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"Undetectable": Safe or Not?

August 28, 2013

Dave R.

Dave R.

This article originally appeared on PositiveLite.com, Canada's Online HIV Magazine.

Positive people, on effective treatment, with an undetectable viral load and healthy immune system, still don't know if they can or can't pass on the virus to their partners. New UK developments suggest that official conclusions may already have been reached.

Recently, the idea that people on HIV medication who are also undetectable (where your viral load is measured at less than 40-50 copies of HIV in every milliliter of blood) might also be non-infectious to others with similar tested levels and a healthy immune system, has naturally got everybody in that situation very excited. There is however, still no definitive proof and although we're assured that proof either way is being worked on, it's going to be some time before that news emerges from behind the locked doors of the research labs.

In the meantime, people with an undetectable status see proven non-infectiousness as a possible, instant solution to many sorts of stigma. If, after indisputable proof, it is widely reported that people on successful treatment are not in danger of passing on the virus, then there is no reason for every sexually active person on the planet not to get tested and if necessary treated because treatment will make you a safe person to have sex with. This is discounting other STDs of course but then you're just as much at risk as any sexual partner of contracting those. If successfully proved, people living with HIV will be seen as living with a chronic illness that is no danger to their partners, pretty much like diabetes patients, cancer patients and others. The world will change overnight, not only for positive people but for LGBT society as a whole. They won't be able to point accusing fingers at us anymore, claiming we're "unclean," "disease spreaders" and a "danger to society."

It's almost a utopian idea but it may well be only a large-scale research study away. Doctors, scientists and HIV-specialists are already giving the idea some credence; politicians and other social groups ... not so much. The idea that people living with HIV can safely have sex with anyone in the community again, sticks in many a craw, including, astonishingly enough, many HIV organizations, who see it as subversive to all the work they've been doing to promote condom use and safe sex!

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The word "undetectable" has already been abused and misused to the point where many claim it to be meaningless. Proof that undetectable means non-infectious, or even proof that undetectable means the possibility of transmission still exists, is essential and you have to ask why research groups across the world aren't moving heaven and earth to get an answer one way or the other. Maybe they are but nobody's telling us.

That all said, there has been a breakthrough in the UK this month which gives a remarkable insight into the way health authorities and government ministries there are currently thinking.

The current ban on health workers in the UK who have HIV, carrying out certain procedures involving possible exposure to blood and fluids, has been lifted! It even hit the breakfast news and made national headlines the same day but it is the reasons behind the decision that have enormous implications for all people living with HIV.

So why has the ban on HIV+ health workers working normally with patients been scrapped?

Remember, this means that HIV positive health workers can deal with contact situations in the same way as all their colleagues and this includes surgery and dentistry. It's a decision that can't have been taken lightly because the ramifications of an HIV transmission from nurse to patient are enormous. You might reasonably assume that they must be sure of their facts.

Both on television and in the press, Professor Dame Sally Davies, England's chief medical officer (second only to the minister responsible for health) explained the decision in refreshing detail, stating that science had moved on and "outdated rules" should be scrapped. She went on to say that modern treatment means that HIV is mostly a chronic condition where people can live long and normal lives. Nothing new so far you might think; but the revolution in thinking is in the details and as she explained:

"At the moment we bar totally safe health care workers who are on treatment with HIV from performing many surgical treatments, and that includes dentists."

Professor Davies continued in a more HIV-friendly tone than we may be used to:

"What we want to do -- and want to get over -- is how society needs to move from thinking about HIV as positive or negative and thinking about HIV as a death sentence, to thinking about whether they're infectious or not infectious."

People with HIV "... are leading lives that are normal in quality and length. With effective treatment, they are not infectious."

The new rules are very straightforward. HIV positive people with a job in health care must have an undetectable viral load; be on an effective combination therapy and must be regularly monitored by their own specialists (every three months). There is a non-obligatory responsibility for medical carers to get themselves more frequently tested if they feel that have been once again exposed to the virus but again, the professional is being trusted to do the right thing. There will be a confidential (barring memory sticks being left in taxis!) register of infected workers lodged with Public Health England but this registered proof of status is as much to protect the health worker as the patient. No excessive government control or checks; no unreasonable demands and no uncertainty as to what the ruling actually means ... refreshing or what!

