Risk of sexual transmission under haart background information on swiss statement
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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“


Court accepts swiss statement

Court accepts Swiss statement


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 german statement aids hilfe

Reactions in EuropeGerman Statement (AIDS Hilfe)


Reactions in europe french statement cns

Reactions in EuropeFrench Statement (CNS)


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


Swiss position open information is mandatory for well educated risk management

Swiss Position: Open information is mandatory for well educated risk management


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