There is life with HIV

Seropositive with undetectable viral load transmits the virus? No! And yes!

Is undetectable equal to non-transferable? Yea...

Seropositive with undetectable viral load transmits the virus? Well, the scientific answer is no. But, many, many times, between science and the fact there is the everyday. The daily life brings, in its core, many times, the imponderable. The jump of the fence, the therapeutic failure, the viral blip and, finally, the good idea, as you can see, with this text, is to combine strategies. But, let's go, answering the question:

Seropositive with undetectable viral load transmits the virus?

Since the human immunodeficiency virus (HIV) was first discovered in 1983, scientists have worked tirelessly to find ways to prevent the spread of the disease. Some of the interventions, such as Condoms, are effective, but far from infallible, if misused. Others, such as pre-exposure prophylaxis (PrEP), are more than 90% effective, but have been poorly adopted by many high-risk groups, including African Americans. 

It was only in 2019 that scientists finally revealed the only intervention that can effectively reduce HIV risk to zero: 

A supportive Undetectable viral load.

The strategy, referred to by public health authorities as “Undetectable = Non-Communicable” (I = I), is based on evidence that antiretroviral therapy in people with HIV can prevent infection if the viral load (the number of circulating viruses) is completely suppressed.

According to the research, a person with HIV cannot infect other people if there is no virus circulating in the semen, blood or other body fluids.

It is a strategy that had been much debated before the launch of the PARTNER 2 2019 study1and the previous PARTNER 1 study in 2016.2The striking studies, involving 1.570 gay and heterosexual serodiscordant couples (in which one partner is HIV-positive and others are HIV-negative) since health officials have declared it the first surefire way to prevent transmission, even when condoms have not been used.

Despite the definitive results, there are some limitations to the I = I strategy, namely the low rate of undetectable viral loads among Americans living with HIV.

Background

The concept of I = I is not entirely new. Actually, it was in 2008 that experts from the Swiss Federal Commission on HIV / AIDS were the first to declare that “a person infected with HIV on antiretroviral therapy with completely suppressed (virus)… cannot transmit HIV through sexual contact.”

It was a bold statement evidenced by a body of epidemiological evidence, but one that lacked clinical research to show that it worked on a one-on-one basis. Even the Swiss Commission admitted that its statement, however convincing it was, should not change the prevention strategies currently in place.

Treatment as Prevention (TasP)

At the same time, scientists at the HIV Prevention Trials Network (HPTN) decided to actively test the hypothesis, armed with a new and more durable generation of HIV drugs. Up to that point, the concept was considered inconceivable, since many of the early antiretrovirals were prone to high rates of resistancea to medicines e early treatment failure.

However, with the launch of the tenofovir in 2001, scientists had a drug that could provide sustained control of the virus with less than perfect adhesion.

The HPTN research team proposed that by maintaining an undetectable viral load with this too recent and more durable form nucleoside, the rate of transmission would be reduced not only in serodiscordant couples, but also in the general population. It was a strategy popularly known as treatment as prevention (TasP).

O study, known as HPTN-052, involved 1.763 serodiscordant couples who received immediate treatment or treatment when their HIV-positive partner counts CD4 it dropped to 350 or less (the starting point of therapy prescribed in 2011). What this meant is that HIV-positive partners without treatment would invariably have higher viral loads than those who did.

At the end of the six-year study, scientists were able to report that early treatment resulted in only one case of HIV transmission, while delayed treatment resulted in 27 transmissions.

For these people, the question [Seropositive with undetectable viral load transmits the virus?] There is only one answer: Yes.

And for them, things are now immutable. They will have the virus for the rest of their lives, or at least until they find a cure, which we have been looking for for forty years. If I were among these four percent, FOR ME, THE TERIOUS FEELING HAS BEEN OF A PERSON WHO CHEATED OR HAS BEEN DECEIVED

This translates into at least 96% reduction in HIV risk.

For 4% the answer to the question ?: HIV positive with undetectable viral load transmits the virus?

Um 2016 follow-up study was able to show that TasP was not only an effective, but durable intervention, reducing the risk of transmission in 93% in the same group of couples after 10 years.

Concerns and controversies

Despite the positive findings, many health officials remained in doubt as to the effectiveness of TasP. Among their concerns, they stated (correctly) that an undetectable virus is not the same as not having a viruss.

