U=U

One of my favorite rotations of my fourth year so far was my HIV Medicine rotation. I spent four weeks at Drexel Medicine’s Partnership Comprehensive Care Practice. The Partnership provides comprehensive care to those living with HIV. Services include (but are definitely not limited to!) primary care, case management, social work, behavioral counseling, nutritional support, and a pharmacist on site. It is the largest HIV care center in the Philadelphia region, and they provide care to everyone regardless of their ability to pay.

I fell in love with the patient population, especially those who had been diagnosed with HIV 35+ years ago at the beginning of the HIV/AIDS epidemic in the United States. These patients were part of history. I loved learning from them and hearing their stories, which many of them readily shared.

This rotation was also the first time I learned about a very important campaign known as U=U, which stands for Undetectable=Untransmittable.  This campaign, which was started in 2016, has been backed by numerous organizations, including the CDC and the NIH. The basis is that if you are living with HIV and you are virally suppressed and taking your ART medications properly, you cannot transmit your virus to another HIV-negative sexual partner. More eloquently, in September 2017 the CDC came out with a statement that read, “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.”


Although the evidence for this has been building for about 20 years, three large studies published within the last 3 years have helped to reinforce the science behind the U=U campaign.
The first was the PARTNER1 study was published in JAMA in 2016. The PARTNER1 study showed that there was no HIV transmissions between 1166 serodiscordant couples (including both male-male and male-female) and over 55,000 condomless sexual acts when the HIV-positive partner was virally suppressed.
The PARTNER2 study was presented in 2018 and continued what was shown in the PARTNER1 study. It focused on 972 MSM serodiscordant couples and almost 77,000 sexual acts. Again, there were no transmissions when the HIV-positive partner’s viral load was undetectable.
The last study was the Opposites Attract study, published in the Lancet HIV in 2018. This study again showed in over 12,000 sexual acts between serodiscordant couples, there was no transmission when the HIV-positive partner was virally suppressed.

Obviously, on my HIV Medicine rotation all the providers were excited about the campaign and stressed it to their patients…even to those patients who were a bit skeptical. But, once I left that rotation and spent time in other primary care clinics or with other physicians who provide care for HIV patients, I found that this important information wasn’t readily known or being shared. This was frustrating to me. I believe that it is so important that providers are equipped with this knowledge and are able to confidently share it with their patients. There are so many benefits to having patients aware and educated about U=U.


This knowledge can motivate patients to become virally suppressed. It can provide them with incentive to take their drugs every day in order to become undetectable and then maintain that suppression once they get there. This can easily increase patients’ compliance with their HIV medications. Compliance is important in limiting drug resistance of the virus. Drug resistance makes treating the virus much more difficult.


Another reason to spread this information, is that it will hopefully help to further stifle the stigma surrounding this virus. The fact that people with HIV/AIDS used to be completely ostracized and now they can live full length lives without fear of transmitting the virus as long as they stay undetectable is truly remarkable. That alone can help change the mindset of this once completely devastating illness.


Finally, when patients are educated and informed, they feel powerful. Providing that power to patients is rewarding and can be life-changing for them.

I recommend visiting https://www.preventionaccess.org for the latest regarding U=U!


Catherine Guariglia   
DUCOM 2020
 
REFERENCES
Bavinton BR, Pinto AN, Phanuphak N, et al. Viral suppression and HIV transmission in serodiscordant male couples: an international, prospective, observational, cohort study. Lancet HIV 2018; 5: e438–47.

Calabrese SK, Mayer KH, Providers should discuss=U with all patients living with HIV. Lancet HIV 2019; published online February 13, 2019, https://doi.org/10.1016/S2352-3018(19)30030-X

Eisinger RW, Dieffenbach CW, Fauci AS. HIV viral load and transmissibility of HIV infection: undetectable equals untransmittable. Journal of the American Medical Association DOI: 10.1001/jama.2018.21167 (2019).

Rodger AJ, Cambiano V, Bruun T, et al. Sexual activity without condoms and risk of HIV transmission in serodifferent couples when the HIV-positive partner is using suppressive antiretroviral therapy. JAMA 2016; 316: 171–81.

Rodger A, Cambiano V, Bruun T, et al. Risk of HIV transmission through condomless sex in MSM couples with suppressive ART: The PARTNER2 Study extended results in gay men. 22nd International AIDS Conference; Amsterdam, Netherlands; July 23–27, 2018. WEAX0104LB.