Undetectable viral load and non-transmission of HIV - an information sheet for people with HIV

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Undetectable viral load and A NO HIV transmission

The amount of HIV in body fluids is called viral load. Effective HIV treatment (antiretroviral therapy) suppresses the amount of HIV in body fluids to the extent that standard tests are unable to detect HIV, or can find only a tiny trace.

Doctors call this “virological suppression“, But it is often known as“ having an undetectable viral load ”or“ being undetectable ”.

Have one undetectable viral load does not mean that you are cured of HIV. If you stopped treatment, your viral load would increase and you would once again be detectable.

Having an undetectable viral load means that there is not enough HIV in your body fluids to transmit HIV during sex. In other words, you are not infectious.

As long as your viral load remains undetectable, your chance of transmitting HIV to a sexual partner is zero. As the campaign slogan says, 'Undetectable is Untransmittable' or 'U = U'.

This fact sheet is written for people living with HIV. This topic is also covered in an information sheet written for people who do not have HIV.

Viral load at different stages

During the first few weeks after someone get HIV, viral load is usually very high - typically several million “viral copies per milliliter of blood”(Copies / ml). There is a considerable risk of transmitting HIV at this time. Indeed, many people acquire HIV from someone who has only recently acquired it (and don't know him).

After this period of early infection, the viral load generally decreases. A typical viral load in someone who is not receiving treatment can be 50.000 copies / ml. There is still a considerable risk of transmitting HIV.

After you start treatment for HIV, viral load generally decreases rapidly. Within three to six months, most people's viral load became undetectable (below 50 copies / ml).

It is recommended that you wait until you have at least two consecutive undetectable results, over a period of six months, before trusting them. If you maintain an undetectable viral load for at least six months and continue to have good accession, the British HIV Association says there is no risk of HIV transmission.

British HIV Association Council

The 'Undetectable equals non-transferable' campaign (U = U) is supported by the British HIV Association (BHIVA), which is the professional association for doctors and other health professionals working with HIV in the UK.

BHIVA says that consistent use of HIV treatment to maintain an undetectable viral load is a highly effective way to prevent sexual transmission of HIV.

BHIVA says that healthcare professionals should share this information with all people living with HIV. Advises healthcare professionals to explain the scientific evidence behind U = U, emphasizing the importance of excellent adherence to HIV treatment and highlighting that U = U is dependent on the maintenance of a sustained undetectable viral load.

Scientific evidence

The first large study indicating that people with low viral loads are not infectious came from a study of 415 heterosexual couples in the year 2000. This found that no HIV-positive partner with a viral load below 1500 copies / ml transmitted HIV.

In 2011, a major scientific study called HPTN 052 concluded that HIV treatment reduced the risk of transmitting HIV to a regular heterosexual partner by 96%. The only reason it was not 100% is that a person in the study acquired HIV, but it happened just days after their partner started treatment. Over the course of the four-year study, no person with an undetectable viral load transmitted HIV to their partner.

PARTNER 1 and PARTNER 2 Studies

The final results of the PARTNER 1 e PARTNER 2 studies were announced in 2016 and 2018, respectively.

Between the two, they recruited 972 gay couples and 516 heterosexual couples in which one partner had HIV and the other did not. Throughout the study, gay couples had 77.000 sex acts without penetration and heterosexual couples 36.000 acts. PARTNER studies did not find a single transmission of HIV from a seropositive partner who had an undetectable viral load (below 200 copies / ml).

In 2017, a similar study with exclusivity of 343 gay couples, Opposites Attract, also found no transmissions from partners with an undetectable viral load in 17.000 acts of anal sex without a condom.

No Transmission Of HIV From A Sex Partner With Undetectable Viral Load

Among the three studies, no HIV transmission from a sexual partner with an undetectable viral load was observed in almost 130.000 acts of sexual intercourse without a condom. This means that the risk of transmission by a partner with an undetectable viral load is statistically equivalent to zero.

Some of the HIV-negative partners in these studies did acquire HIV. But, using genetic tests, the researchers managed to show that all of these infections came from other people and not from their main partner.

What this means to me?

Many people with HIV see the fact that they are not infectious as a major relief from transmission anxiety as a very important benefit of HIV treatment. Increasing public awareness of U = U can also reduce stigma towards people living with HIV.

