In this transcript, Rebecca Bunnell, Sc.D., of the U.S. Centers for Disease Control and Prevention, discusses the impact that antiretroviral use has had on the sexual behavior and HIV risk activities of HIV-infected people in rural Uganda.

Rebecca Bunnell: In our study, we assessed changes in sexual behavior in HIV transmission risk in a cohort of over 900 persons taking antiretroviral therapy in rural Uganda, over a 3-year period.¹ And this cohort was provided with an integrated ART and HIV prevention intervention. Overall, in this population that had very high adherence and large decreases in viral load, there was a 91% reduction in HIV transmission risk that was sustained over a 3-year period. We did find that over the three years, there was only one transmission event that occurred among 64 HIV discordant couples, which is considerably less than the 10% or so per year transmission rates that have been documented in other studies in Uganda, before the availability of ART.

Rebecca Bunnell, Sc.D.

We also found that over the three years, there were significant increases in sexual activity, for both men and women, at the same time that there were significant increases in quality of life and decreases in depression. So we saw this as a very positive sign, in terms of the wellbeing of people living with HIV in sub-Saharan Africa.

During the time that there were increases in sexual activity, there were no increases in the rates of unprotected sex, both with HIV uninfected or unknown partners. Our findings, I think, really allay fears about widespread risk compensation, which many people expressed before we started scaling up ART in Africa. But they do suggest the importance of partner testing and also suggest that we should be doing more in terms of alcohol interventions, since alcohol was significantly associated with risky sex -- to support people living with HIV to reduce their HIV transmission risk.

From the bigger public health perspective, stepping back a second from our study, I would like to just emphasize, though, that our study was done with people who were in ART programs. But if you look at HIV infected people in sub-Saharan Africa, 75% have never had an HIV test, do not even know they have HIV infection. Another big section are in care programs, but not yet having access to ART, or not yet clinically eligible for ART. And it's that bigger group of people who would have higher viral loads, which we found to be the most important factor in reducing HIV transmission. So though our study is very encouraging, and certainly supports the integration of prevention into ART programs, we should also look at the bigger public health picture of addressing the HIV transmission reduction needs, the whole population of HIV infected persons in sub-Saharan Africa; and that would need to begin with universal access to testing.

This transcript has been lightly edited for clarity.

Footnote

1. Bunnell R, Ekwaru J, King R, et al. 3-year follow-up of sexual behavior and HIV transmission risk of persons taking ART in rural Uganda. In: Program and abstracts of the 15th Conference on Retroviruses and Opportunistic Infections; February 3-6, 2008; Boston, Mass. Abstract 29.