PrEP, Serodiscordant Couples and ART, Pre-Exposure Prophylaxis and Antiretroviral Therapy, is what has kept people alive and their hopes from a picture where death was certain.
All deaths are certain and, thus, ART is what it is, a drug therapy that improves survival and prolongs life!
ART HAS HELPED TO REDUCE, IN TRUTH, THE SUFFERING CAUSED BY AIDS
Serodiscordant couples (when one partner is HIV negative and the other is HIV positive) are often considered to be at “high risk” of HIV transmission. However, new understandings about the biology of HIV transmission and the appearance of new STD infections (using other HIV prevention options with different forms of prevention) show that the risk of transmission of HIV infection within couples serodiscordants are of low or very low proportions, even reaching insignificant levels.
ART does not prevent the spread of the virus!
In fact, the attitudinal set that prevents HIV transmission may be easier to achieve by serodiscordant couples than compared to relationships with couples in other types of relationships, as is assumed in the case of HIV-negative couples and serum concordant (in which both partners believe they are HIV negative) or in individuals in casual relationships.
This article examines this paradigm shift and the risk of contracting HIV in serodiscordant relationships, and the initial counseling should be given by service providers, a kind of front-line, can help people in serodiscordant relationships with known ways to reduce their risks of HIV transmission.
Note: We can define a serodiscordant couple for two people (one HIV positive and the other negative for HIV) who are in a sexual relationship in which both partners have been tested for HIV and who has been completely sure of the serological status for the infection by HIV.
How common are serodiscordant relationships?
We do not have good estimates of how many people in Canada, or in other parts of the world, are in serodiscordant relationships. While "HIV-related" surveys within the scope of Canadian population studies often ask participants about HIV from their sexual partners, the full nature of such sexual relationships is rarely explored in detail.
The risk of contracting HIV, ART changing the paradigm
Serodiscordant couples are often assessed as a “high risk” population for HIV transmission. Therefore, it may come as a surprise to learn that the risk of HIV transmission within these couples can be reduced to very low, and even insignificant levels. This reality is the result of our relatively new knowledge about the biology of HIV transmission and the appearance of new HIV infections, in view of the already large number of prevention options.
Unfortunately, many people are still afraid of entering into serodiscordant relationships, suggesting that this new information on HIV transmission and prevention is not reaching those who need it. For example, in a telephone poll of more than 1.000 homosexuals and other men who have sex with men (MSM) across Canada conducted in 2011-2012, 49% of men said they did not want to have sex with an HIV-positive patient, even if they were very attracted to him.1 In addition, 68% of HIV-infected men in this survey said they worried about being rejected by gay and bisexual men in their community because of their positive HIV status.
ART, antiretroviral therapy, fighting, in addition to AIDS, the spread of HIV
Contrary to common belief, avoiding HIV infection may actually be easier for serodiscordant couples for relationships compared to couples in other types of relationships,se seropositive couples in relation to relationships based on reciprocal trust where both relationship are HIV-negative (where both partners believe they are HIV negative). This is because, in a discordant serum relationship, you can:
- Opens the option to use treatment with antiretrovirals (ART) as an HIV prevention strategy. ART can reduce the amount of virus (viral load) in the body fluids of an HIV-positive partner to very low levels and this can dramatically reduce the risk of HIV transmission.
- Provide motivation for the adoption of risk reduction strategies to prevent HIV transmission. In HIV-negative individuals who are serodiscordant and are not in a relationship, it can often be difficult to assess the risk of HIV transmission. Low perception of risk of contracting HIV can reduce motivation to adopt risk reduction strategies.
- Eliminate uncertainties related to HIV status partner. In serum concordant HIV-negative relationships, it can be difficult to know for sure whether both partners are actually HIV negative (especially if the relationship is not monogamous). If one partner is HIV-infected unknowingly, the risk of HIV transmission in the couple may be very high because the HIV-positive viral load without treatment is high and the couple may not take preventive measures.
