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Some Men With Urethritis Have HIV in
Semen While Suppressed in Blood
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HIV Research for Prevention (HIVR4P), October 21-25, 2018, Madrid
Mark Mascolini
An undetectable viral load in blood does not guarantee undetectable HIV in semen among men with acute urethritis, according to a 56-man study from the University of North Carolina (UNC) at Chapel Hill [1]. Nine of these men (16%) had 13 episodes of simultaneous viral suppression in blood but detectability in semen.
Many perceive an undetectable viral load in blood as a guarantee that a person will not transmit HIV during sex. But UNC researchers pointed out that sexually transmitted infections (STIs) like urethritis cause genital tract inflammation and may raise seminal HIV loads. Semen, they noted, comprises a viral compartment distinct from blood. To assess the frequency of HIV breakthrough in semen during viral suppression in blood, they conducted this study.
The analysis involved 79 HIV-positive men taking antiretroviral therapy for at least 12 weeks who came to an STI clinic in Malawi with acute urethritis between January 2017 and May 2018. Men had follow-up visits at weeks 1, 2, 4, 8, 12, 24, 36, and 48 and additional visits if they had repeat urethritis. They gave blood, semen, and urethral swab samples and completed a survey including questions on antiretroviral adherence. All men had their urethritis treated with gentamicin, doxycycline, and metronidazole.
The 79 study participants had a median age of 35 years, 72% were married and 18% separated or divorced. They reported a median of 8 sexual encounters per month, and only 16 men (20%) used a condom the last time they had sex. Besides urethritis, 64 men (81%) had gonorrhea, 2 chlamydia, 2 trichomonas, and 8 syphilis.
Most men, 86%, were taking an efavirenz regimen. While 71% of men had a viral load below 1000 copies in blood, 67% had a load below 1000 copies in semen. Median CD4 count stood at 347.
Among the 56 men with a viral load below 1000 copies in blood, 9 (16%) had 13 episodes of simultaneous viral suppression in blood and detectable virus in semen. During these 13 episodes, median viral load in semen stood at 4.3 log10 copies, or about 20,000 copies. All episodes of seminal viral breakthrough began in the 2 weeks after the men came to the clinic with urethritis and resolved 8 weeks after urethritis treatment ended.
The UNC team concluded that "a notable percentage" of men with acute urethritis had detectable HIV in semen but not in blood. They observed that "the replication competence and fitness of these breakthrough [HIV] variants will have important implications for the potential for onward HIV transmission during acute urethritis, as well as for HIV cure research."
Reference
1. Chen JS, Matoga M, Massa C, et al. Back to the future: even in the ART era, men co-infected with HIV and urethritis pose a potential transmission threat. HIV Research for Prevention (HIVR4P), October 21-25, 2018, Madrid. Abstract P28.21LB.
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