VIRAL LOAD AND HETEROSEXUAL TRANSMISSION OF HUMAN IMMUNODEFICIENCY VIRUS TYPE 1

In sub-Saharan Africa, the predominant mode of transmission of HIV-1 is through heterosexual contact associated with a wide variety of behavioural and biological risk factors. An improved understanding of the risk factors could greatly facilitate the efforts being made to curb the transmission of the virus. To deliniate the risk factors specifically associated with heterosexual transmission of HIV-1 more clearly, Quinn et alconducted a community-based study of 15,127 persons in the rural Rakai district of Uganda. The study which lasted from November 1994 to October 1998 grouped rural communities located on secondary roads into 10 clusters. 5 of these community clusters were randomly assigned to receive intervention for sexually transmitted diseases, and 5 clusters were randomly assigned to a control group. Community-based surveys were conducted at 10 month intervals.

Individuals eligible for the study were read a consent form that explained the study and its potential risks and benefits, and they were informed of their rights to decline all or part of the study activities without loss of access to clinical and educational services. Furthermore, the subjects were encouraged to obtain the results of their HIV-status and share it with thier partner.
 

ISSUES

• For upto 30 months 415 individuals with HIV infection were observed but not treated <see Tuskegee Syphilis Study>. Furthermore, the subjects that tested positive for other sexually transmitted diseases were left to seek their own treatment. If such a study were to be conducted in the United States the caregiver would be expected to provide adequate treatment to both HIV infected individuals and those infected with other sexually transmitted diseases. Are we then provided with ample justification since, "Antiretroviral drugs are not available in rural Uganda," to forego the ethical standards that would apply in the developed world?
• In most of the developed world the caregiver is expected to inform a seronegative partner of his/her special risk. But in this study conducted in Uganda it was left entirely up to the seropositive partner to inform the seronegative partner, despite the fact that both partners were regualrly seen by the investigators.
• The study conducted by Quinn et al may be relevant to the Ugandan population from which the subjects were drawn but are these individuals also going to be the ones that benefit from the results? <see The Belmont Report>

REFERENCES

1) Quinn et al: Viral Load and Heterosexual Transmission of Human Immunodeficiency Virus Type 1. NEJM 342 (13): 921-929, 2000