Objectives In low-income settings treatment failure is often identified using CD4 cell count monitoring. Consequently, patients remain on a failing regimen, resulting in a higher risk of transmission. We investigated the benefit of routine viral load monitoring for reducing HIV transmission. Design Mathematical model Methods We developed a stochastic mathematical model representing the course of individual viral load, immunological response and survival in a cohort of 1,000 HIV infected patients receiving antiretroviral therapy (ART) in southern Africa. We calculated cohort viral load (sum of individual viral loads) and used a mathematical relationship between individual viral load values and transmission probability to estimate the number of new HIV infections. Our model was parameterized with data from the IeDEA Southern African collaboration. Sensitivity analyses were performed to assess the validity of the results in a universal ‘test and treat’ scenario where patients start ART earlier after HIV infection. Results If CD4 cell count alone was regularly monitored, the cohort viral load was 2.6*106 copies/mL and the treated patients transmitted on average 6.3 infections each year. With routine viral load monitoring, both cohort viral load and transmissions were reduced by 31% to 1.7*106 copies/mL and 4.3 transmissions, respectively. The relative reduction of 31% between monitoring strategies remained similar for different scenarios. Conclusions While routine viral load monitoring enhances the preventive effect of ART, the provision of ART to everyone in need should remain the highest priority.

Since the advent of AIDS, discrimination has remained at the core of the experience of people living with HIV (PLHIV). PLHIV who belong to minority groups are exposed to discrimination not only on the grounds of their HIV infection but also because of rejecting attitudes towards drug users, homosexuals and black people. This article aimed to measure the frequency of discrimination and assess its correlates among PLHIV in France. We used data from a national representative survey, the ANRS-Vespa2 study, conducted in France in 2011 among 3022 male and female HIV-positive patients followed at hospitals. Respondents answered a face-to-face questionnaire documenting their health status and living conditions. Discrimination was documented during the previous two years on the grounds of HIV infection, gender, country of birth, skin colour, sexual orientation, place of residence, and substance abuse in a variety of contexts. For each context, we performed logistic regressions on discrimination, controlling for socio-epidemiological group, age, education level and employment status. Discrimination is frequently experienced by PLHIV in France (26%), particularly when applying for a job (24%), interacting with family (11%) or seeking health services (8%). Women from sub-Saharan Africa reported the highest levels of discrimination, whereas heterosexual non-African men reported the lowest. Men who have sex with men experienced levels of discrimination that fell between those of these two groups. The major perceived reason for discrimination was HIV status (13%). Nationality, skin colour and sexual orientation were cited by 5% each, whereas gender was cited by 1% of respondents. Our analyses show that discrimination is a frequent and cross-cutting experience with differences across the various contexts and among the diverse subpopulations. The intertwining of HIV-related stigma with sexism, racism and homophobia needs to be addressed to understand why discrimination against PLHIV persists when the disease itself has greatly evolved.

The prevalence of depression varied across the different groups of PLWHIV, with levels much higher than in the general population. Moreover, there was a strong association with socioeconomic status and HIV experience.