Antiretroviral Therapy to Prevent Sexual Transmission of HIV (Treatment as Prevention)
Clinical trials have shown that using effective antiretroviral therapy (ART) to consistently suppress plasma HIV RNA levels to <200 copies/mL prevents transmission of HIV to sexual partners. When ART is used to prevent HIV transmission, this strategy is called treatment as prevention (TasP), commonly known as Undetectable = Untransmittable or U=U.
The Panel on Antiretroviral Guidelines for Adults and Adolescents (the Panel) has added a new section to help providers integrate TasP into their clinical practice. The key recommendations include:
- Providers should inform persons with HIV that maintaining HIV RNA levels <200 copies/mL with ART prevents HIV transmission to sexual partners (AII).
- Persons starting ART should use another form of prevention with sexual partners for at least the first 6 months of treatment and until an HIV RNA level of <200 copies/mL has been documented (AII). Many experts recommend confirming sustained suppression before assuming that there is no risk of sexual HIV transmission (AIII).
- Persons with HIV who rely on ART for prevention need to maintain high levels of ART adherence (AIII). They should be informed that transmission is possible during periods of poor adherence or treatment interruption (AIII).
- Providers should inform patients that maintaining an HIV RNA level of <200 copies/mL does not prevent acquisition or transmission of other sexually transmitted infections (AII).
Dolutegravir Recommendations for Individuals of Childbearing Potential
The latest data on neural tube defects (NTDs) in infants born to women who received dolutegravir (DTG) around the time of conception have shown that the prevalence of NTDs is lower than initially reported (the rate has been reduced from 0.9% to 0.3%). However, this rate is still higher than the rate reported for infants born to individuals who received ART that did not contain DTG (0.1%).
In the previous version of the guidelines, the Panel did not recommend the use of DTG in persons who are pregnant and within 12 weeks post-conception or persons of childbearing potential who are planning to become pregnant or who are sexually active and not using effective contraception. Based on the new data, the Panel has revised these recommendations:
- Providers should discuss the benefits of using DTG and the risk of NTDs with the person of childbearing potential, to allow the person to make informed decisions about care.
- DTG may be used as an alternative antiretroviral (ARV) drug for individuals who are of childbearing potential and trying to conceive (BII) and those who are sexually active and not using contraception (BII).
- For individuals who are using effective contraception, DTG may be used as a recommended option (AII).
- Providers should refer to the Perinatal Guidelines for recommendations on the use of DTG during pregnancy.
More detailed recommendations on the use of DTG and other integrase strand transfer inhibitors (INSTIs) in persons of childbearing potential can be found in Table 6b, as well as in different sections of the guidelines where DTG is discussed.