To put things in perspective, this meeting was also held in Amsterdam 16 years ago. Since that time, the advances we have made have been extraordinary and unprecedented for any medical condition. During this period, we witnessed this disease transformed from a death sentence to a chronic manageable disease, like asthma or diabetes.
Nevertheless, in light of all this progress, more than a million people continue to die from HIV infection every year; more than the entire population of Amsterdam (about 900.000). Not surprisingly, most of these deaths are among blacks in Africa, the Caribbean and the US but also other peoples of color have disproportionately high rates of death.
So what did we learn from the meeting that can help us in our ability to detect, treat and retain HIV patients in care? What can we do better to prevent HIV? And, are we any closer to developing a cure?
U=U. Undetectable= Untransmittable
Let me start by discussing the issue ofprevention. A few months ago, I posted case illustrating multiple ways HIV medicines can work for preventing new infections. In that case, a young woman had protected her child from being HIV infected at birth by consistently taking her medication. Her husband, who was not infected had opted to gain extra protection by taking PrEP (Pre-Exposure Prophylaxis). But that article allowed me an opportunity to introduce the concept of “Treatment as Prevention”.
Quite simply, that means if an HIV-infected person is consistently taking their medicines and the medicines are effectively suppressing the virus in the blood (undetectable) then that person does not transmit the virus to their partner. The rallying cry of the conference was U=U; Undetectable equals Untransmittable. We have seen increasingly more evidence to support that this is indeed the reality. A few years ago, some large studies with heterosexual discordant couples provided the first really good evidence of this.
In the study HPTN052 (HIV Prevention Trials Network), among heterosexual couples (male-female) where one individual was HIV-infected and the other partner not infected (serodiscordant couples), there were no cases of transmission to the uninfected partner when the infected partner was undetectable. The couples were not using condoms during sex. At the conference another important study provided reinforcement.
In a large study of serodiscordant male-male partners, there were almost 75,000 acts of condom-less sex. Out of all these sexual acts, there were NO transmissions between the undetectable partner on treatment and the uninfected partner. Now, to be totally accurate, there were a few individuals who did become infected. Importantly, they were not infected by their partners. Genetic analysis indicated that the virus they were infected with DID NOT come from their partner.
So they were infected by someone outside the relationship. A similar pattern was seen in the studies of heterosexual couples where a small number of infections were not caused by the partner on treatment. So, Treatment IS prevention.
This is very good news! So does this mean we can control the epidemic? The really big problem is that everyone who is infected is NOT on treatment. In the US, it is estimated that out of all infected individuals, there are about 15% who do not know they are infected. We can’t treat what hasn’t been diagnosed. Of those whoknow their status, not all of them are on treatment and of those on treatment, many are not undetectable.
Based on recent estimates, only about 49% of people who are HIV infected (including those who do not know their status) are undetectable. For African-Americans, that figure falls to 43%.
This is not good. At the conference, researchers from Namibia presented data showing that in their country, 77% of HIV-infected individuals are undetectable! This developing country in Africa with limited resources is doing so much better than the US in controlling their HIV epidemic!
There are many reasons why people who are infected do not have undetectable virus in their blood. Many of these people who are not suppressed have been prescribed medicine but they are not taking it properly for one reason or another, and they are not suppressed. Not only could they infect someone else but they are at risk for developing resistance to their medicines. The following segment illustrates one of the factors why infected people may not be taking treatment and undetectable.
Criminalization of High-Risk Populations
On the final day of the conference, President Bill Clinton delivered a speech. The Clinton Foundation has been fighting the global HIV epidemic for over 18 years. One of their important initiatives has been negotiating with pharmaceutical companies and manufacturers to secure HIV medicines at costs to make these treatments accessible to millions of people in developing countries. I have had the privilege of doing work in collaboration with the Foundation. But Clinton’s speech was interrupted by a planned protest. An international group of protestors was raising issues around the criminalization of sex work.
The criminalization of behaviors that are high risk for HIV transmission is a major barrier to controlling the epidemic. Laws prohibiting prostitution, recreational drug use or sex between consenting adults of the same gender are widespread around the world. So in many countries on every continent, sex workers, drug addicts, and gay men are at risk for incarceration and are often forced underground as a result of fear, intimidation and stigma.
In dozens of countries, women who engage insex work (prostitution) will not come forward to get medicines to treat their infection or prevent getting infected if they are threatened with arrest. Individuals who are heroin addicts cannot get any treatment for their addiction and are at risk of being incarcerated. In many countries, gay men live in the shadows for fear of being arrested simply because of their sexual orientation.
These dynamics pretty much guarantee that HIV epidemics get worse, often much worse. It also important to remember that people from high-risk groups do not exist in isolation but their lives intersect with those who live in mainstream communities. This conference brought these sensitive issues to the forefront and spotlighted individuals from communities across the globe working to ensure access to treatment and prevention for everyone.
In the next article, I will bring you some updates from the meeting on research related to HIV treatment.
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.