Using Plasma Viral Load to Guide Antiretroviral Therapy Initiation to Prevent HIV-1 Transmission

Pamela M. Murnane, James P. Hughes, Connie Celum, Jairam R. Lingappa, Nelly Mugo, Carey Farquhar, James Kiarie, Anna Wald, Jared M. Baeten, Mary Campbell, Lawrence Corey, Robert W. Coombs, Amalia Magaret, M. Juliana McElrath, Rhoda Morrow, James I. Mullins, David Coetzee, Kenneth Fife, Edwin Were, Max EssexJoseph Makhema, Elly Katabira, Allan Ronald, Susan Allen, Kayitesi Kayitenkore, Etienne Karita, Elizabeth Bukusi, Craig Cohen, William Kanweka, Bellington Vwalika, Saidi Kapiga, Rachel Manongi, Grace John-Stewart, Mubiana Inambao, Sinead Delany-Moretlwe, Helen Rees, Guy de Bruyn, Glenda Gray, James McIntyre, Nelly Rwamba Mugo

Research output: Contribution to journalArticle

7 Scopus citations


Background: Current WHO guidelines recommend antiretroviral therapy (ART) initiation at CD4 counts ≤350 cells/μL. Increasing this threshold has been proposed, with a primary goal of reducing HIV-1 infectiousness. Because the quantity of HIV-1 in plasma is the primary predictor of HIV-1 transmission, consideration of plasma viral load in ART initiation guidelines is warranted. Methods: Using per-sex-act infectivity estimates and cross-sectional sexual behavior data from 2,484 HIV-1 infected persons with CD4 counts >350 enrolled in a study of African heterosexual HIV-1 serodiscordant couples, we calculated the number of transmissions expected and the number potentially averted under selected scenarios for ART initiation: i) CD4 count <500 cells/μL, ii) viral load ≥10,000 or ≥50,000 copies/mL and iii) universal treatment. For each scenario, we estimated the proportion of expected infections that could be averted, the proportion of infected persons initiating treatment, and the ratio of these proportions. Results: Initiating treatment at viral load ≥50,000 copies/mL would require treating 19.8% of infected persons with CD4 counts >350 while averting 40.5% of expected transmissions (ratio 2.0); treating at viral load ≥10,0000 copies/mL had a ratio of 1.5. In contrast, initiation at CD4 count <500 would require treating 41.8%, while averting 48.4% (ratio 1.1). Conclusion: Inclusion of viral load in ART initiation guidelines could permit targeting ART resources to HIV-1 infected persons who have a higher risk of transmitting HIV-1. Further work is needed to estimate costs and feasibility.

Original languageEnglish (US)
Article numbere51192
JournalPloS one
Issue number11
StatePublished - Nov 30 2012

ASJC Scopus subject areas

  • Biochemistry, Genetics and Molecular Biology(all)
  • Agricultural and Biological Sciences(all)
  • General

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    Murnane, P. M., Hughes, J. P., Celum, C., Lingappa, J. R., Mugo, N., Farquhar, C., Kiarie, J., Wald, A., Baeten, J. M., Campbell, M., Corey, L., Coombs, R. W., Magaret, A., Juliana McElrath, M., Morrow, R., Mullins, J. I., Coetzee, D., Fife, K., Were, E., ... Rwamba Mugo, N. (2012). Using Plasma Viral Load to Guide Antiretroviral Therapy Initiation to Prevent HIV-1 Transmission. PloS one, 7(11), [e51192].