Undetectable = untransmittable

How do gay men come to trust that “Undetectable = Untransmittable” (U=U)? Australian researchers conducted in-depth interviews with men who were in relationships where one partner had HIV and the other did not in order to find out.

The interviews were done three years ago, after the presentation of the first results of the PARTNER study, but before most HIV organisations had stated clearly that HIV-positive people who have an undetectable viral load do not transmit HIV to their sexual partners. 

The study is most relevant to couples, but the interviewees have some interesting comments about applying U=U when meeting casual partners.

The researchers spoke to 21 men – ten who were HIV positive and eleven who were HIV negative. Most of the couples lived together and had been together for between one and five years. Just under half the couples were monogamous.

Most couples had a history of taking great care to avoid HIV transmission. Over time, they learnt about the possibility of relying on an undetectable viral load as a prevention measure.

In general, when the subject of sex without condoms came up, it was the HIV-negative partner that initiated the discussion.

The HIV-positive partners were often apprehensive and anxious about the idea, and the HIV-negative partners often needed to reassure them that they were making a well-informed decision, asserting their responsibility for their own sexual health.

Though couples agreed together to stop using condoms, HIV-negative partners ultimately made the decision because they were the ones ‘at risk’. One partner living with HIV said: “It was a mutual decision, but the ball was pretty much in his court”.

Some couples tried sex without condoms, but the partner living with HIV wanted to return to them. In negotiating these kinds of situations, partners usually made compromises when the other had strong feelings.

The men talked about factors that helped them get used to relying on an undetectable viral load. The experience of receiving consistent test results while having sex without a condom was often important. Test results made the concept of relying on an undetectable viral load less abstract – both the HIV-negative partner’s results showing he still did not have HIV and the HIV-positive partner’s results showing he was still undetectable.

One man said:

“As each year went on, you tended to worry about it less because I’d been with [my partner] for a while and had many incidents of unsafe sex, and I was still negative, so I could see that the risk wasn’t high. The worry about catching something became less.”

Being in a strong, communicative relationship was important. One HIV-negative partner said:

“I know his personality and he’s structured and organised. But I also know that he takes responsibility for his part in my health and so I have faith and trust in him that if there was an issue with bloods, we would talk about it.”

It was a different case with casual partners, as an HIV-negative man explained:

“[My partner] and I have trust and an understanding. But when you first meet someone and they tell you that [they are undetectable], then I’m like,‘Yes, but I only just met you. So I don’t know your history. I don’t know who you are.

The couples had worked out these strategies for themselves. Drawing recommendations from them for other couples, the researchers advise they discuss the following issues and negotiate a clear, spoken agreement covering:

  • monogamy – or otherwise
  • the possibility of not using condoms within the primary relationship but maintaining condom use and/or PrEP (pre-exposure prophylaxis) with any casual partners
  • regularity of viral load and HIV testing
  • regularity of STI testing for non-monogamous couples
  • the importance of medication adherence
  • ongoing communication about test results – and this agreement.

For more information, read NAM’s factsheet ‘Viral load and transmission’. It is available in versions for both HIV-positive and HIV-negative people.

Breastfeeding with undetectable viral load

Women with HIV on effective HIV treatment who have an undetectable viral load should not be discouraged from breastfeeding, but should be supported to make their own decisions after a full discussion of the risks and benefits, a group of Swiss doctors has concluded, after reviewing the available evidence.

They argue that given there is genuine uncertainty on risk, it is up to healthcare workers to provide unbiased information about the potential harms and benefits of breastfeeding to women living with HIV. They should support women in whatever choice they make.

The Swiss doctors carried out a review of the scientific literature to identify any clearly documented cases of HIV transmission through breastfeeding when the mother had a viral load below 50 copies/ml, was in continuous care and was fully adherent to antiretroviral treatment.

While some other experts have drawn attention to cases of transmission where it is difficult to be certain if the mother was definitely undetectable, the Swiss doctors did not identify any documented cases of HIV transmission through breastfeeding in the scenario they describe.

However, there has not been a formal study, equivalent to the PARTNER study of sexual transmission, evaluating the risk of transmission through breastfeeding when viral load is fully suppressed. Healthcare workers should explain this. They should also make it clear that mixed feeding (breast milk plus any other liquids, such as formula, or solids) may increase the risk of transmission; because of this, exclusive breastfeeding for the first four months is recommended in Switzerland.

They should also explain that breastfeeding has numerous health and psychological benefits for both the baby and the mother, which is why it is recommended in most European countries for HIV-negative mothers.

Recent guidance from the British HIV Association advises that, in the UK and similar settings, the safest way to feed infants born to mothers with HIV is with formula milk. Nonetheless, women with an undetectable viral load who choose to breastfeed should be supported to do so. The guidance emphasises the importance of breastfeeding mothers remaining in close contact with their medical teams. Both mother and baby should come in for monthly testing. Mothers should breastfeed for as short a time as possible, ideally no more than six months..

Pain

Pain is commonly reported by people with HIV. There are several reasons for it being such a common experience. These include peripheral neuropathy, caused by either HIV itself or older anti-HIV drugs; pain caused by HIV-related inflammation; and shared risk factors for pain and HIV, including poor mental health and drug use.

A study of over 2000 Americans living with HIV asked “How much bodily pain have you had during the last week?”. It asked them to indicate severity and how long the pain had lasted.

A quarter of respondents reported moderate or worse pain that had gone on for at least three months (chronic pain).

The most common locations for chronic pain were the lower back, knees, and neuropathy in the hands or feet. Most people with chronic pain had it in more than one place.

People with chronic pain who did not get opioid treatment to relieve it were at increased risk of missing follow-up appointments, and of having a detectable viral load. But the authors warn that opioids have risks, including addiction and overdose.

Many doctors believe that a better approach to pain is providing psychological interventions, such as cognitive behavioural therapy, that help people cope better.

For more information, read NAM’s factsheet ‘Pain’.

Another drop in HIV diagnoses

New HIV diagnoses in the UK have fallen again, with the greatest reduction seen in gay and bisexual men – a 31% fall between 2015 and 2017. They fell 41% among gay and bisexual men in London.

Public Health England say that more frequent testing and early uptake of HIV treatment are the main factors behind this improvement.

Looking at all population groups, a total of 4363 people were newly diagnosed with HIV in 2017. This amounts to a 28% fall since 2015. 

For the first time, diagnoses in heterosexuals of non-black ethnicity have fallen (by 20%). It’s not yet clear what the explanation is.

However, the proportion of people diagnosed late has not improved – in 2017, 42% of all diagnoses were made with a CD4 cell count below 350/mm3.