TARV The Miracle That Saved Millions
HIV prevention can also be easier for individuals in relations serodiscordant compared to those in casual relationships. For people who are in stable relationships, there is more opportunity for the continuous exchange of information that is important to make informed sex safe decisions, such as the results of HIV and STDs, screening and viral load tests. In addition, partner support can play an important role in ensuring HIV prevention, a strategy that is used consistently and correctly.
Counseling to serodiscordant couples and discussing risk of contracting HIV
There are several HIV prevention strategies that can dramatically reduce the risk of HIV transmission in serodiscordant couples. Integrating information on strategies for patient education and counseling can help raise awareness of these options and facilitate informed decisions to adopt them. Since mismatch and misuse can be common and commitment to strategy effectiveness, consulting can also play an important role in ensuring a couple optimizes the prevention and benefit of these strategies.
Before discussing highly effective strategies with a customer, you may want to consider the following:
Couples with basic counseling
Counseling both serodiscordant partners in a simultaneous session (couples counseling) may be more effective in reducing risk behaviors over individual partner counseling.2
Couples with basic counseling can create a space where partners can reach a consensual agreement on how to reduce the risk of HIV transmission and develop ways to support each other using HIV prevention strategies consistently and correctly. Couples can also be supported to discuss relevant issues potentially sensitive to HIV prevention, such as sexual intimacy, relational dynamics and whether there are sexual partners outside the relationship. Through counseling, heterosexual couples can also explore whether the plan to have children can influence the adoption of HIV prevention strategies.
Assess baseline risk
Before discussing strategies for risk reduction, service providers should seek to know what type of sexual relationship a couple is holding, how high or low they perceive HIV transmission risk, and correct any misconceptions, and try to observe how they feel comfortable with their relative level of risk.
In order to determine if there are activities with a lower base risk for transmission of the HIV virus, a possible option, for example, would be to engage in oral sex instead of penetrative sex, be it anal or vaginal or, further reducing the frequency receptive anal sex - where the HIV-negative partner is receptive it can be important to discuss the types of sex they like best, what they want from sex, and how types of sex with a lower risk can be eroticized. If a couple's basic risk is very high, decreasing the risk may require the use of a combination of HIV prevention strategies.
Report Cumulative Risks
The potential risk for ongoing HIV exposures within a relationship means that transmission risks can accumulate quickly. Highly effective strategies can reduce the risk of HIV transmission from single exposure to very low or insignificant levels, but these small risks can accumulate and become larger in the long term with multiple exposures. Combining more than one HIV prevention strategy can help reduce the risk accumulation and minimize the couple's risk for long-term HIV transmission.
Explore highly effective HIV prevention strategies
In this article, highly effective strategies are defined as strategies that can reduce the risk of HIV transmission by more than 90% when used consistently and correctly. Unfortunately, research shows that misuse and inconsistent use of these strategies may be common and may reduce their effectiveness in preventing transmission of the HIV virus. In other words, a highly effective strategy can become ineffective if it is not well used.
When discussing prevention options with patients, it is important to explore well as a couple will be able to use an prevention option in order to facilitate the adoption of a strategy that will work best for them.
Use of antiretroviral treatment as prevention
Antiretroviral treatment can reduce the viral load on a person's HIV-infected body fluids to undetectable levels and this can reduce the risk of HIV transmission by anal and vaginal sex. Several studies show that ART can reduce the risk of HIV transmission by 90% or more, if used consistently and correctly,345
However, research suggests some couples are not optimizing HIV prevention through the benefit of ART. For example, in an analysis combining the results of nine studies, ART reduced only the risk of HIV transmission among serodiscordant couples in 42%.5
In fact, two studies included in the analysis found that ART does not always provide the desired protection against HIV transmission.
