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Title: A case scenario cutting across different HIV prevention issues

Article Number: EC2/2015/143

Authors: Dr Matin Ahmad Khan

Topic: Medicine



Most new HIV infections are acquired from stable, long-term partners. HIV serodiscordant relationships are among the most vulnerable to acquiring????  It is not uncommon getting exposed to body fluids of an HIV infected partner in a

sero -discordant (magnetic couples) set ups.  This is an interesting case scenario  cutting across   many issues about the transmissibility of HIV infection in. There may be queries from apprehensive people – seeking advice reg? ? HIV’s  probability of acquisition under some very  uncommon  conditions  which  may  be helpful for training/teaching purposes


The scenario (A non-HIV Patient getting exposed to semen of a HIV positive man with an  undetectable  viral load –VL at the hand having an open cut )  is an  interesting ,educative  and unique case scenario  as it involves almost all issues related to HIV prevention  i.e.  scanty information --withholding his/her name and gender possibly due to stigma/discrimination issues forwarded by the questioner and issues  involving responses  to various  situations in sero-discordant couples (‘magnetic couples ‘)   exposure in  an unique non-occupational yet non- sexual  mode  , counseling& testing issues,  initiating  nPEP ( Non-occupational Post Exposure Prophylaxis ) and PrEP (Pre- Exposure Prophylaxis) , TasP (Treatment as Prevention )  and   HTPN 052 Study.The importance of answering this  kind of scenarios lies in the fact that it  would help many-- including the questioner itself.


Descriptive study   discussing the different aspects  of HIV Prevention.


The questioner’s  HIV-acquisition risks  are  extremely  low (theoretically)  & unwarranted still  we will try  to put his/her  fears to rest  by  examining  the issues involved in this  case  critically and  coming up with scientifically based  explanations and accordingly advice  him/her taking into the considerations of HIV Testing and Treatment policies and Guidelines  of the land available .


This scenario is a very   interesting  one ,requiring many basic concepts of prevention of HIV/AIDS   for answering  and may be used for teaching/training  even medical professionals . .The questioner’s   HIV-acquisition risks  are  extremely  low (theoretically)  & unwarranted   and we will try  to put his/her  fears to rest  by  examining  the issues involved in this  case  critically and  coming up with scientifically based  explanations and accordingly advice  him/her taking into the considerations of HIV Testing and Treatment Policies and Guidelines  of the land available. The importance of answering   this  kind of scenarios lies in the fact that it  would help other  health professionals and  questioners  alike and may be useful in teaching/training settings. 

Key words : nPEP, PrEP, Discordant couple  TasP, 


    COMMENT - 1

  • Matin Ahmad Khan (Author) 16th Nov 2015 - 3:38 PM
    This is one case scenario which I was asked in a site where I answer question from people who get exposed to supposedly infected body fluids.and this question was the unique and that is why I incorporated for teaching purpose as it involves various modalities of HIV prevention.It is going to educate general population too.Pl ask questions .DR MATIN A KHAN

  • COMMENT - 2

  • Matin Ahmad Khan (Author) 17th Nov 2015 - 9:10 AM
    This case scenario discusses many modalities of prevention like Treatment as Prevention (TasP), nPEP ( non-occupational Post Exposure Prophylaxis),ans PrEP( Pre exposure Prophylaxis).and it is interesting that all three modalities can accomodated in this case scenario.DR MATIN AHMAD KHAN

  • COMMENT - 3

  • Matin Ahmad Khan (Author) 17th Nov 2015 - 9:37 AM
    Pre-exposure prophylaxis, or PrEP, for HIV prevention is a strategy that involves use of antiretroviral medications (ARVs) to reduce the risk of HIV infection in people who are HIV-negative. All of the current effectiveness and follow-on trials are testing tenofovir-based regimens—using either TDF/FTC (an antiretroviral containing tenofovir (TDF) and emtricitabine (FTC) that is sold under the brand name Truvada) or TDF (an antiretroviral pill marketed under the brand name Viread). Based on the data that have been collected to date the US Food and Drug Administration (FDA) announced its approval of daily oral TDF/FTC for PrEP in 2012.

