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In January 2008, the Swiss National HIV/AIDS Commission published a highly controversial statement indicating that HIV-infected individuals could consider discontinuing condom use in a stable partnership if they were receiving antiretroviral therapy (ART), had been virologically suppressed for at least 6 months, and had no other sexually transmitted infections. Now, researchers (many of whom coauthored the statement) describe how this guidance may have affected sexual risk behavior in Switzerland.
Using data from the Swiss HIV Cohort Study, the investigators evaluated predictors of inconsistent condom use among 7309 HIV-infected patients who were seen at least once between 2007 and 2009. Most of the patients (66%) were receiving ART and had achieved virologic suppression.
Condom use varied substantially by type of partner (stable versus occasional) and serostatus of the partner. In stable serodiscordant partnerships, inconsistent condom use was reported more frequently in patients who were receiving suppressive ART than in those who were not — and was also more common after the publication of the “Swiss statement” than before. Noninjection-drug use and substantial alcohol use were also associated with inconsistent condom use.
Hasse B et al. Frequency and determinants of unprotected sex among HIV-infected persons: The Swiss HIV Cohort Study. Clin Infect Dis 2010 Dec 1; 51:1314.
Cohen MS. HIV treatment as prevention and “The Swiss statement”: In for a dime, in for a dollar? Clin Infect Dis 2010 Dec 1; 51:1323.
Comment
This study could not answer the question of whether the “Swiss statement” has led to increased HIV transmission, but it does indicate that the statement has led to decreased condom use, at least in Switzerland. Whether this is also true outside of Switzerland is unclear, but a word of caution is in order. Although several observational studies of serodiscordant couples have shown reduced likelihood of HIV transmission when the HIV-infected partner is receiving ART, most of these studies were of relatively short duration. Furthermore, there have been reported cases of transmission even from virologically suppressed patients, and viral replication can occur in the genitourinary tract despite virologic suppression in the plasma. Although ART is a promising avenue for preventing the spread of HIV, we need data, not opinions, before we encourage serodiscordant couples to skip the condoms.