If you want to stop using Condoms, it’s probably a good idea to discuss this with your partners and see if they’re comfortable with the decision. Likewise, if your partner is using PrEP (pre-exposure prophylaxis), but you feel you don't need it anymore, you will need to discuss it with them.

Discussing what an undetectable viral load means with seronegative partners can help reduce anxiety about HIV transmission. But that information is likely to be new to most people who do not have HIV, and it may take some time for someone to understand and trust what you are saying.

NAM has also produced an information sheet for people who do not have HIV to help them understand the impact of an undetectable viral load on HIV transmission.

Knowing that “Undetectable is equal to non-transferable” is especially useful for people who wish to have a child. Couples where one person has undetectable HIV and the other is HIV negative can have unprotected sex to conceive.

However, the HIV law may not have reached science. In some countries, sex without a condom without revealing your HIV status is a crime, regardless of the likelihood of HIV transmission. For information on specific countries, visit criminalisation.gnpplus.net

What about Sexually Transmitted Infections (STDs)?

It is important to remember that while HIV treatment protects your partners from HIV, it does not protect you or you from other sexually transmitted infections (STDs). For this reason, sexual health check-up is recommended.

The use of condoms will help prevent STDs.

Another concern is whether having an STI can lead to an increase in viral load. This happens with people with HIV who are not receiving treatment: for example, syphilis can double their viral load. HIV-negative partners are also more likely to contract HIV if they have an STI.

But it is not the case for people being treated for HIV who have an undetectable viral load. In the PARTNER and Opposites Attract studies, there has not been a single transmission of HIV, although many people have STDs.

If you maintain good adherence to HIV treatment, the detection of an STI will not increase your viral load from "undetectable" to "detectable". Effective treatment prevents sexual transmission of HIV, even if other STDs are present.

If I have an undetectable viral load, I can transmit the HIV?

People with an undetectable viral load sometimes experience so-called “beeps” in their viral load. Your viral load increases from undetectable to a low, but detectable level, before becoming undetectable again in the next test.

For example, the viral load may temporarily increase to 60 copies / ml or 150 copies / ml. This should not be a cause for concern.

Remember that in the PARTNER and Opposites Attract studies, 'undetectable' was defined as below 200 copies / ml. These studies have shown that transmission does not occur below this level.

However, a blipe can indicate a problem if it occurs at about the same time as missed or late doses of your medication, or if your viral load remains above detectable in two consecutive tests.

Isn't viral load in semen, vaginal fluids or the rectum more important than viral load in blood?

The viral load in the blood and other body fluids is generally very similar - if the HIV in your blood is undetectable, it is likely to be undetectable elsewhere. Occasionally, people have undetectable HIV in their blood and have low levels of HIV in other body fluids, but very rarely at infectious levels.

Does HIV Treatment Always Work?

About one in six people on their first HIV treatment regimen never have an undetectable viral load or their treatment stops working in the first year. During the second year of treatment, the chance of your therapy failing to work is one in twenty, and that further decreases in the next decade to about a 50 in XNUMX chance of failure in any year.

So the longer you are on HIV-specific therapy, the less likely you are to stop working. Almost everyone who goes on a second or third regimen reduces their viral load to an undetectable level.

Adherence is very important

If someone's treatment does not make their viral load undetectable, this is usually because they are having trouble taking the treatment as prescribed, meaning they do not take all of their pills at the right time, without missing doses. If you are having trouble maintaining your treatment, talk to your doctor and they will be able to find a combination of medications that suits you best.

U = U Applies To All Types Of Sex?

An undetectable viral load will prevent HIV transmission during oral sex, vaginal sex and anal sex. Condoms are not needed to prevent HIV transmission when your viral load is undetectable.

U = U Does it apply to non-sexual transmission of HIV?

This page is about the transmission of HIV during sex.

But an undetectable viral load is also crucial for conception, pregnancy and birth. If you maintain an undetectable viral load during pregnancy, the risk of being transmitted to your baby is only 0,1%, or one in a thousand.

Breast-feeding

During breast-feeding, an undetectable viral load greatly reduces the risk of HIV transmission, although it does not completely eliminate this possibility. In the UK and other countries where clean water and sterilization equipment are available, a milk formula bottle is the safest way to feed your baby.

If you use injectable drugs and share needles or other equipment, HIV treatment and undetectable viral load greatly reduces the risk of HIV transmission, but we don't know how much.

This technical sheet should be revised in January 2022

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