New science is changing how we define responsible sex and could empower some couples in which one person is living with HIV and the other isn't. But with great power, comes great responsibility. (Reuters)

Redefining risk: When it's okay to be HIV-positive and have sex without a condom

Kevin Rebe
HIV-positive people who have very low levels of HIV in their blood can’t sexually transmit the virus. Here’s what it means for you & SA.

COMMENT

What if I told you that people who were on effective HIV treatment and who had repeatedly shown undetectable levels of the virus in their blood could have sex without a condom with no risk of transmitting the virus.

Sound too good to be true?

In January 2008, the Swiss Federal Commission for HIV and Aids released a statement saying just this: people whose antiretroviral treatment (ART) had brought the level of HIV in their blood to very low or undetectable levels could not sexually transmit the virus.

When ART lowers the amount of HIV in the blood to the point where it is difficult to detect, this is known as “viral suppression”.

But the declaration was based on fairly small studies, which the scientific community did not consider robust enough to support a statement with huge implications for health messages and, in turn, people’s choices. If the advice turned out to be wrong, people who might stop using condoms after hearing it could be exposed to HIV and sexually transmitted infections (STIs).

Consequently, the declaration failed to gain much traction and left the public confused.

Almost a decade later, this has changed. We finally have enough credible scientific evidence from several strong studies to convince us beyond any reasonable doubt: effective treatment and viral load suppression prevent HIV transmission.

Globally, this concept has become known as “Undetectable equals untransmittable” or U=U.

Healthcare workers should now feel confident in backing the U=U campaign, promoting its message and discussing what it means with their patients.

For people living with HIV, U=U means they should start ART as soon as they are diagnosed and take the medication exactly as directed. If they do so, they can be confident that they won’t pass on the virus, even in the absence of condoms during sex.

For HIV-negative people, this finding demonstrates that they can safely have condomless sex with an HIV-positive person without fear of infection, provided their partner is on ART and has suppressed their viral load. But we’re not advocating for a decrease in condom use. In fact, the opposite is true.

U=U is one part of a set of ways that people can use to reduce their risk of HIV infection, including condoms, STI screening and pre-exposure prophylaxis (PrEP) — the HIV prevention pill. But U=U will not protect you against unwanted pregnancies or contracting other STIs that can put you at risk of HIV infection.

And condoms alone could prevent most HIV transmissions.

However, in the real world, it is obvious that some people can’t or won’t use condoms consistently and effectively. For people like this, U=U provides a powerful HIV prevention tool, even in the face of risky sex.

For example, couples in which one partner is living with HIV and who have the desire to have children may have been warned against unprotected sex.

These couples can now conceive naturally without the fear of spreading HIV to their loved one if viral loads are undetectable.

So the science has spoken and we have a powerful method of preventing HIV transmission in our communities. But we need to implement the science correctly and create a culture of responsibility about taking treatment as directed if we are going to reap its benefits.

The South African health department has already followed the science and guidelines now advise regular HIV testing and allow people to start ART immediately to help people achieve U=U. The government is also expanding access to the HIV prevention pill.

But at a community level, we have to spread the message and explain the science behind it. If we don’t, we’ll sow doubt and suspicion about of U=U’s effectiveness, which could discourage people from starting and adhering to ART.

Second, we all need to change the way we test for HIV. We need to get used to frequent HIV testing so that, when we test positive, we can start treatment immediately and decrease the risk of passing HIV on to anyone else.

In the past, responsible sex meant sex with a condom.

People who didn’t use condoms were branded as “irresponsible” and this fed into the stigma about HIV.

Today, responsible sex won’t always mean sex with a condom.

After 40 years of limited HIV prevention choices and condom programming, this new dispensation will take some time to get used to, but it holds the promise not only of reducing new infections but also the fear and stigma we still attach to the virus.

Dr Kevin Rebe is an infectious diseases physician who works for the Anova Health Institute’s Health4men project in Cape Town. Follow the institute on Twitter @AnovaHealthSA.

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