The power of U=U

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02 Aug 2018

There was a considerable amount of hype surrounding the AIDS 2018 U=U pre-conference, and considerable interest from delegates. I attended this pre-conference believing it would simply reinforce what I already knew about this global campaign, but was pleasantly surprised with the content presented — and extremely grateful to be present among some of the world’s greatest and most respected individuals working within the HIV sphere.

Back in 2017, I attended an HIV forum at the Alfred Hospital in Melbourne, where a number of HIV clinicians expressed concern about how risk was defined in the context of treatment as prevention, and how they communicate this with their patients. Those present were concerned about how information may be relayed to sexual partners of positive patients, and the professional implications of patient notes. I was taken aback and thought at the time that if some of the best clinicians are concerned regarding undetectability, what would it be like for others such as general practitioners?

I’ve also been concerned with the attitudes of a number of young doctors that I’ve spoken to about HIV over recent years — some of which are specialising — who would not consider having a relationship or sexual partner with someone who was HIV-positive. When I asked why, they responded that they were concerned about the risk of acquiring HIV, and, if they ever tested positive, that it would render them unable to perform exposure-prone procedures in Australia. For them, they worked too hard to become medical professionals and it simply wasn’t worth it regardless of treatment advances and dramatic changes in recent years to the overall HIV landscape.

While it’s great that PrEP training has been rolled out across the country for GPs and other medical professionals since PBS listing in April, what was missing from the sessions I attended was any mention of undetectable viral load (UDL) as an HIV prevention tool; UDL was only discussed by the professionals present after I called them out on it.

We cannot expect that general practitioners will have up-to-date information on UDL, nor that patients initiating PrEP will already understand U=U. Medical professionals have a pivotal role to play in supporting U=U, as HIV-positive community members cannot be the sole educators working to get the message out into the wider society.

Thankfully, ASHM launched a Guide for Clinicians to Discuss U=U at AIDS 2018, which aims to provide information to clinicians and healthcare providers about how HIV treatments prevent sexual transmission of HIV. This document needs to be disseminated as widely as possible to PrEP prescribers, sexual health physicians, HIV clinicians and other health professionals.

It's also promising to see that global experts published the Expert Consensus Statement on the Science of HIV in the Context of Criminal Law at the conference. This document provides a summary of the latest scientific and medical evidence about HIV transmission, treatment effectiveness and includes a specific section focusing on the fact that a “viral load that is low or undetectable” significantly decreases or eliminates the possibility of HIV transmission”.

This consensus statement follows a document titled Sexual Transmission of HIV and the Law: an Australian Medical Consensus Statement that was drafted by some of the best HIV clinicians and scientists in Australia and was published in the Medical Journal of Australia in November 2016. It’s about time that the law reflected the reality of HIV today, as HIV-positive individuals who are privileged enough to be virally suppressed can still face prosecution around the world for such things as non-disclosure of status.

World-renowned immunologist Anthony Fauci opened the pre-conference by outlining all of the data to date associated with undetectable viral load and risk of transmission:

  • U=U … but only when U really is U (undetectable). Achieving and maintaining an undetectable viral load is key for positive individuals.
  • There is some risk of HIV transmission throughout the first 6 months following ART initiation. The message of ‘effectively no risk’ associated with undetectable status is following 6 months of consistent adherence to ART.
  • Nothing in life is risk free. It’s up to individuals to weigh up the cost-benefit ratio of various activities in an evidence-informed way.

Meanwhile, Dr. Pietro Vernazza — one of the authors of the Swiss Statement — received the Lifetime Achievement in Health and Human Rights award. The room erupted into a standing ovation. Ten years after the Swiss Statement, and following extensive global criticism, we now know that the information contained in this document was accurate and ahead of its time. It was such an incredible privilege to meet him in person.

Final key messages about U=U include:

  • PARTNER 2 results were released at the conference. There remains no linked HIV transmissions between serodifferent gay couples when the HIV+ partner is undetectable (under 200 copies/ml), following 77 000 acts of condomless sex. U=U is just as true for gay men as for heterosexuals.
  • While more research must be conducted to determine whether U=U holds true for injecting drug use, the European AIDS Clinical Society and, some American guidelines now state that mothers with HIV who wish to breastfeed should be supported, with increased clinical and virological monitoring.
  • Unfortunately there has been considerable pushback experienced by those spearheading U=U in the US, and funding has been withheld from at least one African individual that presented at the pre-conference because of his support for U=U. Many AIDS councils (and some HIV organisations) have not yet endorsed U=U in Australia. We need to continue to advocate for its endorsement by all key organisations, as well by other governments in the country (as Victoria is the only state to endorse U=U).
  • The transformative nature of this global campaign was demonstrated by many positive quotes from positive women in Africa about undetectable status. The quotes outlined the power of U=U for families, communities, their health, and their bodies. It’s great to see this message being supported across various African countries.
  • Matthew Hodson, ED of NAM, responded to an audience question regarding whether the U=U campaign stigmatises individuals who are unable to achieve undetectable viral load. He responded that it did not; that while some individuals will unfortunately experience challenges with reaching viral suppression, the message is incredibly important for destigmatising so many positive people worldwide (that are privileged enough to access treatment, and who have access to viral load monitoring).

So the science is clear, and we have more evidence than ever before to support U=U. Campaign momentum must continue so that HIV-positive individuals can live their lives free of fear and stigma.