On 7 September, The United States, Centers for Disease Control (CDC) joined the chorus of nations, health departments and non-profits servicing people living with HIV, in admitting that treatment does equal prevention. The government stopped short in joining the online campaign of #UequalsU, which has been endorsed by over 360 organizations from 49 countries, but it did post the following tepid statement to its website.
- The goals of HIV treatment are to improve health and prevent transmission of HIV. The best marker of successful treatment is reducing the amount of HIV in the blood and elsewhere in the body to very low levels. This is called viral suppression. Three different studies of the prevention effectiveness of viral suppression to reduce the risk for sexual HIV transmission have shown similar results: across thousands of couples and many thousand acts of sex without a condom or PrEP, no HIV transmissions were observed when the HIV-positive person was virally suppressed. This means that getting and staying virally suppressed is not only the best thing people living with HIV can do to maintain their health, but also one of the best ways to prevent new infections through sex. CDC is working with other federal agencies to ensure that we consistently and accurately describe the prevention effectiveness of HIV treatment and viral suppression for sexual transmission of HIV. We will update our messages accordingly.
- People living with HIV on ART with an undetectable viral load in their blood have a negligible risk ( so small or unimportant as to be not worth considering; insignificant). of sexual transmission of HIV. Depending on the drugs employed it may take as long as six months for the viral load to become undetectable. Continued and reliable HIV suppression requires selection of appropriate agents and excellent adherence to treatment. HIV viral suppression should be monitored to assure both personal health and public health benefits.
NOTE: An undetectable HIV viral load only prevents HIV transmission to sexual partners. Condoms also help prevent HIV transmission as well as other STIs and pregnancy. The choice of HIV prevention method may be different depending upon a person’s sexual practices, circumstances and relationships. For instance, if someone is having sex with multiple partners or in a non-monogamous relationship, they might consider using condoms to prevent other STIs.
What is the evidence?
The conclusion is based on the force of real world and research experience including PARTNER, HPTN 052, Opposites Attract, and the Swiss Statement. For instance, in the PARTNER study, there were ZERO transmissions out of 58,000 condomless sex acts between people with HIV with undetectable viral loads and their partners who are HIV negative. In the the most recent study called Opposites Attract, there were no transmissions out of 17,000 condomless sex acts between men. Since the advent of combination therapy, there have been no confirmed reports of anyone with an undetectable viral load sexually transmitting HIV.
Is the risk zero?
In real world terms, yes the risk is zero. In theoretical terms, the risk is a tiny fraction close to zero. The challenge is that scientific studies can never prove the risk is zero. Through statistical analysis that number will keep getting closer and closer to zero. Researchers agree that because the actual HIV transmission risk is either zero or extremely close to zero, a person with HIV with an undetectable viral load is considered “not infectious” to their sexual partners.
Why are some groups saying an undetectable viral load reduces risk by 93-96%?
It’s a widespread mistake when reporting the HPTN 052 study’s findings. This study looked at the transmission risk from the first day a person with HIV starts treatment. The reason there was a 96% risk reduction (based on the study’s interim results) and a 93% risk reduction (based on the study’s final results) is because there were HIV transmissions before ART had the chance to suppress the virus and because treatment did not work properly for a small number of the participants. If only transmissions after the first six months of ART are considered, the risk reduction would have been 100% with a transmission risk of zero.
Why isn’t my medical provider telling me this information?
Some medical providers are not up-to-date with the current science. Others agree with the science but are concerned about 1) an increase in condomless sex among people with HIV which may result in an increase in other STIs; and 2) patients’ potential lack of understanding that maintaining an undetectable viral load requires excellent treatment adherence and monitoring; if they interrupt treatment by choice or circumstances outside of their control, their virus will likely rise to detectable levels. Some medical providers selectively choose to discuss this information only with patients and clients whom they judge are “responsible” (for example: monogamous and with a stable linkage to treatment) rather than directly address the concerns described above through education.
