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Undetectable: A Drama in Three Parts

September 25, 2014

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

Undetectable: A Drama In Three Parts

The HIV landscape is ever changing. Rooted in tragedy, the plot twist introduced in 1996 with the advent of antiretroviral therapy is still playing out, with fresh twists coming thick and fast. The future is uncertain but targeting the end of the epidemic has never been more focused.

It's like a huge three-part drama, with HIV prevention in all its forms -- once there was just one -- taking center stage.


Prologue

The plot has never been quite this complicated. At one time, prevention messaging was simpler and, short of abstinence, centered on using condoms. It was that simple. But things became more complicated when the ability of antiretroviral therapy to substantially reduce the risk of transmission became evident. Not only did people have more choices, but these choices became more -- well, complicated. Frequently they involved knowing more about risk than ever before, more about the science of transmission and more about the comparative effectiveness of various prevention alternatives. Throw in controversy, mixed messages, a little bit of moralizing and proselytizing and HIV prevention choices became a bit of a minefield to navigate for the average Joe or Jill.

That has become particularly true for people living with HIV with undetectable viral loads.

Not convinced? Ask yourself this question. You are a gay poz man with an undetectable viral load. You want to know the risk of anal sex without a condom with a partner who is HIV-negative. So you go to your local AIDS Service Organization and ask them to tell it to you straight up -- "low, medium, high risk -- or non-existent? What's the deal?"

The answers you get will be as varied as there are stars in the sky. And chances are many of them will be wrong. Simply put, many of those working in the field don't know or don't agree.

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This can be frustrating, indeed infuriating, as the recent chatter in social media illustrates. A good example is Dave R.'s recent post, "I'm Positive, I'm on Treatment, I'm Undetectable, So Get Off My Case!" In it the clearly exasperated Dave, in what one commenter called "Best Rant Ever!," points the finger at the source of the problem of why his inability to transmit the virus -- or very slim likelihood of same -- is not taken seriously.

Says Dave "I rile at the inherent cowardice of HIV organizations and the LGBT media, who are reluctant to publish any findings that may damage the safe sex message ..." He goes on: "The problem is that the word, 'undetectable' means very little to so many. The word hasn't got out that it means an almost impossible chance of infection. The word isn't being put out there and I want to know why."

Why, Dave? The answer is as complicated as the science behind it. But first let's hear more of what people living with HIV are saying on social media about being undetectable. There's lots to choose from but a good place to start is Mark S. King's article which came out shortly after the interim PARTNER results were released at CROI 2014 this past March in Boston. Mark, in a widely read article "Will HIV Ever Be Safe Enough for You?" aimed his barbs at fellow LGBTers for pooh-poohing PARTNER findings that indicated the risk of transmission from one act of condomless sex where one partner is undetectable was close to zero.

Says Mark: "The willful ignorance isn't coming from uneducated residents of a southern town you can barely find on a map. It's coming from gay men. And they are just as threatened, frightened, and dismissive of science as the townsfolk of Williamson were thirty years ago. ... The PARTNER study also threatens the view that positive men are nothing more than risks that must be managed. The study kills the HIV positive boogeyman. It means positive gay men who know their status might actually care enough about their health to seek out care, get on treatment, and become undetectable. And, once the positive partner is no longer a particular danger, both partners would bear responsibility for their actions. What an enormous psychic change that would require in our community."

He goes on to say "I have some 'what if?' questions of my own. What if these unrealistic fears were meant to stigmatize and isolate HIV positive people?"

Mark perhaps, in his frustration, goes too far here -- I don't see willful stigmatization lurking in the bushes -- but his basic tenet that one of the major benefits of being undetectable has been neutered by fear and ignorance and that this neutering is unnecessarily perpetuating HIV stigma for many of us is genuine.

Those many people subject to unnecessary stigma include me. And I resent it as much as Dave and Mark do.

As Mark points out, the arguments used in the PrEP wars are similar in that they unreasonably challenge the ability of antiretrovirals to do the job they have been very good at doing. Says Mark: "Resistance to the PARTNER study corresponds with stubborn doubts about PrEP (pre-exposure prophylaxis, or HIV negative people taking the drug Truvada to prevent infection). Although virtually every nervous argument against PrEP has been overruled by the facts, naysayers continue to either reject the evidence outright or make moral judgments about the sex lives of HIV negative gay men on PrEP."

Undetectable: A Drama In Three Parts

To put it bluntly, there is no telling in the eyes of a few detractors what unbridled licentiousness, what unchecked promiscuity undetectable people (or PrEP users) will engage in if they are told they are capable of risk-free sex. Or so it seems.

Be that as it may, resistance to the PARTNER study and in fact all prior research which pointed to reduced infectivity through viral suppression might be said to be part of a continued thread of prevention messaging which has continued to stress the superiority of condoms, even when some are arguing condoms don't work for some/many people and even where the evidence suggests to some people that condoms may be a second-choice solution with very variable efficacy. Have dogma and denial prevailed over science and sense, some are asking? And are the victims people living with HIV?

The answers may depend on where you live. Numerous jurisdictions have belief in the science and revised their messages about the reduced risk of transmission. It's not hard, for instance, to find condomless anal sex where one partner is undetectable defined as -- horrors -- "low risk." But other less progressive authorities insist that condoms provide a better level of protection. (That's pushing it. It's likely that no brand of condom, even where properly and regularly used, affords quite the level of protection that we have seen that ART is capable of.)

