Facts about AIDS PREP Treatment as Prevention (TASP)

Undetectable means not infectious?

The challenge of explaining the results of the study of Non-HIV Transmission of the Partner Study. To read through and reflect long ...

The editorial and the press release accompanying the recent results of the PARTNER study arouse concerns Prevention Access Campaign.

Photo Bruce Richman
Bruce Richman

As the executive director and co-founder of the Access to Prevention Campaign (PAC), Bruce Richman focuses on telling everyone about the benefits of HIV treatment not only for people living with the virus but also for their sexual partners - it focuses specifically on the ways that medicines can prevent the spread of HIV. To continue his militancy, Richman POZ launched a blog. Check out his inaugural speech in the post ""Loud and Clear: Undetectable = Uninfectious"To learn how feelings of fear and anxiety about their positive HIV status to HIV has given rise to a sense of freedom once he realized that having an undetectable viral load meant that he was not a danger to his / her partner / partner.

While we were creating the post, POZ reports on PARTNER study finds, Which still supports HIV treatment as prevention (TasP). Richman expressed his concerns about the article and the alert tone of the follow-up study and the press release, which he felt should have been more auspicious. As we discussed the challenges of explaining and interpreting the results of the study on the risk of HIV transmission, both realized that it was an important conversation to share.

Below is part of our exchange of e-mails, edited for clarity and length.

Hunger, poverty and AIDS in Africa
This photo is from fifteen years ago (2002) and I can hardly believe that he survived the atrocities perpetrated by the "civilized world" to this day. I show the photo to reveal contextualizations and, in my view, in Africa, 96% security is an excellent index. But ... In a country with almost two hundred million inhabitants, that stinks of a humanitarian crisis and of unprecedented disasters

Bruce, thank you for talking about the results of the PARTNER trial, which were presented at the International AIDS Conference XXI (AIDS 2016) held in Durban, South Africa. The study followed heterosexual and gay couples in which one person has HIV and the other no [Serodiscordant couples]. The Commission did not find HIV transmissions between couples in whom the person with HIV had an undetectable viral load. Our story about the study was titled "PARTNER Findings, tentatively published, reinforce antiretroviral power to avoid transmission:

"I agree we should have been more specific. Maybe something like "Study finds Zero HIV infections among serodivergent sexual partners where the carrier is undetectable."

Thank you for being so open in responding. That really revised the words of our title. He highlights the importance of the findings. Going one step further, the study is specifically about the risk of unsafe sex, so it could be more effective to say, "Study finds Zero HIV infections in unprotected sex with undetected partners."

Like a hotter sex, fine. But do not give up condom
Like a hotter sex, fine. But do not give up condom

I think you can highlight what's really important about this study for people with HIV, their partners and their providers.

For example, the article cites the new analysis focused on 888 serodiscordant couples for HIV and a few paragraphs ahead says that there were 22.000 incidents of unsafe sex between gay couples and 36.000 among heterosexuals. Combining these numbers into some parts of the article would make it clearer that there were 58.000 sex acts without a condom. This is a significant number and, on the other hand, can be ignored if we report the acts separately. And it is important to emphasize the role of sex without condoms in the study.

It is a deep mental, cultural and social change to recognize that people with HIV who are undetectable can have sex with HIV negative without transmitting the virus.

I understand your point of view for the most part. But in fact, I see the PARTNER, study in an accompanying editorial and press release include quotes as "physicians need to be clear that although the overall risk of HIV transmission may be small, the risk is not zero and the actual number is not known, especially for high-risk groups such as MSM [men who have sex with men]. "

The editorial of the press release, which is not officially the study, is less supported and more cautious piece of information that accompanied the study.

Why do you think it takes that tone?

Aim of Life
There is light at the end of the tunnel. But the tunnel is long ...