Many participants in these studies may not have sido triggered in regular visits to be adherent to their therapeutic regimens (ART) (adherence is important to keep the viral load undetectable) or regularly tested for STDs (infections in any partner can increase the risk of HIV transmission).
Advice on the use of ART as prevention should include:
- Discuss the benefits of HAART in HIV prevention and conditions that can maximize its effectiveness. These conditions include:
- 1) an undetectable viral load in the blood for at least 6 months;
- 2) A Non-existence of untreated DSTS in the partner; and
- 3) regular medical visits to monitor viral load and the DSTS test.
- Incentive for the couple to discuss viral load test results on an ongoing basis and emphasize the importance of not assuming that the viral load is undetectable.
- Support for adherence to TRAV and commitment to care.
- It should explore potential barriers to adherence / commitment (and how to overcome them) and the important role the partner can play in supporting accession.
If the HIV-positive partner is not currently being treated, counseling should include:
- Providing information about the health benefits of ART and its potential side effects. This information is important to ensure a patient's decision to start ART is based on well-informed status.
- An assessment of readiness to start ART. Efforts should be made to ensure that the HIV-positive partner is ready to commit to ongoing adherence to HIV treatment and is not being coerced into initiating treatment (by his or her partner or health care provider).
- Facilitate articulation to care for and access to treatment if the HIV-positive partner is not currently receiving care.
Condom The Great Containment Factor, Stronger Than PrEP
Condoms act as a barrier to prevent HIV-containing bodily fluids from coming into contact with parts of the body that are vulnerable to HIV.
There are two main types of condoms:
- the external (masculine);
- internal (female).
The outer condom is placed on the erect penis; and the inner condom is placed inside the vagina or rectum. If the condom is used properly and does not tear, slip or leak, there is no risk of HIV transmission due to the impossibility of exposure to HIV.
Condoms are the only HIV prevention strategy that can also reduce the risk of STD transmission and prevent unplanned or undesirable pregnancy, such as adolescent pregnancy for example.
Research suggests many people struggle to use condoms effectively. For example, analyzes combining the results of several studies consistent condom use only reduced the risk of HIV transmission by 70 or 80%,67 while participants in these studies said that they had used the condom ever, many participants may not have been able to have used the condoms correctly. Bad condom use may compromise the effectiveness of such strategy and research shows errors in condom use are common and,8 inconsistent condom use it is also common and can drastically reduce the effectiveness of the condom.9
Counseling on the use of condoms should include:
- The supply of condoms and lubricants.
- Information on how to use condoms correctly. This should include guidance on how to open, insert and remove condoms. It is also important to note that the correct use of condoms means that they are used for the entire duration of sex and in combination with a lubricant that is compatible with the type of condoms used. Various sizes and external forms of condoms are available and encouraging a young person to find a brand with a good level of comfort, suitable for the expression “use with pleasure”, can help prevent breakage / slippage and even increase the pleasure with a great feeling of security.
- Exploitation of barriers to the use of condoms in all sexual relations involving penetration and the provision of support by caregivers in an attempt to overcome them. Obstacles common to the consistent use of condoms include lack of availability at the time of sex, erectile dysfunction, decreased pleasure or intimacy, and feeling of discomfort.
Possible solutions for discussing with patients include planning in advance and ensuring that condoms are always available, as well as the use of lubricants, and, importantly, finding a condom brand with the greatest “feeling of comfort, pleasure and security” with the condom.
- It should also be discussed the use of the female condom to couples as an alternative potential to the male condom (for both anal and vaginal sex).
- Counseling may also want to explore the relationship between condoms and intimacy or encourage patients to seek medical care for patients with erectile dysfunction.
Pre-exposure prophylaxis (PrEP)
PrEP refers to the continued use of anti-HIV medications by a HIV-seronegative person in order to reduce the risk of HIV infection. Several studies have shown that using a daily pill of the antiretroviral drug Truvada as PrEP can reduce the risk of HIV transmission by more than 90% if used consistently and correctly.10,1112 PrEP also involves regular visits to a service provider to monitor side effects, HIV testing and other STDs, as well as receiving a prescription for more pills.
