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Combined antiretroviral therapy is effective on blood plasma HIV-1-RNA: what about semen HIV-1-RNA levels?

HIV is mainly transmitted via the sexual route. Thus, semen plays a major role in the transmission of HIV. Empirical studies conducted in serodiscordant couples have estimated the risk of HIV-1 transmission per sexual act in the absence of treatment to range between 0.0005 and 0.01 depending on the type of sexual intercourse with receptive anal intercourse among men who have sex with men (MSM) bearing the highest risk [1,2]. The risk of HIV transmission has been shown to be significantly correlated with blood plasma HIV-1 RNA [blood plasma HIV viral load (bpVL)] [3]. The increasing availability over the last couple of years of newer, simpler, more potent and better tolerated antiretroviral drugs had allowed the achievement of durably sustained full viral suppression in blood plasma for the vast majority of patients, including pretreated patients harboring resistant HIV strains. The Swiss federal Commission for HIV/ AIDS recently stated that HIV-infected individuals receiving effective antiretroviral therapy (ART), with undetectable HIV-RNA in blood plasma for at least 6 months, with optimal adherence to their treatment and no other genital infections, cannot transmit HIV through sexual contact [4]. This statement has been highly debated because our understanding of the activity of combined ART (cART) in the male genital tract is poor, and because there are no data on precise quantification of the residual risk of HIV transmission in the context of effective cART [5].