What Works for Women and Girls

viral load below 400 copies/ml but data were compatible with one transmission per 79person-years. In ten studies with HIV-positive people not receiving antiretroviral therapywith 9,998 person years of follow-up, the overall HIV transmission rate, irrespectiveof viral load category and sexually transmitted diseases, the transmission rate was 5.64per 100 person years. The largest number of serodiscordant couples was reported infive studies from sub-Saharan Africa. “There was insufficient data to allow estimationof summary rates of transmission through sexual intercourse without condoms, or toseparate female-male and male-female transmission” (Attia et al., 2009: 1399). “Thissystematic review did not identify any study from which the risk of HIV transmissionper act of unprotected sexual intercourse among persons with suppressed viremiafollowing ART could be quantified directly. The available studies found no episodesof HIV transmission in discordant heterosexual couples If the HIV-infected partnerwas treated with ART and had a viral load below 400 copies/ml…The comparison ofoverall rates in patients on ART and not on ART nevertheless indicated that heterosexualtransmission was reduced by 92%” (Attia et al., 2009: 1401). (Gray V) (treatment,sex behavior, Sub-Saharan Africa)“The Commission of Experts of Clinical HIV/AIDS Therapy of the Federal Office ofPublic Health of Switzerland concluded that an HIV-positive person who does not havean STI and is on HAART, with undetectable viral load under 40 copies per ml cannottransmit HIV sexually, as long as the person is completely adherent; viral load is undetectablefor at least six months; and has no other STIs. It is estimated that in the caseof complete suppression of viral load, the risk to transmit HIV through sexual intercoursewithout using condoms is less than 1 in 100,000. The Commission cautionedthat this should apply only to patients who are highly motivated to be adherent, are in astable relationship, are regularly followed by a physician, have no STIs, are in a mutuallymonogamous relationship and the HIV-negative partner is counseled and agreesto not use condoms. The HIV-negative partner must be the one to decide, since if theydo acquire HIV, the consequences are most significant for the HIV-negative partner.Both partners must be counseled jointly (Vernazza et al., 2008). However, ability todetect viral load below 40 copies ml, regular physician monitoring and partner counselingas described in Switzerland in Vernazza et al., 2008 has not been described in adeveloping country context. Others have argued that treatment alone is not reliable, aswomen receiving antiretroviral therapy shed HIV (Cohen et al, 2009). (Gray V) (treatment,condoms, Switzerland)Data from 3,408 heterosexual HIV serodiscordant couples from seven African countries(Botswana, Kenya, Rwanda, South Africa, Tanzania, Uganda, and Zambia) wasanalyzed and found that ART use was associated with substantially lower risk for HIVtransmission. Of 103 couples, only one transmission occurred when the HIV-positivecouple had initiated treatment. Couples were followed for up to 24 months, with HIVtesting of uninfected partners every three months. None of the HIV-positive partnerswho initiated treatment met national eligibility criteria for ARV treatment initiation180 CHAPTER 7 TREATMENT