Being HIV positive and undetectable, also known as having an undetectable viral load (UVL), is a big deal. Why? Because people living with HIV who manage this over time have effectively no risk of sexually transmitting the virus! And that means Undetectable = Safe
On 27th September 2017, the United States Centers for Disease Control and Prevention (CDC) made a clear announcement. In an online letter stating that: “…people who take ART [Antiretroviral Therapy] daily as prescribed and achieve and maintain an undetectable viral load have effectively no risk of sexually transmitting the virus to an HIV-negative partner.”
“…people who take ART daily as prescribed and achieve and maintain an undetectable viral load have effectively no risk of sexually transmitting the virus to an HIV-negative partner.”
What is an undetectable viral load (UVL)?
When an HIV positive person is taking treatment (antiretroviral therapy), the amount of HIV in their blood, also known as their viral load, can effectively be reduced to a level that is undetectable. This doesn’t mean they are cured or free of HIV. It simply means that their treatment has suppressed the virus from replicating. Effectively eliminating any risk that the virus can be passed on.
An undetectable viral load was defined as having a viral load with less than 200 copies/mL. This study found that there were no linked HIV transmissions from an HIV positive and undetectable partner to a negative partner. Even after an estimated 58,000 acts of condom-less sex between partners in the study.
Why is this important?
While there’s been a huge amount of energy and excitement in Australia about advances in biomedical HIV prevention strategies like PrEP, there’s another discovery that deserves equal attention.
As far back as 2008, scientists suspected that people living with HIV who also used antiretroviral therapy to maintain an undetectable viral load, were not sexually infectious. In other words, they were not passing on the virus through sex. Even when not using condoms! From 2017 we have evidence and scientific consensus of this fact.
“Undetectable = Safe”
Can everybody living with HIV be undetectable?
Most people living with HIV who are on treatments which suppress their HIV will reach an undetectable viral load. However, a very small number will not achieve this. Even in these small number of cases, the virus may still be suppressed to very low levels. That will result in a greatly reduced risk of them transmitting HIV to their sexual partners compared to not being on treatment.
How does a person become undetectable if they’re HIV positive?
By starting and staying on HIV treatment, over 90 per cent of people will reach an undetectable viral load within 3 to 6 months. An undetectable viral load will be sustained by consistently taking medication every day. There are over a dozen different treatment options. A GP authorised to prescribe HIV medications will work with the person living with HIV so that they have the best treatment to suppress their HIV.
“By starting and staying on HIV treatment, over 90 per cent of people will reach an undetectable viral load within 3 to 6 months, or even sooner!”
Of course, treatment can only start once someone has had an HIV test and knows their status. Getting tested for HIV and other STIs is easier than ever before. Wherever a person lives in Australia, there are options available to them. Testing services can be located nearby and across Australia.
LGBTI health organisations Thorne Harbour Health in Victoria and ACON in New South Wales promote HIV testing in specially produced videos, and in quite different ways:
When should somebody start treatment?
Research from the START study has demonstrated that early, if not immediate, HIV treatment increases life expectancy, improves health and prevents serious illness by more than 50 per cent compared to those who delay starting treatment. Since 2014, guidelines have been changed so people can start treatment immediately.
“Early, if not immediate, HIV treatment increases life expectancy, improves health and prevents serious illness by more than 50 per cent compared to those who delay starting treatment.”
In the earlier days of HIV care when only a few older treatments were available, people living with HIV and their doctors would often delay starting treatment until the person’s CD4 count fell below 500. At the time, this was thought to be wise, as the treatments available then sometimes caused side effects. Today, however, antiretroviral treatments are more effective and far better tolerated by the body with hugely reduced side effects. And we know that having unsuppressed HIV is associated with greatly increased risk of poorer health and wellbeing.
The consensus of doctors and health organisations worldwide is that all people living with HIV should receive effective HIV treatments, both to preserve their good health and to help prevent new HIV transmissions. If a person is living with HIV, the recommendation is to start and stay on treatment. Doing otherwise will jeopardise their health and wellbeing.
What if someone stops using their HIV treatment?
If a person is HIV positive, consistently taking their HIV medications and staying connected to their HIV doctor, this will maximise their chances for maintaining their health as well as being the key to staying undetectable.
If a person stops taking their medication or misses doses frequently, HIV may no longer be suppressed. It will begin to impact their immune system more harmfully. Not only will this jeopardise their wellbeing, but can also mean HIV may once again become detectable in their blood. As a result, it may be possible to transmit the virus to other people.
What if someone gets a sexually transmitted infection (STI)?
As for people who are on effective HIV treatment, STIs appear to have no or very little impact on viral load.
A person living with HIV who is not on treatment, acquiring an STI can cause an increase in viral load. For example, having syphilis can cause a significant increase in viral load. Making it more likely for them to pass on the virus. STIs in people not on treatment can have worse symptoms and can cause significant harm.
“For people who are on effective HIV treatment, STIs appear to have no or very little impact on viral load.”
All sexually active gay and bisexual men should have regular STI tests, to protect their own health and that of their partners, and to reduce STI transmission between men.
What if someone is HIV negative and has condomless sex with someone who says they are undetectable?
Research consistently informs us that condomless sex with a person with HIV who has suppressed their virus to undetectable levels has no risk of sexually transmitting HIV. Full stop – period!
While the viral load may have been undetectable at the last test, there are other things worth considering . The increased risk of STI transmission with condom-less sex and the possibility that the person on treatment may have lost full suppression of HIV and may no longer have an undetectable viral load. The key to good sexual health in relationships remains as talking, choosing a prevention method that is right for the individual and STI testing.
For someone who is HIV negative and has had condom-less sex with an HIV positive person known to have an undetectable viral load, there is no risk of acquiring HIV from the positive person. In such cases, PEP (post-exposure prophylaxis) is no longer recommended because it is not required.