Reducing the viral load to suppress the virus is the primary goal of ART. Because it has the potential to lower HIV prevalence, a secondary goal of ART is to reduce the risk of transmission. 

CYNTHIA RIVERA, MD: I’d like to know why are prevention counselling efforts and behavioral health counseling important in preventing secondary transmission of HIV, Leandro? 

LEANDRO MENA, MD: That’s a great question. I think HIV in the United States is largely sexually transmitted. Of course, a proportion of our infections happen from sharing injecting drugs, but even the numbers of those infections have been reduced. Same thing has happened with our new cases of HIV infection. We should talk to or patients about how they can reduce the risk of transmitting HIV to others. Being at the top of the list making sure that they adherent to their medications. You know, treatment is prevention. 

DERRICK BUTLER, MD: Yeah, absolutely. The patient, they may buy into your treatment, but they have to understand that HIV is an infection that they can give to someone else. 

CYNTHIA RIVERA, MD: So true, I think if we take the time to listen to them, they listen to us, and our advice about behavioral modifications, and about the risk of transmission with concomitant sexually transmitted diseases increasing HIV transmission, for example. I really do think that has an impact. If done constantly on every visit, we will make an impact on the behaviors of our patients. So, Derrick, you alluded to some data that has shown that antiretroviral therapy is actually quite effective at reducing secondary transmission of HIV, and I’d like to know what conditions do you really like to see in your patients to make sure that that takes place? 

DERRICK BUTLER, MD: Well, the idea is that with their antiretroviral regimen and good adherence, they can maintain viral suppression, therefore, reducing their risk of transmission. That’s what this study, HPTN 052 and other subsequent studies have shown, although we know that, again, nothing is 100% even on good antiretroviral therapy. 

LEANDRO MENA, MD: It takes weeks, months from the point that someone achieves viral suppression to the point that the amount of virus in vaginal secretions, rectal secretions and semen is minimum. So, it is thought that at least someone needs to be suppressed for at least six months before they are considered to be at very low risk of transmitting HIV. The challenge is, and I talk to my patients, especially to my HIV-negative patients, how much can you trust that someone, in spite of all those challenges in life that we have talked about, nothing happens throughout their day, nothing happens throughout their life that may interfere with them taking medication, and the moment that they stop taking medication, there’s always a chance that their viral load is going to rebound. 

CYNTHIA RIVERA, MD: Absolutely right. So, Leandro, do you have any tools in your clinical practice that you use to help be effective in preventing sexual and blood borne transmission of HIV? 

LEANDRO MENA, MD: The main tool is really the consistent and effective use of antiretroviral therapy to achieve suppressed viral load, that consequentially will have the biggest impact, I believe, in the recent transmission of HIV. Certainly, having safer sex practices or drug use practices. I believe in also being aware of HIV status and the status of your partners. Using condoms correct and consistently is important, and then behavior, of course. 

DERRICK BUTLER, MD: Absolutely. One point that Leandro alluded to is the idea of understanding the patients’ partners or having the patients, especially those who have say one partner or a few that they know are HIV negative. Sometimes the patient understanding that they want to protect their own partners too, and part of, again, that patient-provider relationship is having the trust to talk about this issue with them, and I’ve asked the patient this, wouldn’t you would have liked to have known before you were infected by someone that they could have told you that they had HIV, and that your infection could have been prevented. 

CYNTHIA RIVERA, MD: Right. Disclosure is key. I think I’m making sure that we empower not only patients, but their intimate contacts to make the decision on whether they would like to be intimate with somebody who is HIV positive and take the appropriate steps is a large part of prevention of transmission along with what you’ve mentioned, the antiretroviral therapy, and consistent barrier methods.