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Risk of Sexual Transmission under HAART Background information on Swiss statement. Pietro Vernazza President EKAF- Swiss Federal Commission on AIDS. Agenda. Why a statement Formal content of the statement Impact on Swiss physicians and patients Influence on other clinical guidance (EU, US).

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risk of sexual transmission under haart background information on swiss statement

Risk of Sexual Transmission under HAARTBackground information on Swiss statement

Pietro Vernazza

President EKAF- Swiss Federal Commission on AIDS

agenda
Agenda
  • Why a statement
  • Formal content of the statement
  • Impact on Swiss physicians and patients
  • Influence on other clinical guidance (EU, US)
the development of the ekaf statement why a statement
The development of the EKAF statementWhy a statement
  • Criminal prosecution (CH > 30 cases!)
  • Couples willing to conceive a child
  • Discrepancy public/ private information
    • Problems of inconsistency of information
    • Risk of uncontrolled diffusion
hiv transmission risk over time

PHI

STDs

HIV-Transmission risk over time

Infectiousness (arbritrary scale)

Months / Years

Weeks

Vernazza, AIDS 1999;13:155–166 (adapted)

the development of the ekaf statement evaluation by expert group fkt
The development of the EKAF statementEvaluation by Expert Group (FKT)
  • High Risk
    • Relevant for Public Health
  • IntermediateRisk:

 Relevant for the individual

  • NegligibleRisk:

 Similar to risks of daily life

Oral Sex

w/o Ejac

Condom,

no Tx

other negligible risk situations
Other “negligible” risk situations
  • Condom-protected vaginal Sex:

 0.9 / 100 py for always users

Davis, 1999, Fam Plan Perspectives

  • Receptive oral Sex (MSM): 0.0004 / act

Vittinghoff, 1999, Am J. Epid

  • 1:2‘500
transmission risk under art risk estimation
Transmission risk under ARTRisk estimation
  • Published partner studies
    • N<600, no Trsm 95%-CI: < 1:200
  • 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

activity of art for prevention art is comparable to condom use
Activity of ART for Prevention ART is comparable to condom use

Sex w/o Condom

Partner under HAART

Mono- / Bi-

Therapy

Triple-

therapy

None

Always

with

condom

>1/Mt.

<1/Mt.

Infection rate partners (%)

Castilla, et al. JAIDS 2005; 40:96-101

ranges of hiv transmission risks
Ranges of HIV transmission risks

Oral sex3

Ejac

Sex under ART

STD

Vaginal sex1

Condom Use2

Anal sex1

10-6

10-5

10-4

10-3

0.01

0.1

Risk per act

1Royce et al, NEJM, 1997

2Davis 1999

3Vittinghoff, 1999

consider biology
Consider biology...
  • STDs: epidemiologic synergy
    • STDs increase genital viral load
    • STDs increase susceptibility to HIV
  • Genital viral load may take some more time to get below <40 cp/ml

 Any Communication about safety under HAART should include statement on duration and STD

the ekaf statement what the statement described
The EKAF statementWhat the statement described
  • It‘s ok. to talk about risk estimates
  • Under optimal conditions, risk is in the range of daily life („negligible“)
    • Long term maximal suppression
    • Perfect adherence, regular checks
    • Absence of STDs
  • Only the informed partner can decide on condom use

 negligible: same range as for condoms

*

*

based on math model by wilson et al
(based on math. Model by Wilson et al.)

Swiss statement challenged

confirmed

In serodiscordant male couple

after 100 anal contacts

Garnett &Gazzard, The Lancet, 27.7.2008, editorialcomment

the ekaf statement what the statement did not say
The EKAF statementWhat the statement did not say
  • No advice against using condoms
  • No change in prevention messages
impact on physicians patients
Impact on physicians & patients

Marianne, teacher, 35 years: „Thank you, for the first time in my 20 years of HIV infection I felt secure. I have been assured that I am not a danger for other people in my life. Even when I worked with children, I feared of infecting one of them“

physicians in switzerland
Physicians in Switzerland ?
  • In general more disclosure regarding risk behavior
  • Discussions with partners encouraged
  • No massive change in risk behavior noted
  • STDs became important issue
reactions in europe french statement cns1
Reactions in EuropeFrench Statement (CNS)
  • On a public healthlevel
    • Increase efforts for HIV testing
    • Promoteresearch in the field of prventionthroughmedicaltreatment
  • General Communication
    • Promote benefits of HIV testing and treatment
      • Inform about risk reduction through treatment
      • Residual risk remains
  • For healthprofessionals
    • Consider treatment as a preventive measure in cases resistant to conventional prevention methods
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