It is no surprise that a study such as PARTNER, which indicates that there is effectively zero risk or negligible risk for the practice of unlicensed sex among serodivergent couples in the serological status, will be hit by a significant backlash and reaction due to politics, culture and public health concerns. This will have an impact where and as soon as it is published, as well as how it is edited and reported. I work closely with Pietro Vernazza, MD, who is on the executive committee of PARTNER, the author of Swiss Statement and the PAC's board of directors, who agreed to pursue the record on the problem:

The publication of this manuscript was delayed not by the author, but by an extremely hesitant group of the editorial process, with extremely long turnaround time. It seemed to me that many editors and reviewers were hesitant to have this information published. This delay in the publication process may indicate that the reasons were not scientific but political.

PARTNER's warning in the press release and editorial as "small," appears "may be small" and "risk is not zero," as many underestimate and minimize the importance of the study. The choice of words such as "negligible", "effectively zero risk" or even "extremely small" would be more accurate and meaningful, and have been used by other experts to describe this PARTNER result.

We could easily see on a discussion of semantics and how people interpret specific words that convey the risk to all, there is a risk measurement agreement - but I can assume that you believe the press release of the tone is intentionally interim?

Even when in agreement with the trial of strength from the real world and clinical trial experience, medical and public health professionals have been reluctant to communicate the importance and significance of the study due to two main concerns:

  1. An increase sex among people with HIV that are undetectable lead to an increase of STDs; and
  2. People with HIV can not understand that firmly adhere to treatment is essential to maintain an undetectable viral load. For example, they can stop treatment by personal choice or due to circumstances beyond its control and unconsciously experience an increase in viral load and the risk of HIV transmission.
HPV manifesto
This is the only picture "light" about HPV that I can show without making people leave the text without finishing it. This is manifest HPV and maintains the condom, at least in part, the transmission thereof. STDs can not be treated as negligible. They are painful, stigmatizing and sometimes perversely cruel

Note Soropositivo.Org the editor: The week published the results of this study, there was a torrential storm of e-mails from people who were eager to be able to stop the drugs, because of side effects and overwhelming majority of the complainers these effects reported the use of efavirenz. Needless to say, I warned everyone that did not stop under any circumstances with their therapies and destroy all e-mails

Many AIDS service organizations, community-based groups and medical providers choose selectively discuss science with patients and clients that they deem to be "responsible" (eg monogamous and stable joint, for treatment) instead of dealing directly risk compensation impacts and disinhibition through education and access.

It is my experience that researchers are against speaking in absolute terms. You will not find them saying that there is absolutely zero risk of HIV infection - even if no one got into the study because, I think, researchers think of distant and unknown factors, as well as the long-term risk factor than the test period). How does this affect your ability to achieve viral load indectable when the last message is "Undetectable = non-infectious"?

We do not expect researchers to call zero risk at all, but some of the world's undisputed leaders on the subject said "negligible risk," "non-infectious," "non-contagious," and "effectively zero risk."

We are happy with all these terms!

The movement 'Undetectable = Not Infective' Been built for a long time. You'll hear more about it from the Prevention Access Campaign and my POZ blog. It is a profound mental, cultural and social change to recognize that people with HIV who are undetectable can have sex with people without HIV without transmitting the virus.

Getting to that point means associating 35 years of deeply entrenched fears against HIV and people who have HIV and challenge the old and unproven assumption that condoms are always needed to prevent HIV transmission. And the stigma of political premises and practices of influence even within the field of HIV prevention.

There is also the fear of being the first. At this point, only the Terrence Higgins Trust UK said "Undetectable = Non-infectious" or "negligible risk." None of the major journals on HIV and federal public health agencies in the United States are even close to saying so. There is a much greater comfort level in remaining cautious and risk averse, and indicate that there is a lower risk but there is still a risk. So, in a sense, people with HIV are still a grenade, smaller, but still a grenade. And, therefore, the disinformation and stigma of HIV continue!

Editor's Note: The Stigma exists because it was planted by scientists as the principle, a disease of people "Reprochável behavior" and opportunistic religious, who said it was the "Wrath of God" ...

