In recent years, a significant milestone has been the continued research and affirmation of a critical principle that remains timeless: HIV-infected individuals do not transmit the virus when they maintain viral suppression through medication. The resounding message remains 'U=U,' signifying 'Undetectable equals Untransmissible.' When a person achieves viral suppression through HIV medication, it means the virus becomes undetectable in their blood. In turn, an undetectable person does not pose a risk of transmitting HIV to another person. This revelation is a cause for celebration, offering a potent tool in our ongoing battle against the HIV epidemic. Yet, despite this breakthrough, the question lingers: Why haven't we achieved widespread success in implementing this principle? The path forward appears clear—ensuring that everyone living with HIV achieves viral suppression and becomes undetectable. So, here is the reality fo the situation.
1. Everyone who is infected is not receiving treatment. Some people who have been diagnosed with HIV infection are not on treatment for one reason or another. Other people do not even know they are infected, and hence, are not on therapy. In the United States, it is estimated that out of all the individuals who are infected, approximately 1.2 million (in 2015), about 13% of these individuals are not aware they are infected. In addition to not getting the treatment to benefit their own health, they are able to infect other people. GET TESTED!
2. People who are prescribed treatment are not taking it properly. By not taking their medicines as prescribed, they do not have sufficient levels of medicine in their bloodstream to control HIV. There is virus replicating in their blood and tissues and they could pass the virus to someone else through unprotected sex, sharing needles for drug use, or having a baby.
So here’s some more good news. There are programs around the world that make HIV treatment available to people who have no resources to provide for their own medical care. Programs like PEPFAR (President’s Emergency Plan For AIDS Relief), established by President George W. Bush, provide medicines and health for HIV patients in developing countries in Africa, South/South-East Asia.
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Here in the US, every state has an AIDS Drug Assistance Program (ADAP) which providesHIV medicines to people who cannot afford them and includes medical care under the Ryan White Care Act. Check with your local health department to get more information on these programs. These treatment programs have endeavored to make treatment available to everyone to save lives and transform HIV-infected persons into productive, vibrant community members. But once we began to learn that treatment of HIV prevents new cases of HIV, these treatment programs now had expanded roles in helping contain the epidemic.
Physicians, pharmacists, nurses, and physician’s assistants have struggled for decades to find ways to make their patients take their medicines. It is not a problem unique to HIV disease but is common to all diseases. A little over twenty years ago, we had combinations of drugs that could totally suppress viral replication in the blood. But the medicines we were using back then required that patients take virtually every dose to keep the virus under control.
The ability for patients to take medicines exactly as prescribed by their medical provider is referred to as adherence. Adherence is important for all diseases. Controlling diabetes, asthma, depression, epilepsy or any other disease means that the patient should take every dose and miss as few as possible. But twenty years ago, we found that HIV patients had to be more adherent than did patients with other diseases. In fact, some older studies showed that HIV patients needed to take greater than 95% of their doses to keep the virus suppressed! That’s hard!
If we take a trip back in time about 22 years ago, there was no such thing as combination therapy given as a single pill once a day (we currently have 6 of these single pill combinations available). The various drugs in a combination would have to be taken two or three times a day, which could be up to 10 pills a day! Some drugs in the same combination might have to be taken with food and some on an empty stomach. Side-effects were common and some of the drugs could produce serious adverse effects. So just imagine having to take over 95% of the doses of a complicated regimen that might cause side-effects but was absolutely necessary to control the virus. Perhaps some of you experienced this nightmare.
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All would agree that having nasty medicines to control the infection was better than having no medicines to control the infection, where patients would be facing a slow death. To make matters worse, many of my patients back then not only had HIV medicine to take but also had to take medicine for high cholesterol, high blood pressure, bipolar disease or other medical condition(s). Taking so many drugs also increases the chance that two or more of the drugs could have an interaction leading either to a reduced clinical benefit or a dangerous adverse effect. It should not surprise anyone why people didn’t always take their medicines under such circumstances.
So fast forward to today where we have many combination regimens that are one pill, once a day. The treatments havemuch fewer side-effects and are easy to tolerate. Some of them may have food requirements, but many do not. So fewer pills, few side effects, and flexibility in dosing means everyone is totally adherent to their HIV meds right? WRONG! Believe it or not, some people do not take one pill, once a day to control their HIV infection. No matter how easy we make it, some people remain non-adherent to their medications.
Because we have better medicines with different properties than the older drugs, we may have a little wiggle room in case a person misses a dose or two. But for the most part, if a person has poor adherence to taking their medicines, they will likely not be suppressed. They will not be undetectable. Such a person could transmit the infection to someone else. This totally throws out “U=U”.
So we need to explore the reasons why people do not take their medicines and what we can do about it. Having the best medicines possible is useless if patients won’t take them. In the next article, we will look at the reasons why people don’t take their medicines and some possible solutions.
Dr. Crawford has over 25 years of experience in the treatment of HIV. While at Howard University School of Medicine, he worked in two HIV-specialty clinics at Howard University Hospital. He then did clinical research as a visiting scientist with the AIDS Clinical Trials Group (ACTG) at Johns Hopkins University School of Medicine. He served as the Assistant Chief of Public Health Research with the Military HIV Research Program where he managed research studies under the President’s Emergency Plan for AID Relief (PEPFAR) in four African countries.
He is currently working in the Division of AIDS in the National Institutes of Health. He has published research in the leading infectious diseases journals and serves on the Editorial Board of the journal AIDS. Any views and perspectives in his articles on blackdoctor.org are not representative of any agency or organization but a reflection of his personal views.
