The Undetectables

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01 Jun 2015

If 'The Undetectables' sound like a bunch of superheroes, working silently to change the world for the better, then maybe — when put into the context of a desire to reduce HIV transmissions — that's kind of what they are. The Australian HIV Observational Database estimates that between 85 percent and 95 percent of people living with HIV who are on treatment have an undetectable viral load (less than 20 copies of the virus in a millimetre of their blood).

Becoming undetectable means the drugs have stopped the virus replicating. Most people living with HIV usually get to undetectable within three to six months of starting treatment. If a person’s viral load hasn’t become undetectable within that period, their HIV medication is usually reviewed. Some people, despite their best efforts, may not get an undetectable viral load (UVL) for some time — if at all. This is not something to get overly concerned about as long as the general blood results are good. However, people with a detectable viral load may need to be extra vigilant to ensure they don’t pass on the virus .

Those people able to achieve a UVL have a better chance of sustaining good health. Research presented at the Conference on Retroviruses and Opportunistic Infections in Seattle in February suggests that the earlier a person with HIV is able to get on treatment and reach a UVL, the more able they are to maintain higher CD4 counts over time. The HIV is also less likely to become resistant to treatment if a person is undetectable.

Apart from the obvious advantages to a positive person’s own health, being undetectable greatly reduces the risk of onward transmission of HIV. Several international studies (such as HTPN 052 and the ongoing PARTNER study) back the science. Indeed, earlier this year, preliminary findings from an Australian study — Opposites Attract — confirmed that treatment as prevention works. 

Conducted by the Kirby Institute at UNSW, the study monitored serodiscordant gay couples (positive-negative) for an average period of 12 months. Out of 6,000 acts of condomless anal sex, zero HIV transmissions were reported. “Essentially, what we are seeing among the gay couples enrolled in Opposites Attract is that HIV transmission is quite unlikely when someone’s viral load is undetectable,” said chief investigator Andrew Grulich. “In fact, no HIV-negative man in the study has contracted HIV from his positive partner.”

Those in serodiscordant relationships experience a real sense of relief about the significant reduction in infectivity that comes with a positive partner’s undetectable status. If the negative partner is also taking the pre-exposure prophylaxis drug Truvada, then the risk of HIV transmission becomes infinitesimal. However, couples engaging in condomless sex need to be mindful of the risk of contracting a sexually transmitted infection (STI). A positive person’s viral load will increase a little in the presence of an STI ,potentially making a negative partner more vulnerable to HIV.

Dr Nick Medland, a clinician at the Melbourne Sexual Health Centre, sees a lot of newly diagnosed clients. Medland says he has noticed a marked change in the numbers of people with HIV wanting to begin treatment as soon as possible, specifically with the aim of achieving a UVL. “Five years or so ago, many doctors would be hesitant to start people on treatments early after diagnosis,” said Medland. “It was thought advisable to let people take time to adjust to their HIV status, to think about whether they are ready to commit to taking treatments — which they may have to do every day for the rest of their lives.” (This is still true for some people and no one should be rushed into the process.)

“These days, however, I have patients who ask in the same consultation when I have given them their positive diagnosis, if they can start treatment,” said Medland. “They have often already talked to their friends with HIV about how they are handling their medications and, as the side-effects are minimal for most people these days, they want to start as early as possible."

And there is no longer a barrier against doing so. Last year, the Australian government changed the Pharmaceutical Benefits Scheme guidelines for HIV antiretrovirals so that anyone who wishes to start treatment can do so any time they want, irrespective of their CD4 count. Anecdotally, HIV-positive people with undetectable viral loads say proactively keeping the virus under control through treatment makes them feel empowered. They feel as if they are keeping the arch-enemy at bay — much like a superhero.