August 3, 2008
In January 2008, the Swiss AIDS Commission issued a controversial report on the transmission of HIV in heterosexual mixed status couples. The report stated that HIV is not likely to be passed on when the positive partner fully adhered to a potent HIV regimen, had undetectable viral load for at least six months, and did not have any other sexually transmitted infection (STI) during that time, even despite sex without condoms.
What ensued after its publication has been tumultuous community discourse and opinion pieces worldwide. Some have denounced the Swiss government as being irresponsible. Others responded with "no comment". Few others, like Project Inform, invited this as a way to discuss issues faced by people living with and affected by HIV.
At the 2008 International AIDS Conference in Mexico City, a Sunday afternoon session, HIV Transmission under ART, provided a forum to discuss this report. Seven panelists attempted to clarify the persistent questions that have lingered ever since. Project Inform attended this session of about 300, which expands our earlier coverage of this topic.
The outcry over the Swiss report stems from the perception that they were saying that people who take effective HIV drugs can stop having safer sex or abandon their condom use without infecting their partners. The panelists were clear: this is not their message. Some have criticized other aspects of the report, arguing it failed to address other important issues, such men who have sex with men.
The possible implications for others living with HIV are about as diverse as the outcry has been. Project Inform believes the report and the conversations it has spurred can help inform these discussions for a wide range of people living with HIV. The main issues brought up by the Swiss Report are broadly outlined below.
The report provides a good deal of applicable data, much buried beneath the vocal backlash. Physicians, community health professionals, and others who interact with HIV-positive people and their partners can and must provide information clearly and accurately. The basic model of fully informed decision-making that has defined Project Inform's approach to HIV treatment decisions is just as applicable to this situation.
We should encourage sophisticated discussions of the issues facing mixed status couples. After nearly three decades of the epidemic, a great deal is known about how HIV is and is not passed. Each partner, along with their doctors, can be encouraged to discuss these issues. These data, when discussed alongside a person's needs for true sexual intimacy, can lead to fuller and more honest discussions between sexual partners.
There's a great degree of disagreement over the effect this report might have on sexual practices and condom use. Lacking any real world data, people are left mostly to conjecture. One of the panelists shared findings from an anonymous survey he helped administer to people with HIV. He stated the report was widely well received by people with HIV, and did not have a marked influence on sexual practices. Interestingly, many did report feeling more able to honestly discuss their sexual practices with their doctors after the report.
Some of the panelists feared the Swiss report would lead to less condom use. One audience member asserted his belief that the report said that condom use was not needed when people were on suppressive HAART. Others felt that the report was likely to increase adherence to both treatment and safer sex practices.
One undeniable take-home message from the Swiss report is the critical importance of having accurate medical information to make informed decisions. Vast inequalities in access to things like viral load tests and STI screening must be accounted for in settings worldwide.
Some panelists felt that these differences render the report largely meaningless to most people with HIV. Project Inform sees it differently. It is much like the early data on combination therapy: information that might have only applied to small numbers of people at that time can have profound implications for far more people down the line. As seasoned AIDS activist Heidi Nass puts it, 'progress in progress.'
The report underscores the need to reach those who are undiagnosed or untested. These discussions can only work when people know their HIV status. Most estimates in the US find that around 1 in 4 people with HIV do not know they have HIV. Project Inform encourages testing as a way to take control of one's life.
The report highlights the role that effective treatment plays in preventing new infections. Project Inform recently revised its mission statement to include biomedical prevention methods to help reduce new infections. This includes interventions such as Pre-Exposure Prophylaxis (PrEP), vaginal and rectal microbicides, and male circumcision, among others. These alternate prevention methods should be considered as being additive and synergistic to behavior interventions such as condom use. Therefore, no one method should preclude the others. The more choices one has, the better. The better the data are, the more confidence people can have in their choices.
One of the stories leading in to this meeting was the CDC's announcement that the number of new HIV infections in the US was 40% higher than previously estimated. This disturbing statistic highlights the crucial need for new prevention methods. The Swiss statement has the potential to help, as it underscores the connection between effective treatment and prevention.