It was also pointed out that there have only been 4 cases worldwide of health carers infecting patients, with none in the UK and to hammer home the point, it was suggested that people have more chance of winning the state lottery than being infected by an HIV+ medical health worker.

Professor Davies went even further to educate the public:

"Many of the UK's HIV policies were designed to combat the perceived threat at the height of HIV concerns in the 1980s and have now been left behind by scientific advances and effective treatments ... It is time we changed these outdated rules which are sometimes counterproductive and limit people's choices on how to get tested or treated early for HIV. ... What we need is a simpler system that continues to protect the public through encouraging people to get tested for HIV as early as possible and that does not hold back some of our best health care workers because of a risk that is more remote than being struck by lightning. The risk is absolutely negligible, we are talking about people being treated so they are not infectious."

How often do we hear such sensible conclusions from government, or health organizational sources? Little wonder that this decision has been welcomed by LGBT and HIV groups and more importantly, the umbrella organizations of surgery and dentistry.

Are there any further implications for undetectable people living with HIV?

Well, let's put this in context. There's still no definitive proof that being undetectable, on treatment and immune-healthy means no risk of transmission. In world terms, this is also a small step to benefit a relatively small number of people in the UK but it suggests that health authorities are beginning to think differently about the issue.

If health workers are deemed to be no risk to their patients, with all the possibilities of cross infection via blood and bodily fluids, then by definition, non-health workers with the same HIV profile must also be of no risk to their partners. Or is that an assumption too far and wishful thinking? Am I missing something? You can't imagine that the top health experts in the UK are taking a risk here, based on a mistaken premise; so when will the rest of the world, including HIV organizations and the media, put two and two together and come up with four, instead of five, six, or seven!

Once again, it can't be stressed enough; you can't escape the fact that there's no official, scientific proof. The studies so far have been grasped at by many as being suggestive of proof but they are few and far between and hardly large scale and none have been directed at gay men having gay sex.

So it seems reasonable to surmise; what do the health authorities in the UK know that the rest of us don't?

Send Dave an e-mail.

Read Dave's blog, HIV, Neuropathy and More: Avoiding Becoming a Nervous Wreck.

Get e-mail notifications every time Dave's blog is updated.


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This article was provided by TheBody.com.
 

Reader Comments:

Comment by: George Hamilton (Brimingham UK) Sun., Sep. 15, 2013 at 6:17 am EDT
It would be nice if someone could get an interview with professor Davies to ask her exactly what she means in relation to the gay community.
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Comment by: Gok W (London UK) Mon., Sep. 9, 2013 at 4:47 pm EDT
It's about time somebody started looking at this question clearly and you do. There's so much BS surrounding HIV infectiousness and everyody's normally left guessing at the truth. At least you demand facts because they are the only things that will set us free from all the half-truths and misconceptions. Sally Davies has said what she and her team thinks to be true and if anyone knows different they should speak up now because it's too important to be met with silence. Thank you for bringing this story to light. If we're not infectious we need to know. Now.
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Comment by: Jeannie Wraight (Bronx, New York) Mon., Sep. 9, 2013 at 10:34 am EDT
As you say, no definitive study has conclusively proven whether or not with an undetectable viral load an HIV positive person can pass on the virus.

However it appears from what we do now know that it may not be a case of undetectable equals safe or not. It seems there are other factors involved that increase or decrease the risk. These include whether there's an STD present (in the case of herpes no one has specified whether that means only active herpes)which increases the risk. Whether the positive person is the insertive person or receptive (more risk if insertive). There may even be a slightly greater risk with the type of sex (vaginal being the safer than anal). Then there's the case of viral blips which we're still not sure what consequences they have.

