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Characterising HIV transmission risk among US patients with HIV in care: a cross-sectional study of sexual risk behaviour among individuals with viral load above 1500 copies/mL
  1. Michael J Stirratt1,
  2. Gary Marks2,
  3. Christine O’Daniels2,3,
  4. Edward R Cachay4,
  5. Meg Sullivan5,
  6. Michael J Mugavero6,
  7. Shireesha Dhanireddy7,
  8. Allan E Rodriguez8,
  9. Thomas P Giordano9,10
  1. 1 Division of AIDS Research, National Institute of Mental Health, Bethesda, Maryland, USA
  2. 2 Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
  3. 3 Carter Consulting, Inc, Atlanta, Georgia, USA
  4. 4 Division of Infectious Diseases, Department of Medicine, University of California San Diego, La Jolla, California, USA
  5. 5 Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
  6. 6 Division of Infectious Diseases, Department of Medicine, University of Alabama, Birmingham, Alabama, USA
  7. 7 Department of Medicine, University of Washington, Seattle, Washington, USA
  8. 8 Division of Infectious Diseases, Miller School of Medicine, University of Miami, Miami, Florida, USA
  9. 9 Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
  10. 10 Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
  1. Correspondence to Dr Michael J Stirratt, Division of AIDS Research, National Institute of Mental Health, MSC-9831, Bethesda, MD 20892, USA; stirrattm{at}


Objectives Viral load and sexual risk behaviour contribute to HIV transmission risk. High HIV viral loads present greater transmission risk than transient viral ‘blips’ above an undetectable level. This paper therefore characterises sexual risk behaviour among patients with HIV in care with viral loads>1500 copies/mL and associated demographic characteristics.

Methods This cross-sectional study was conducted at six HIV outpatient clinics in USA. The study sample comprises 1315 patients with HIV with a recent viral load >1500 copies/mL. This study sample was drawn from a larger sample of individuals with a recent viral load >1000 copies/mL who completed a computer-assisted self-interview (CASI) regarding sexual risk practices in the last 2 months. The study sample was 32% heterosexual men, 38% men who have sex with men (MSM) and 30% women.

Results Ninety per cent of the sample had their viral load assay within 60 days of the CASI. Thirty-seven per cent reported being sexually active (vaginal or anal intercourse) in the last 2 months. Most of the sexually active participants reported always using condoms (56.9%) or limiting condomless sex to seroconcordant partners (serosorting; 29.2% overall and 42.9% among MSM). Among sexually active participants who reported condomless anal or vaginal sex with an at-risk partner (14%), most had viral loads>10 000 copies/mL (62%).

Conclusions A relatively small number of patients with HIV in care with viral loads above 1500 copies/mL reported concurrent sexual transmission risk behaviours. Most of the individuals in this small group had markedly elevated viral loads, increasing the probability of transmission. Directing interventions to patients in care with high viral loads and concurrent risk behaviour could strengthen HIV prevention and reduce HIV infections.

Trial registration number NCT02044484, completed.

  • HIV
  • HIV infections
  • viral load
  • risk-taking
  • sexual behaviour
  • sexual partners
  • condoms
  • serosorting
  • treatment as prevention
  • antiretroviral therapy
  • highly active
  • heterosexuality
  • homosexuality
  • male

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  • Handling editor Catherine H Mercer

  • Contributors MJS conceived the idea, contributed to conceptualisation of statistical analyses and wrote the manuscript. GM contributed to idea, conducted statistical analyses and helped write and edit the manuscript. CO’D consulted on statistical analysis and edited manuscript. ERC, MS, MJM, SD, AD and TPG contributed to the idea, edited the manuscript and served as site investigators for the parent study.

  • Funding The study was funded by the US Centers for Disease Control and Prevention (CDC) and National Institute of Mental Health (NIMH).

  • Disclaimer The findings and conclusions in this report are those of the authors and do not necessarily represent the view of the U.S. National Institutes of Health (NIH) or Centers for Disease Control and Prevention (CDC).

  • Competing interests None declared.

  • Patient consent Obtained.

  • Ethics approval This study received IRB review and approval at the following six institutions (representing the six academically affiliated clinic sites): (1) Institutional Review Board for Baylor College of Medicine and Affiliated Hospitals; IRB approval H-32781. (2) Boston University Medical Campus Institutional Review Board; IRB approval H-32301. (3) University of Alabama at Birmingham (UAB) Institutional Review Board; IRB approval X130715003. (4) University of California, San Diego, Human Research Protection Program; IRB approval 130733. (5) University of Miami Institutional Review Board; IRB approval 20120619. (6) University of Washington Institutional Review Board; IRB approval 45249.

  • Provenance and peer review Not commissioned; externally peer reviewed.