by David Brown

In 1985, I was working in an STD clinic in Nashville, Tennessee, and was one of two HIV counselors doing pre-test and post-test counseling for people most likely getting the very first HIV test of their lives. There were NO anti-HIV medications available at that time, and the only ounce of hope you could impart to these newly infected people was that there appeared to be more HIV-positive (POZ) people not yet ill than POZ persons who were having symptoms. In 1985, untreated POZ people most likely had VERY high HIV viral loads (high amounts of active HIV virus in the body), were therefore very infectious and highly likely to pass HIV on to other sex or needle sharing partners.

In 2019, by contrast, we have a total of 51 medications at our disposal to fight HIV (33 individual anti-HIV meds and 18 combination anti-HIV meds). We are also finding that the majority of HIV patients consistently taking these anti-HIV meds have achieved undetectable levels of HIV in their bodies (defined as less than 200 copies/ml or a less than 200 HIV viral load). We know that current treatments are prolonging life for HIV POZ people. And in a true game-changer for the future of the epidemic, multiple studies have shown that HIV-positive people who are undetectable DO NOT transmit the virus to others!

A person is most infectious with the HIV virus during the first 3 months after they have been infected, if they are not taking meds. These newly HIV POZ persons often have a viral load between half a million to over TEN million in their blood, semen or vaginal fluids. The clinical implications of having a viral load of millions compared to having a viral load of under 200 are huge! That is why aggressive programs today seek to test people as early in HIV infection as possible, connect them to medical care, and start them on anti-HIV meds immediately.

Across three different studies, including thousands of couples and many thousand acts of sex without a condom or pre-exposure prophylaxis (PrEP), no HIV transmissions to an HIV-negative partner were observed when the HIV-positive person was virally suppressed. This means that people who take anti-HIV meds daily, as prescribed, and who achieve and maintain an undetectable viral load have effectively NO risk of sexually transmitting the virus to an HIV-negative partner.” (U.S. Centers for Disease Control & Prevention (CDC) September, 2017)

Tony Fauci, MD, director of the National Institute of Allergy and Infectious Diseases (NIAID), in an address he gave at the 2018 International AIDS Conference in Amsterdam, concluded “that the body of scientific evidence to date has established that there is effectively no risk of sexual transmission of HIV when the partner living with HIV has a durably undetectable viral load, validating the U=U [Undetectable = Untransmittable] message of HIV treatment as prevention.”

Results from the from recent PARTNER2 study, which only recruited gay couples, were presented in 2018. In total they documented 75,000 barrier-free instances of anal sexual intercourse between sero-discordant gay couples (one positive and one negative partner). The PARTNER2 study recruited HIV sero-discordant couples at 75 clinical sites in 14 European countries. They tested the HIV-negative partners every six to twelve months for HIV, and tested viral load in the HIV-positive partners. Both partners also completed behavioral study surveys. In cases of HIV infection in the negative partners, their HIV was analyzed to see if it came from their regular partner or if they had been with someone else.

The study found no transmissions between gay couples where the HIV-positive partner had a viral load under 200 copies/ml – even though there were nearly 75,000 acts of condomless sex between them. The results suggest, “A precise rate of within-couple transmission of ZERO” for gay men (a previous study had shown zero transmission in heterosexual couples).

Dr. Alison Rodger (lead author of the PARTNER2 study in an International AIDS Conference presentation – July, 2018) put it best when she said “I just want to pay tribute to the U=U campaign. It has been astonishing. I think the time for excuses are over. I think it is very, very clear that the risk (of transmission) is zero. I very much think we have to promote this… if you are on suppressive anti-HIV meds, you are sexually non-infectious and the time for excuses is over.”

The latest San Francisco, CA HIV epidemiology report shows that the number of new HIV diagnoses continues to decline, falling to only 221 cases in 2017 (the lowest number since the start of the epidemic). This represents a five percent decline from 2016 , following two years of steeper drops of around 15 percent in SF, CA . Much of this is attributed to more and more HIV POZ persons being on anti-HIV meds and being unable to transmit HIV. The increasing use PrEP (pre-exposure prophylaxis) in which an HIV-negative person takes a daily anti-HIV med to block infection, is another reason.

In 2016, statistics showed that 92 percent of all HIV POZ Marin County residents on treatment had achieved undetectable HIV viral loads (of the 522 HIV POZ people who had their labs tested in Marin, 480 of them achieved viral load suppression). It is essential that HIV service agencies in the County, including The Spahr Center, work to further increase the percentage of HIV POZ people achieving undetectable status.

All of this important news isn’t just good for HIV prevention, but also for HIV POZ individuals. Every HIV POZ person I know wants to avoid passing the virus on to others. It is important news for those who have not tested for HIV yet, or who have not started treatment yet, that becoming U=U can lift a huge burden of worry off their shoulders. And finally, having HIV-NEGATIVE people know about U=U helps them to realize that they do not have to stigmatize and avoid HIV-POZ people!

I encourage you to please do everything you can to pass on this information regarding the U=U campaign, as it will help (a) encourage people to know their HIV status; (b) encourage HIV POZ people to be taking meds and be adherent with their med schedules, (c) reduce the stigma and fear directed toward HIV POZ persons; and (d) help sero-discordant couples better navigate their relationships without fear.