Belt AND Suspenders?
Treatment as prevention inevitably raises the issue of how much protection is enough. Ken Monteith says “there are governments in this country who would like the rule to be disclosure, undetectable viral load AND condom.”
In 2008, the Swiss Federal Commission for HIV/AIDS issued a statement, distilled from an extensive literature review and much discussion, that can be summarized as follows:
"An HIV-infected person on antiretroviral therapy with completely suppressed viraemia (“effective ART”) is not sexually infectious, i.e. cannot transmit HIV through sexual contact."
This, as long as the person continues to follow effective anti-retroviral therapy, regularly evaluated by a physician, has maintained a suppressed viral load for at least six months and there are no other sexually transmitted infections present.
Almost to a person, public health authorities in other jurisdictions hastily issued statements distancing themselves from the Swiss Statement, just not ready to affirm what many treating physicians have opined for a long time.
Now many are coming around, sort of. The more we hear about the strategy that can go under the name "Treatment as Prevention", "Test and Treat", "Seek, Test and Treat" or "Seek, Test, Link to Care, Treat, Retain in Care", the more it becomes obvious that these things are largely the children of the Swiss Statement: a recognition that effective treatment controls viral load to the point that the person living with HIV will not transmit the virus to others. But our public health authorities are still not ready to say that, are they?
They are willing to assert that treatment is effective in reducing transmission rates as a reason for people with HIV to be treated as early as possible, but not ready to say that effective treatment for people with HIV will protect their sexual partners. Yes, that seemed a little like talking out of both sides of their mouth to me, too.
Let's look at the kinds of things that public health authorities are saying.
"There is no zero risk." I think we all know that, but nothing in our collective lives is without risk, even walking down the sidewalk. This is not to say that all risks are scientifically significant, however.
"The studies were among heterosexual serodifferent couples, so we cannot draw the same conclusions for gay men." So you're not recommending early treatment for gay men as a public health measure to reduce infections? Oh, you are? Hmmm. Can you explain that one to me?
"Earlier treatment will be beneficial to the person living with HIV." This, of course, is based on theories that may well bear out in studies to be conducted, but they remain theories for the time being. The last time there was a study comparing different starting points for treatment, it found no significant benefit for starting treatment above a CD4 count of 500, versus one above 350. If you can't extend the conclusions of studies conducted with heterosexual couples to gay ones, then how can you assert that early treatment is beneficial for the health outcomes of people with HIV when your assertion is not backed by the same degree of scientific proof?
Now don't get me wrong: I am not against treating to prevent transmission. What I am against is providing dubious information and doubletalk as the means to get people to agree to embark on treatment earlier than might be necessary (or especially beneficial) for their own health. Yes, people can choose treatment in order to protect their partners, too, but that is an explicit choice the person taking the treatment ought to make.
So now that we all agree on the fabulous wonders of treatment, whence the condom? Oh, our wise public health authorities are not ready to let go of that. Treatment AND condom, then. This adding early treatment thing is starting to look like something of an additional burden instead of a liberation for us. I have to add that many of our own community organizations take this cautious public health approach, too.
I'm not trying to say here that condom and undetectable viral load is some kind of fashion faux pas (like belt and suspenders definitely is!). Some people will always be extra cautious (I count myself among these) and that is a valid choice. Just maybe not something we should be making everyone make when the science tells us it is not really necessary.
Now if we look back at the arguments that were presented before the Supreme Court of Canada in the Mabior and D.C. cases (on the duty to disclose one's status, with condom use or with undetectable viral load), there are governments in this country who would like the rule to be disclosure, indetecetable viral load AND condom.
Anecdotally, the disclosure is already taking place (though not to legal standards) when we ask our partners to wear condoms. It seems that only the HIV positive are such sticklers for that these days. And whether it's presumed disclosure or explicit disclosure, we all risk exposing ourselves to rejection and discrimination for trying to be responsible in these ways.
It's starting to look like the "shared responsibility" for ending HIV is becoming a little heavy on the side of the people living with HIV, and a little light on the other side. Yes, a little like belt, suspenders and tattoo across the forehead.