The situation is challenging in Ontario, where I happen to live and work, and where some still call all barebacking "unprotected anal intercourse." (Even the CDC won't use that term) Problem is that terminology downplays the good news -- yes it IS good news -- coming down the research pipeline about the ability of ART to reduce the risk of transmission. (The situation has similarities with the much criticized AIDS Healthcare Foundation (AHF) and their rearguard defense of condom use for negative men by trying to discredit the efficacy of Truvada when used as PrEP.)

Anyway, back to the history. Call it "The Defense of Condoms," a Play in Three Acts.


Oh the Drama!

Undetectable: A Drama In Three Parts

Act One, set in 2008. The Swiss release a report on a cohort study which indicates that HIV-positive people who are taking antiretroviral drugs cannot transmit the virus during sex provided a) they have adhered to their treatment regimes and have had suppressed HIV viral loads for at least six months and b) are otherwise free of sexually transmitted infections. Sample prevention response: the ASO warns that the study population is heterosexual, that there is danger of virus in the semen even though it may be absent or not measurable in the blood and that viral load can vary over time. The bottom line? "There is always a level of risk associated with condomless sex." And the organization "stresses that all people should continue to practice safer sex, including those who are in a serodiscordant relationship or have multiple sexual partners."

ACT Two, set in 2011. A large scale study, HPTN 052, shows a 96% reduction in transmission when the HIV-positive partner starts treatment early. (Note that neither this nor the Swiss Study pertained to undetectable viral load but rather the impact of treatment, period.) Predictably, the objections from detractors were the same as for the Swiss study. Sample prevention response: "Although the results from trial 052 are greatly encouraging, as the proportion of MSM (men who have sex with men) couples in this trial was relatively small, firm conclusions cannot yet be drawn about the impact of ART on HIV transmission via unprotected anal sex among MSM."

Act Three, set in 2014. PARTNER interim results tell us that in a study that covered 44,000 condomless sex acts, one quarter of them homosexual, where one partner was poz but undetectable, not one HIV transmission occurred between any of the couples enrolled in the study. Estimating transmission risk based on these numbers, the theoretical risk per act was pegged between 0.5% and zero, with more time required to be more definitive. Sample prevention response "(We) maintain that condoms are the most effective way of preventing HIV transmission and encourage the use of latex or non-latex condoms . . . Having an undetectable viral load does not prevent the transmission of HIV or STIs. . . More evidence is needed to quantify the level of protection from HIV treatment."

The argument that more time is needed -- PARTNER results were indeed interim -- is used often here in agreeing with researchers that they need much more refinement than the indicated risk of somewhere between 0.5% and zero per act, But concurrently that same risk was characterized by numerous bodies, including our legal and medical representatives, as "negligible." Meanwhile people living with HIV began voicing the view that they had heard enough and a risk of between 0.5% and 0% needed little refinement. (In fairness, it must be mentioned that the researchers' quite valid warnings that multiple sex acts over a period of time increased the risk to the negative individual did not gain much traction.)

Supporting cast: There have also been introduced over the years what some characterize as a series of red herrings seen as an attempt to convince that while no infections may be occurring between serodiscordant couples where one is undetectable there are nevertheless dangers lurking in every shadow. Think virus in the semen, think virus in rectal fluids even as we are told "it is unclear how significant it is in terms of HIV transmission." (My take, given no transmissions occurring in PARTNER, is that these factors have no real significance. But like the danger of superinfection (remember that?) and the "'superiority" of condoms over other prevention techniques, we need to be careful not to allow dogma to triumph over science in what some characterize as a rearguard defense of all things condom. (But how well is that defense working, when we see continuing high HIV incidence, year after year, in gay and bisexual men?)

STIs? That's another story. There is no doubt that STIs pose a risk for condomless sex enthusiasts whether you are undetectable or not. If there is any evidence that the implications of STI infection are greater for poz folks with undetectable viral load than they are for a negative individual I have yet to see it. (The research to date does expose the damaging impact of STIs on HIV-positive people in general but makes no distinction between those who may be virally suppressed and those who are not, a common feature of much research on poz men and women.)

Given that perhaps up to 60% of those diagnosed with HIV have undetectable viral loads in Ontario, according to soon-to-be-released data, prevention authorities probably need to be more explicit about what the risks arising from STI infection represent for the majority of us who are undetectable.)

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Related Stories

I'm Positive, I'm on Treatment, I'm Undetectable, So Get Off My Case!
Will HIV Ever Be Safe Enough for You?
Safer Sex Without a Condom: The PARTNER Study
Fact Sheet: HIV/AIDS and Young Men Who Have Sex With Men
Quiz: Are You at Risk for HIV?
10 Common Fears About HIV Transmission
More Personal Views on HIV Prevention for Gay Men


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Bob Leahy

Bob Leahy

A banker turned AIDS activist, Bob Leahy is the busy Editor of PositiveLite.com, Canada's globally read online HIV magazine by and for people living with HIV. Diagnosed with HIV in 1993, Bob has held almost every volunteer position in the HIV community imaginable, including chairing his local ASO and serving on the boards of the Ontario HIV Treatment Network and the Canadian AIDS Society. Recognized on the Ontario AIDS Network's prestigious Honour Roll, his interests lie in social media, gay men's sexual health and making HIV research intelligible for all. A long-time blogger, this ex-Torontonian lives the rural life with his three dogs and partner of thirty-one years.


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