  • COMMENT - 4

  • Matin Ahmad Khan (Author) 17th Nov 2015 - 9:40 AM
    Since 1996, ART using a combination of medications has helped keep millions of people living with HIV alive and healthy. Today, ART is widely viewed as the cornerstone of a comprehensive prevention response, too. This is based on evidence from trials of serodiscordant couples (in which one person is living with HIV and the other is not) that ART for the HIV-positive partner significantly reduced the chances of onward transmission. There is also evidence that effective ART reduces women’s risk of transmitting HIV via breastfeeding; and there are a range of strategies that use ARVs (individual antiretroviral drugs and/or combinations) to reduce risk of HIV transmission during pregnancy and labor.

    The term “treatment as prevention” is sometimes used to describe this expanded role of ART as an intervention that has a benefit for the individual’s health and as a prevention tool. This designation can be confusing, however, suggesting that there are times when ART is exclusively for clinical benefit. In fact, whenever an individual living with HIV is on ART and is virologically suppressed (e.g., he or she has an undetectable viral load), there is a prevention benefit, whether or not that is the reason the individual chose to be on treatment. It is important to note that right now, the decision about whether an individual with HIV begins ART is based on several factors, including the treatment guidelines in use wherever he or she lives. These guidelines may use factors like the individual’s clinical health, infection with other diseases and opportunistic infections, T-cell count and/or viral load tests (where available) to help an individual make the decision whether to start ART. There is no strong evidence on viral load and reduction in transmission to needle-sharing partners; the data on the effect of treatment as prevention is limited to individuals whose primary risk of HIV is via sexual exposure.

    Today the global AIDS response is being shaped by campaigns to expand access to ART for both clinical and prevention benefits. In June 2013, the World Health Organization updated its ARV guidelines to reflect treatment and prevention benefits—and suggests that countries offer ART to all HIV-positive individuals with CD4 cell counts of 500 or below, and to specific groups (pregnant or breastfeeding women, HIV-positive people in serodiscordant couples) regardless of CD4 cell count. In mid-2015, UNAIDS has launched the 90-90-90 “fast track” goals to ending the AIDS epidemic by 2030. These goals call for 90 percent of people living with HIV to know their status; 90 percent of those individuals to be on ART; and 90 percent of those individuals to be virologically suppressed by the year 2020. Advocates have a critical role to play to ensure that access is expanded in the context of choice, effective, community-led programming, an absence of coercion, and attention to the full range of other prevention strategies needed to begin to end AIDS.

  • COMMENT - 5

  • Matin Ahmad Khan (Author) 17th Nov 2015 - 9:47 AM
    Post-exposure prophylaxis (PEP)
    PEP is the use of HIV medicine to reduce the risk of HIV infection after a possible exposure to HIV. PEP may be used, for example, after a person has sex without a condom with a person who is infected with HIV or after a health care worker is accidentally exposed to HIV in the workplace. To be effective, PEP must be started within 3 days after the possible exposure to HIV.

  • COMMENT - 6

  • Matin Ahmad Khan (Author) 17th Nov 2015 - 9:50 AM
    PEP should only be used right after an uncommon situation with potential HIV exposure. If you are often exposed to HIV, for example, because you often have sex without a condom with a partner who is HIV-positive, repeated uses of PEP are not the right choice. That’s because, when drugs are given only after an exposure, more drugs and higher doses are needed to block infection than when they are started before the exposure and continued for a time thereafter. That’s an approach called pre-exposure prophylaxis, or PrEP. PrEP means taking a daily pill (brand name, Truvada) for months or years. This keeps medication in your body to keep HIV from making copies of itself and spreading infection through your body anytime you are exposed. If you are at ongoing risk for HIV, speak to your doctor about PrEP.