In some parts of the world, it's a privilege to have access to the spectrum of health care that's necessary to fully inform these decisions. For most people, this just isn't possible. Some health care systems are overburdened and cannot accommodate the discussions. For many, viral load or STI tests are just not available. For others, medical infrastructures barely exist. Though the world has reacted to this report, it may very well not apply to most of the planet.
Another obvious weakness of the report is that the authors only had data from studies of heterosexual sex to guide them. In the US, the CDC estimates that just over half of new HIV infections are among men who have sex with men, reinforcing the importance of studying the impact of treatment on prevention among this group.
Too often critics of the Swiss report have used its limitations to dismiss the report entirely. This is both scientifically and ethically unsound. No study, or review of studies, is above critique. Science works best when studies and reports are examined honestly, taking into account both their strengths and weaknesses.
Some have said it's premature to talk about these kinds of data until such time that there are more mature and definitive results. One panelist reminded the audience of the experience of male circumcision where 17 years elapsed between the emergence of supportive circumstantial evidence of its role in reducing HIV infection rates, and the definitive results from prospective, randomized studies.
Although the medical resources may not be available to most who face these issues, it is still possible to encourage conversations with couples on issues that they can do something about. This includes encouraging each partner to disclose his/her status, to discuss their fears, or to even start engaging in safer sex, among many others.
The Swiss report does not suggest individuals abandon using condoms or other safer sex practices. In fact, it spotlights the necessity for a couple's continued diligence in this area. One panelist argued that condom use without treatment provides similar levels of protection as treatment without condoms. It is common and fairly uncontroversial to recommend that people with HIV use condoms regardless of whether they're on treatment. The report argues that the best possible prevention comes from combining treatment and condoms. Accurate information on transmission risk should drive these decisions.
At various points throughout this epidemic, many medical, social and behavioral issues have emerged. We have grappled with the risk of casual transmission and the risk of oral sex -- each without the benefit of definitive research. In these cases, observations and an understanding of the mechanics of HIV transmission helped mold recommendations that have stood the test of time.
What now is taking place is a study called HPTN 052 is currently enrolling and is designed to answer the risks of transmission under HAART. The results likely won't be available until 2016, at which point we may look back and wonder what the commotion was all about. We also might ask ourselves, as many have in light of the male circumcision saga, how many new infections could have been prevented in the meantime?
Much new data need to be uncovered to more fully answer the concerns raised by the community. How do STIs play a role in transmission and at what level? Do different strains of HIV affect its transmission? Do different classes of HIV drugs affect the levels of HIV in genital tract secretions differently? How do viral load blips affect the likelihood of transmission? How much do we know about HIV transmission through oral, vaginal or anal sex? Pursuing these and other questions are critical to help better inform those faced with these decisions.
One interesting point raised by a panelist was the asymmetry of risk. If you say something is dangerous, and it turns out not to be so, there's usually little consequence. However, if you claim something is not risky and it turns out to cause harm, the repercussions can be catastrophic. This can lead groups to be overly conservative in protecting their own interests. Looked at in this light, the Swiss statement is remarkable.
Also worth pointing out is how little attention has been paid to issues of pleasure, intimacy and stigma facing people with HIV throughout these public debates. While researchers might not place much emphasis on these issues, they're of great importance to people living with HIV. They have profound implications for their day-to-day lives, not to mention their emotional and sexual well being. A full discussion of treatment and prevention must take these issues into account, or risk being of little use to people living with HIV.
Project Inform encourages sophisticated conversations among mixed status couples and others. As we have stated in our March 2008 response to the Swiss Report, we encourage all sexually active individuals to learn their status by regularly testing for HIV; we encourage treating HIV as early as individuals are ready to start and the medical information suggests; we encourage adhering to HIV treatment while practicing safer sex; and we encourage the honest conversations between partners and their providers on the medical and behavioral issues of transmission.