- 33 ADDITIONAL EXPERT QUOTES, SOURCES, AND EXPLANATIONS
1.”Last month, the global medical and scientific community at the forefront of HIV research and care came together in Paris for the ninth International AIDS Society Conference, where they announced – unequivocally – that an undetectable HIV viral load means HIV is untransmittable.” Dr. Julio Montaner, UBC-Killam Professor of Medicine; UBC-St. Paul’s Hospital Foundation chair in AIDS Research Editorial (August, 2017)
2. “If you diligently take your medicine and keep your viral load to below detectable levels, you will not be dangerous to your partner. We now have the scientific data to say you may be “infected” but you are not “infectious”. That goes a long way toward eliminating the stigma associated with HIV.” Anthony S. Fauci, M.D., Director, NIAID, NIH Video interview (July, 2017)
3.“Scientists never like to use the word ‘Never’ of a possible risk. But I think in this case we can say that the risk of transmission from an HIV-positive person who takes treatment and has an undetectable viral load may be so low as to be unmeasurable, and that’s equivalent to saying they are uninfectious. It’s an unusual situation when the overwhelming evidence base in science allows us to be confident that what we are saying is fact.” Anthony S. Fauci, M.D., Director, NIAID, NIH NAM aidsmap (July, 2017)
4.”People who take their ART effectively and in whom the virus is suppressed to undetectable levels are no longer infectious. A massive public health and social justice response has led to unprecedented scale up of this miraculous treatment.” UNAIDS Science Report, Issue #6 (July, 2017)
5.“As the UK’s leading voice for HIV health professionals, our backing for U=U is unequivocal. There should be no doubt about the clear and simple message that a person with sustained, undetectable levels of HIV virus in their blood cannot transmit HIV to their sexual partners.This fact is a testament to the preventive impact of effective HIV treatment and highlights the need to maximise access to treatment in order to minimise and ultimately eradicate HIV transmission. Spreading the U=U message is also an important way to help reduce the stigma experienced by people living with HIV, whose sexual partners may fear infection unnecessarily.” BHIVA Chair, Professor Chloe Orkin, statement from BHIVA (July, 2017)
6.“This is a landmark development in the response to HIV and too many people are not hearing this message and receiving its full benefit. A person living with HIV with a sustained suppressed viral load poses no risk of transmitting HIV. This development puts each one of us living with HIV at the forefront of stopping new infections, and gives everyone strong, clear and direct language to stop the stigma and move all communities faster towards ending the epidemic.” Jesse Milan, Jr., President & CEO, statement from AIDS United (March, 2017)
7. “Research demonstrating that people living with HIV who are virally suppressed cannot transmit HIV to others is one of the most important developments in HIV prevention in the last decade. It is now more important than ever that we ensure universal access to antiretroviral therapy and educate our communities about the public health benefits of effective HIV treatment.” Craig E. Thompson, Chief Executive Officer, statement from APLA Health (March, 2017)
8. “Desmond Tutu HIV Foundation strongly endorses the Prevention Access Campaign core message: Undetectable HIV is Untransmittable HIV (U=U). An HIV-positive person who maintains an undetectable viral load with the aid of regular, successful treatment cannot transmit HIV sexually. This knowledge has the potential to alter negative perceptions around the disease, yet the message still hasn’t reached everyone.” Statement from Desmond Tutu HIV Foundation (March, 2017)
9. “NAM aidsmap, one of the foremost sources of HIV information in the world, strongly endorses the ‘Undetectable Equals Untransmittable’ (U=U) Consensus Statement issued by the Prevention Access Campaign. The scientific evidence is clear. Someone who has undetectable levels of virus in their blood does not pose an infection risk to their sexual partners. This understanding transforms the way that HIV is considered with enormous implications for what it now means to live with HIV and the best ways to prevent it.” Statement from NAM aidsmap (February, 2017)
10. “NASTAD joins public health experts and leaders in affirming that there is now conclusive scientific evidence that a person living with HIV who is on antiretroviral therapy (ART) and is durably virally suppressed (defined as having a consistent viral load of less than <200 copies/ml) does not sexually transmit HIV.” Statement from NASTAD (February, 2017)