  • COMMENT - 7

  • Matin Ahmad Khan (Author) 17th Nov 2015 - 10:01 AM
    Antiretroviral Drugs—PEP, PrEP and Treatment as Prevention
    HIV drugs (antiretrovirals, or ARVs) are gaining considerable attention, not only for their ability to prolong disease-free survival for those living with HIV, but also for the role they may play in preventing transmission of the virus:
    Post-exposure prophylaxis (PEP): PEP involves taking a short course of ARV drugs, usually for a month, after a high-risk exposure. To be most effective, PEP should be started immediately after possible exposure, waiting no more than 72 hours.
    If you suspect a high-risk exposure to HIV—semen leaking out of a condom during intercourse with an HIV-positive insertive partner; receptive anal sex without a condom with a partner who is either HIV positive or whose status you do not know or you have shared drug-injection works with someone who is either HIV positive or whose status you do not know—contact your health care provider or local hospital emergency room as soon as possible.

    Pre-exposure prophylaxis (PrEP):PrEP (pre-exposure prophylaxis) is an HIV prevention tool in which an HIV-negative person takes antiretroviral medication to reduce the risk of contracting HIV. Currently, the available form of PrEP entails taking the pill Truvada, which is made of two drugs—tenofovir and emtricitabine. When these meds build up in the human body, they can stop HIV from replicating and establishing an infection. In 2012, the U.S. Food and Drug Administration (FDA) approved Truvada as PrEP with the requirement that it be used every day, even during periods of minimal or low-risk sexual activity. Future studies are exploring intermittent dosing strategies (for example, using PrEP only during high-risk periods). Researchers are also looking into injectable, long-lasting forms of PrEP as well as different medications that could be used as PrEP.
    The Centers for Disease Control and Prevention (CDC) recommends Truvada for those at high risk of HIV, including: those in a relationship with an HIV-positive partner; men who don't use condoms when having sex with men; men who have been diagnosed with a sexually transmitted infection (STI) in the past six months and who are not in a mutually monogamous relationship with an HIV-negative partner; heterosexuals who don't always use condoms for sex with partners who are themselves at high risk for HIV; and anyone who, in the past six months, has shared equipment when injecting illicit drugs or who has been in an injection drug treatment program.
    According to CDC recommendations, before prescribing PrEP, health-care providers should thoroughly assess a patient's HIV risk behaviors and also administer an HIV test. (More sensitive HIV tests can detect a more recent, or acute, infection; however, most home tests will not detect HIV during this "window period.") Tests for STIs are recommended. So, too, are tests for kidney function—tenofovir is associated with kidney toxicity—and hepatitis B virus (HBV), given that Truvada is also active against HBV and must be used cautiously.
    It is recommended that providers prescribe no more than a 90-day supply of PrEP and to offer extensive HIV risk-reduction counseling, adherence counseling and condoms. It is recommended that, before renewing Truvada scripts, providers follow up with patients every two to three months to test again for HIV, to assess adherence and HIV risk behavior, and to provide ongoing support and counseling. Kidney function testing is again recommended three months after a person first starts PrEP and yearly thereafter. Tests for common STIs are also recommended every six months, even if a person has no symptoms.
    PrEP is appropriate for periods of time when people have greater risk for contracting HIV. Those periods may be short or long or recurrent, depending on the individual. The CDC also recommends that before people discontinue PrEP—whether because of safety concerns, a positive HIV test result, or a person requests to stop treatment—their providers should link them to HIV care (if a person has become infected) or ongoing HIV risk-reduction counseling and support. For people who have hep B, their providers should also discuss whether to continue treatment as a means to control their hepatitis.
    Treatment-as-prevention: Whereas PrEP focuses on prescribing ARVs to people who aren't infected with HIV to help them remain free of the virus, treatment-as-prevention (TasP) involves prescribing ARVs to those who are infected with HIV in order to reduce the amount of virus in their blood (and genital fluids) so that they are less likely to infect others.
    One clinical trial, initially reported at a conference in July 2011, suggested TasP may be effective. The study, HIV Prevention Trials Network (HPTN 052) demonstrated that the use of ARVs by HIV-positive heterosexual men and women cut the chance that their HIV negative partner would become infected by roughly 96 percent.
    The U.S. Department of Health and Human Services now recommends ARV treatment for all people living with HIV, regardless of their CD4 cell count, based in part on the findings of HPTN 052 and other studies. This recommendation has been somewhat controversial, as the studies used to support it (including HPTN 052) primarily involved heterosexual couples in long-term monogamous relationships (TasP has not been studied in populations of men who have sex with men or injection drug users) and do not account for the variables in real-world situations (e.g., HIV-positive individuals with multiple partners, individuals engaging in unprotected anal sex, people on ARV treatment with drug resistance and detectable viral loads, etc.). These lingering questions have prompted additional research to explore not only the personal benefits of treatment—AIDS-free survival for the person infected with HIV—but also the public health implications of getting all HIV-positive people, especially those who are unaware of their status, in to care and on treatment to reduce the ongoing spread of HIV.
    Vaginal and Rectal Microbicides: Microbicides are an emerging technology designed to allow at-risk HIV-negative women and men to protect themselves from HIV. A microbicide has not yet been approved for this purpose.
    In July 2010, a clinical trial (CAPRISA 004) found that a microbicide gel containing the ARV Viread (tenofovir) demonstrated a 39 percent level of efficacy at preventing HIV infection when applied vaginally within 12 hours before and within 12 hours after sex. In November 2011, however, an interim review of data from another clinical trial (the VOICE study) revealed that the tenofovir gel was no more effective than a placebo gel at preventing HIV infection among females who used the microbicide once daily, regardless of the timing or frequency of sexual acts.
    Microbicide gels, applied vaginally and anally, continue to be explored in clinical trials. Researchers are also beginning studies of silicone rings containing ARVs that can be inserted vaginally and replaced on a monthly basis, making the microbicide easier to use (and potentially more effective).

