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Review
. 2006:117:213-24; discussion 225.

Amplified transmission of HIV-1: missing link in the HIV pandemic

Myron S Cohen  1
Affiliations
Review

Amplified transmission of HIV-1: missing link in the HIV pandemic

Myron S Cohen. Trans Am Clin Climatol Assoc. 2006.

Abstract

Sexual transmission of HIV most closely reflects the concentration of HIV in the genital tract; HIV in the genital tract of subjects with acute HIV and some "classical" STDS is 8-10 times greater than in control subjects. It seems likely that these latter subjects lead to spread of HIV. Accordingly, the state of North Carolina committed to HIV testing that detects subjects with acute, recent, and established infection. We tested 109,500 samples over 9 months. We found 563 people with undiagnosed HIV infection. The majority of subjects were in STD clinics. This included 23 subjects with (pre-seroconversion) acute HIV infection (HIV RNA positive, antibody negative). The median blood HIV was 209,000 copies/ml, more than 10 times higher than in subjects with established HIV infection. Recognizing the increased number of subjects with unrecognized acute HIV infection in STD clinics, we conducted similar studies in STD Clinics in Malawi and South Africa. Between 1 and 2% of subjects had undetected acute HIV infection. The median viral burden in blood of subjects in Malawi was greater than 1,000,000 copies/ml. STDS and HIV are often co-transmitted, and STDS set the stage for subsequent HIV transmission. Prevention of sexual transmission of HIV likely requires maximal suppression of genital tract HIV viral burden, either through treatment of STDS or use of antiretroviral agents.

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Figures

Fig. 1
Fig. 1
The probability of HIV transmission from a man to a female sexual partner through heterosexual intercourse based on the concentration of HIV in semen (adapted from reference 20). HIV transmission probability is also affected by the density of endocervical CCR5 receptors, represented as percentages in the population.
Fig. 2
Fig. 2
Comparison of the concentration of HIV in blood (n = 22) and semen (n = 33) of men in Malawi and the US at a similar stage of HIV disease and CD4 count. A horizontal bar represents the median concentration and vertical lines the standard error of the mean (adapted from reference 21). The differences between American and Malawian men are significant (p < 0.05).
Fig. 3
Fig. 3
Comparison of HIV concentration in blood of subjects with established and acute HIV infection in the US (3A) and Malawi (3B) adapted from references and , respectively.
Fig. 4
Fig. 4
The location of subjects with newly detected HIV infections through screening in public testing sites in North Carolina over 9 months (adapted from reference 34). A total of 109,500 people were screened: 45,656 in STD Clinics, 11,658 at local free testing sites, 3,053 in jails, and 7,575 at “other” venues reporting to the State. The majority of subjects with acute HIV infection (16/23) were found in STD Clinics.
Fig. 5
Fig. 5
Effects of treatment of urethritis on excretion of HIV in semen in 87 subjects in Malawi. Bars represent the median values (adapted from reference 40).
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References

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