N Engl J Med. 2016 Jul 18. [Epub ahead of print]
Antiretroviral Therapy for the Prevention of HIV-1 Transmission.
Cohen MS1, Chen YQ1, McCauley M1, Gamble T1, Hosseinipour MC1, Kumarasamy N1, Hakim JG1, Kumwenda J1, Grinsztejn B1, Pilotto JH1, Godbole SV1,Chariyalertsak S1, Santos BR1, Mayer KH1, Hoffman IF1, Eshleman SH1, Piwowar-Manning E1, Cottle L1, Zhang XC1, Makhema J1, Mills LA1, Panchia R1,Faesen S1, Eron J1, Gallant J1, Havlir D1, Swindells S1, Elharrar V1, Burns D1, Taha TE1, Nielsen-Saines K1, Celentano DD1, Essex M1, Hudelson SE1,Redd AD1, Fleming TR1; HPTN 052 Study Team.
Background An interim analysis of data from the HIV Prevention Trials Network (HPTN) 052 trial showed that antiretroviral therapy (ART) prevented more than 96% of genetically linked infections caused by human immunodeficiency virus type 1 (HIV-1) in serodiscordant couples. ART was then offered to all patients with HIV-1 infection (index participants). The study included more than 5 years of follow-up to assess the durability of such therapy for the prevention of HIV-1 transmission. Methods We randomly assigned 1763 index participants to receive either early or delayed ART. In the early-ART group, 886 participants started therapy at enrollment (CD4+ count, 350 to 550 cells per cubic millimeter). In the delayed-ART group, 877 participants started therapy after two consecutive CD4+ counts fell below 250 cells per cubic millimeter or if an illness indicative of the acquired immunodeficiency syndrome (i.e., an AIDS-defining illness) developed. The primary study end point was the diagnosis of genetically linked HIV-1 infection in the previously HIV-1-negative partner in an intention-to-treat analysis. Results Index participants were followed for 10,031 person-years; partners were followed for 8509 person-years. Among partners, 78 HIV-1 infections were observed during the trial (annual incidence, 0.9%; 95% confidence interval [CI], 0.7 to 1.1). Viral-linkage status was determined for 72 (92%) of the partner infections. Of these infections, 46 were linked (3 in the early-ART group and 43 in the delayed-ART group; incidence, 0.5%; 95% CI, 0.4 to 0.7) and 26 were unlinked (14 in the early-ART group and 12 in the delayed-ART group; incidence, 0.3%; 95% CI, 0.2 to 0.4). Early ART was associated with a 93% lower risk of linked partner infection than was delayed ART (hazard ratio, 0.07; 95% CI, 0.02 to 0.22). No linked infections were observed when HIV-1 infection was stably suppressed by ART in the index participant. Conclusions The early initiation of ART led to a sustained decrease in genetically linked HIV-1 infections in sexual partners. (Funded by the National Institute of Allergy and Infectious Diseases; HPTN 052 ClinicalTrials.gov number, NCT00074581 .).