  • COMMENT - 8

  • Matin Ahmad Khan (Author) 18th Nov 2015 - 12:29 PM
    Prevention benefits of HIV treatment
    The advent in 1996 of potent combination antiretroviral therapy (ART), sometimes called HAART (highly active antiretroviral therapy) or cART (effective combination antiretroviral therapy), changed the course of the HIV epidemic.These “cocktails” of three or more antiretroviral drugs used in combination gave patients and scientists new hope for fighting the epidemic, and have significantly improved life expectancy—to decades rather than months
    For many years, scientists believed that treating HIV-infected persons also significantly reduced their risk of transmitting the infection to sexual and drug-using partners who did not have the virus. The circumstantial evidence was substantial, but no one had conducted a randomized clinical trial— the gold standard for proving an intervention works. That changed in 2011 with the publication of findings from the HIV Prevention Trials Network (HPTN) 052 study, a randomized clinical trial designed in part to evaluate whether the early initiation of ART can prevent the sexual transmission of HIV among heterosexual couples in which one partner is HIV-infected and the other is not. This landmark study validated that early HIV treatment has a profound prevention benefit: results showed that the risk of transmitting HIV to an uninfected partner was reduced by 96%
    As a concept and a strategy, treating HIV-infected persons to improve their health and to reduce the risk of onward transmission—sometimes called 'treatment as prevention' (TasP) — refers to the personal and public health benefits of using ART to continuously suppress HIV viral load in the blood and genital fluids, which decreases the risk of transmitting the virus to others. The practice has been used since the mid- 1990s to prevent mother-to-child, or perinatal, transmission of the virus.
    Research published in 1994 showed that zidovudine, more commonly known as AZT, when given to HIV-infected pregnant women and to their newborns reduced the risk of perinatal transmission from about 25% to 8% . Since then, routinely testing pregnant women and treating infected mothers with ART during pregnancy, delivery, and while breastfeeding, when practiced according to recommendations, has reduced the mother’s risk of transmitting HIV to her child by 90%. In one study, women who received at least 14 days of ART reduced the risk of transmitting HIV to their babies to less than 1%

  • COMMENT - 9

  • Surya Narayanan Sethumadavan (Viewer) 19th Nov 2015 - 3:13 PM
    The biggest problem that researchers have found with anti retro-viral drugs is, the moment an anti retro viral drug is synthesized, the cell-wall structure of the virus changes so many drugs become redundant and obsolete with time. What can be done towards this? What is the possibility of an AIDS vaccine becoming a reality?

