A Controversy about HIV Transmission
by Daniel S. Berger, M.D.
Many HIV experts have recently become embroiled in a new controversy: Does an undetectable viral load translate to significant reduction in HIV transmission during sex? If so, are condoms necessary? What message should be imparted by physicians to their patients who confront this situation in their daily lives?
In January 2008, an important and prestigious panel of experts from the Swiss Federal Commission for HIV/AIDS boldly produced the first-ever consensus statement saying that HIV-positive individuals on effective antiretroviral therapy and without sexually transmitted infections (STIs) are sexually non-infectious. This opinion was also published in the Bulletin of Swiss Medicine (Bulletin des médecins suisses). Hotly discussed at the International AIDS conference in Mexico City this summer, it was soon followed by a rejection statement by a joint Australasian group of experts.
The members and authors of the Swiss Federal Commission for HIV/AIDS are made up of the most reputable Swiss HIV experts, including professor Pietro Vernazza, of the Cantonal Hospital in St. Gallen, and President of the Swiss Federal Commission for HIV/AIDS, and professor Bernard Hirschel from Geneva University. Their opinion was based on a review of the medical literature and extensive discussion. They concluded with this statement: “An HIV-infected person on antiretroviral therapy with completely suppressed viremia (‘effective ART’) is not sexually infectious, i.e. cannot transmit HIV through sexual contact.” The Swiss also considered study data from Rakai, Uganda, where no transmission event occurred in individuals who had viral loads lower than 1,500 copies/ml, although this was a relatively small study.
In laymen’s terms, this means that barebacking among HIV-infected persons who are on the cocktail who have undetectable viral load, would not transmit HIV to their partners.
However, the Australasian group soon rejected the Swiss expert consensus and responded that condom use and effective treatment of STIs is the only way to prevent HIV spread. They went further to suggest that there could be a fourfold rise in transmission if condom use is left awry. They based this on a mathematical model that utilized published data estimating relationships between viral load and HIV transmission risks; they also assumed that transmission does occur at all viral load levels, regardless of how low they may be. Without true data, many question the utility of using mathematical models to form factual declarations. One doesn’t forget the mathematical model that was used by Dr. David Ho to regrettably forecast HIV eradication in patients who were at undetectable levels of HIV on treatment. HIV latency was not well understood at that time.
With these two differing opinions at hand, a more balanced editorial commentary which was more practical emerged from the UK. Drs. Geoffrey P. Garnett and Brian Gazzard state that ignoring the effect of undetectable viral load would be dishonest. They welcomed the Swiss statement for having opened up the discussion to where we can further suggest to patients to consider HIV treatment and urge better adherence. This may promote a reduction in the risks for HIV transmissions and other infections.
Past and present
Sexual behavior has been an evolution throughout the AIDS epidemic. During the first years of the HIV epidemic, without the knowledge of how HIV transmission occurred, most gay men continued to have unprotected sex. Without a clear dissemination of information, there was little caution during sex. Places such as bathhouses were a booming business. Eventually, as the AIDS epidemic progressed, individuals were in fear of contracting the virus and practiced safe or safer sex. “Safe sex” became a household term. HIV was at that time an incurable, progressive disease. Thus bathhouses were closed in various cities such as New York and San Francisco, and clientele dropped sharply since bathhouses were felt to be a reservoir for HIV transmission.
Real progress finally occurred in the field of HIV treatment with the arrival of the “cocktail” and soon coincided with many patients achieving undetectable levels of virus. The practice of safe sex was still heavily promoted. But this eventually led to a “safe sex fatigue,” especially since HIV infection was no longer viewed as a “death sentence.” Not safe sex but safe sex fatigue (which I am coining here) has become the pervasive attitude. In the real world, many patients admit that condoms hamper spontaneity during sex and have become too much of an inconvenience, not to mention the resulting reduction or loss in pleasurable sensations during anal intercourse, for some individuals. Not uncommonly, condoms are also a “turn off” and cause some individuals to lose their erections.
Not confronting safe sex, too many HIV-positive individuals avoid having the “conversation” about their HIV status. They’ve grown tired of feeling the need to re-assure their negative partners about reduced transmission. There’s already been the consensus in the men-having-sex-with-men (MSM) community that undetectable patients only remotely pose risk for HIV seroconversion. Also, oral sex has never been considered to be of significant HIV risk nor has it ever been adequately proven to cause HIV seroconversion. However, a common solution for HIV-positive men had been to act as the receptor of anal intercourse or “bottom” for someone HIV-negative, thereby further limiting exposure to their partner.
