Problem is that by routine testing the low risk population (non-iv drug

user heterosexuals) we are uncovering HIV positive people who never
get sick and don’t have a disease, called Elite Controllers.  We know
from
experience that when you notify people in low risk groups that they
have HIV, they are fired from their jobs, cant get health insurance,
ostracized from the community  and some commit suicide.  Considering
this kind of downside to uncovering this information, it is not
valuable.  It is harmful .

By the way, after 20 years of HIV research, there has never been a
documented case (in the medical literature) of HIV or AIDS disease
transmitted from Elite
Controller to another person (spouse or partner) through heterosexual
contact, so the idea that by testing these people we will reduce
transmission rate is false.   There is no transmission risk from Elite
Controllers.

In addition, heterosexual transmission between couples is actually
quite rare and may never happen after many years of contact in some
couples as reported by Dr.
MacGregor, Horsburgh and Levy: (see references below)

MacGregor RR et al. Failure of culture and polymerase chain reaction to

detect human immunodeficiency virus (HIV) in seronegative steady sexual

partners of HIV-infected individuals. Clin Infect Dis. 1995
Jul;21(1):122-7.

Horsburgh CR et al. Concordance of polymerase chain reaction with HIV
antibody detection. J Infect Dis. 1990 Aug;162:542-5.

Levy JA. The transmission of AIDS: the case of the infected cell. JAMA.

1988;259(20):3037-8.

Regards from www.drdach.com

The great thing about telling somebody they’re dying is it tends
to focus their priorities. You find out what matters to them.
What they’re willing to die for. What they’re willing to lie for.
– Dr. Gregory House, Three Stories

http://en.wikipedia.org/wiki/House_%28TV_Series%29
http://fox.com/house/

George M. Carter

**
Allen S, Meinzen-Derr J, Kautzman M, Zulu I, Trask S, Fideli U,
Musonda R, Kasolo F, Gao F, Haworth A.  Sexual behavior of HIV
discordant couples after HIV counseling and testing. AIDS. 2003 Mar
28;17(5):733-40.

Department of Epidemiology and International Health, School of Public
Health, University of Alabama in Birmingham, 35294, USA.

BACKGROUND AND OBJECTIVES: Sexual behavior following voluntary HIV
counseling and testing (VCT) is described in 963 cohabiting
heterosexual couples with one HIV positive and one HIV negative
partner (‘discordant couples’). Biological markers were used to assess
the validity of self-report. METHODS: Couples were recruited from a
same-day VCT center in Lusaka, Zambia. Sexual exposures with and
without condoms were recorded at 3-monthly intervals. Sperm detected
on vaginal smears, pregnancy, and sexually transmitted diseases (STD)
including HIV, gonorrhea, syphilis, and Trichomonas vaginalis were
assessed. RESULTS: Less than 3% of couples reported current condom use
prior to VCT. In the year after VCT, > 80% of reported acts of
intercourse in discordant couples included condom use. Reporting 100%
condom use was associated with 39-70% reductions in biological
markers; however most intervals with reported unprotected sex were
negative for all biological markers. Under-reporting was common: 50%
of sperm and 32% of pregnancies and HIV transmissions were detected
when couples had reported always using condoms. Positive laboratory
tests for STD and reported extramarital sex were relatively
infrequent. DNA sequencing confirmed that 87% of new HIV infections
were acquired from the spouse. CONCLUSIONS: Joint VCT prompted
sustained but imperfect condom use in HIV discordant couples.
Biological markers were insensitive but provided evidence for a
significant under-reporting of unprotected sex. Strategies that
encourage truthful reporting of sexual behavior and sensitive
biological markers of exposure are urgently needed. The impact of
prevention programs should be assessed with both behavioral and
biological measures.

PMID: 12646797 [PubMed - indexed for MEDLINE]

***
Fideli US, Allen SA, Musonda R, Trask S, Hahn BH, Weiss H, Mulenga J,
Kasolo F, Vermund SH, Aldrovandi GM.  Virologic and immunologic
determinants of heterosexual transmission of human immunodeficiency
virus type 1 in Africa. AIDS Res Hum Retroviruses. 2001 Jul
1;17(10):901-10.

Department of Epidemiology and International Health, School of Public
Health, University of Alabama at Birmingham, Birmingham, Alabama
35294, USA.

