by Siyabonga Gema (Health Systems Trust Communications Officer)
The concept of Undetectable = Untransmittable (U=U) is an exciting development in the global HIV response and a massive step towards achieving the 95–95–95 HIV testing, treatment and viral suppression targets. However, as with many health challenges, much should still be done to educate our communities, raise awareness of this concept, and answer various questions that people may have. This role falls squarely upon organisations such as the Health Systems Trust (HST) and other role-players in the public health sector who interact with communities and promote health care. Dr Douglas Ngcobo ‒ Community Co-ordinator of HST's project demonstrating community-based HIV treatment (DO ART) ‒ unpacks U=U and answers a few questions.
What's meant by U=U and how does it work?
In general, passing or transmitting HIV to another person depends on the amount of the virus in the body fluids of an HIV-positive person. When someone is diagnosed with HIV and is initiated on antiretroviral therapy (ART), HIV drugs prevent the virus from reproducing or making copies of itself in the body. If the prescribed HIV drugs are taken and are working properly, the viral load usually declines after starting the drugs, making it difficult for HIV to reproduce its copies and to infect new cells in the body, and this supports achievement of a low viral load.
When someone's viral load is low, that person is more likely to have a healthy immune system. The lower the viral load, the less likely is it that an HIV-positive person will transmit HIV to another. When a person is virally suppressed such that the virus is undetectable, this means that they cannot infect their partner. That is what is meant by 'U=U'. Having an undetectable viral load means that there is barely a trace of the virus to be found in body fluids that transmit HIV such as blood, vaginal fluids, or semen. It is therefore important for people to take their HIV drugs as prescribed, so that they have an undetectable viral load and can prevent their partners from being infected with HIV.
How long does one need to be on treatment to achieve U=U?
Studies show that for almost everyone who is initiated on ART and starts taking HIV medication correctly, their viral load is likely to drop to an undetectable level within six months or less. Patients on ART whose viral load is undetectable must continue taking the treatment correctly in order to maintain viral suppression, thus ensuring a strong immune system.
Is 'undetectable' the same as being HIV-negative?
It is important to note that there is currently no cure for HIV. Scientific evidence shows that even if one's viral load is undetectable, latent HIV cells remain in some parts of the body such as the gastrointestinal tract, brain, or bone marrow. Therefore, having an undetectable viral load is not the same as being HIV-negative.
What is the science behind the U=U concept?
Various randomised controlled trials have supported the finding of 'undetectable = untransmittable'. These clinical trials include one conducted in Switzerland in 2008, where experts agreed that people whose viral load is undetectable cannot sexually pass HIV to their intimate partners.
The largest study, called HIV Prevention Trails Network (HPTN 052), was conducted in 2005 at 13 sites in nine countries (Brazil, Botswana, Malawi, Kenya, India, United States, Zimbabwe, Thailand and South Africa).
In 2016, a PARTNER study looked at the risk of HIV transmission among heterosexual and gay mixed-status couples in which the partner living with HIV took HIV treatment and achieved an undetectable viral load. The PARTNER study results showed that after 58 000 instances of sexual contact among 1 166 couples who were not using condoms, there were zero cases of HIV acquisition among the couples. The study results for these clinical trials showed that people with an undetectable viral load cannot transmit the virus to another person.
Does U=U mean that condoms are no longer important to use?
Condom usage is still important even if the person has achieved U=U. Condoms protect us from other sexually transmitted infections (STIs) and unwanted pregnancies. It is therefore important to use condoms.
How does this concept shift perceptions of HIV and reduce stigma?
The U=U concept is likely to shift people's perceptions about HIV and reduce the stigma associated with it. If our families, colleagues and friends, and society in general, understand the principle of U=U, they are likely to accept that HIV is a chronic medical condition (like any other) which should and can be properly managed. With current advanced technologies and emerging research for the HIV response, people will begin to understand that HIV is no longer a death sentence.
What gaps still exist in educating the public about the importance of taking up treatment and staying on treatment should one become HIV-positive?
Unfortunately, there is still a gap in educating the public about the importance of taking up HIV treatment. Important information on HIV management should be given during pre- and post-test counselling, and clients who are initiated on ART should be informed about the benefits of taking treatment as prescribed and what to do if they experience side-effects, rather than stopping their medication without reporting this to the healthcare worker.
People's cultural beliefs and misconceptions about HIV contribute to poor adherence and treatment interruptions. While some clients may have relevant information about the importance of taking and staying on HIV treatment, the current unemployment levels in South Africa mean that people's socio-economic status makes it difficult for them to reach a healthcare facility to collect their medication. Other factors include facility infrastructure challenges, long waiting periods in congested clinics, negative attitudes from the staff, and patients' non-disclosure due to stigma.
Just as health education is imperative to inform the public about the importance of taking HIV medication, it is equally vital to address these other barriers that contribute to poor adherence by making treatment easily accessible and providing psychosocial support based on individual patients' needs.
What is society's role in supporting efforts aimed at promoting the uptake of ART?
Society can play a meaningful role by supporting HIV-positive patients on ART, rather than judging them. Caring for and supporting one another in our communities can help us to recognise the challenges faced by our friends and neighbours, provide the necessary support, and stop stigmatisation based on their HIV-positive status. As community members, we are responsible for loving and supporting one another towards health and wellbeing.