Approximately 40% of HIV-positive people in a stable relationship with an HIV-negative person in Kenya have reservations about starting antiretroviral therapy early for the purposes of prevention, investigators report in the online edition of the Journal of Acquired Immune Deficiency Syndromes.
Willingness to use pre-exposure prophylaxis (PrEP) was high among the HIV-negative partners. However, this finding is likely to have been influenced by the fact that the study involved couples involved in a PrEP study.
The investigators believe that their findings could have implications for the use of HIV treatment in prevention.
“A possible HIV-1 prevention strategy for serodiscordant couples that will utilize both ART [antiretroviral therapy] and PrEP is for the HIV-1-uninfected partner to use PrEP until the HIV-1 infected partner is willing and able to initiate ART,” suggest the authors. “Such a strategy would be cost-effective, provide HIV-1 infected partners an opportunity to decide when to start ART, and may allow a ‘bridge period’ for a few months after the infected partner starts ART, when transmission may still be high because viral load is not yet suppressed.”
Antiretroviral-based strategies are among the most promising new approaches to HIV prevention.
Research involving serodiscordant heterosexual couples showed that early antiretroviral therapy reduced the risk of transmission of the virus by 96%.
Some research has also shown that antiretroviral drugs taken by HIV-negative people (PrEP) can reduce their risk of transmission.
Serodiscordant couples are a priority population for the use of HIV treatment. But, before strategies for its use are developed, it is important to understand the couples’ preferences for and concerns about the use of antiretrovirals for this purpose.
Investigators therefore recruited 181 serodiscordant couples in Kenya, enrolled in the Partners PrEP study, to a substudy enquiring about their willingness to use HIV treatment as prevention.
The HIV-positive partners all had a CD4 cell count above 350 cells/mm3 and were therefore ineligible for antiretroviral therapy according to Kenyan national guidelines. The study was conducted between March and July 2011, before the publication of research showing the efficacy of PrEP in heterosexual couples and of the results from the HTPN 052 study, which showed that early HIV therapy reduced HIV risk by 96% in serodiscordant heterosexual couples.
Both the HIV-negative and HIV-positive partners completed questionnaires.
HIV-negative individuals were asked: “If we find that PrEP works to keep people free from HIV, would you be willing to take PrEP tablets every day for the next five years?”
HIV-infected partners were asked: “Would you be willing to start antiretrovirals before your CD4 count reaches 350 if it would lower your chances of giving HIV to your partner?”
Participants were asked to describe their main concerns about early HIV treatment or PrEP. They were also asked to say which of these strategies they preferred.
Some 69% of HIV-positive men and 58% of HIV-positive woman said that they would be willing to take early treatment for the purposes of prevention.
An overwhelming majority of HIV-negative people (94% of men and 86% of women) expressed a willingness to take PrEP.
When asked to state a preference between the two approaches, 61% of HIV-positive men and 50% of HIV-negative women said they would prefer early HIV therapy.
A majority of HIV-negative participants expressed a preference for PrEP (57% of men and 56% of women).
In just over a quarter of couples (26%), both members preferred to have the HIV-negative partner take PrEP and in 22% of couples both members preferred early antiretroviral therapy for the infected partner.
Among HIV-positive participants, the primary concerns about early treatment for prevention were side-effects (51%), stigma (21%), pill burden (19%) and fears about resistance (18%).
A total of 14 HIV-negative people were unwilling to use PrEP. Their primary concerns were the duration of treatment (6/14), taking treatment when they were not sick (3/14), and side-effects (3/14).
“In our study, not all couples would be willing to use ART prior to the HIV-1 infected partner having clinical symptoms and a perceived need for initiation; PrEP could be a suitable alterative for these couples,” conclude the authors. “As antiretroviral-based HIV-1 prevention strategies are incorporated into prevention policies and programs, it will be important to understand and accommodate couples’ preferences and willingness to use antiretroviral-based HIV-1 prevention.”
Heffron R et al. Willingness of Kenyan HIV-1 serodiscordant couples to use antiretroviral based HIV-1 prevention strategies. J Acquir Immune Defic Syndr, online edition. DOI: 10.1097/QAI.0b013e31825da73f, 2012.