  • COMMENT - 10

  • Matin Ahmad Khan (Author) 20th Nov 2015 - 11:24 AM
    Yes, vaccines are the most powerful public health tools available—and an AIDS vaccine would play a powerful role in ensuring the end to the AIDS epidemic .The reason you stated . is indeed one of the the most important obstacles why we are still away from HIV Vaccines .Ideally an effective preventive AIDS vaccine would teach the body how to prevent HIV infection.
    While effective vaccines remain years away, there are more reasons for hope than ever before. Researchers are expanding on the result of a 2009 trial that showed, for the first time, that a vaccine can reduce the risk of HIV infection. They’re also pursuing ground breaking research with other novel vaccine strategies, including broadly neutralizing antibodies that target a wide range of HIV strains. At the same time, there is also exciting work in efforts to understand if and how to cure HIV in people who are already infected. The timeline for this work is long and uncertain. Here, too, advocacy is needed to sustain momentum.
    Today’s momentum depends on sustained funding. Policy makers and funders around the world must have the courage to sustain vital AIDS vaccine research for years to come, and advocates must keep the pressure on them to maintain their commitments.

  • COMMENT - 11

  • Matin Ahmad Khan (Author) 20th Nov 2015 - 11:30 AM
    I understand there the scientific world had made considerable progress towards HIV Vaccines and want to share the following advancements made in the field of AIDS Vaccines ::
    AIDS vaccine development has proven extremely challenging. HIV comes in many varieties and mutates rapidly, and it primarily attacks the very cells needed to mount an effective immune response. In fact, most vaccines to date have been developed by replicating the immune response of a person who had successfully eliminated an invading pathogen. Since no human to date has eliminated HIV using their own immune system, scientists cannot employ that important strategy.
    Five AIDS vaccine efficacy trials failed to show any impact on preventing infection. But in 2009 a trial called RV144 released results showing that those who received the vaccine were 31 percent less likely to become infected than those who received placebo. The RV144 vaccine regimen was a combination “prime-boost” vaccine requiring six injections over a six-month period. It used a vector derived from canary pox, called ALVAC, to “prime” the immune system. The “boost” was a manufactured protein modeled after the gp120 protein on the outer surface of the virus. RV144 results were the first proof of concept that a preventive AIDS vaccine was possible, and a major milestone for the field. RV144 was conducted at sites in Thailand only, and 31 percent is a relatively modest level of efficacy. A primary focus for the field has been to build on RV144 results toward a vaccine for licensure.
    An international consortium known as the Pox-Protein Public Private Partnership (or P5) is working together to examine whether changing the RV144 vaccine regimen, e.g., replacing the protein with a better formulation of gp120; adding an “adjuvant”, a substance to increase the body’s response to the vaccine; and/or increasing the number of boosts could result in greater efficacy.
    The HIV Vaccine Trials Network (HVTN) is focused on redesigning the RV144 regiment for the “clade C” subtype of HIV that is most prevalent in Southern Africa. HVTN 100—an early phase trial of the modified vaccine regimen—finally launched in South Africa in January 2015. Results are expected in late-2016. If there is a positive outcome, a large-scale clinical efficacy trial, HVTN 702, will start in late-2016 or early-2017. Positive efficacy results could lead to licensure of this vaccine.

