Current WHO guidelines for use of ART as prevention will benefit only a "fraction" of people with higher CD4 counts and their partners

World Health Organization (WHO) guidance on the use of antiretroviral treatment (ART) for the prevention of transmissions are likely to benefit only a “fraction” of the targeted population, according to research published in AIDS. Investigators in Côte d’Ivoire found that only 12% of patients with higher CD4 counts would be eligible for therapy under the present guidance. Almost two-thirds of individuals with CD4 counts above 500 cells/mm³ would be ineligible for ART for prevention, either because they had no stable partner or were unaware of the HIV infection status of their partner.

“Recommending ART to patients with high CD4 cell counts who live with a seronegative partner is an important new step to reduce HIV transmission,” comment the authors. “However, 64% of our participants are sidelined by these recommendations, and this has repercussions.”

With early ART patients with HIV can now have a normal life expectancy. Long-term ART that suppresses viral load to undetectable levels also virtually eliminates the risk of HIV transmission to sexual partners. Therefore, since 2013 WHO has recommended ART for all HIV-positive patients, irrespective of their CD4 count, if they have an HIV-negative partner.

Investigators wanted to see how many patients would benefit from this recommendation. Therefore they interviewed 929 adult patients about their partnership status and the HIV infection status of their partners.

The patients were enrolled in a larger ongoing study assessing the benefits of early ART. The interviews were conducted in 2012.

Approximately three-quarters (78%) of patients included in the analysis were women. Median baseline CD4 count was 491 cells/mm³ and the median age was 38 years.

Overall, 72% of patients said they were in a stable sexual partnership. Of the patients in a stable partnership, 67% had declared their HIV infection status to their partner and 59% were aware of the status of their partner. The proportion of patients knowing the status of their partner was higher for those who had disclosed their own status, compared to those who had not (82% vs. 10%, p < 0.001).

When the study was conducted, 49% were already on ART and 51% were not taking anti-HIV drugs. Almost half (47%) of this latter group had a CD4 count above 500 cells/mm³ and would thus, depending on their relationship status, be possible candidates for the initiation of ART for prevention according to WHO guidelines.

However, 30% were not in a stable sexual partnership, 24% were in a sexual relationship with a partner who was HIV-positive, 12% were in a relationship with a HIV-negative partner and 34% were in a stable sexual partnership but did not know the HIV status of their partner.

“Thus, only 12% of adults with more than 500 CD4 cells/mm³ who participated in this survey would be recommended to start ART, because their partner was seronegative, according to the present WHO guidelines,” write the investigators. They were especially concerned that almost two-thirds “could not be given any recommendations regarding ART early initiation because they either had no stable partnership or a stable partnership with a partner whose status they no had knowledge.”

They recommend “steps should be taken to encourage screening in couples, to look in detail into factors associated with the lack of disclosure between partners, and to put in place interventions to breakdown barriers to sharing serostatus within couples.” They conclude there is a risk of WHO guidelines being only “marginally implemented and reaching only a fraction of the targeted population.”