year of follow-up and was seen across most baseline demographic characteristics, with a few exceptions.
Antiretroviral treatment as a
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