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How hard is it to say that HIV-positive people who have suppressed the virus through effective antiretroviral drugs do not pose any transmission risk to their sexual partners? Pretty hard, it seems, as just about every day I see some commentator fudge their response, with statements using terms such as “extremely unlikely” or “reduces the risk”.
Such woolly statements are no help to people living with HIV.
From the very early days of effective HIV treatment, researchers noticed a correlation between increases in access to treatment and decreases in new infections. It took until 2008 for scientists to poke their heads far enough above the parapet to state that someone on antiretroviral therapy who was undetectable could not transmit HIV sexually, in what later came to be known as the Swiss Statement.
Since then, successive studies have searched for a case of transmission from someone who is virally suppressed; yet all the studies have failed to find a single case.
The understanding that HIV cannot be sexually transmitted when the virus is undetectable has gone from concept, to confidence. Now, with the results of the PARTNER 2 study, which found no transmission of HIV following 75,000 condomless sex acts, it has moved to certainty.
The final slide in the report presentation at the AIDS 2018 Conference in Amsterdam in July employed the same phrase that activists have used to celebrate the impact of HIV treatment as prevention, “Undetectable equals Untransmittable”.
At the conference, Dr Alison Rodger, an honorary consultant in infectious diseases and HIV at the Royal Free Hospital in London, summed it up perfectly. “You would have to have condomless sex for 419 years to have transmission,” she said. “The risk is effectively zero. U equals U.”
For those of us who live with the virus, this simple message has changed our lives.
Many of the commentators who are wary about declaring that “U equals U” are happy to admit that HIV can’t be transmitted by everyday domestic interactions but they still balk at saying the same about sex when the virus is undetectable. We know that HIV can’t be transmitted by kissing, spitting or by sharing teacups because no cases have ever been found. After all these years, “no cases” is sufficient to give us confidence that these are not transmission routes.
We can now say the same thing about sex when the positive partner is undetectable. And this is important.
Since the AIDS crisis first hit, many people’s sex lives have been tainted by fear. The sex we have, which should be an expression of intimacy, passion, lust, tenderness and joy, has all too often been accompanied by thoughts of “Is this safe enough?”, “Will I be OK?” or “Will he be OK?”
Treatment as prevention has made our sex not merely safer, but safe. It has granted us freedom from the fear of passing the virus on during our most intimate moments.
The goal of HIV treatment is a long and healthy life; its preventative impact is a side effect – but what a great side effect it is. “U equals U” underlines the importance of expanding access to treatment and of improving its uptake and adherence for all people living with HIV worldwide.
HIV stigma remains a public health crisis resulting, in extreme cases, in murder and suicide. It should be a public health duty to inform all of us who are living with the virus, and all of those whom we encounter, that effective treatment prevents transmission.
It is vital that when we educate people about HIV we rely on facts rather than fear. The news that HIV+ people on treatment present no risk of sexual transmission is too valuable, too exciting and too important for it not to be shared, understood and celebrated as far and as widely as possible.
by: Matthew Hodson