The difference between the danger to healthcare workers and the danger in sex is the levels of viral load may be diffrent in seman and vaginal fluid verses blood.
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Comment by: Dave R (Amsterdam) Wed., Sep. 11, 2013 at 9:44 am EDT
But we don't know and that's my point. Maybe the whole definition 'undetectable' is diminished by the fact that not enough large scale studies on viral levels in semen, saliva and vaginal fluid in undetectable people have been done. The question is why, or were those levels not regarded as being significant when declaring someone undetectable.
By the way, the danger is not to healthcare workers, it's to patients (if it exists)and as HIV is transmitted via blood contact whatever the situation, it's a bold move by a national health authority to state that for instance, an undetectable, HIV+ childbirth medical assistant, has no risk of passing the virus on to mother or baby and basically that's what they're saying. Unless the UK authorities have been especially incompetent or negligent in not studying the risks and have missed something vital, they must surely be sure of their facts. This is why I close the article by saying: 'What do they know that we don't?' Personally, I think that the sort of physical contact with bodily fluids and blood a medical health worker has with a patient, especially on a surgery ward or in a dentist's chair, is such that the potential for viral transmission is as great as during sexual contact. That said, you're of course right to bring up the semen/vaginal fluid issue and we need to know exactly how much and what sort of viral particles exist there when it's virtually disappeared in the blood. Why hasn't that information been properly studied and researched as part and parcel of creating the definition 'undetectable'? Otherwise, it's only half the story. It's time we stamped our collective feet and demanded answers as far as I'm concerned.


Comment by: Rob (NY) Sun., Sep. 8, 2013 at 3:47 pm EDT
Thanks for the informative article. It's very encouraging to say the least.

One question though. I haven't seen much written about whether there is a correlation between undetectable HIV in the blood vs semen. I've often wondered why testing isn't available to allay those fears. My doctor tells me that we can't assume a person's semen is also undetectable. Can you direct me to any current statistics or do you have any info to share?
Much appreciated!
Rob
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Comment by: Mary Cowell (Vancouver Canada) Sun., Sep. 8, 2013 at 5:31 am EDT
You know what, I want to know what the Body experts say about this! They seem to be conspicuous by their silence. Do they agree with Dave R, who says himself he's no medical expert? If not why not? It must be true that if they're going to let positive medical people mess around with people's bodily fluids then sex partners must also be safe because that's also dealing with internal contact. Dave R rightly says that without firm evidence you can't be sure, whatever the UK's national health body says about it. I want to know what The Body doctors think don't you?
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Comment by: Grigor (Des Moines) Sun., Sep. 8, 2013 at 5:23 am EDT
I don't know what to make of this. It's temtping to draw the sort of conclusions you're seeming to draw and I can't deny the logic of what you say or even what the chief medical officer says. thsi could be really big but as somebody else says, it would be best to know on what basis that lady and her department came to their conclusions. There must be evidence that they used to be able to say something so revolutionary.
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Comment by: Thane2020 (Palm Springs, CA) Fri., Sep. 6, 2013 at 10:34 pm EDT
I seroconverted this year, so I'm writing this from someone who was recently negative and is now positive.
I get a little tired of hearing people complain that they are being rejected because they are HIV+ and then chalking it up to stigma. Take time to really think about the definition of stigma: it is the marginalization of a class of people by labeling them as different and understanding them only in terms of stereotypes. When someone believes that "All HIV positive people are bad," or "All HIV positive people got infected by being promiscuous," - then that is stigma. When someone says they don't want to have sex with you or date you because they are HIV- and you are HIV+, that is an individual doing a risk asessment and then making a choice (stay with me before you get all bent out of shape -- read on). And they aren't rejecting you outright - they are rejecting the idea of having sex with you. Is that all you are comprised of? Let's keep sex in perspective here...
I'm HIV+ but I am HEP C negative. And I've made a decision that I don't want to have sex with anyone who is HEP C positive. This isn't a decision based on stigma. This is a decision based on risk factors. For one thing, I am not always great at following safe sex practices one hundred percent of the time, especially when I'm dating someone and engaging in ongoing sexual intimacy with them. I know myself, and know that it is better that I just don't have sex with HEP C positive people. Not because of them. Because of me.
Perhaps this is why a negative person doesn't want to have sex with a positive person. And this is a viable choice on his part. If it hurts you, okay. But don't paint him with the brush of stigma.
Similarly, it might be cold-hearted, but sometimes people don't want to become involved with someone who is dealing with a chronic illness. I might not want to date a diabetic who has to watch what he eats and takes medication every day. That sounds cold, but it isn't stigma. You get it?
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Comment by: Queen (East Cleveland, OH) Mon., Sep. 9, 2013 at 2:48 pm EDT


