title: Antiretroviral Therapy to Prevent HIV Acquisition in Serodiscordant Couples in a Hyperendemic Community in Rural South Africa.
abstract: Antiretroviral therapy (ART) was highly efficacious in preventing human immunodeficiency virus (HIV) transmission in stable serodiscordant couples in the HPTN-052 study, a resource-intensive randomized controlled trial with near-perfect ART adherence and mutual HIV status disclosure among all participating couples. However, minimal evidence exists of the effectiveness of ART in preventing HIV acquisition in stable serodiscordant couples in "real-life" population-based settings in hyperendemic communities of sub-Saharan Africa, where health systems are typically resource-poor and overburdened, adherence to ART is often low, and partners commonly do not disclose their HIV status to each other.
  
  
  
  Data arose from a population-based open cohort in KwaZulu-Natal, South Africa. A total of 17 016 HIV-uninfected individuals present between January 2005 and December 2013 were included. Interval-censored time-updated proportional hazards regression was used to assess how the ART status affected HIV transmission risk in stable serodiscordant relationships.
  
  
  
  We observed 1619 HIV seroconversions in 17 016 individuals, over 60 349 person-years follow-up time. During the follow-up period, 1846 individuals had an HIV-uninfected and 196 had an HIV-infected stable partner HIV incidence was 3.8/100 person-years (PY) among individuals with an HIV-infected partner (95% confidence interval [CI], 2.3-5.6), 1.4/100 PY (.4-3.5) among those with HIV-infected partners receiving ART, and 5.6/100 PY (3.5-8.4) among those with HIV-infected partners not receiving ART. Use of ART was associated with a 77% decrease in HIV acquisition risk among serodiscordant couples (adjusted hazard ratio, 0.23; 95% CI, .07-.80).
  
  
  
  ART initiation was associated with a very large reduction in HIV acquisition in serodiscordant couples in rural KwaZulu-Natal. However, this "real-life" effect was substantially lower than the effect observed in the HPTN-052 trial. To eliminate HIV transmission in serodiscordant couples, additional prevention interventions are probably needed.
authors.affiliation: Department of Epidemiology.
authors.forename: Catherine E
authors.initials: CE
authors.lastname: Oldenburg
authors.affiliation: Department of Global Health and Population Africa Centre for Population Health, Mtubatuba.
authors.forename: Till
authors.initials: T
authors.lastname: Bärnighausen
authors.affiliation: Africa Centre for Population Health, Mtubatuba Faculty of Health Sciences, University of KwaZulu-Natal, Durban, South Africa.
authors.forename: Frank
authors.initials: F
authors.lastname: Tanser
authors.affiliation: Africa Centre for Population Health, Mtubatuba.
authors.forename: Collins C
authors.initials: CC
authors.lastname: Iwuji
authors.affiliation: Department of Biostatistics, Harvard T. H. Chan School of Public Health.
authors.forename: Victor
authors.initials: V
authors.lastname: De Gruttola
authors.affiliation: Department of Epidemiology.
authors.forename: George R
authors.initials: GR
authors.lastname: Seage
authors.affiliation: Department of Epidemiology Department of The Fenway Institute, Fenway Community Health Departments of Behavioral and Social Sciences and Epidemiology, Institute for Community Health Promotion, Brown University School of Public Health, Providence, Rhode Island.
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Mimiaga
authors.affiliation: Department of Global Health and Population Department of The Fenway Institute, Fenway Community Health Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
authors.forename: Kenneth H
authors.initials: KH
authors.lastname: Mayer
authors.affiliation: Africa Centre for Population Health, Mtubatuba Division of Infection & Immunity, University College London, United Kingdom.
authors.forename: Deenan
authors.initials: D
authors.lastname: Pillay
authors.affiliation: Department of Global Health and Population Africa Centre for Population Health, Mtubatuba.
authors.forename: Guy
authors.initials: G
authors.lastname: Harling
mesh_terms: D000293:Adolescent; D000328:Adult; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D015331:Cohort Studies; D030881:Disclosure; D005260:Female; D006678:HIV / Q000276:immunology*; D015658:HIV Infections / Q000188:drug therapy / Q000453:epidemiology / Q000517:prevention & control* / Q000635:transmission; D006679:HIV Seropositivity; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D012424:Rural Population; D012747:Sexual Partners; D013019:South Africa / Q000453:epidemiology; D055815:Young Adult
chemical_list: D019380:Anti-HIV Agents
keywords: HIV; South Africa; antiretroviral therapy; serodiscordant couples; treatment as prevention