Two interesting reports studying correlations in HIV-1 setpoint viral loads (spVLs) and early viral loads within transmitting couples [1,2] were published recently, an observation which was foreshadowed in Zambia [3] and which we also recently showed in Uganda [4]. We wish to highlight that even weak correlation between spVL of individuals in transmitting couples can correspond to a large estimate for the role of viral genetic factors in determining spVL. Our difference in interpretation can be clarified by consideration of the sources of variance contributing to spVL (Fig. 1).Fig. 1: Influences on setpoint viral load (a) Analysis of variance of within-couple and between-couple variance tries to estimate the proportion of variance in setpoint viral load (spVL) explained by shared viral factors. (b) Shared viral factors cause spVL to be correlated, but the proportion of variance in spVL of the secondary case explained by knowledge of the spVL of the index case will be lower than that shown in (a), as both are affected by nonviral factors. spVL, setpoint viral load.The spVL of index and secondary cases within transmitting couples may be determined by a combination of factors related to the broadly similar viral genotype (viral factors), and other nonviral factors including host factors, coinfections, specificity and nature of immunological response or chance effects (Fig. 1a). Nonviral factors affect the spVL of both index and the secondary cases in couples, explaining the difference between correlation between patients (Fig. 1b) and estimates of the strength of viral factors (Fig. 1a). Hecht et al.[1], van der Kuyl et al.[2] and Tang et al.[3] estimate the Pearson correlation coefficient, r, between spVL values of index cases and secondary cases in transmitting couples. We propose that if the aim is to infer the strength of viral factors on spVL, a better estimate can be obtained using analysis of variance (ANOVA) of within and between couple variance [4]. The coefficient of determination (R2) of the ANOVA is a lower-bound estimate for the proportion of variance in spVL explained by viral factors. An additional benefit of ANOVA is that the analysis is easily adjusted for confounders such as sex of the host and viral subtype. A drawback is that the method is less transparent and requires extra adjustments for the parameters introduced into the model. In an idealized case wherein spVL values are normally distributed with identical variance, the estimates are related in a simple manner: the coefficient of determination (R2) of the ANOVA, as used in [4], is equal to the correlation coefficient (r), as used in [1–3]. Thus, the raw numbers are unchanged, but their interpretation in terms of the strength of viral effects in determining spVL is radically altered. The unadjusted estimates for the proportion of variance in spVL explained by viral genotype in the four studies are 20% [3], 25% [2], 27% [4] and 55% [1]. These estimates are all higher than unadjusted estimates of 13% of variance in spVL explained by host genetic factors to date [5], although, of course, these latter estimates may increase as more host factors are discovered, and some host–virus interaction effects may be dually counted in individual analyses. The additional observation that the relationship between spVL in transmitting pairs may depend on the stage of infection of the recipient [2] (based on a small sample size) is plausible and interesting, and may aid the detailed elucidation of the mechanisms linking viral factors to spVL. The four published studies together represent 250 couples, and the link in spVL within couples seems consistent and robust. Attributing variation in viral load to viral, host and interaction effects will undoubtedly shed light on the mechanisms of HIV pathogenesis. These results also support the hypothesis that spVL has evolved at the population level [6].
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