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(SUPERINFECTION, 2009) (SUPERINFECTION DEBATE 2009)
Apr 9, 2009

i can hardly believe how blatantly you spin the facts, Dr. You say a person with undetectable viral load 'conclusively' has been proven to be able to pass that virus onto others. Then you tell the reader to "(read below)". The article below also says "(read below)", and the next and the next, and finally, if the reader has enough diligence to finally find your cite, they find discover the article about the German study of a single case, where the strains aren't even identical, and that they admit they are relying on the patient's word of fidelity, which they admit if iffy at best. And in the same article, is the Swiss study which has a completely different conclusion on the topic. this is your idea of 'conclusivity'? When you take such a hardline approach, it really weakens the credibility. i don't care if you print this or not.. i'm posting it in the forums.

Response from Dr. Frascino

Hello,

Relax Max and take a hard look at the facts! As you will note in my response to which you took such umbrage, I posted the entire article by Michael Carter related to the findings suggesting HIV can be transmitted from MSM with undetectable viral loads. It included the criticism of the report. That way the readers can draw their own conclusions. I found the phylogenetic analysis compelling. The viral strains "suggested a close relationship between the virus in the patient and his partner." I agree with the authors of this report who suggest that HIV transmission can occur despite an undetectable HIV plasma viral load. Yes, as with many case report studies there are some weaknesses that can be pointed out. However, there are glaring weaknesses within the Swiss report as well. (I've discussed these at length in the archives. Have a look!)

It's important to note that additional studies have now concluded that there can be a detectable HIV viral load in semen even when the HIV plasma viral load is undetectable! This could explain a mechanism for transmission.

All major AIDS agencies and the scientific community have concluded that the Swiss study suggests that in heterosexual partnerships the risk of HIV transmission is low in the presence of effective combination antiretroviral therapy. However, the risk is not zero! (Note the Swiss study did not study MSM! A major "weakness.")

There are a number of potential problems and unseen risks if an individual where to decide his partner's undetectable status was sufficient to prevent HIV infection. Drug resistance could develop causing a spike in viral load without the patient or partner knowing. Nonadherence to the drug regimen could cause a transient increase as well. A concurrent STD in the patient can increase HIV viral load in a patient who was previously undetectable. Conversely an STD in the partner could potentially make him or her substantially more susceptible to contracting the virus.

Adding all these facts together, I feel the evidence is quite convincing that unprotected sex cannot be considered safe even if the partner claims to be "undetectable". The case report merely adds more weight to my assessment. OK?

As a prevention strategy for individuals the use of combination antiretroviral therapy (cART) alone cannot be recommended or considered effective. However, as a population strategy effective cART has real synergies with condom use in reducing HIV transmission.

Public health projection models indicate that if individuals relied only on "undetectable viral load" for HIV prevention and this resulted in reduced condom use, there would potentially be a substantial increase in HIV incidence. To sum up, the balance of scientific evidence continues to show that undetectable viral load in the blood does not equal zero risk for HIV transmission.

As always the choice to be safe or sorry remains yours.

Dr. Bob



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