Sexual transmission of HIV most closely reflects the concentration of HIV in the genital tract; HIV in the genital tract of subjects with acute HIV and some "classical"
STDS is 8-10 times greater than in control subjects. It seems likely that these latter subjects lead to spread of HIV. Accordingly, the state of North Carolina committed to HIV testing that detects subjects with acute, recent, and established
infection. We tested 109,500 samples over 9 months. We found 563 people with undiagnosed
HIV infection. The majority of subjects were in STD clinics. This included 23 subjects with (pre-seroconversion) acute
HIV infection (HIV
RNA positive, antibody negative). The median blood HIV was 209,000 copies/ml, more than 10 times higher than in subjects with established
HIV infection. Recognizing the increased number of subjects with unrecognized acute
HIV infection in STD clinics, we conducted similar studies in STD Clinics in Malawi and South Africa. Between 1 and 2% of subjects had undetected acute
HIV infection. The median viral burden in blood of subjects in Malawi was greater than 1,000,000 copies/ml.
STDS and HIV are often co-transmitted, and
STDS set the stage for subsequent HIV transmission. Prevention of sexual transmission of HIV likely requires maximal suppression of genital tract HIV viral burden, either through treatment of
STDS or use of
antiretroviral agents.