11. “All of us here at CATIE, and indeed around the world, are celebrating the most significant development in the HIV world since the advent of effective combination therapy 20 years ago – people living with HIV with sustained undetectable viral loads can confidently declare to their sexual partners “I’m not infectious!” This is an absolute game-changer and those who live with HIV can proudly share this information. At the same time, service providers working in HIV must get up to speed fast and share this far and wide with their communities.” Laurie Edmiston, Executive Director, Statement from CATIE – Canadian AIDS Treatment Information Exchange (January, 2017)
12. “The scientific evidence is clear and unequivocal: effective treatment reduces HIV transmission risk to zero. The Consensus Statement highlights unprecedented scientific consensus that early diagnosis and treatment with antiretroviral therapy (ART) not only restores people living with HIV to a normal life expectancy, but it also has far-reaching public health impacts.” Joint statement from ICASO (International Council of AIDS Service Organizations) and INA (M?ori, Indigenous & South Pacific) HIV/AIDS Foundation (January, 2017)
13. “…studies have proven that when an individual living with HIV is on antiretroviral therapy and the virus is durably suppressed, the risk that he or she will sexually transmit the virus is negligible.” Anthony S. Fauci, M.D., Director, National Institute of Allergy and Infectious Diseases; Carl W. Dieffenbach, Ph.D., Director, Division of AIDS, NIAID. NIH Statement on World AIDS Day 2016 (December, 2016)
14. “If you are durably virologically suppressed you will not transmit to your partner… I’ll say this again, for somebody who is in a discordant couple, if the person [with HIV] is virologically suppressed, ‘durably’ –there is no virus in their system, hasn’t been for several months — your chance of acquiring HIV from that person is ZERO. Let’s be clear about that: ZERO. If that person the next day stops therapy for two weeks and rebounds, your chance goes up. That’s why we talk about ‘durable’ viral suppression…You’re as durably virologically suppressed as good as your adherence.” Carl W. Dieffenbach, Ph.D., Director, Division of AIDS, NIAID, NIH. NIH Video interview (November, 2016)
15. “When an HIV positive person first starts on treatment, it takes a few months before viral growth is completely suppressed. During that short window of time, the couple should use condoms. Alternatively, the HIV negative partner might use antiretroviral agents as pre-exposure prophylaxis [PrEP].” Dr. Myron Cohen Chief, Division of Infectious Diseases, UNC School of Medicine, North Carolina, USA; Principal Investigator, HPTN 052. POZ magazine (September, 2016)
16. Suppressing the viral load of a person living with HIV to undetectable levels “not only saves their lives but prevents them from infecting others. So the higher percentage of people who are on treatment, in care and get their viral loads to undetectable, the closer you get to literally ending the epidemic.” Anthony S. Fauci, M.D., Director, NIAID, NIH. NIH Video Interview (August, 2016)
17. “..Once you begin therapy, you stay on therapy, with full virologic suppression you not only have protection from your own HIV….. but you also are not capable of transmitting HIV to a sexual partner. With successful antiretroviral treatment, that individual is no longer infectious.” Carl W. Dieffenbach, Ph.D., Director, Division of AIDS, NIAID, NIH. NIH Video interview (August, 2016)
18. “We can now say with confidence that if you are taking HIV medication as prescribed, and have had an undetectable viral load for over six months, you cannot pass on HIV with or without a condom.” Dr. Michael Brady, Medical Director, Terrence Higgins Trust, London, England (July, 2016)
19. “The force of evidence in both real world and clinical trial experience confirms that individuals with suppressed viral loads have a negligible risk of transmitting HIV. Treatment as prevention, pre-exposure prophylaxis, and traditional prevention measures, like condoms, make up an HIV prevention toolkit based in harm-reduction that allows individuals to make personalized and enlightened decisions to both maintain their health and prevent HIV and STI transmission.” Dr. Demetre C Daskalakis, MPH – Assistant Commissioner, Bureau of HIV/AIDS Prevention and Control New York City Department of Health and Mental Hygiene (July, 2016)
20. “Does this work over a long period of time for people who are anxious to be suppressed? The answer is absolutely yes, we now have 10,000 person years (of follow-up) with zero transmissions from people who are suppressed.” Dr. Myron Cohen. Medpage; NEJM. (July, 2016)
