AIDS 2018: Undetectable equals Untransmittable

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Science Speaks is covering the 22nd International AIDS Conference this week live from Amsterdam, the Netherlands, with breaking news, updates and analysis of new research findings, evidence-based responses, and community action for global access to HIV treatment and prevention.

AMSTERDAM – A year after activists marched onto the stage of an International AIDS Society 2017 Paris Conference plenary session to unfurl a banner proclaiming “Undetectable = Untransmittable,” the data-backed public health message — U = U — that became a movement was endorsed by past and current presidents of the world’s largest association of HIV professionals, during a session here Sunday.

While the concept that people on treatment for HIV with viruses suppressed to undetectable levels do not transmit the virus first became a topic of wide discourse in HIV advocacy and professional circles with the release of a statement from the Swiss National AIDS Commission in 2008, the all-day preconference session Monday was the first IAS event dedicated to exploring its ramifications.

The ramifications, speakers here said, include using the data that supporting the U=U message, reviewed at the session by National Institute of Allergy and Infectious Disease Director Dr. Anthony Fauci, to further challenge HIV-specific criminal laws. Those include laws penalizing people living with HIV for acts that include spitting at, biting, scratching, or having sex with people who are uninfected.

“These laws were unjust and not scientifically based when they were passed, now they are medieval,” IAS Past-President Dr. Chris Beyrer said.

“U equals U is based on the best evidence we’ve seen,” Dr. Beyrer said. “I’m a conservative epidemiologist and I would be willing to stake my reputation on it.”

Even now, however, questions from audience members highlighted the difficulties facing clinicians and advocates alike seeking to gain acceptance of the concept.

Are people with undetectable viral loads “absolved” from notifying partners of their infection, asked a questioner from Florida, one of more than 30 American states with criminal penalties specific to HIV on its books.

Yes, it does, panel members, including the Dutch co-founder of PROUD, an organization of sex workers agreed.

Still: Does the second U mean unlikely to transmit, or definitely won’t transmit, another asked.

“Do you want me to tell you what I do as a physician?”   Dr Pietro Vernazza, who also is co-author of the Swiss Statement, asked. “I do the same thing I do with household contacts. I say there is no risk.”

“If Tony Fauci says zero, it’s zero,” said Dr. Demetre Daskalakis, who is deputy commissioner for disease control for the New York City Health Department and described his efforts to secure the city’s endorsement of U = U. He noted potential exceptions, that in theory people with a “blip” raising their viral load briefly to detectable, or with a separate sexually transmitted infection, could transmit, “but they just don’t,” he added.

In addition, both justice and semantics aside, resource constraints standing between people living with HIV and knowledge of their viral load around the world pose another challenge to benefiting from the science supporting that a virus that is undetectable is untransmittable. And, an audience member asked, are we creating a new stigma for people who can’t achieve undetectable viral levels?

Most of those are people who can’t access treatment, panel members noted. The U = U message underscores the importance of making effective, consistent treatment universally accessible, one noted.

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