As long as these messages are not undone, and the print, television or radio media here in Brazil do not seem interested in doing this, with the honorable exception of MTV, this stigma will not disappear! A little further down comes an affirmation that treatment is also prevention. But in this case, I ask, How much money will you get out of it? Would all people have access to this? Who would pay? And who could not tolerate the remedies organically? What a Damn Hell !?

Bruce Richman founded the Campaign for access to prevention

There was a breakthrough last week in the United States: the pioneer Demeter Daskalakis, MD, MPH, Deputy Commissioner of the Office of Prevention and Control of HIV / AIDS, Department of Health of New York City became the first public official in the country to support officially the "negligible risk" when he read the opinion of the CAP. Undetectable Primer /Consensus Statement together with other globally recognized experts on this topic from the United States, Australia, Switzerland and Denmark (including Myron Cohen, MD, Andrew Grulich, PhD, Jens Lundgren, MD, DMSc, and Vermazza). Many of the PAC Community partners will be shifting their positions to deliver similar messages in the coming months.

Why is PARTNER so important to your disclosure? Other studies, such as the HPTN 052 study, also proved that the treatment is prevention?

"PARTNER is the largest study to include extensive data on vaginal and anal sex without a condom. It also included anal sex among heterosexual couples, not just MSMs. Another critical finding in PARTNER is that having a sexually transmitted disease (STD) or probably a viral peal does not affect risk, which is also a conclusion of the Canadian consensus on treatment in the context of criminal law - signed by more than 70 experts on HIV and the largest association of infectious diseases in Canada.

Our discussion brings to the different roles of researchers, journalists and activists.

Speaking for myself, I do not feel comfortable saying to a reader, "Look, these results mean you have no risk and you should feel confident that HIV is transmitted from an undetectable person." But I feel comfortable in including this perspective of what "From a reputable source." Or trying to put the level of risk in a context that readers can better understand.

I feel the same way. None of us are in a position to make a judgment about the comfort of another person and the acceptable level of risk. The Campaign for Access to Prevention points and aggregates studies and consensus prepared by high-level researchers, so people can make decisions based on information that also make sense for them. And we can help point out certain studies, decisions or opinions that can not be driven by science, but by other factors. A large part of our role is to investigate and break the policy, stigma and phobias that interfere with the free flow of information.

While this is not in the study, it is important to note a few things:

  • Depending on the drug used it may take up to six months, or even longer, for the viral load to become undetectable.
  • Staying undetectable requires excellent compliance.
  • Having an undetectable viral load only prevents HIV transmission and no other STIs or pregnancy. Condoms protect against HIV and other STDs and pregnancy.
  • Many people with HIV may not be in a position to reach detectability due to several factors related to access to treatment (eg, health care systems, poverty, denial, stigma, discrimination, criminalization) or the toxicity of antiretroviral therapy; or may not be ready or ready to begin treatment. There are many barriers to testing, treatment and long-term adherence beyond the control of people living with and vulnerable to HIV which must be addressed.

Finally, PARTNER is part of a substantial and growing set of facts in the "real world" and clinical evidence that is proving that while HIV is not always transmitted, even with a detectable viral load, when a person living with HIV is under treatment and has undetectable viral load, this both protects their own health and prevents new HIV infections.

I again: I contracted HIV from a young woman whom I will call FRO: She was HIV positive and knew it. I infected on purpose. It was my mistake not to guard me because two beaked not kiss. But it was an overwhelming number of sex for months and months and I got to suffer from lack of seminal fluid (sperm) in the last relations. I exhaust. Soft water in hard rock, both hits until it sticks ... This endless sequence relationships can have a similar effect. And if the transaction occurs at a time of "blip Viral"?

To learn more about the CAP, visit PreventionAccess.org, where you can also get information about your Undetectable = Uninfectious campaign. And you can read Bruce Richman POZ's inaugural Blog here.

Translated from original in Does Undetectable Mean Uninfectious? The Challenge of Explaining HIV Study Results from Trenton Straube by  Claudio Souza.

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