Well said Thane2020! I agree with you 10000%
Comment by: Tom (Garden Grove) Fri., Oct. 11, 2013 at 10:32 pm EDT
Wow, have you learned nothing from your diagnosis? "History repeats itself, first as tragedy, second as farce". Have fun demanding that your partners be "HEP C negative". I've no doubt it will be as effective as your previous quest to remain HIV negative. What's the definition of insanity? I believe it's thought of as doing the same thing and expecting a different result.

In the meantime, please remain pedantic about definitions. Technically, refusal to associate with people who are labeled poz, for reasons not legitimately related to risk, may not be "stigma". It's certainly discrimination though, and most people find discrimination unacceptable in contexts outside HIV and sex. That people make an exception to discriminate against people with HIV based solely on the fact that it is HIV is a pretty textbook example of social stigma.


Comment by: Sheila Borton (Canada) Thu., Sep. 5, 2013 at 5:04 pm EDT
It show's that I am undetected to for 2 years now,since my last lab test results.What does this mean that I am undetected.Can I still pass on HIV without unprotected sex and will that person get a different strand of HIV from me.I never did understand the meaning about 'undetected'.I would like to know more about it.
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Comment by: Eduardo (Miami Beach, FL) Thu., Sep. 5, 2013 at 4:30 pm EDT
I am in a serodiscordant relationship with a positive fellow. Somehow even if I take all precautions still feel at danger (potential). It's something psicological in the subconsciousness. I am going to therapy.
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Comment by: TC (NY, NY) Wed., Sep. 4, 2013 at 7:56 am EDT
Wait....being "undetectable" is related to the amount of virus in your blood. However, I have also read that just because the amount of virus in your blood is undetectable, the amount of virus in semen could be detectable. I can't speak for all people, but I am much more concerned about exposing someone to my semen during sex rather than my blood......so being "undetectable" with regard to viral amounts in your blood is of no consolation when speaking of sexual behavior.
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Comment by: KC (PA) Tue., Oct. 29, 2013 at 10:35 am EDT
This is such a great point! Do we even have a test that detects viral load in semen, vaginal fluid, or breastmilk at this point?


Comment by: Helen Lawrence (Nigeria) Wed., Sep. 4, 2013 at 5:04 am EDT
If it is safe to have unprotected sex when undetected, is it possible that if a positive, undetected woman breastfeed, or mix-feed, there may be no risk to the baby?
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Comment by: Victor (Oregon) Tue., Sep. 3, 2013 at 11:25 pm EDT
I agree that science is onto something. I have been with my his and for 10 years, have been undetectable for >10 years, and have always had unprotected sex our whole relationship. He gets tested once a year and remains negative. A true testament to science and healthy living.
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Comment by: Dougie Roberts (Southampton UK) Fri., Aug. 30, 2013 at 9:11 am EDT
There are so many things written about this subject at the moment but this one does seem to suggest official approval for having sex with undtectable people who are healthy. I can't find a hole in the argument, when the top medical officer in the UK tells people to stop being hysterical about something that seems so obvious. Now the final proof please.
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Comment by: rm (uk) Thu., Aug. 29, 2013 at 4:42 pm EDT
Its a bit wierd that we never seem to see any research results from UK NHS. 70 million population all under a 'universal' care system - among that 100,000 plus hiv+ patients.

