The role of coinfections in HIV epidemic trajectory and positive prevention

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Abstract
Objectives: Recurrent or persistent coinfections may increase HIV viral load and, consequently, risk of HIV transmission, thus increasing HIV incidence. We evaluated the association between malaria, herpes simplex virus type 2 (HSV-2) and tuberculosis (TB) coinfections and their treatment on HIV viral load. Design: Systematic review and meta-analysis of the association of malaria, HSV-2 and TB coinfections and their treatment with HIV viral load. Methods: PubMed and Embase databases were searched to 10 February 2010 for studies in adults that reported HIV plasma and/or genital viral load by coinfection status or treatment. Meta-analyses were conducted using random-effects models. Results: Forty-five eligible articles were identified (six malaria, 20 HSV-2 and 19 TB). There was strong evidence of increased HIV viral load with acute malaria [0.67 log10 copies/ml, 95% confidence interval (CI) 0.15–1.19] and decreased viral load following treatment (−0.37 log10 copies/ml, 95% CI −0.70 to −0.04). Similarly, HSV-2 infection was associated with increased HIV viral load (0.18 log10 copies/ml, 95% CI 0.01–0.34), which decreased with HSV suppressive therapy (−0.28 log10 copies/ml, 95% CI −0.36 to −0.19). Active TB was associated with increased HIV viral load (0.40 log10 copies/ml, 95% CI 0.13–0.67), but there was no association between TB treatment and viral load reduction (log10 copies/ml −0.02, 95% CI −0.19 to 0.15). Conclusion: Coinfections may increase HIV viral load in populations where they are prevalent, thereby facilitating HIV transmission. These effects may be reversed with treatment. However, to limit HIV trajectory and optimize positive prevention for HIV-infected individuals pre-antiretroviral therapy, we must better understand the mechanisms responsible for augmented viral load and the magnitude of viral load reduction required, and retune treatment regimens accordingly.

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