title: The role of coinfections in HIV epidemic trajectory and positive prevention: a systematic review and meta-analysis.
abstract: OBJECTIVE
  Recurrent or persistent coinfections may increase HIV viral load and, consequently, risk of HIV transmission, thus increasing HIV incidence. We evaluated the association between malaria, herpes simplex virus type 2 (HSV-2) and tuberculosis (TB) coinfections and their treatment on HIV viral load.
  
  
  METHODS
  Systematic review and meta-analysis of the association of malaria, HSV-2 and TB coinfections and their treatment with HIV viral load.
  
  
  METHODS
  PubMed and Embase databases were searched to 10 February 2010 for studies in adults that reported HIV plasma and/or genital viral load by coinfection status or treatment. Meta-analyses were conducted using random-effects models.
  
  
  RESULTS
  Forty-five eligible articles were identified (six malaria, 20 HSV-2 and 19 TB). There was strong evidence of increased HIV viral load with acute malaria [0.67 log(10) copies/ml, 95% confidence interval (CI) 0.15-1.19] and decreased viral load following treatment (-0.37 log(10) copies/ml, 95% CI -0.70 to -0.04). Similarly, HSV-2 infection was associated with increased HIV viral load (0.18 log(10) copies/ml, 95% CI 0.01-0.34), which decreased with HSV suppressive therapy (-0.28 log(10) copies/ml, 95% CI -0.36 to -0.19). Active TB was associated with increased HIV viral load (0.40 log(10) copies/ml, 95% CI 0.13-0.67), but there was no association between TB treatment and viral load reduction (log(10) copies/ml -0.02, 95% CI -0.19 to 0.15).
  
  
  CONCLUSIONS
  Coinfections may increase HIV viral load in populations where they are prevalent, thereby facilitating HIV transmission. These effects may be reversed with treatment. However, to limit HIV trajectory and optimize positive prevention for HIV-infected individuals pre-antiretroviral therapy, we must better understand the mechanisms responsible for augmented viral load and the magnitude of viral load reduction required, and retune treatment regimens accordingly.
authors.affiliation: Department of Global Health, University of Washington, Seattle, USA. rbarnaba@uw.edu
authors.forename: Ruanne V
authors.initials: RV
authors.lastname: Barnabas
authors.forename: Emily L
authors.initials: EL
authors.lastname: Webb
authors.forename: Helen A
authors.initials: HA
authors.lastname: Weiss
authors.forename: Judith N
authors.initials: JN
authors.lastname: Wasserheit
mesh_terms: D017088:AIDS-Related Opportunistic Infections / Q000150:complications* / Q000188:drug therapy / Q000453:epidemiology; D000328:Adult; D015658:HIV Infections / Q000150:complications* / Q000517:prevention & control / Q000635:transmission; D006558:Herpes Genitalis / Q000150:complications* / Q000188:drug therapy / Q000453:epidemiology; D006801:Humans; D008288:Malaria / Q000150:complications* / Q000188:drug therapy / Q000453:epidemiology; D014376:Tuberculosis / Q000150:complications* / Q000188:drug therapy / Q000453:epidemiology; D019562:Viral Load