HIV: Undetectable Equals Untransmittable

Segment Description: Joseph Eron, MD; Paul Sax, MD; W. David Hardy, MD; Eric S. Daar, MD; Ian Frank, MD, have a discussion on the undetectable equals untransmittable concept (U=U) and its effectiveness in preventing the transmission of HIV.

Joseph Eron, MD: David, this is an opportunity that maybe we should talk about U=U now, before we get into specifics about choosing a regimen.

W. David Hardy, MD: You know U=U is simply a new term that basically just stands for “undetectable equals untransmissible” or “untransmittable.” And it’s 1 that actually in many ways was generated in the community, and then it was actually the scientific individuals like [Anthony Fauci, MD, of the National Institute of Allergy and Infectious Diseases, part of National Institutes of Health], and Robert Redfield, MD, at the CDC, also approved it because there are great data behind it that say that it’s all very true. I think some of the most powerful data are the PARTNER 1 and 2 studies that really show how hard you can stress an undetectable person’s ability to transmit by having them have unprotected, condomless sex with their partner on repeated occasions with ejaculation and have no transmission. Both heterosexual and homosexual. And I think that’s really very powerful.

Joseph Eron, MD: And Eric, whom is this important for, do you think?

Eric S. Daar, MD: I’d personally think it’s mostly for people who are in a discordant relationship, a stable relationship. You know the message is important for everybody. There’s no reason to withhold the message, but the practicality is that if you have lots of people you’re exposed to, it’s impossible to know what their status is.

Joseph Eron, MD: Sure.

Eric S. Daar, MD: So I mean, I think it’s for people in stable relationships. They can feel comfortable that they don’t need to use condoms, as long as the partner is stably suppressed on antiretrovirals.

Joseph Eron, MD: I think it’s for the person who’s infected.

Regardless of the relationship, because it’s so stigmatizing to think; you know you hear these stories about people who are transmitting HIV all over the place. On the other hand, most of my patients.

Paul Sax, MD: Are terrified.

Joseph Eron, MD: Terrified that they might give this to someone else. And to me, there’s the public health message.

Paul Sax, MD: So our social workers describe patients who start crying when they hear that this is a scientifically proved fact, that they can go on treatment and become uncontagious to others.

W. David Hardy, MD: The stigma lowering—you know I think that’s why it’s so important. Because this actually came from the community in many ways, what we see in terms of biologic stopping transmissions and treatment equals prevention is interpreted very differently in the community in terms of how it makes people who are HIV positive feel. For years, I know in the gay community there has been a very strong prejudice against HIV-positive individuals within their own community because they’re HIV positive. And this really sends that away because they can’t transmit the virus anymore, so they no longer can be stigmatized. I think it’s a little more difficult in some other communities, but you know the message should really be continued to be put out there.

Eric S. Darr, MD: The other place that I think it has value is when you’re counseling that newly infected person. The whole discussion about trying to engage them and get them on care. Now we can tell them that not only will they be able to initiate therapy that is simple to take, is well tolerated, and will always suppress their virus to undetectable levels, and that they’ll presumably live forever from an HIV perspective on treatment. But they also don’t have to worry about transmitting to their partners.

Joseph Eron, MD: Yeah, I know, I think that’s exactly right.

Ian Frank, MD: We have cities like New York and San Francisco that have “Getting to Zero” programs in which they hope to at least level off the number of new infections.

Paul Sax, MD: It’s gone down.

Ian Frank, MD: At some point, no new infections.

Joseph Eron, MD: So that’s the public health benefit.

Ian Frank, MD: That’s right. So there’s a huge public health benefit to this. This is a major component of ever “Getting to Zero” urban campaign or rural campaign.

Eric S. Daar, MD: And you have to assume any reduction in which we’re going to see an incidence. You know, we think we’ve seen a reduction. Any further reduction is going to be completely driven by getting people diagnosed on treatment and getting high-risk people on PrEP [pre-exposure prophylaxis].

W. David Hardy, MD: Right.

Joseph Eron, MD: And doing it in areas where we know there’s transmission. Recently, the CDC presented data that 50% of new infections in 2016 were in 46 counties.

Paul Sax, MD: Amazing.

Joseph Eron, MD: There are, like, thousands of counties in the United States. And again, yeah, I think that there are hot spots where we can really focus this.