Even with the most sensitive viral load tests, HIV can persist below detectable levels. Current technologies define undetectable as being below 20 to 40 copies per milliliter of blood. What that means is that a test can be undetectable, but it still there may be competent viruses in circulation. Can this be enough to establish the infection?

Others expressed concern that, of the 1.763 couples involved in HPTN 052, the majority (97%) were heterosexual. Even the most open experts doubt that the results seen in heterosexuals are mirrored in gay and bisexual men, which not only account for more than 65% of new infections in the United States, but they also have very different vulnerabilities to HIV infection.

PARTNER 1 study and the question: HIV positive with undetectable viral load transmits the virus? No! And yes!

In an effort to expand the scope of the research, an international effort known as the PARTNER (People on People on (treatment) Antiretroviral- A New Risk Assessment) study was launched in September 2010 to observe the effect of TasP on homosexual and homosexual couples male.

The study was conducted in 14 European countries and involved 1.166 serodiscordant couples who had had sex without condoms for an average of two years. 

What made the PARTNER study especially attractive was that only couples whose HIV-positive partner had a CD4 count below 200 (a clinical definition of AIDS) were eligible to participate.

Of the 888 couples capable of sustaining undetectable viral loads - 548 of whom were heterosexual and 340 of whom were gay - only 11 infections occurred during the four-year study period. Of these, none were genetically linked to your partner's HIV strain (meaning that the infection occurred outside the relationship).

Based on the findings of the PARTNER 1 study, scientists were able to confidently report that no cases of HIV transmission occurred in serodiscordant relationships if an undetectable viral load was maintained.

Despite the positive results, statistical certainty was not as convincing for gays (or anal sex) as it was for vaginal sex, a 10 out of 11 infections occurred in gay couples.

PARTNER Study 2 and the question: HIV positive with undetectable viral load transmits the virus? No! And yes!

The PARTNER 2 Study, launched in September 2010, was designed to assess the risk of transmission only in serodiscordant gay couples. The study was specifically designed to assess the impact of a totally suppressed viral load on couples who did not use condoms consistently for anal sex.

Of the 997 couples recruited from 14 European countries, 90 were excluded because the HIV-positive partner was unable to maintain an undetectable viral load or the HIV-negative partner used PrEP or post-exposure HIV prophylaxis (PEP) to prevent infection.

During the seven-year trial period, the 782 eligible couples reported anal sex without a condom a total of 76.088 times. In addition, no less than 288 of HIV-negative men (37%) reported sex without a condom with partners outside the relationship.

At the end of the PARTNER 2 study, a total of 15 HIV infections occurred, but none were genetically linked to the HIV-positive partner.

In short, the risk of transmission in gay couples with an undetectable viral load was effectively zero, confirming I = I as an effective means of preventing HIV in serodiscordant partners, whether heterosexual, gay or bisexual.

Concept policy and action HIV positive with undetectable viral load transmits the virus

As a result of the PARTNER trials and other landmark studies, the Prevention Access Campaign, a global community of health equity partners, launched the Undetectable = Non-Communicable initiative to help undermine the fear and shame they promote the stigma of HIV and delay HIV care.

The initiative aims to encourage people with HIV to start and maintain antiretroviral therapy, to carry out pregnancy and family planning to feel less anxious about infecting other people.

It was an effort that supported the International AIDS Society in its 2019 Annual Letter, in which the committee called for a “change in our collective mentality” to adopt I = I as the new HIV prevention standard.

A point to ponder

From the point of view of a compromised relationship, an undetectable viral load offers the most effective means of protection against HIV, even greater than PrEP. But, this does not necessarily mean that you should completely abandon condoms.

Condoms are still the best way to prevent pregnancy and other sexually transmitted diseases, especially if you have multiple partners.

It is also important to remember that taking antiretrovirals is not the same as undetectable. In fact, according to the Centers for Disease Control and Prevention, less than 60% of people on HIV therapy in the United States have an undetectable viral load.

Ultimately, it is not enough to skip condoms simply because the person you are having sex with is "in treatment". 

Unless you are in a relationship, and fully aware of your partner's treatment status and viral load results, seriously, don't take anything for granted. 

Use condoms and other forms of safe sex to protect yourself.

 


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