It is unfortunate that MSMs avoid discussing HIV status during first sexual encounters. One would expect that encountering HIV-positive men within the gay community is not uncommon. It should be a positive experience for a partner to disclose their status and have a reasonable discussion. In particular situations, it’s usually a relief to both partners when discovering what they’re each dealing with. If it is revealed that both partners are HIV-positive, it’s a tremendous relief and stress reducer for both. Alternatively, if only one partner is positive, it opens a conversation about harm reduction during sex. The absolute worst that can happen is that a negative person does not want to proceed with the situation and thus neither need waste the other’s time. HIV status is a personal issue, but individuals should all act responsibly without being inhibited about disclosure from the start.
Undetectable viral loads and transmission
The Swiss expert statement had been originally downplayed in the media for fear of encouraging more unsafe sex. One applauds the Swiss for encouraging individuals to get tested and begin effective treatment, thereby slowing the transmission of the virus within the community. The Swiss statement and referenced studies, however, were also criticized due to being heterosexually based and debated as to its application to the MSM population or gay community. But it also generated irrational fear that HIV transmission would get out of control.
Hence the Australasian rejection and conclusion of only the strict use of condoms plus early treatment of STIs being the only means to reduce transmission of HIV. However this continues to beg for further debate. It is fruitless to ignore that effective antiretroviral therapy eliminates HIV from genital secretions, and that HIV RNA, measured in sperm, declines below the limits of detection on antiretroviral therapy. HIV RNA also falls below the detection limits in female genital secretions during effective antiretroviral therapy. Moreover, usually sperm cell viral particles rise only after an increase in viral load from the blood. The cell-associated viral gene particles, present in genital secretions during effective antiretroviral therapy, are actually non-infectious virions; HIV-containing cells in sperm lack markers of viral proliferations such as circular LTR-DNA.
Thus it’s logical to abstract that less virus (undetectable) translates to less ability to transmit HIV to others. There can never be a prospectively conducted ethical study since one can’t ask HIV-negative individuals to participate in having unprotected sex with undetectable positives. However, patients infected with hep C are usually not undetectable and can also transmit hepatitis C sexually. Thus, unsafe sex, although protective for HIV if the partners are undetectable, does not protect against hepatitis C or syphilis.
Let us reconcile ourselves to the widespread existence of safe sex fatigue. While many HIV-positive men abandon safe sex, some do this while engaging themselves primarily with other HIV-positive men. Incomprehensibly, many HIV-negative gay men have accepted the idea that they’ll eventually seroconvert to HIV and thus avoid safe sex.
Addiction has also had a major impact on behavior. Methamphetamine addiction often results in irrational and relentless search for lust and sex with multiple partners by means of higher risk behavior. It is also associated with HIV seroconversions; other STIs while using is also associated with non-adherence to antiviral treatment. As a physician engaged in the research and treatment of HIV infection within the MSM community, I have observed a burgeoning epidemic of increasing HIV, hepatitis C, syphilis, and MRSA (resistant staphylococcal) infections.
Individuals who take extra precautions are always better off. Once becoming HIV and/or hepatitis C infected, there are tough consequences to face. Sexually active men should be responsible and have frequent HIV, hepatitis, and STI testing. Anal warts should be treated quickly to discourage the transmission of HPV. Anal Pap smears should be done when indicated. Finally, vaccination for HPV in gay men as a preventative step against development of anal cancer should be studied. At Northstar Healthcare in Chicago, Gardasil, the HPV vaccine, is currently offered to patients for this reason but is pending further study. HPV is the cause of anal cancer (and anal warts) and is a quickly rising problem among HIV-infected individuals.
Sexually active HIV-positive individuals are better off knowing their status and undergoing effective treatment and therefore reducing HIV transmission. Although HIV transmission has been curtailed among individuals who are undetectable and barebacking may be considered safe in some situations, there is still the prevalence of hepatitis C, syphilis, and resistant staph infection. On the other hand, HIV-positive persons in stable relationships with HIV-negatives, or individuals who understand the importance of adherence to HIV treatment while getting frequent STD (sexually transmitted disease) screening may provide effective harm reduction. Still, condoms should always be considered when sexually interacting with unknown partners.
Daniel Berger is Clinical Associate Professor of Medicine at the University of Illinois at Chicago, and founder and medical director of Northstar Medical Center. He serves on the Medical Issues Committee for the Illinois AIDS Drug Assistance Program, and is a member of the board of directors of AIDS Foundation of Chicago. Dr. Berger has been honored by Test Positive Aware Network with the Charles E. Clifton Leadership Award.