    The HVTN is also conducting a series of clinical trials in Southern Africa to compare different prime-boost pox-protein vaccine regimens and hopefully identify more potent regimens and perhaps an immune correlate. An “immune correlate” is a vaccine-induced immune response such as an antibody or specific type of T cell that is linked to protection from HIV—the biological marker that tells scientists why the vaccine works. Finding an immune correlate for an AIDS vaccine could help scientists focus research, shorten trials, bring down costs, and guide regulatory and policy decisions in the future.
    In addition, the US Military HIV Research Program, the research group that conducted RV144 in Thailand, has conducted follow-up trials and is planning a series of additional clinical trials to build upon the RV144 results in the Thai population. An efficacy trial of an improved RV144 regimen for the Thai population could begin in 2018..

  • COMMENT - 12

  • Matin Ahmad Khan (Author) 22nd Nov 2015 - 1:50 PM
    Prevention is always better than cure and it is more valid if the disease is HIV/AIDS.This articles deals with all possible modalities of prevention and this scenario is really interesting and learning. Pl have a look at this article. .

  • COMMENT - 13

  • Matin Ahmad Khan (Author) 23rd Nov 2015 - 1:09 PM
    Thanks Dr Surya Narayanan Sethumadavan for your comments. Though RV 144 trials have proved to be 31.2% effective but still it gave something to cheer about for medical fraternity. With International funding shrinking for AIDS vaccine research and results of The HPTN 052 study showing the efficacy of treatment as prevention to be 96% ( in other words HIV-positive people taking ARVs were more than 20 times less likely to infect their partners than untreated people.) , more and more research is being conducted in the field of functional cure . Still we have a hope for a vaccine in near future because atleast 8 trials namely RV 306, NCAIDS X111012202, ,HVTN 100, HIV-V-A004, HIV-CORE 004, TAMOVAC-02, and HVTN 084, have moved into Phase II Trials.

  • COMMENT - 14

  • Haseemdeen (Viewer) 23rd Nov 2015 - 6:24 PM
    what about your opinion using condom it effective to prevent virus from leaking through condom wall ??

  • COMMENT - 15

  • Matin Ahmad Khan (Author) 24th Nov 2015 - 11:07 AM
    Thanks Dr Haseemdeen for your comments. Yes. Long-term studies involving couples where one partner is HIV-positive and the other is not (called
    serodiscordant couples) allow researchers to estimate the incidence of transmission among condom users and nonusers. Studies of these couples have found that consistent condom use reduces the risk of HIV transmission by between 80 and 94%.
    Resources :1 Centers for Disease Control and Prevention (CDC). Condoms and STDs: Fact Sheet for Public Health
    Personnel. Available at:
    2 Weller S, Davis K. Condom effectiveness in reducing heterosexual HIV transmission. Cochrane Database
    Syst Rev. 2002:CD003255.

  • COMMENT - 16

  • Matin Ahmad Khan (Author) 24th Nov 2015 - 11:12 AM
    Dr Haseemdeen For other STI viruses like HPV and Herpes though ,, condoms only can protect against these diseases if the sores are in areas covered by the condom..

  • COMMENT - 17

  • Amitabha Ray (Viewer) 25th Nov 2015 - 10:25 PM
    Interesting work, provides considerable food for thought.

  • COMMENT - 18

  • Matin Ahmad Khan (Author) 25th Nov 2015 - 11:26 PM
    Thanks Dr Amitabha Ray for your comments..In fact this article covers almost all the modalities of prevention of AIDS.

  • COMMENT - 19

  • PETHURU.D (Viewer) 26th Nov 2015 - 5:36 PM
    Dear Dr, Very nice case scenario giving answers to almost all aspects of HIV prevention education.

    But in real HIV education sessions, many rare but real instances are been unnecessary discussed while conveniently forgetting on responsible sexual behavior.

  • COMMENT - 20

  • Matin Ahmad Khan (Author) 26th Nov 2015 - 7:35 PM
    Thanks for your comments Dr Pethguru D. Yes responsible sexual behavior is an ideal , but can ideal things are not always achievable.

  • COMMENT - 21

  • Sincy Joseph (Viewer) 27th Nov 2015 - 5:33 PM
    Greeting ... this case study is very useful and has given answer to HIV prevention.....informative .