In 2012, when 38-year-old Dave* was just diagnosed to be HIV-positive and his CD4 count was less than 10, he was a “regular” of a treatment hub in Metro Manila, be it because “I’d have fever for days, or I’d have rashes all over my body, or whatever,” he recalled. It was during one of his visits to the hospital when the supervising nurse supposedly told him that “ngayong may HIV ka na, huwag na mag-sex ha. Dadami lang kayo (not that you are HIV-positive, stop having sex. If you do so you’ll just help increase the number of HIV cases like yours).”
This of course highlights the discrimination experienced by PLHIVs from medical practitioners themselves. But this particular emphasis on sex/not having sex to stop the spread of HIV also puts a spotlight on the lack of knowledge even among those who are supposed to know better to be able to properly deliver much-needed services (e.g. in this case, there are safer sexual practices available, after all).
And perhaps when particularly considered in a newer context (say, 2017), the ignorance becomes even more apparent since it is now scientifically proven that people living with HIV who are undetectable cannot transmit the virus to their negative partners.
In 2008, Pietro Vernazza, M.D. released a statement (“Advice Manual: Doing without condoms during potent ART”, which was approved by the Executive Board of Swiss Aids Federation) in the Bulletin of Swiss Medicine that claimed that “an HIV-infected person with potent antiretroviral treatment (ART) is not sexually infectious (that is, he/she does not transmit the virus via sexual contacts).”
There were parameters set for the claim, i.e.:
- As long as the therapy is practiced consistently and monitored regularly by the treating physician;
- The viral load on ART has been below the limit of detection for at least six months; and
- No infections with other STI are present.
Viral load, which is the level of HIV in a PLHIV’S blood, shows how active HIV is in one’s system. Usually (though not always), if the viral load is high, the CD4 (or T cells, which help activate immune response) count is low, so that the body’s response to the virus is compromised. A low or undetectable viral load indicates that the immune system is actively working to help keep HIV in check.
ART is medication that helps to keep under control the viral load in the body. The viral load is considered undetectable if test shows lower than 40 to 75 HIV virus particles in a milliliter of the blood. If the viral load is considered undetectable, it means the ART medication is working.
Vernazza’s claim – eventually dubbed as the Swiss Statement – that “under (the above) circumstances, potent ART therefore definitely prevents HIV transmission as safely as condoms” did not sit well with many, including public health and professional organizations (e.g. the US Centers for Disease Control and Prevention or CDC), which questioned Vernazza re his data, and even more pointedly, what he was thinking when he made the supposedly premature claim that was “getting ahead of science”.
Vernazza was, nonetheless, resolute about the message, largely derived from his work with HIV-positive straight people on treatment who wanted to have children with their HIV-negative partners. Condomless sex obviously happened between the serodifferent couples, but of 8,000 patients, not a single report of HIV transmission happened to a partner. This therefore became an ethical dilemma for a clinician like Vernazza since they are supposed to present all equally valid options available and let the patients decide for themselves.
Particularly eight years years later, in 2016, Vernazza was vindicated when studies validated the undetectable=untransmittable (U=U) message – i.e. HPTN 052 and the PARTNER study. But more than the vindication, this also helped evolve the messaging re HIV.
STAY UNDETECTABLE=STAY UNINFECTIOUS
The concept is not completely new, since treatment as prevention (TasP) has long been advocated to curb the spread of HIV. But there is now newer and strengthened push for this with the U=U message.
There’s the PARTNER study, which involved 1,166 serodifferent couples at 75 clinical sites in 14 European countries. To be included in the study, one partner had to be HIV-positive and have an undetectable viral load on ART, and the couple did not always use condoms when they had sex. Between September 2010 and May 2014, 1,000 positive/negative couples had 58,000 acts of penetrative sex without condoms. The study reported that not a single infection happened between the couples.
It is worth noting that 11 people involved in the study became HIV positive. However – and this is noteworthy – none of these infections were phylogenetically linked transmissions; meaning, they got infected not from their HIV-positive partners but from others.
The PARTNER study is particularly important because it included both gay and straight couples.