Research shows that using this strategy effectively can be a challenge. For example, an analysis combining results from several studies found that PrEP only reduced the risk of HIV infection in 47%.13 In fact, two studies under analysis found that PrEP did not provide any protection against HIV infection. Many of the participants in these studies did not consistently take Truvada pills and there were also excessive difficulties among those involved in providing the services (and therefore may not have received a new prescription from their service provider and therefore there was a failure in PrEP).
Advice on PrEP should include: 6 +
- Information on preparing and helping to determine if preparing is the right choice for the couple, which should include an evaluation, as PrEP is only recommended only for HIV-negative patients with “high risk” of HIV infection (because it is expensive and can cause side effects).
- Discussing the risks and benefits of starting PrEP can help facilitate an informed decision about this strategy. If a couple is already using a highly effective and consistent prevention strategy (such as condoms and / or the use of ART as prevention), the risks and costs of PrEP can outweigh the benefits because the risk of HIV transmission can already be very low.
- Diagnostic assistance
- 1) a health care provider who is willing to require consistent preparation of PrEP and
- 2) a way to cover expenses. Patients should be encouraged to discuss PrEP with their family physician or the prescribing physician to the HIV-positive partner. Patients should also contact their private health insurance company (if available) to determine if the cost of PrEP is covered. Public health insurance should also be contacted to see if they can cover some or all of the costs in some locations.
- Support with commitment and commitment to prepare services. It should explore potential barriers to adherence / commitment (and how to overcome them) and the important role the partner can play by helping the HIV negative partner join PrEP.
The use of ART for prevention and preparedness are safe and effective options for couples who wish to conceive through unprotected sex and reduce the risk of HIV transmission. However, other highly effective alternatives such as breeding vitro and specific prevention options also exist and should be discussed with patients. These options include sperm washing and assisted reproduction.14
Additional prevention measures
Below is a description of HIV prevention strategies that are not highly effective when used alone but may help reduce some of the overall risk of HIV transmission when used in combination with highly effective strategies.
Post-exposure prophylaxis (PEP)
PEP refers to the use of anti-HIV drug drugs by an HIV-negative person to reduce the risk of HIV infection from a single exposure because you need to15 be started as soon as possible (but usually within 72 hours) after exposure and consists of taking the medications every day for an entire month. PEP is not intended to be used as a regular method of preventing HIV infection, but only in case of an emergency. It also involves multiple visits with a provider to monitor the side effects and test for HIV.
Research shows that PEP is effective in reducing the risk of HIV infection from exposure, however.15 , waiting longer to access PEP, low adherence to the daily pill, and additional exposure to HIV during the use of this strategy has been associated with less PEP effectiveness.16
Counseling should include:
- The discussion of when PEP is an appropriate HIV prevention tool. PEP should only be used for “high-risk” individuals at exposures because it is expensive and has side effects. Discussing the risks and benefits of PEP can help facilitate an informed decision on what types of exposures PEP should be accessed on. If a couple is already using a highly effective correct and consistent prevention strategy (such as condoms and / or the use of ART as a prevention), the risks and costs of PEP may outweigh the benefits because the risk of HIV transmission can already be very high low. Couples may want to prioritize PEP when highly effective strategies are not being used or in situations where they have been compromised, such as when the condom breaks, ART is impaired when some pill intakes are lost, an STD is present , or rupture of the genitals or rectal mucous membranes occurs.
- Assistance in developing a quick access plan to the PEP if it is needed. Ideally, this planning should occur before the need for PEP, to ensure that it can be accessed quickly when needed. The Hospital / Local emergency services should be contacted to determine if PEP is available and how much it costs. Emergency services are the ideal place to access PEP as they are usually open 24 hours a day. Other potential sources of PEP include a family doctor, HIV-positive patients from the HIV medical partner, or local health centers. Efforts should be made to determine whether public health insurance covers some or all of the costs of PEP. If patients have private health insurance, they should be encouraged to determine that their health insurance company covers PEP.