More than 80% of the world’s HIV-infected adults live in sub-Saharan
Africa, where heterosexual transmission is the predominant mode of
spread. The virologic and immunologic correlates of female-to-male
(FTM) and male-to-female (MTF) transmission are not well understood. A
total of 1022 heterosexual couples with discordant HIV-1 serology
results (one partner HIV infected, the other HIV uninfected) were
enrolled in a prospective study in Lusaka, Zambia and monitored at
3-month intervals. A nested case-control design was used to compare
109 transmitters and 208 nontransmitting controls with respect to
plasma HIV-1 RNA (viral load, VL), virus isolation, and CD4(+) cell
levels. Median plasma VL was significantly higher in transmitters than
nontransmitters (123,507 vs. 51,310 copies/ml, p < 0.001). In
stratified multivariate Cox regression analyses, the risk ratio (RR)
for FTM transmission was 7.6 (95% CI: 2.3, 25.5) for VL > or = 100,000
copies/ml and 4.1 (95% CI: 1.2, 14.1) for VL between 10,000 and
100,000 copies/ml compared with the reference group of <10,000
copies/ml. Corresponding RRs for MTF transmission were 2.1 and 1.2,
respectively, with 95% CI both bounding 1. Only 3 of 41 (7%) female
transmitters had VL < 10,000 copies/ml compared with 32 of 93 (34%) of
female nontransmitters (p < 0.001). The transmission rate within
couples was 7.7/100 person-years and did not differ from FTM (61/862
person-years) and MTF (81/978 person-years) transmission. We conclude
that the association between increasing plasma viral load was strong
for female to male transmission, but was only weakly predictive of
male to female transmission in Zambian heterosexual couples. FTM and
MTF transmission rates were similar. These data suggest
gender-specific differences in the biology of heterosexual
transmission.

***
Gray RH, Wawer MJ, Brookmeyer R, Sewankambo NK, Serwadda D,
Wabwire-Mangen F, Lutalo T, Li X, vanCott T, Quinn TC; Rakai Project
Team.  Probability of HIV-1 transmission per coital act in monogamous,
heterosexual, HIV-1-discordant couples in Rakai, Uganda. Lancet. 2001
Apr 14;357(9263):1149-53.

Departments of Population and Family Health Sciences, School of
Hygiene and Public Health, Johns Hopkins University, Baltimore, MD
21205, USA. rg…@jhsph.edu

BACKGROUND: The probability of HIV-1 transmission per coital act in
representative African populations is unknown. We aimed to calculate
this probability overall, and to estimate how it is affected by
various factors thought to influence infectivity. METHODS: 174
monogamous couples, in which one partner was HIV-1 positive, were
retrospectively identified from a population cohort in Rakai, Uganda.
Frequency of intercourse and reliability of reporting within couples
was assessed prospectively. HIV-1 seroconversion was determined in the
uninfected partners, and HIV-1 viral load was measured in the infected
partners. Adjusted rate ratios of transmission per coital act were
estimated by Poisson regression. Probabilities of transmission per act
were estimated by log-log binomial regression for quartiles of age and
HIV-1 viral load, and for symptoms or diagnoses of sexually
transmitted diseases (STDs) in the HIV-1-infected partners. RESULTS:
The mean frequency of intercourse was 8.9 per month, which declined
with age and HIV-1 viral load. Members of couples reported similar
frequencies of intercourse. The overall unadjusted probability of
HIV-1 transmission per coital act was 0.0011 (95% CI 0.0008-0.0015).
Transmission probabilities increased from 0.0001 per act at viral
loads of less than 1700 copies/mL to 0.0023 per act at 38 500
copies/mL or more (p=0.002), and were 0.0041 with genital ulceration
versus 0.0011 without (p=0.02). Transmission probabilities per act did
not differ significantly by HIV-1 subtypes A and D, sex, STDs, or
symptoms of discharge or dysuria in the HIV-1-positive partner.
INTERPRETATION: Higher viral load and genital ulceration are the main
determinants of HIV-1 transmission per coital act in this Ugandan
population.

***
Johnson AM, Laga M.  Heterosexual transmission of HIV. ]AIDS. 1988;2
Suppl 1:S49-56.

\Academic Department of Genito-Urinary Medicine, University College
and Middlesex School of Medicine, London.

PIP: Recent developments concerning heterosexual transmission of HIV
(review of 1988 literature only) suggest improved understanding of the
pattern of spread and role of risk behaviors and biological cofactors
in its transmission. 3 distinct patterns if HIV infection are known:
heterosexual spread in sub-Saharan Africa and the Caribbean, spread
primarily among homosexuals and injecting drug users in Europe, North
American and much of Latin America and Australia, and both homosexual
and heterosexual transmission in Asia, the Pacific, the Middle East
and Eastern Europe, where prevalence is low. In Africa an estimated
80% of cases are acquired heterosexually. Important risk factors are
number of sex partners, sex with prostitutes, being a prostitute,
being a sex partner of an infected person, and having a history of
other sexually transmitted diseases. Prevalence rates have risen
rapidly in Zaire and Kenya. In Africa, acquisition of HIV is related
to sexual activity only. In contrast, in the U.S., heterosexual cases
make up only 4% of all cases, and in Europe only 6%. Data on types of
sexual transmission of HIV are mounting, in aggregate suggestive of a
marked heterogeneity in infectivity and possibly susceptibility
between individuals. Among couples where the man is positive, in some
places individuals appear to be highly infective, notably those from
Kinshasa, Zaire and Haiti, while other series of discordant couples
the receptive partner remained seronegative for several years.
Transmission from women to men appears to be less efficient than from
men to women, as has been observed with other STDs such as gonorrhea.
Biological cofactors implicated in enhanced HIV transmission appear to
be advanced CDC Stage IV AIDS disease, with low T-helper lymphocyte
counts and high antigenemia; concomitant STDS, especially those with
genital ulceration; lack of circumcision; oral contraceptive use;
practice of anal intercourse; inconsistent or no use of condoms.
Theoretical models for future heterosexual spread emphasize number of
partners, use of condoms, and treatment of STDs

