This is the second installment of a series looking at new and emerging HIV-prevention options and the barriers that are slowing down the beginning of what could be a sexual revolution for queer men. Previously: PrEP
A person who is living with HIV and taking effective medication cannot sexually transmit HIV to their partners.
It’s a statement that is bold as it is scientifically sound. If you are surprised to hear it, you are not alone. Getting this incredible, hopeful and game-changing message out has proven to be a challenge, but it’s a fight that can be won. Lets talk about how we got here.
In July 2016, two major HIV studies published their final results. The Partner Study and HPTN 052 followed hundreds of couples where one of the partners was living with HIV and the other was not in order to quantify the effect of HIV treatment on lowering the risk of sexual HIV transmission.
The goal of HIV treatment is to suppress the virus and stop it from making copies of itself in the body of a person living with HIV, and treatment has gotten quite good at doing this – a person living with HIV who is consistently taking their meds can generally bring the amount of virus in their body down to a point where it ‘undetectable’, that there are so few copies per ml of blood that the test won’t see any, or a very sensitive test may see less than 80 copies per ml (Health Canada’s standard for what can be considered an ‘undetectable viral load’). Generally a person can become undetectable within six months of beginning treatment, and can consider their viral load to be stable if they remain undetectable for six months. When treatment is effective and a persons viral load is stable at an undetectable level, they have the best health outcomes and are generally able to live long and healthy lives.
The researchers conducting Partner and HPTN 052 already knew going into the studies that in addition to the health benefits for a person managing HIV, that an undetectable viral load lessened the risk of sexual HIV transmission substantially. The goal of the research was to quantify it, to find out in numbers just how much the risk was lowered.
Even so, I doubt they were anticipating the number of transmissions they found, which in both studies was zero. Not a single case of HIV transmission occurred when the HIV+ partner was undetectable over the two studies. We are talking hundreds of incidents of condomless sex between hundreds of ‘serodiscordant’ (mixed-HIV-status) couples. And not a single case of HIV transmission was observed between them.
We of course cannot ever say that anything in medicine is 100%. Medicine is as complicated and weird as the bodies it works to keep healthy. But it is rare for something to be this close to 100%. A scientifically appropriate word is ‘negligible’ risk – but ‘negligible’, while accurate is certainly not the right message. What negligible means to a scientist is ‘not worth considering’, which is different than what a layperson might interpret as simply meaning ‘small’. Negligible means small in a way that it’s as good as none. You have a negligible risk of being struck in the head by a piece of satellite that has broken up in orbit. You have a negligible risk of being mauled by an escaped circus tiger on your way to the pub. What science means by negligible is that ‘while there conceivably is a chance of this happening, it would be incredibly silly and not at all productive to live your life being concerned about it”.
For those of us who are not living with HIV it may be difficult to understand the magnitude of this – finally there is concrete scientific evidence supporting what has until now been widely believed amongst the poz community and its allies and hinted at in research findings, but never so unquestionably demonstrated in a scientific context. For the first time in the history of this epidemic, there is a prevention message that does not place a disproportionate burden of responsibility on people living with HIV, that doesn’t frame people living with HIV as a menace to public health, and that undermines decades of problematic bullshit, ranging from stigmatizing prevention campaigns presenting people living with HIV as untrustworthy or dangerous, to Canada’s outrageously draconian and internationally lampooned HIV non-disclosure laws. It is also a dramatic corroboration of what we who have a stake in HIV prevention efforts have been trying to say for a long time – that the bulk of HIV transmission occurs when a person is HIV+ and does not know their status.
Because of this magnitude, negligible did not feel like the right word to many folks. It is a word that is technically correct but fails to convey the real message, that the risk is in any practical sense, as good as zero. The Prevention Access Campaign, a US-based multi-agency health-equity initiative decided to tackle the issue by inventing a word that is much catchier and suitably conveys both the meaning as well as the message: Untransmittable. And the Undetectable = Untransmittable or ‘U=U’ awareness campaign was launched.
Since last summer, hundreds of agencies worldwide have signed the Prevention Access Campaigns consensus statement (including to my personal delight, as of April 25th 2017 The AIDS Network here in Hamilton). Although the campaign has not been universally met with excitement and the expected amount of paternalistic, pearl-clutching concern has been raised, it is building momentum and more and more organizations are signing on.
The greatest challenge to getting the word out on U=U is certainly going to be confronting messages that exaggerate risk. It is a telling sign of HIV stigma in the global prevention community that Treatment As Prevention messaging is sometimes focusing in on a risk that is in the most generous of terms, incredibly small. It is true that, as said, nothing in medicine is 100% – however you very rarely find sexual health education focusing on the failure rate of condoms, or the very small number of cases where PrEP has failed. It is important to call out risk-focused framing out for what it is, HIV stigma and discomfort with the idea of people living with HIV enjoying full and healthy sex lives. These attitudes are not okay, and now there are hard numbers showing that they are wrong both in terms of social justice and in terms of science.
Because at the end of the day, we now know with the most certainty we have ever had, that a person who has a stable undetectable viral load is a safe bet as a sexual partner, regardless of what prevention strategies an HIV negative person is using. We know that the greatest risk of HIV transmission is people who believe themselves to be HIV-negative and are unaware of their positive status. We know that it is totally unacceptable both in terms of social justice and in terms of science to position people living with HIV as bearing the bulk of HIV-prevention responsibility. And we need to shout it out from the roof-tops. This game has changed, and the U=U campaign is leading the way forward. People living with HIV can loudly and proudly declare that they cannot pass on HIV to partners, and those of us who consider ourselves allies to the poz community need to signal boost the hell out of that.
For more information about U=U and Treatment as Prevention, or if you have any questions about gay men’s sexual health in Hamilton, contact the Men4Men program of The AIDS Network at email@example.com or 905-528-0854 x 231