Policy Statement: Risk of Sexual Transmission of HIV from Virally Suppressed People Living with HIV

By Murray Penner February 28, 2017

OVERVIEW
NASTAD joins public health experts and leaders in affirming that there is now conclusive scientific evidence that a person living with HIV who is on antiretroviral therapy (ART) and is durably virally suppressed (defined as having a consistent viral load of less than <200 copies/ml) does not sexually transmit HIV. This statement accelerates our longstanding work to end the dual epidemics of HIV and HIV-related stigma and to dramatically reduce new HIV infections, and is supported by policies and public health practice grounded in science.

WHY IT’S IMPORTANT
The conclusive evidence about the highly effective preventative benefits of ART provides an unprecedented opportunity to improve the lives of people living with HIV, improve treatment uptake and adherence, and advocate for expanded access to treatment and care.  

People living with HIV who are on ART and are durably virally suppressed are not only less likely to develop HIV-related complications, they also do not transmit the virus to others. The new evidence will help ameliorate decades of HIV-related stigma and discrimination by confirming that treatment is a powerful preventive intervention. The added preventive benefit of treatment encourages people living with HIV to initiate and adhere to a successful ART regimen, closely monitor their viral load, and stay in regular medical care.  It is important to note that while viral suppression prevents the transmission of HIV, consistent and correct condom use and pre-exposure prophylaxis (PrEP) also prevent the transmission of HIV, and condoms provide additional protection for other STIs and pregnancy.    

Despite our efforts to achieve universal viral suppression, many people living with HIV face immense barriers in achieving viral suppression that must be addressed, including social determinants of health (e.g., inadequate health systems, poverty, racism, denial, stigma, discrimination, and criminalization) and previous ART treatment that may have resulted in resistance or ART toxicities. Some people may choose not to be treated or may not be ready to start treatment.

WHAT WE KNOW AND WHAT IT MEANS
At the International AIDS Society (IAS) Conference in 2015 in Vancouver, the final results of the HPTN 052 trial studying whether ART can prevent sexual transmission of HIV demonstrated:

  • A 93% reduction in the risk of HIV transmission within mixed-status couples when the HIV positive partner started treatment early
  • At the end of the study, 1,171 couples remained in follow-up. Half of the couples had been assigned to start treatment early; half were assigned to delay treatment until their HIV positive partner’s immune systems were declining
  • While eight transmissions did occur between couples in the early treatment group, no transmissions occurred when ART durably suppressed the partner’s virus

At the International AIDS Conference in 2016 in Durban, new data presented from the PARTNER study showed:

  • A refined estimate from two years ago that established the chance of an HIV-positive person with an undetectable viral load (defined as <200 copies/ml for the purposes of this study) transmitting HIV to be very low, if not zero
  • These final results are based on experiences from 888 couples, 38% of them same sex male couples, which encompassed an estimated 58,213 sex acts
  • While 11 people did acquire HIV during the study, none of these transmissions were phylogenetically linked (i.e., linked to the HIV-positive partners in the study)

The evidence demonstrates:

  • Zero new linked transmissions in the PARTNER study and zero transmissions from virally suppressed partners in HPTN 052 equates to there being effectively no chance of sexual HIV transmission from people living with HIV who are on ART and durably virally suppressed.
  • An FAQ on the PARTNER study notes that STIs and likely small short-lived increases in viral load or ‘blips’ did not increase HIV transmission risk during sex in this study. STIs and viral blips have not been shown to increase transmission risk from an HIV positive person who is on ART and virally suppressed in any study or empirical evidence to date.    

These findings have been embraced by leading experts in the field:

  • Dr. Anthony Fauci, Director of NIAID, at the National Institutes of Health, said in an August 2016 NIH Interview, “Suppressing the viral load of a person living with HIV to undetectable levels not only saves their lives but prevents them from infecting others. So the higher percentage of people who are on treatment, in care and get their viral loads to undetectable, the closer you get to literally ending the epidemic”
  • Dr. Carl Dieffenbach, Director of the Division of AIDS, NIAID, at the National Institutes of Health, said in a Nov 2016 NIH interview, “Once you begin therapy and you stay on therapy, with full durable virologic suppression, you are not capable of transmitting HIV to a sexual partner.” Dr. Dieffenbach went on to explain, “With successful ART, that individual is not infectious”
  • Dr. Demetre Daskalakis, Acting Deputy Commissioner, Division of Disease Control at the New York City Department of Health and Mental Hygiene commented in July 2017 that "the force of evidence in both real world and clinical trial experience confirms that individuals with suppressed viral loads have a negligible risk of transmitting HIV”
  • Bruce Richman, executive director of the Prevention Access Campaign noted in a December 2016 interview that “advances in medicine and science are changing lives in ways that we never thought possible.Twenty years ago we learned that effective HIV treatment would save lives. Now we know it also prevents HIV transmission to others. If we focus on the facts instead of fear, we have unprecedented opportunities to end HIV stigma and end the epidemic" 

ACTION STEPS
NASTAD and its members will widely share this new scientific understanding of the risk of sexual transmission of HIV from virally suppressed people living with HIV to both promote optimal health outcomes and reduce stigma.  We will continue to support efforts to examine and support evidence-based public health policies, approaches, and resources to promote and reduce barriers to HIV prevention and care. NASTAD members will also continue to emphasize the importance of providing comprehensive prevention and care services for people living with HIV to improve their quality of life and reduce risk of transmission to others.

In conjunction with new and existing partners, our members also pledge to:

  • Promote public education and an evidence-based understanding of HIV transmission risk
  • Use this information to provide unequivocal public health leadership on decriminalizing HIV status
  • Promote comprehensive care services for individuals living with HIV and work to achieve viral suppression among all people living with HIV
  • Promote comprehensive prevention services for individuals at high-risk for HIV acquisition

NASTAD will continue to advocate at the national level to raise awareness about the latest science of HIV transmission risk and implement policies and practices grounded in our best science void of stigma and discrimination. Finally, NASTAD will continue to monitor the scientific landscape for advances that will enhance our understanding of how to reduce new HIV infections and optimize the quality of life for people living with HIV.

NASTAD (National Alliance of State & Territorial AIDS Directors) is a leading non-partisan non-profit association that represents public health officials who administer HIV and hepatitis programs in the U.S. and around the world. Our singular mission is to end the intersecting epidemics of HIV, viral hepatitis, and related conditions. We do this work by strengthening domestic and global governmental public health through advocacy, capacity building, and social justice.