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The extent to which ART (anti-retroviral therapy) reduces HIV transmissionhas received attention in recent years. Using data on the relationship betweentransmission and viral load we show that transmission saturates at high viralloads. We fit a power-law model and an exponential converging to an asymptote.Using data on the viral load in HIV-positive people we show that ART is likelyto reduce transmission by 91.6% (81.7%-96.2%) under the first and 99.5%(98.5%-99.8%) under the second model.  The role of the acute phase in HIV transmission is still debated. High levelsof transmission during the acute phase have been used to argue that failure toidentify people in the acute phase of HIV may compromise the impact oftreatment on preventing new infections and that having concurrent sexualpartners during the acute phase is an important driver of the epidemic. We showthat the acute phase probably accounts for less than 1% of overalltransmission. We also show that even if a significant proportion of infectionsare transmitted during the acute phase, this will not compromise the impact oftreatment on population levels of transmission given the constraint implied bythe doubling time of the epidemic.  This analysis leads to other relevant conclusions. First, it is likely thatdiscordant-couple studies significantly underestimate the risk of infection.Second, attention should be paid to the variability in set point viral loadwhich determines both the infectiousness of HIV-positive people and thevariability in the susceptibility of HIV-negative people. Third, if ART drugsare in short supply those with the highest viral load should be given priority,others things including age, gender and opportunistic infections being equal,but to reduce transmission ART should be offered to all those with a viral loadabove about 10k/mm.3

Determinants of sexual transmission of HV: implications for control