Bernard M. Branson, MD
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Geneva University Hospital
December 13, 2006
Risk of HIV transmission with undetectable viral load
To quote the author:
"The unfavorable transmission scenario assumes that HIV screening and treatment increase HIV transmission by prolonging life (and therefore the duration of infectiousness) and that infected persons might increase sexual risk-taking because they mistakenly think that having an undetectable viral load means that they are not infectious."
Why "mistakenly"? HIV viral load is by far the most important determinant of infectiousness (1). Where is the evidence that transmission from persons with a undetectable viral load play a role in the HIV epidemic? Even isolated case reports are difficult to find.
(1) Quinn,T.C.; Wawer,M.J.; Sewankambo,N.; Serwadda,D.; Li,C.; Wabwire-Mangen,F.; Meehan,M.O.; Lutalo,T.; Gray,R.H. Viral load and heterosexual transmission of human immunodeficiency virus type 1. Rakai Project Study Group. N Engl J Med 2000;342:921-29.
Curt G Beckwith
Brown Medical School
January 5, 2007
Routine HIV Testing in Jails
We applaud Drs. Paltiel and co-authors and Dr. Branson for their recent articles [1-2] that support routine HIV testing. However, their recommendation for routine, voluntary HIV testing as part of primary medical care may miss most of the 750,000 individuals who are incarcerated in U.S. jails on any given day . Most of these individuals do not have primary care providers and are not clients of our nations' mainstream healthcare system. The prevalence of known HIV infection in U.S. jails is estimated to be 1.3 %  which is over 3 times greater than the prevalence rate for the general U.S. population however the true HIV prevalence in jails may be significantly higher. An estimated one-fourth of all people living with HIV in the U.S. each year are released from a correctional facility that same year . In particular, African-American men (the demographic group with the highest rate of HIV infection) are incarcerated in jail five times more frequently than White men . The Centers for Disease Control and Prevention recommend routine opt-out HIV testing in incarcerated settings but most jails have not yet implemented it. Focused advocacy is needed now by AIDS activists and the public health community to initiate routine HIV testing in jails with real possibility for opt-out voluntary testing, appropriate protection for confidentiality of results, and linkage to HIV care both within correctional facilities and in the community post-release.
1. Paltiel DA, Walensky RP, Schackman BR, Seage GR, Mercincavage LM, Weinstein MC, et al. Expanded HIV screening in the United States: Effect on clinical outcomes, HIV transmission, and costs. Ann Int Med. 2006; 145: 797-806.
2. Branson BM. To screen or not to screen: Is that really the question? Ann Intern Med. 2006; 145: 857-859.
3. Harrison PM, Beck AJ. Prison and jail inmates at midyear 2005. NCJ publication no. 213133. Bureau of Justice Statistics, US Department of Justice, Office of Justice Programs. Washington, DC, 2006.
4. Maruschak LM. HIV in prisons and jails, 2002. NCJ publication no. 205333. Bureau of Justice Statistics, US Department of Justice, Office of Justice Programs. Washington, DC, 2004.
5. Hammett TM, Harmon MP, Rhodes W. The burden of infectious disease among inmates of and releasees from U.S. correctional facilities, 1997. Am J Public Health. 2002; 92: 189-94.
Branson BM. To Screen or Not to Screen: Is That Really the Question?. Ann Intern Med. ;145:857–859. doi: 10.7326/0003-4819-145-11-200612050-00011
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Published: Ann Intern Med. 2006;145(11):857-859.
HIV, Infectious Disease.
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