It’s been swirling around inside my head for a few days now, that video, so intriguing are the isssues raised. I’m talking about what Mark S, King and Sean Strub said in last week’s post : Five Things about HIV (They’re Not Telling You). Here’s an excerpt from their conversation:
MSK Fact number one: an undetectable viral load may rival a condom
SS A person who is undetectable and has been undetectable for some time, there is very little chance of them transmitting the virus sexually. The Swiss Federal AIDS Commission issued a statement two years ago saying that in sero-discordant couples - where one person is positive and the other is negative – if the positive person has been on treatment and is undetectable for at least six months they didn’t even think that condoms were necessary because the chance of transmission was so remote. The person who is on treatment and undetectable is really unlikely to transmit the virus sexually. That doesn’t mean they NEVER transmit, it’s POSSIBLE they CAN. In fact condoms DO have a failure rate – it might be 1%, it might be 3%, it might be 8% - there are different studies . . . Unprotected sex with people who are undetectable MAY be, it’s POSSIBLE, be LESS risky than only having sex with a condom and being indifferent to the HIV status of the partners. Because sometimes that condom will break and sometimes – those partners will be positive and NOT be undetectable . They may not even know they are positive. They may be full of virus and very infectious.
SS We have neglected to recognize the extent to which a person who is on treatment and is undetectable is rendered non-infectious.
MSK Just SAYING that is going to drive some people nuts. Condoms will hopefully be part of the equation for anyone trying to lower their risk. So you’re not saying throw that one out. You’re simply just saying . . .
SS The safest route is the belt AND suspenders approach – using a condom AND with a positive person who is also undetectable.
So . . . . yes, this dialogue is intriguing. There have been many, many words devoted to exactly how infectious someone with an undetectable load really is – or can be. But much less on comparing that risk of infection to the risk assumed when one uses a condom. Accidents happen, yet we seldom discuss that latter risk also.
Certainly prevention workers everywhere have been understandably cautious in touting the possibly low risk associated with undetectable viral load. There are reasons for this. Some will argue, for instance, that the Swiss Study was not as reliable a reference point for gay men to hang their hat on as is implied in the video. And it’s certainly true that undetectable viral load in the blood does not ALWAYS translate to undetectable in the semen, where it counts, although most frequently it does. Also of note: undetectable means less than 50 copies in the blood; it has never meant that the virus is not present at all . And let’s face it, the suggestion that we undetectables can dispense with condoms is fraught with other problems, not the least of which are STI’s, generally not good news for HIVers’ health, and let's not forget murmurings about superinfection, although that concept remains iffy.
Sometimes too we confuse population health statistics with individual health realities. Some things that apply to the vast majority of HIVers will NOT necessarily apply to you, however great the odds are. There are in fact a number of scenarios where, for instance, you THINK you are undetectable, but may not be. I’m sure you can think of a few.
Be that as it may, there seems to be an underlying truth that undetectable viral load CAN often translate to low risk of transmission– perhaps even extremely low risk. Here’s the problem; from my perspective at least, our community has been hesitant to confront, share or discuss that fact in any meaningful way. One result of that – and one more side-effect I dislike immensely by the way - is that we HIVers have never really been encouraged to celebrate that we have reached a real milestone in our treatment history - a red letter day, if you will - because that milestone has been deemed of little consequence. Reason? There is an over-riding fear that HIVers will act recklessly with that news.
I don’t buy that one bit. There’s just no evidence to suggest reckless behaviour follows HIVers reaching undetectable. It’s all supposition, based on paternalism and lack of trust, and it drives me nuts!
Yes, reaching undetectable WAS a milestone for me. Why? For years I had lived with the concept that my blood was tainted, that I was dangerous, that I was highly infectious to others. Every time I cut my finger I was reminded of it. That I MAY not now be any of these things is something I for one consider entirely worth celebrating.
Why doesn’t my community, my support network, my colleagues join me in recognizing not only the improved health that can come my way with being undetectable but the likelihood of much reduced infectiousness? Why not celebrate, while we’re at it, the revived spirit that comes with no longer having tainted blood, the appeal to one’s very psyche. All ignored. All considered nothing.
In truth, I’m not alone in recognizing the important step that reaching undetectable represents. The “treatment as prevention” brigade, for instance, has been quick to trumpet the low risk of transmission associated with undetectable viral load. That in fact is the basis for suggesting treatment be started on diagnosis and damn the consequences, something which I and many others are not comfortable with.
Our friends and advocates in the HIV legal community have also been trumpeting the very strong connection between undetectable viral load and the inability to transmit the virus. That issue has been at the core of a number of cases where people with HIV have been charged with non-disclosure of their HIV status. And we are starting to see the courts agree that undetectable viral load, and its associated lack of significant risk, may constitute a viable legal defence.
So . . . we have some in the community being extremely cautious about the significance of undetectable viral load and some embracing it. Both factions use essentially the same set of data. It gives me concern that this might leave average Joe Poz dazed and confused. And dazed and confused, when issues of risk are concerned, is not a good state to be in.
I think I agree with Mark on this, in his comments that followed this interview. I think we need to bring conversations on this topic to a new level. One based on three things – a) knowledge of the facts, b) complete honesty and c) implicitly trusting each other to use those facts to make the right decisions. I’m sensing there is a way to go before we reach that point. But listening to guys talking openly like Mark and Sean do here - intelligent and informed guys too, whether we agree with them 100% or not - is an excellent starting point.
What do you think?
You need to make up on your own mind on this one. Here are some resources to get you started - readings on this topic from around the globe covering a spectrum of view. (Or google “undetectable viral load” and “infectiousness” for more).
George House Trust (UK)
The Body (USA)
Conference on Retroviruses and Opportunistic Infections Montreal, (Canada)
CATIE- The Positive Side (Canada)
Positive Life (Austraila)
SA HIVPoz (South Africa)
Want still more? This video touches on most of the major issues dicussed here.