PERSPECTIVE Role of Acute HIV Infection in Driving HIV Transmission: Implications for HIV Treatment as Prevention

Using simulated cohorts that account for previously unmeasured bias, Steve Bellan and colleagues provide new estimates of the duration and relative infectivity of the HIV-1 acute phase based on data from the retrospective cohort of serodiscordant couples in Rakai, Uganda. Not many issues have been debated in the HIV community more than the role of acute HIV in-fection in driving HIV transmission in sub-Saharan Africa (SSA) [1]. Acute infection refers broadly to the first stage of progression following onset of infection during which, for several weeks, HIV viral load peaks at high levels (up to 107 virions/ml of plasma), before leveling off at the viral set point for several years [2]. The debate is well beyond being an academic debate; the impact of different HIV prevention strategies is contingent on the role of acute infection in the epidemic. A large role for acute infection may erode some of the utility of antiretroviral treat-ment as prevention (TasP), the most promising HIV prevention intervention in our time [3]. TasP is a costly investment in HIV prevention. For it to be impactful and cost-effective, HIV-infected persons must be diagnosed early in their infection and linked to care and treatment. De-spite promising developments [4], it is difficult in practice in resource-poor settings to identif