LETTERS From CAMP Rehoboth

CAMP Safe

As soon as the announcement came out and, in turn, posted on www.aidsmap.com, I was bombarded with telephone calls and emails. In February, an article published by Switzerland's Federal Commission for HIV/AIDS stated that "people with HIV who have undetectable HIV viral load and no sexually transmitted infections are not sexually infectious for HIV." I thought this would be a good time to look at this research and have a discussion of its HIV health promotion possibilities.

The research that the Swiss research shows is that you have certain conditions that must be met before you can have unprotected sex:

The person must adhere to their HIV treatment, and the effectiveness of that treatment must be regularly evaluated by their doctor. Their viral load must be undetectable for at least six months. The person must have no other sexually transmitted infections (STIs).

I think it's important to note that some other expert groups have disagreed with the Swiss group's conclusions. The U.S. Centers for Disease Control and Prevention (CDC) issued a brief statement, saying that the CDC "underscores its recommendation that people living with HIV who are sexually active use condoms consistently and correctly with all sex partners".

So, what exactly did the Swiss experts say? And why is it controversial?

Based on their review of several medical studies, the Swiss group concluded that an HIV-infected person who is on HIV treatment and has a consistently undetectable viral load "is not sexually infectious, that is, cannot transmit HIV through sexual contact."

The Swiss group also acknowledges that "medical and biologic data available today do not permit proof that HIV infection during effective antiretroviral therapy is impossible," but they believe that the risk is "negligibly small."

Critics of the Swiss statement have emphasized that research on HIV transmission and viral load has focused on heterosexual couples and vaginal intercourseand does not necessarily apply to anal intercourse.

A number of people have also pointed out that, even if the Swiss experts are right, their conclusions about unprotected sex would apply to only a small number of HIV-infected persons: people who have excellent adherence to their HIV regimen, a consistently undetectable viral load, and no other STIs.

Practically speaking, the "no STIs" restriction could probably be met only within a monogamous relationship in which both partners were tested for STIs before stopping condom use. STI testing would be essential, because many people with STIs have no symptoms.

Several studies have shown that reducing a person's HIV viral load tends to reduce their risk of transmitting the virus. This is very heartening, but it does not mean that people with undetectable viral loads have no risk of transmitting the virus.

Given the limitations of current data, I personally believe it would be unwise to endorse a "no-condoms-needed-if-your-viral-load-is-undetectable" approach.

However, recent studies on viral load and HIV transmission give reason to hope that, if effective HIV treatment were widely available worldwide and properly used, the number of new HIV infections could be substantially reduced.

Universal access to treatment could be an important element in a comprehensive HIV prevention strategy that would include widespread access to HIV testing, use of the full range of existing prevention techniques and technologies, and the continued research and development of new prevention technologies, including microbicides and vaccines.

Sal Seeley is Program Director of CAMPsafe, an HIV/AIDS program funded through a contract with the Delaware Division of Public Health. E-mail salvatoreseeley@aol.com.

LETTERS From CAMP Rehoboth, Vol. 18, No. 02 March 07, 2008