The PARTNER study is being continued, with PARTNER 2 expected to continue until 2019.
The same results from the PARTNER Study were reported in the HIV Prevention Trials Network (HPTN) 052 study, a Phase III, two-arm, randomized, controlled, multi-center trial to determine whether ART can prevent the sexual transmission of HIV-1 in HIV-1 serodiscordant couples. One thousand seven hundred and sixty-three (1,763) HIV serodiscordant couples at 13 sites in nine countries were enrolled in HPTN 052; one person is HIV-infected and the other is not.
In 2011, the study initially showed a 96% reduction of HIV transmission within the couples involved. The final results (reported in 2015) showed a sustained 93% reduction of HIV transmission within couples when the HIV-infected partner was taking ART as prescribed and viral load was suppressed.
The HPTN 052 study was, in fact, relevant in the recommendation of the World Health Organization (in 2013) that ART be offered to all PLHIVs who have uninfected partners to reduce HIV transmission.
U=U is now endorsed by numerous international organizations, including AIDES –France, AIDS Foundation of Chicago, Australian Federation of AIDS Organizations, British Columbia Centre for Excellence in HIV/AIDS – Canada, Human Rights Campaign, National Alliance of State and Territorial AIDS Directors (NASTAD), National Black Justice Coalition, New York City Department of Health and Mental Hygiene, San Francisco AIDS Foundation,, and the Terrence Higgins Trust – United Kingdom.
Various experts responding to HIV also already came out to back U=U.
For instance, Dr. Carl Dieffenbach, director of the Division of AIDS of National Institutes of Health (NIH), stated in an earlier interview: “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.”
Dr. Michael Brady, medical director of the Terrence Higgins Trust in London, England was quoted as saying that “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.”
Meanwhile, Dr. Myron Cohen, chief of the Division of Infectious Diseases of the UNC School of Medicine; and principal investigator of HPTN 052 stated: “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… When you treat a person who is HIV infected you render them no longer contagious. Over a period of years that benefit is further realized… Sexual relationships can be much safer because [treatment] suppresses transmission. There is a societal benefit, a public health benefit, an altruistic benefit. ”
RESISTANCE TO THE MESSAGE
The benefits of U=U go beyond the medical – e.g. in helping serodifferent couples conceive. For instance, worth noting is how U=U can help deal with HIV criminalization, particularly since there are countries that still prosecute PLHIVs who do not disclose their HIV status to their sexual partners. The US, for instance, is infamous for sending to jail PLHIVs who spit, scratch or bite others sans disclosure of HIV status, and even if there were no known risks of transmission.
The Philippines’ own Republic Act No. 8504, or the Philippine AIDS Prevention and Control Act of 1998, also makes it necessary to disclose one’s status – albeit (unlike in other countries) it is mum on the possible criminal liability of those who fail to disclose. Section 34 (under Article VI, which deals with confidentiality) mandates disclosure to sexual partners – i.e. “Any person with HIV is obliged to disclose his/her HIV status and health condition to his/her spouse or sexual partner at the earliest opportune time.”
But despite the pluses of U=U, not everyone is on board (perhaps as of yet) with its promotion.
Interestingly – and this is a major point worth stressing, too – many of those who express reluctance (if not blatant opposition) to U=U are HIV community advocates and organizations. In the US, for instance, Bruce Richman of the Prevention Access Campaign was able to gather signatures of health experts from all over the world for a consensus statement about U=U; but he reported having a challenging time coaxing US HIV organizations to adopt language that removes the stigma of infectiousness from people who are undetectable.
The Prevention Access Campaign stated that “the majority of PLHIV, medical providers and those potentially at risk of acquiring HIV are not aware of the extent to which successful treatment prevents HIV transmission… Much of the messaging about HIV transmission risk is based on outdated research and is influenced by agency or funding restraints and politics which perpetuate sex-negativity, HIV-related stigma and discrimination.”
“We had a difficult time in the beginning because NGOs are not always early adopters, and some have been driven by 35 years of fear of HIV and PLHIV. They may not be confident in the science and are understandably concerned about saying anything that will lead to more transmissions,” Richman said to Outrage Magazine.
