Gay men living with HIV factor being 'Undetectable' into decisions about sex
A few years ago, large randomized controlled research studies of serodiscordant couples started to offer definitive evidence that effective HIV treatment prevents HIV transmission. The HIV community learned that people who maintain “undetectable” viral loads do not transmit HIV to sex partners from studies including HPTN 052 and PARTNER. Years before results from these landmark studies were released, the Swiss Statement offered the perspective that people with completely suppressed viral loads are not sexually infectious.
Now, researchers want to know: Is this message reaching people living with HIV? And, if so, how is it changing how people who maintain undetectable viral loads have sex?
A team of researchers recently investigated this question with HIV-positive men who have sex with men in San Francisco. A sample of 68 men answered survey questions about how they were having sex over the previous six months and if they had a detectable viral load (among other questions). In addition to asking men about their viral load (i.e. if they had a detectable or undetectable viral load), the researchers also verified viral loads using a viral load lab test.
Overall, the researchers found that men were highly accurate in saying whether or not they were undetectable, and were likely using that information to make informed decisions on how to have sex. (The size of this study’s sample was small, however, which makes the study’s outcomes susceptible to bias and limits generalizability.)
Of the 68 men in the sample, 59 self-reported that they were undetectable. A total of 57 of these men (96.6%) had undetectable viral loads (<200 copies/mL) when they were checked with a viral load lab test. Said another way, 96.6% of men who said they were undetectable, actually were. Most men who had detectable viral loads (78%) knew and reported that they had detectable viral loads.
“I wasn’t surprised by this finding,” said H. Fisher Raymond, DrPH, the study’s corresponding author. “In San Francisco, for example people largely know their HIV status. Because we have good testing services and also many treatment options, men who have sex with men are generally well-connected to the health service system, and educated and savvy about their health.”
The study also showed that men were having sex differently if they knew they were undetectable. Men who were undetectable were less likely to use “seroadaptive” strategies (using condoms all of the time, not having anal sex) than men who were not undetectable. This study suggests, if not proves, that men living with HIV in San Francisco are incorporating treatment as prevention in their own lives.
“For folks living with HIV, one of our biggest fears is passing the virus onto our partners,” said Jimmy Gale, manager of HIV-positive services at San Francisco AIDS Foundation (who was not affiliated with the study). “For long-term survivors, the message that undetectable equals untransmittable is an especially groundbreaking revelation. Many folks living with HIV have been too afraid to have the sex lives they needed.
Pictured above: Dr. Fauci, MD
Do you know U=U?
Promoters of the Undetectable = Untransmittable (U=U) message were out, proud and visible this year at the International AIDS Conference, spreading the message that people living with HIV with undetectable viral loads do not transmit HIV to partners.
Numerous conference attendees could be seen sporting U=U t-shirts, and supporters of the campaign spoke at an official conference press conference about treatment as prevention and U=U. More than 300 community partners have signed on to support the campaign: At the conference, the City of Paris, UNAIDS, and Planned Parenthood Federation of America (among others) announced their support.
The science behind U=U, said Anthony Fauci, NIAID director, goes back many years to a time when empiric observations happened outside the realm of clinical trials. Now, in more recent years, we have data from large clinical trials including HPTN 052, PARNTERand Opposites Attract.
Anthony Fauci, MD
“Sometimes clinical studies don’t hold true when you follow them up for years. That has not been the case with treatment as prevention…When you went out into cohorts, like the PARTNER study…there were 53,000 condomless sex acts among discordant couples. And there was not one single linked infection. I think it’s one of the unusual situations in science when the overwhelming accumulated evidence base allows us to be able to confident in what we’re talking about,” said Fauci.
U.S. Global AIDS Coordinator Deborah Birx, MD, also shared support for U=U, saying, “I think what the U=U campaign does is it provides a message to communities that is based on the scientific details, and really provide those details in a real way so that people understand that when you have HIV—which once was a death sentence for many people we are privileged to work alongside—has become an ability to live healthy, productive lives as long as people are adherent to treatment.”
The founder of U=U, Bruce Richman, shared a more personal perspective.
“When I was diagnosed with HIV in 2003, I felt like I was a walking infection. I was terrified about passing HIV on to someone that I love. I didn’t start treatment because taking a pill every day would remind me that I was infectious, every day. After I started treatment in 2012, when my health started to deteriorate, I learned from my doctor that because I was undetectable, I couldn’t transmit HIV. I couldn’t pass it on. I was elated.
“But very soon I became outraged. Because every HIV treatment site, every media outlet, every ASO, every federal health department, every state health department, everywhere, was saying that I was still a risk. And millions of people with HIV were still a risk. It was clear, for many reasons, that the breakthrough science wasn’t, and still isn’t, breaking through to the people it was intended to benefit. It wasn’t accepted or understood outside of well-informed medical and public health communities.
“To clear up the confusion, a group of us living with HIV collaborated with researchers on a consensus statement and advocacy campaign called Undetectable is Untransmittable.”
Richman shared a few more thoughts about the U=U campaign with BETA including the reactions to the campaign, and what he hopes for the message moving forward.
"Yes. It’s surprising the lengths to which people will go to keep HIV stigmatized. People will seek out data that’s inconsistent with science in order to reinforce their stigmatizing beliefs. This is about unlearning decades of fear of HIV. It has been much harder than I thought. It’s also been much better now." Bruce Richmond, Founder U=U Movement.
He is a Louisiana native and lives in the Lafayette area.