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Real Talk: Undetectable -- The New Negative?

By Liz Highleyman

May 23, 2014

Moderator David Evans and panelist David Waggoner (photo: Liz Highleyman)

Moderator David Evans and panelist David Waggoner (photo: Liz Highleyman)

More than 100 participants packed an auditorium on May 20 for San Francisco AIDS Foundation's latest Real Talk forum on HIV prevention strategies, including pre-exposure prophylaxis (PrEP) and antiretroviral treatment as prevention.

Given the latest data showing that effective HIV treatment dramatically reduces the chances of sexual transmission -- potentially to zero -- we need new ways of talking about HIV before hooking up. To make informed decisions about risk today, it's not enough to know whether someone is HIV positive or HIV negative (or thinks he is) but also what he's doing about treatment, if positive, or biomedical prevention, if negative.

Treatment as Prevention

"We have to think about what it means to have sex today -- in 2014, not in 1992," urged moderator David Evans of Project Inform. "I remember those very dark years, but we're not there anymore. New research has given people more options."

Not long after the introduction of effective combination antiretroviral therapy (ART) in the mid-1990s, researchers in Uganda and Thailand reported that people on treatment seemed much less likely to transmit the virus to their partners.

In 2011, the HPTN 052 study with (mostly heterosexual) mixed-HIV-status couples showed that starting treatment early -- instead of waiting until CD4 cell counts drop -- not only led to better outcomes for HIV-positive partners but also reduced transmission to negative partners by 96%.

More recently, an interim analysis from the PARTNER study revealed no cases of HIV transmission among more than 700 mixed-status couples -- who altogether had condomless sex more than 30,000 times -- when the positive partner was on treatment with an undetectable viral load. Unlike the earlier studies, 40% of the PARTNER study participants were gay men, most of whom reported having receptive anal sex without condoms. (But, as Evans cautioned, seeing no transmissions so far does not mean the risk is zero.)

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