There’s also the “longstanding history in the field of overprotecting people who do not have HIV at the expense of people with HIV’s basic human rights to accurate information about our social, sexual and reproductive health. We’ve also come across the shortsighted view that this information only improves the lives of people living HIV, when in fact this is a game changer for the epidemic because of its impact on HIV stigma, testing, treatment uptake and adherence, which will ultimately lead to more people knowing their status and getting to undetectable,” Richman added.
There have been pluses, and “we’re happy to see momentum now. NGOs are beginning to catch on because leaders in the US, like NYC Department of Health and Mental Hygience, National Association of State and Territorial AIDS Directors (NASTAD), Housing Works, and San Francisco AIDS Foundation have made statements and updated their public information and social marketing campaigns. Just (a few weeks ago), Canada’s official source for HIV information, CATIE, endorsed U=U.”
In the Philippines, however, no HIV-servicing body has yet to openly and officially back U=U.
CHALLENGES IN PHL CONTEXT
Dr. Jose Narciso Melchor Sescon, who helms the AIDS Society of the Philippines (ASP), said that U=U may still be considered a “medyo (somewhat) sensitive issue in the Philippines.”
For one, this is the number of PLHIVs availing of ART continues to be low. In November 2016, for instance, the total number of Filipinos living with HIV was pegged at 38,872. But only 17,388 are on ART.
Secondly, “ARV adherence is (still) a major concern.” Among people working in the HIV advocacy, it is not uncommon hearing about PLHIVs who are “lost to follow-up”.
Thirdly, “we should also consider co-morbidities,” Sescon said. One may have undetectable viral load yet still engage in other unsafe sexual practices, such as having numerous sexual partners. “So I’d still offer using (other forms of) protection.”
And fourthly, Sescon expressed apprehension based on “real life” situations particularly “in a context like the Philippines.” While clinical trials may have yielded desirable results, “how much of these can be translated and put into reality or the true context of the Philippines?”
Sescon said that “even with scientific evidence showing non-transmission, it will still take time for this to sink in the minds among serodiscordant couples.”
The consensus statement from the Prevention Access Campaign admitted certain limitations – e.g. that many PLHIVs may not be in a position to reach an undetectable status because of factors limiting treatment access (including inadequate health systems, poverty, racism, denial, stigma, discrimination and criminalization); pre-existing ART treatment resulting in resistance or ART toxicities; and refusal to start treatment. All the same, it stressed that “understanding that successful ART prevents transmission can help reduce HIV-related stigma and encourage PLHIVs to initiate and adhere to a successful treatment regimen.”
But Richman believes that in a resource-lacking setting like the Philippines (where less than half of PLHIVs access ART), “this is a platform for expanded access to HIV treatment. The more PLHIV on treatment in the Philippines, the closer the country will get to ending the epidemic. Test and treat is the most effective method. Reducing HIV stigma will encourage both testing and treatment.”
BOLSTERING THE U=U CONVERSATION
And while the conversation on U=U continues, perhaps worth underscoring is the relevance of this on how PLHIVs view themselves.
Back in the treatment hub in Metro Manila where Filipino PLHIV Dave goes to (and where he is now “with CD4 count over 500 – way better than the nine when I started; and with undetectable viral load to boot,” he said), U=U has helped him see himself as “a human again.”
“I must admit that there were times in the past when I felt like the virus itself, as if just waiting to make others ‘sick’; and even internalized this oft-repeated notion that people like me are ‘dirty’,” Dave said. “Now I know that if we truly want to deal with stigma and discrimination – not just the health benefits – linked with HIV, we should start talking about U=U.”
*IN THE PHILIPPINES, WHEN A PERSON LIVING WITH HIV IS ENROLLED/REGISTERED INTO A TREATMENT HUB, HE/SHE IS ASKED TO PROVIDE: 1) YEAR OF ENROLLMENT; 2) INITIALS OF FIRST NAME, MIDDLE NAME AND SURNAME; AND 3) NICKNAME. THIS IS THE CODE NAME USED BY THE INTERVIEWEE.