Clinical round-up

EARLY ANTIRETROVIRAL THERAPY (ART) THAT SUPPRESSES REPLICATION REDUCES HIV TRANSMISSION BY 96% The findings of the first randomised control trial investigating the role of early ART on the prevention of HIV transmission were reported at the International AIDS Society Conference in Rome, Italy earlier this year with simultaneous publication in the New England Journal of Medicine. The HIV Prevention Trials Network 052 study, a multinational study, recruited 1763 serodiscordant couples. Fifty per cent of infected participants were male and 97% of couples were heterosexual. The HIV infected partner required a CD4 count between 350 and 500 cells/ml with no previous ART, except for the short-term prevention of mother-to-child transmission, and no active tuberculosis. They had to be willing to disclose HIV status to the uninfected partner, with whom they were in a stable relationship for at least the last 3 months, and reported three episodes of vaginal or anal intercourse during the same time period. The couples were randomised on a 1:1 basis to receive immediate ART (early therapy group) or when CD4 count declined to #250 cells/ml or following an AIDS defining condition (delayed therapy group). Following enrolment, participants attended monthly for the first three visits and quarterly thereafter. An additional visit occurred at any time if a participant was unwell and at 2 weeks following initiation for those commencing ART. Uninfected partners were encouraged to attend at the same time to undertake counselling on risk reduction/condom use, to receive treatment for STI or other medical conditions, and to be tested quarterly for HIV seroconversion. The study was interrupted when an interim analysis revealed that 39 transmissions had occurred (4 early group vs 35 delayed group, p<0.0001). Further analysis demonstrated 28 genetically linked transmissions of which one 1 occurred in the early arm in a patient who was yet to suppress viral load. This corresponds to an HR of 0.04 (95% CI 0.01 to 0.27, p<0.0001). Following these findings, all infected study participants have been offered ART. Undoubtedly, the study findings call for universal test and treat. But, the parallel implementation of other strategies in the prevention tool box are likely to be required, especially in populationsdsuch as men who have sex with men who are disproportionately affected in developed countriesdwho may not be represented by the participants in this trial. HEPATITIS C VIRUS (HCV) TESTING STUDY IN BURKINABÉ PREGNANT WOMEN REVEALS INCONSISTENT RESULTS IN TERMS OF ASSOCIATED RISK FACTORS FOR INFECTION A reference centre for the prevention of motherto-child HIV transmission in Ouagadougou, Burkina Faso, recruited 607 pregnant women aged 16e 45 years to undergo serological testing, for HIV and HCV, and to undertake a confidential questionnaire. Of these, 378 (62.67%) women tested HIV positive. Thirteen (2.14%) tested HCV-immunoglobulin G positive and all were confirmed to have active HCV infection with PCR. While numbers are small, of those with HCV, nine women were HIV coinfected but HIV serostatus was not significantly associated with HCV status (p1⁄40.81). This is surprising given the often shared route of transmission. While a higher proportion of HCV positive women reported genital excision (69.23% vs 42.8%), the difference just failed to meet significance with p>0.05. This would be in keeping with other ritual practices, such as ethnic scarification and gum tattooing, which were not found to be significantly different. As expected, HCV positivity was significantly associated with previous receipt of blood transfusion (7.74% vs 53.89%; p<0.01). The prevalence of HCV infection found in this cohort is consistent with that reported in other populations in the geographic region. These data support universal antenatal screening for HCV in this population; areas where HCV is less prevalent may wish to consider risk assessing patients to ensure that those who would benefit from testing are not missed, especially those who have received blood transfusion in countries where universal precautions are not or have not been in place. Sexual health services may even deem it appropriate to screen all women with female genital mutilation for HCV.