On the undetectable and partner - an hiv+ worker treating an hiv- patient is a one off event (with no doubt 'precautions' in place) , a mixed hiv+ / hiv- couple and sex is (one hopes !) a multi event risk.
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Comment by: Dave R (Amsterdam) Fri., Aug. 30, 2013 at 5:43 pm EDT
You could also say that a significant number of potential risk situations amongst gay men are also 'one off events' and more and more of them don't involve 'precautions in place'. If that were truly as risky as we have always been told, wouldn't the virus be out of control by now? It's true that numbers of infections are not declining, or slightly rising, especially in urban centres but they're not exploding out of sight,as you might expect, with new mutations carrying the virus to the next level. The greatest danger lies with those who are positive but untested and thus untreated and they may be responsible for the levels not dropping as hoped. Those who are under treatment and undetectable may not be spreading the disease at all. Again, as I say in the article, absolute proof one way or the other is essential. Research bodies need to be properly funded to do the necessary large-scale research and if it's found that undetectable, otherwise healthy people are almost risk-negligible then governments could logically insist on everybody getting tested as a matter of course. Those found to be carrying the virus can get treated and their risk to others will be minimalised but vitally, people with HIV should then not be seen as spreaders of death and disease and stigma should be significantly reduced. The media will have a vital role to play in getting the word out to the general public. However, the same thing stopping the necessary research may be the same thing deciding the media response and that is political influence from the anti-LGBT lobbies.


Comment by: CG (Portugal) Thu., Aug. 29, 2013 at 3:29 pm EDT
I do not know if you can generalize, but I can talk about me.In my case, I have a monogamous relationship for 7 years, with a negative partner. I am undetectable for 5 years, with a CD4 count always between 1600-2200, and since then decided to have unprotected sex. My partner makes analyzes every year, and always keeps seronegative. Nearly six years passed and nothing happened. So something happens here!. thank you
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Comment by: SG (Paris, France) Wed., Sep. 4, 2013 at 4:26 am EDT
Well it may be true but you may be wrong as well. Some may depend on what type of relationship you are (top/bottom), how frequent you guys have intercourse, do you (or your friend) sometime have sex with a third party .... ?
My friend and I actually take part of a large, long study that involves a lot of magnetic couples europa wide, it is called PARTNER STUDY. It exactly tries to respond to the question on a large scale.


Comment by: Charles (New Jersey) Thu., Aug. 29, 2013 at 2:54 pm EDT
I am so tired of being rejected by HIV- gay men because I am HIV+ even though I am undetectable. I really don't think the stigma will change any time soon. Having HIV sucks undetectable or not.
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Comment by: Mishma (Salt Lake City, Utah) Tue., Sep. 3, 2013 at 7:56 pm EDT
Couldn't agree with you more but what choice do we have. On too many occasions I let my rage consume me to my determent. Now I take it out on steel or paper targets with a .45 ACP. I'd like to travel to Russia and teach our brothers and sisters how to defend themselves.
Comment by: Tom (Garden Grove, CA) Mon., Nov. 4, 2013 at 1:24 am EST
We could demand a cure. We could demand an end to these ridiculous disclosure laws which compel us into self segregation without actually reducing anyone's risk. We could call out the so called "experts" whenever they overstate the supposed risk of people who are undetectable. There's plenty we could do. The lack of tangible answers to the question of what we can do is an indictment of what "HIV activism" has become.


Comment by: dyc22 (nyc) Wed., Aug. 28, 2013 at 5:42 pm EDT
all very good news about movement in the right direction. however, to throw a party for the demise of stigma is premature. no, wait, ridiculous. facts do not change minds or behavior very swiftly. stigma, like racism, classism, sexism and what other ism, is an INDULGENCE of the ignorant. one cannot teach those who do not want the information.
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Comment by: Dave R (Amsterdam) Thu., Aug. 29, 2013 at 2:08 pm EDT
I'm afraid you may well be right (I'm cynically minded too) but at least they'll have less ammunition to use against us if scientific proof shows that being undetectable, on treatment and immune-healthy makes a safe sexual partner.


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