Risk of Sexual Transmission of HIV from a Person Living with HIV who has an Undetectable Viral Load

Reprinted with permission from the Prevention Access Campaign

From PHN Issue 34, Fall 2017

There is now evidence-based confirmation that the risk of (sexual) HIV transmission from a person living with HIV (PLHIV), who is on Antiretroviral Therapy (ART) and has achieved an undetectable viral load in their blood for at least 6 months is negligible to non-existent. (Negligible is defined as: so small or unimportant as to be not worth considering; insignificant.) While HIV is not always transmitted even with a detectable viral load, when the partner with HIV has an undetectable viral load this both protects their own health and prevents new HIV infections.[i]

However, the majority of PLHIV, medical providers and those potential- ly at risk of acquiring HIV are not aware of the extent to which successful treat- ment prevents HIV transmission.[ii] Much of the messaging about HIV transmis- sion risk is based on outdated research and is influenced by agency or funding restraints and politics which perpetuate sex-negativity, HIV-related stigma and discrimination.

The consensus statement below, addressing HIV transmission risk from PLHIV who have an undetectable viral load, is endorsed by principal investigators from each of the leading studies that examined this issue. It is important that PLHIV, their intimate partners and their healthcare providers have accurate in- formation about risks of sexual transmission of HIV from those successfully on ART.

At the same time, it is important to recognize that many PLHIV may not be in a position to reach an undetectable status because of factors limiting treatment access (e.g., inadequate health systems, poverty, racism, denial, stigma, dis- crimination, and criminalization), pre-existing ART treatment resulting in resistance or ART toxicities. Some may choose not to be treated or may not be ready to start treatment.

Understanding that successful ART prevents (sexual) transmission can help reduce HIV-related stigma and encourage PLHIV to initiate and adhere to a successful treatment regimen.

People living with HIV on ART with an undetectable viral load in their blood have a negligible risk of sexual transmission of HIV. Depending on the drugs employed it may take as long as six months for the viral load to become undetectable. Continued and reliable HIV suppression requires selection of appropriate agents and excellent adherence to treatment. HIV viral suppression should be monitored to assure both personal health and public health benefits.

NOTE: An undetectable HIV viral load only prevents HIV transmission to sexual partners. Condoms also help prevent HIV transmission as well as other STIs and pregnancy. The choice of HIV prevention method may be different depending upon a person’s sexual practices, circumstances and relationships. For instance, if someone is having sex with multiple partners or in a non-monogamous relationship, they might consider using condoms to prevent other STIs.

“NEGLIGIBLE” = so small or unimportant as to be not worth considering; insignificant.

[i] Much of the current prevention messaging refers to this as Treatment as Prevention or TasP. As of the writing of this primer, there have been no confirmed cases of HIV transmission from a person with an undetectable viral load in any studies. The official cut-off point for an undetectable viral load as defined by the WHO ranges from <50 copies/ml in high-income countries to <1,000 copies/ml in low to middle-income countries. For the purposes of this statement, an undetectable viral load is defined as under <200 copies/ml, which is also the measurement for viral suppression.

[ii] Only a small proportion of people living with HIV in a large US treatment study regarded themselves as non-infectious after up to three years on antiretroviral therapy (ART), and a third of participants regarded their chance of transmitting HIV to a partner as still ‘high’, even though only 10% of participants actually had a detectable viral load.” NAM aidsmap (2016)

The health organization CATIE states, “for people with HIV who inject drugs, the risk of transmitting HIV is also considerably reduced if they are on treatment and maintain an undetectable viral load, but there is currently not enough evidence to conclude that the risk is negligible…. The available research suggests that this strategy is effective at preventing HIV transmission among people who inject drugs; however, there is not enough evidence to conclude that the risk is negligible….For people who inject drugs, other prevention programs and strategies (such as the distribution and use of new injecting equipment) are important to help prevent HIV transmission, as well as other blood-borne infections such as hepatitis C.”

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