http://www.wired.com/news/wireservice/0,71492-0.html?tw=wn_index_7

Reuters 09:45 AM Jul, 29, 2006

WASHINGTON — The AIDS virus hides out inside people’s intestines,
researchers said on Saturday in a report that offers new understanding of
the incurable infection. The virus replicates in the lining of the gut and does
much of its damage to the immune system there, Satya Dandekar,
chairwoman of the Department of Medical Microbiology and Immunology
at the University of California Davis Health System, and colleagues reported.

Writing in the Journal of Virology, Dandekar said the study was the first
to explain why the drug cocktails taken by HIV patients so often fail to
work completely. "The real battle between the virus and exposed individuals
is happening in the gut immediately after viral infection," she said in a
statement. "We need to be focusing our efforts on improving treatment of
gut mucosa, where massive destruction of immune cells is occurring.
Gut-associated lymphoid tissue accounts for 70 percent of the body’s
immune system. Restoring its function is crucial to ridding the body of
the virus."

HIV cannot be cured but the drugs, known as highly active antiretroviral
therapy, or HAART, can keep the virus under control. At first, doctors
had hoped that years of treatment might eventually eradicate the virus,
but, 25 years into the epidemic of AIDS, it is clear that cannot happen.
That is because the virus can hide out quietly in reservoirs, which include
certain immune cells. The gut is clearly important, too, Dandekar’s team
said. "We found a substantial delay in the time that it takes to restore the
gut mucosal immune system in those with chronic infections," Dandekar
said. "In these patients the gut is acting as a viral reservoir that keeps us
from ridding patients of the virus." The mucosa are the wet tissues that
line the nose and throat, the genitals and the inside of the gut. HIV often
infects people via the mucosa.

Dandekar’s team has been studying HIV-infected patients who, even
without treatment, have survived more than 10 years with healthy immune
systems, including the T-cells that are attacked by the virus. "We looked
at their gut lymphoid tissue and did not see loss of T-cells there. This
correlated with better clinical outcomes," Dandekar said. So they started
the current study, following 10 patients being treated with HAART, taking
blood and gut samples before and after three years of treatment.

They found evidence of inflammation, which disrupts tissue function,
promotes cell death and upsets the normal balance of gut bacteria.
Dandekar said these findings suggest anti-inflammatory drugs may
help HAART work better.

The Crown Prosecution Service is seeking final views on a public
document to explain the way in which it deals with cases
involving the intentional or reckless sexual transmission of
infections which cause grievous bodily harm. To date, there have
been eight convictions in England and Wales under Section 20 of
the Offences Against the Person Act 1861 (OAPA), all based on the
reckless transmission of HIV.

Seamus Taylor, Director of Equality and Diversity, said: "We wish
to issue a clear statement that explains the way we handle cases
involving the intentional or reckless sexual transmission of
infections. We wish to set out our postion clearly as we want to
promote greater confidence in the criminal justice system – a key
aim for all agencies involved."

Some of the seven specific consultation questions deal with the
relevance, if any, of the defendant’s reliance on
medical/clinical advice that he/she received, if any weight
should be given to their ability to ensure the use of protection,
and if the context in which the sexual behaviour occurred should
be a relevant factor when determining whether it is the public
interest to prosecute.

The CPS has consulted members of sexual health community
organisations with professional knowledge in the fields of crime
reduction and victim and witness support in drafting the policy,
but the content is the responsibility of the CPS alone. The final
version of the public document will be published in early 2007.

Notes to Editors
1. Media enquires to CPS press office on 020 7710 6088.

2. The document is published in the CPS News section under the
   heading Consultation on our website during the length of the
   consultation, including how to respond.
http://www.cps.gov.uk/news/consultations/index.html

3. The types of Sexually Transmitted Infections covered by the
   policy are:
   Chlamydia;
   Genital Herpes;
   Gonorrhoea;
   Hepatitis A;
   Hepatitis B;
   Hepatitis C;
   HIV and AIDS;
   LGV (lymphogranuloma venerum);
   Non-Specific urethritis (NSU);
   Syphilis.

4. The CPS consulted the following organisations:
   African HIV Policy Network (AHPN);
   National AIDS Trust;
   Terrence Higgins Trust;
   UK Coalition of People Living with HIV and AIDS.
http://www.cps.gov.uk/news/pressreleases/151_06.html