The challenge of explaining the results of the study of Non-HIV Transmission of the Partner Study. To read through and reflect long ...
- 1 The challenge of explaining the results of the study of Non-HIV Transmission of the Partner Study. To read through and reflect long ...
- 2 Why do you think it takes that tone?
The editorial and the press release accompanying the recent results of the PARTNER study arouse concerns Prevention Access Campaign.
As executive director and co-founder of the Prevention Access Campaign (PAC), Bruce Richman focuses on telling everyone about the benefits of treating cancer. HIV not only for people living with the virus, but also for their sexual partners - it focuses specifically on ways that drugs can prevent the spread of HIV. To continue his activism, 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 his HIV positive HIV status gave way to a sense of freedom once he realized that having viral load undetectable meant that he was not a danger to his / her 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.
Bruce, thank you for speaking about the results of the PARTNER trial, which were presented at the XNUMXst International AIDS Conference (AIDS 2016), held in Durban, South Africa. The study followed straight and gay couples where one person has HIV and the other does not [Serodiscordant couples]. The Commission did not find HIV transmission among couples in whom the person with HIV had an undetectable viral load. Our story about the study was titled "PARTNER Findings, Provisional Published, Strengthen 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."
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 in the PARTNER study, the accompanying editorial, and the press release that quotes are included as "doctors need to be clear that although the overall risk of HIV transmission may be small, the risk is not zero, and real number is not known, especially for the higher-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?
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.
The PARTNER 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 in a discussion about semantics and how people interpret specific words that convey the risk to everyone, there is no risk measurement agreement - but can I assume that you believe the tone of the press release is intentionally precautionary?
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:
- An increase sex among people with HIV that are undetectable lead to an increase of STDs; and
- 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.
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 selectively choose to discuss science with patients and clients whom they believe are "responsible" (eg, monogamous and with a stable joint for treatment) rather than treating directly the impacts of risk compensation 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 say 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 UK Terrence Higgins Trust said "Undetectable = Non-infectious" or "negligible risk." None of the major journals about 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 misinformation 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 by religious opportunists, 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 great progress last week in the United States: pioneer Demeter Daskalakis, MD, MPH, subcommittee of the Office of HIV / AIDS Prevention and Control at the New York City Department of Health 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 the 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 get HIV from a girl whom I will call FRO: She was HIV positive and knew it. It infected me on purpose. It was my mistake to not be on my guard because two beaks do not kiss. But it was an overwhelming number of sexual relations, for months and months and I even suffered from lack of seminal fluid (sperm) in the last few relationships. I was exhausted. Soft water in hard stone, both beats until it sticks ... This endless sequence of relationships can have a similar effect. And if the transaction occurs at a time of "blip Viral"?
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