21. “Among serodifferent heterosexual and MSM couples in which the HIV-positive partner was using suppressive ART and who reported condomless sex…there were no documented cases of within-couple HIV transmission” among 58,000 condomless sex acts. Reporting on PARTNER study Dr. Alison Rodger, et al. JAMA. (July, 2016)
22. “These results are simple to understand – zero transmissions from over 58,000 individual times that people had sex without condoms…[PARTNER study] provides the strongest estimate of actual risk of HIV transmission when an HIV positive person has undetectable viral load – and that this risk is effectively zero.“ Simon Collins, Steering Committee, PARTNER, i-BASE (July, 2016)
23. “The [Swiss] statement [was the first position statement that] addressed the infectiousness of an HIV-positive person once the virus was stably suppressed for at least 6 months with ART. [T]he [Swiss Federal Commission for AIDS-related Issues] felt, based on an expert evaluation of HIV transmission risk under therapy, that the risk of HIV transmission in such a situation was negligible.” Dr. Pietro Vernazza, chief of the Infectious Disease Division, Cantonal Hospital in St. Gallen, Switzerland; Executive Committee, PARTNER Swiss Medical Weekly (Jan., 2016, confirming the original 2008 Swiss statement)’
24. “[T]he HPTN 052 study saw only cases of transmission during ART that occurred shortly (days) after the initiation of therapy. If only transmissions after the first six months of ART are considered (as stipulated in the Swiss statement) the efficacy would have been 100% with a transmission risk of zero.” Dr. Pietro Vernazza, Swiss Medical Weekly (Jan., 2016)
25. “Achieving viral suppression protects the body’s immune system, helps people living with HIV stay healthy and prevents transmission of HIV to other people.” UNAIDS – Joint United Nations Programme on HIV/AIDS (2016)
26. “We have…rigorous confirmation that treatment prevents the spread of HIV and improves the health of infected people.” Dr. Thomas R. Frieden, Center for Disease Control Director, USA New England Journal of Medicine sourcing HPTN 052 & PARTNER studies (Dec., 2015)
27. “EATG calls for much better public information to be made available in Europe and globally about the prevention benefits of antiretroviral therapy (ART), and in particular (about) the fact that HIV-positive people with undetectable viral loads are not infectious. Widespread ignorance of this fact helps perpetuate stigma against and criminalisation of people living with HIV and it should be the subject of a funded public awareness campaign, possibly to run in conjunction with a PrEP awareness campaign.” European AIDS Treatment Group (EATG) (October, 2015)
28. “If people are taking their pills reliably and they’re taking them for some period of time, the probability of transmission in this study is actually zero.” Dr. Myron Cohen, Chief, Division of Infectious Diseases, UNC School of Medicine, North Carolina, USA; Principal Investigator, HPTN 052 Interview with plus (August, 2015)
29. “[People with HIV] will not pass on the infection, if the virus is undetectable, to their partners…” Professor David Cooper – Director of the Kirby Institute for Infection and Immunity in Society. University of NSW, Australia; ABC AU interview (May, 2015)
30. When asked what the study tells us about the chance of someone with an undetectable viral load transmitting HIV, presenter Alison Rodger said: “Our best estimate is it’s zero.” Reporting on PARTNER study interim results. Dr. Alison Rodger, University College London, United Kingdom; Lead Author PARTNER, NAM -AIDSMap (March, 2014)
31. People living with HIV “are leading lives that are normal in quality and length. With effective treatment, they are not infectious.” Health care workers on effective HIV treatment are “totally safe.” Professor Dame Sally Davies, Chief Medical Officer, England. The Telegraph (Aug., 2013)
32. “Many people want to know their status, because they want to be rendered not contagious, because of confidence in living their lives normally. So I’ve heard dozens of stories of people who came in and said, ‘I want to be tested, because if I’m infected I don’t want to be transmissible.’ Inspiring.” Dr. Myron Cohen, Chief, Division of Infectious Diseases, UNC School of Medicine, North Carolina, USA; Principal Investigator, HPTN 052; MEDPAGE Today (Jan., 2013)
33.“In reality, if you give the treatment the opportunity to get on with its work, you will have zero transmission.” Dr. Julio Montaner, Director of the British Columbia Centre for Excellence in HIV/AIDS; Director of IDC and Physician Program Director for HIV/AIDS PHC: TED Talk referring to HPTN 052 (Nov., 2011)