- Support with membership and commitment to streamline services. This should explore potential barriers to adherence / commitment (and how to overcome them) and the important role of partner can play by helping support adherence.
Sexually transmitted infections in both HIV-positive and HIV-negative patients may increase the risk of HIV transmission17 , prevention and treatment of STDs can help reduce a couple's risk of HIV transmission.
Counseling should encourage couples to take tests for DSTS (and treated if necessary) before engaging in sex and that could lead to STDs or transmission of the HIV virus. If a relationship is not monogamous and there are no other sexual partners, a couple may want to have tested for DSTS on a regular basis. Couples should be advised to use a condom when there is a risk of STD transmission.
Negotiated agreements Sexual / security
Counseling should encourage couples to discuss the state of their relationship (monogamous or non-monogamous) and reveal if there are sexual partners outside the couple. Sex with external partners can introduce STIs into key relationships and this can increase the risk of Sexually Transmitted Infections and even transmission of the HIV virus. In addition, for a serodiscordant couple as a highly effective and consistently correct strategy, the primary risk of HIV infection for the HIV-negative partner may have or have had sexual intercourse with sexual partners.34
In order to avoid the introduction of DSTS into a relationship, counseling should encourage and support non-monogamous couples with developing agreements about what is (and is not) with partners outside the relationship. This advice should establish the importance of disclosure when an agreement is broken as disclosure can help inform the decisions related to STI testing and necessary testing or even a change in prevention strategy.
There are several HIV prevention strategies available to avoid HIV transmission in serodiscordant couples. While these can drastically reduce the risk of HIV transmission, research shows that misuse and / or inconsistent use of these strategies can dramatically reduce their effectiveness. The Front Line Service Providers can play an important role in helping serodiscordant couples in choosing and accessing these HIV prevention strategies to promote and optimize defined strategies.
Adaptation and revision: originals in Canadian English for Brazilian Portuguese (it does not exist Brazil with “z” and “Brazil” is, in the idiomatic question, an aberration created for people that only God knows why they do it and that may obscure the intention they may have ...)
The original "PrEP as a bridge to ART" strategy dramatically reduces risk of HIV transmission for heterosexual serodiscordant couples by Claudio Souza 20 in April 2015. Know and enjoy our Facebook page
This information "was provided by CATIE (Canada Exchange of information on AIDS treatment). For more information, I am adding to the coast with CATIE, 1.800.263.1638 or by email at Catie. The first mention should appear in any online publication, with a link back to the original.
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Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations - The World Health Organization (WHO)
HIV viral load, HIV treatment and sexual HIV transmission - CATIE Factsheet
Treatment and viral load: what do we know about their effect on HIV transmission? -Prevention in Focus
Pre-exposure prophylaxis (PrEP) - CATIE Fact Sheet
Moving PrEP into practice: an update on research and implementation - Prevention in Focus
- Cohen MS, Chen YQ, McCauley M, et al. Prevention of HIV-1 infection with early antiretroviral therapy. New England Journal of Medicine. 2011;365(6):493-505.
- Baeten JM, Haberer JE, Liu AY, Sista N. Preexposure prophylaxis for HIV prevention: where have we been and where are we going? Journal of Acquired Immune Deficiency Syndromes. 2013; 63 Suppl 2: S122-S129.
- Baeten J, Heffron R, Kidoguchi L, et al. Near Elimination of HIV Transmission in a Demonstration Project of PrEP and ART. In: Program and abstracts of the22nd Conference on Retroviruses and Opportunistic Infections (CROI), Seattle, USA, Feb 23-26, 2015. Abstract 24.