“We are not dirty, we are not a threat, and we are not disease vectors!” Dr. Richard Wolitski, director of the Office for HIV/AIDS and Infectious Disease Policy at the U.S. Department of Health and Human Services told the crowd at the 2016 U.S. Conference on AIDS. “People living with HIV who achieve viral suppression, who become undetectable, are the solution to the end of new HIV infections in the United States. When we look back 20 years from now we’re going to judge ourselves in terms of how well we responded to this opportunity.”
Wolitski’s closing remarks drew a standing ovation. This is indeed a remarkable moment, and one we must embrace. Several on-going studies (HPTN 052 and the PARTNER study), have demonstrated that people living with HIV who are on medication and have reduced their viral loads to undetectable levels are not transmitting the virus to their HIV-negative partners.
How wonderful that something many of us have believed for years has been proven to be true! What great news and a terrific reason to seek treatment and stick with it. There’s nothing like a little intercourse au naturel with your partner to reward yourself for being undetectable, am I right?
And yet there’s strong resistance to the message equating undetectable to untransmittable, and it’s not coming from where you might think. So, let’s break down the arguments for and against embracing the message:
1. Is anything ever zero risk?
The PARTNER Study has recorded 58,000 acts of penetrative sex without condoms between 1,000 serodiscordant partners (where one is HIV-positive and one HIV-negative), in which the HIV-positive partner had an undetectable viral load. There was not a single case of transmission between the couples. Zero.
The same results were reported in the HPTN 052 study in which 1,763 serodiscordant couples relied only on the one partner’s antiretroviral medication as their HIV-prevention method. Absolutely no documented cases of HIV being transmitted between partners have happened when one is undetectable. As Dr. Wolitiski said in his USCA address, “this is a game-changing moment in the history of the HIV epidemic.”
Detractors argue that nothing, really, is without risk, statistically speaking. Even if the risk is miniscule — say equivalent to being struck by lightning twice — it still carries risk. Weird things happen. Some folks are convinced that people who drink alcohol sometimes spontaneously combust. But you don’t see warning labels about it slapped on every bottle of Wild Turkey by overzealous worrywarts.
And yes, there is the possibility that someone might think they were still undetectable and yet develop a viral load if they aren’t adherent to treatment (or if they become resistant to one of their meds), and then they could transmit the virus. But that doesn’t detract from the message that people who are undetectable cannot transmit HIV. If you stay on treatment and remain undetectable you will not transmit HIV. Can we please just celebrate this simple fact for a moment without qualifying it with all the remote possibilities?
READ ALSO: Study shows zero HIV transmissions from people who are undetectable.
2. Not all major HIV organizations are on board.
Community advocates and organizations have been reluctant to get on board, citing a theoretical risk of infection. A review of the websites and statements from major HIV organizations shows that there’s no consensus about whether to proclaim undetectable people cannot transmit HIV. Worse, some organizations still seem to be exaggerating the risks of transmission from those who are undetectable. While I will defer from shaming anyone by name, with the hope that they are just taking their time updating their official language, I do wonder how such an amazing breakthrough can be met with ignorance or apathy by our own leaders.
The skepticism suggests that those of us who have achieved undetectability don’t have the judgment to keep taking our medications—or to see our physician regularly — to ensure our treatment plan is still effective. It keeps us in the role of untrustworthy victimizers unable to make decisions that will keep the rest of you safe. What infuriating, stigmatizing nonsense.
Meanwhile, public health leaders, from the New York Department of Health to the National Institutes of Health, have embraced these findings and their meaning to people with HIV. The Prevention Action Campaign and their seminal message “U=U” (undetectable equals untransmittable) was founded on the energetic efforts of a man named Bruce Richman. He entered the HIV advocacy scene just a few years ago, seemingly out of nowhere, carrying aloft the banner of undetectability. Richman gathered signatures of health experts the world over for a consensus statement about the research, while cajoling U.S. HIV organizations to adopt language that removes the stigma of infectiousness from people who are undetectable.
3. Will embracing U=U lead to more STIs?
Auxiliary issues often creep into debates around preventing HIV, such as the fear that promoting the message that undectable equals untransmittable will lead to more sexually transmitted infections. (Similar arguments have come from critics of PrEP, the birth control pill, and any other vehicle that might lead to unbridled sexual pleasure). Rates of STIs — which had already been rising before the advent of PrEP or news from the PARTNER Study — are deeply concerning. We are in desperate need of comprehensive sexual health programs, to be sure. But, ultimately, this is about being HIV untransmittable, not syphilis impermeable. Being undetectable will not prevent other infections, or address promiscuity, or remove stubborn stains.
Other advocates are concerned about the continued compartmentalization of our community, between those who are positive or not, who is on PrEP or not, and now, between those with HIV who are able to achieve viral suppression and those who cannot — which include those who are unable to do so despite their best efforts. I sympathize with those not wanting a new divide among HIV-positive people. But I also believe the greater good — eliminating shame and stigma from those who are no longer capable of transmitting HIV — shouldn’t be downplayed. Rather than discount this development, we should celebrate it; and continue our efforts to help all people living with HIV suppress their viral loads to undetectable levels.
4. Proclaiming U=U couldforward HIV criminalization reform.
Terribly important work is being done to repeal and reform HIV criminalization laws that prosecute people with HIV for not disclosing their status to a sexual partner. Our lead defense is often that the defendant never posed a risk to their partner in the first place, due to their use of protection or the fact that the defendant was undetectable at the time and therefore rendered harmless.
Of course, we still have the point that HIV isn’t the kind of death-sentence zealous legislators once imagined it to be. But imagine the glee with which prosecutors might punch holes in an undetectable defense, if HIV organizations themselves are still insisting that “zero risk” is statistically impossible. The prosecutor could use that to explain to a jury that Joe Positive did, in fact, pose a risk to his sexual partner and should thus be jailed for doing so. Put that doubt into the heads of a jury, and another person with HIV may get a 30-year sentence for daring to have sex at all.
5. This could profoundly change how people with HIV view themselves.
Internalizing the information that I cannot transmit HIV has had an effect on me that is difficult to describe. I can only liken it to the day the Supreme Court voted for marriage equality. Intellectually, I knew I was, as a gay man, a human being worthy of equal rights. But on the day of the court’s decision I walked through the streets of my neighborhood with my head held higher. Something had changed. I felt whole. Recognized. Vindicated.
In my thirty-five years living with this virus, I have never felt that way about being HIV-positive. I deserve to. So do millions of other people living with HIV. We’ve been told we’re diseased, dirty, infectious, and hazardous to those we love. Proclaiming U=U can start to undo all of those stigmatizing messages. We can hold our heads high, knowing we cannot transmit the virus to our partners.
Of all the arguments, that enhanced feeling of self-worth may be the most important of them all.
Plus magazine contributing editor, Mark S. King, is the twice nominated GLAAD award blogger behind My Fabulous Disease, where this piece was originally published.