U=U - How science can deliver us from fear and stereotypes
By Esther Dixon Williams & Nikos Dedes, European AIDS Treatment Group
One of the most significant findings that has taken place in HIV prevention and the strategies of national and international HIV health policy over the last few years, is the emphasis of the role of HIV treatment as a method of prevention, otherwise known as Treatment as Prevention (TasP). Universal access to antiretroviral therapy (ART) is a human right for the benefit of the individual but it is also the corner stone of any strategy to end the transmission of HIV, providing yet another powerful advocacy tool.
In 2016, the Undetectable=Untransmissable (U=U) campaign was launched by the Prevention Access Campaign to ensure that the scientific evidence of U=U, which has been building for over two decades, is delivered to people living with HIV, their health care providers, the general population and, why not mention it, the LGBT community itself. The U=U campaign is based on the fact that people who take ART daily as prescribed and achieve and maintain an undetectable viral load have effectively no risk of sexually transmitting the virus to an HIV-negative partner, and has rapidly gathered momentum, having been endorsed by more than 567 organisations from 71 different countries including national and international HIV and public health organisations.
And this is where it gets technical but bear with us! The scientific evidence accumulated across several studies, starting with the seminal 1994 paper describing the ‘Reduction of Mother to Child transmission’ with the use of AZT monotherapy, to the famous Rakai Cohort findings presented in 2000 where no transmission occurred to sero-different couples (one infected, the other not) when the viral load was lower that 1500 copies, up until the all but definitive evidence from the HPTN 052 study. That study was stopped early in May 2011 since it demonstrated only one possible transmission from someone on treatment versus 27 from those not on treatment. That one transmission occurred before the HIV+ person had the opportunity to make the viral load undetectable.
Nevertheless, the significance of those results were downplayed by people who argued that this did not sufficiently cover anal sex and therefore gay men and men who have sex with men were once again left in limbo. This led to the design of the PARTNER study which has had zero transmissions after 58.000 acts of anal sex without a condom or pre-exposure prophylaxis (PrEP).
It is important for people living with HIV to receive and understand this message so they can be confident in their ability to have healthy sex lives, uninhibited by fear and self-stigma. Understanding U=U will also reduce HIV fear and stigma to all people interacting socially or personally with people living with HIV. In a paradoxical reversal of given wisdom, having sex with a person on successful treatment is the only certain way to not be exposed to HIV transmission risk.
In the 1980’s HIV/AIDS was depicted by homophobic and religious fanatics as a punishment for the sins of gay sex. The LGBT movement responded with amazing mobilisation but there is no doubt that members of the LGBT community and some groups felt increasingly conflicted and tried to disassociate themselves from HIV. Some groups in Europe distanced themselves from those 'promiscuous and drug-using' gays in America. This internalised stigma in the community was even more pronounced in the people living with HIV themselves. Today some of those most negative to PrEP use are people living with HIV. And as far as the U=U messages goes, it is denigrated by some as a self-indulgent and irresponsible invitation for condomless sex, exposing people to all those horrible, sexually transmitted infections.
The majority of millions of people living with HIV do not know U=U, and many still do not have access to the foundations of disease management, the diagnostics, treatment, and care they need to get to and maintain an undetectable viral load. There are still confusing messages, outdated websites, and uninformed policy makers and healthcare workers who are unsure about sharing this information. Many don’t know about U=U, or do not understand the significance and the impact of this information on the lives of people living with HIV.
We welcome ILGA-Europe’s role in addressing this information gap and trust that science will dispel all misconceptions towards a more understanding and inclusive society.
Esther Dixon Williams and Nikos Dedes are board members of the European AIDS Treatment Group.
Disclaimer: The ILGA-Europe Blog is a place for views, ideas and debate. The views expressed by authors do not necessarily reflect the policy of ILGA-Europe, or the views of its board members or staff.
Picture: Fight AIDS Foundation