HomeOpinion & AnalysisHIV literacy: Undetectable equals untransmittable

HIV literacy: Undetectable equals untransmittable


Stanslaus Madende
IT is now well-known that the HIV treatment not only improves the health of people living with HIV, but is also the most highly effective strategy to prevent transmission.

This is because HIV treatment in adherent patients reduces the amount of virus (viral load) in the blood and other bodily fluids (semen, vaginal fluids and rectal fluids) to undetectable levels.

A person living with HIV is considered to have an “undetectable” viral load when antiretroviral treatment has brought down the level of virus in their body to very low levels that blood tests cannot detect the virus.

Therefore, the person can live a typical normal healthy life and a typical “normal sex life”. To become and remain undetectable people living with HIV (PLHIV) must take their HIV medication everyday without fail.

In addition to taking HIV medication, regular medical visits are important to monitor viral load to make sure it stays and remains undetectable and to receive other medical support.

The subject of HIV transmission and sex raises a lot of questions and discussions. Based on current HIV evidence-based science, the probability of patients with undetectable viral load to transmit HIV to their sexual partner is very low.

The risk of transmitting HIV is practically negligible though it must not be ignored. The UNAids July 2018 report endorses the concept of undetectable equals untransmittable (U=U).

Further the UNAids cautions that an HIV patient on treatment can only know whether he or she is virally suppressed by taking a viral load test.

The undetectable viral load is the desired treatment outcome for HIV treatment. The scientific evidence gathered so far is clear and convincing. Someone with undetectable HIV load does not pose an infection risk to his/her sexual partner.

Therefore, they can live a normal sex life without apprehension as long as HIV load remains undetectable. We all agree and know that sex is a major factor in human life and not just because of procreation, it’s more important than we would dare to admit in public.

To most people, if not all people, sex is a lullaby of life. In our African communities, sex is a core part of the social fabric. The U=U is very good news for PLHIV to live a normal sex life all round. The U=U is a piece of incredible health fact which we should be celebrating at health facilities, within HIV treatment programmes and in the community. It has massive public health implications, prevention implications and more importantly massive legal implications.

The big question is why isn’t this message more public? The U=U fact means that PLHIV, with undetectable viral load, can all but stop thinking about the possibility of HIV transmission to their sexual partners. It also renders various laws that sought to criminalise PLHIV for endangering sexual partners when they don’t disclose their HIV status. The undetectable equals untransmittable fact also serves to reduce internal and external stigma suffered by PLHIV, who are often made to feel as if they are third class citizens for harbouring an infectious virus.

However, despite the fact that undetectable equals untransmittable has evidently attained global health and advocacy consensus, HIV stakeholders have done very little if not nothing to populate this incredible fact to the general public.

Most HIV country programmes are not stating clearly to the public that PLHIV with undetectable viral load are incapable of transmitting the virus. All what is preached is that PLHIV with undetectable viral loads “greatly reduce” the chance of HIV transmission which is true at face value but not deep enough.

Such conservative language is more in line with what we already know from data almost 30 years ago and does very little to impact health literacy for the general public. Again, the question is why that information that concerns PLHIV’s social, sexual and reproductive health is somehow being withheld and not populated to the maximum?

If PLHIV are educated to understand the undetectable equals untransmittable fact, particularly those already on treatment, it will lift their spirits forever. It’s a big life incentive.

Country HIV programmes should explicitly populate the message and advocate for decriminalising PLHIV (on treatment) having sex. The core message for HIV treatment domain must be adherence to achieve undetectable viral load.

This message must be relayed directly through various platforms to those who are on HIV treatment.

They must know, by any means necessary that, they are not “HIV vectors” and they can have a happy life, healthy life and long safe sex life. This is actually the best incentive to stay on treatment.

It is equivalent to “return on investment”. It’s a massive release of apprehension and fear, for people to know that they cannot transmit HIV if they are virally suppressed.

Sexual HIV transmission is the key driver of the HIV new infections. The undetectable equals untransmittable is one of the several highly effective, affordable and sustainable options for preventing sexual HIV transmission.

However, it must be noted that the undetectable equals untransmittable, does not and will not offer protection against sexually transmitted diseases. The undetectable equals untransmittable phenomena cannot substitute condom use.

In the 1990s we learned that effective HIV treatment would save lives and we have seen it all along.

Now we know that effective HIV treatment prevents HIV transmission to sexual partners. This game-changing fact is the “nuclear weapon” to dismantle HIV internalised stigma, external stigma, and fear and to a lesser extent shame, that PLHIV have lived with, are living with and some, unfortunately, died with.

From a public health point of view, the undetectable equals untransmittable must by now be the “national war cry” for country HIV treatment programmes across Africa.

Why not when the evidence is on the wall? What are we waiting for? There is nothing to wait for, it’s game on “stay on treatment, stay undetectable and stay uninfectious”.

Most of the current messaging about HIV transmission somehow propagate sex-negativity, HIV-related stigma and discrimination.

Understanding that successful HIV treatment prevents transmission can help reduce HIV-related stigma and incentivise PLHIV to initiate and adhere to successful treatment regimen.  Speaking about HIV is a point of pride, not a source of shame, regret, humiliation or distress.

There must be no more sticking heads in the sand, no more embarrassment, no more hiding behind the veil of apathy and morality.

  • Stanslaus Madende is a biomedical public health pharmacist. He writes here in his personal capacity

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