PI Perspective #46
September 2008 View PDF En
español
HIV sexual transmission under HAART:
Project Inform comments on 2008 Swiss Statement
by Paul Dalton and Alan McCord
In January 2008, the Swiss AIDS Commission issued a controversial
Statement on the transmission of HIV in heterosexual mixed status
couples. It stated that HIV is not likely to be passed on when
the positive partner fully adhered to a potent HIV regimen, had
undetectable viral load for at least six months, and did not have
any other sexually transmitted infection (STI) during that time,
even despite sex without condoms.
What ensued has been tumultuous
community discourse and opinion pieces worldwide. Some have denounced
the Swiss Government as irresponsible. Others responded with “no
comment”. Few others, like
Project Inform, invited this as a way to discuss issues faced by
people living with and affected by HIV.
This outcry stems from the
perception that the Swiss Government was saying that people who
take effective HIV drugs can stop having safer sex or abandon their
condom use without infecting their partners. The panelists were
clear: this is not their message. Some have criticized other aspects
of the Statement, arguing it failed to address other issues, such
men who have sex with men.
The Sunday afternoon session, HIV Transmission
under ART, provided a forum to discuss this Statement. Seven panelists
attempted to clarify the persistent questions that have lingered
ever since to a crowd of about 300. Project Inform believes the
conversations the Statement has spurred can help inform discussions
formany people living with HIV, as detailed below.
Understand this statement in its context.
At various points throughout
this epidemic, many medical, social and behavioral issues have
emerged. We have grappled with the risks of casual transmission
and oral sex — each without definitive
research. In these cases, observations and an understanding of
the mechanics of HIV transmission helped mold recommendations that
have stood the test of time. A study called HPTN 052 is currently
enrolling, designed to answer the risks of transmission under HAART.
The results likely won’t be available until 2016, at which
point we may look back and wonder what the commotion was all about.
We also might ask ourselves, how many new infections could have
been prevented in the meantime?
Understand the limitations of the
statement.
Too often critics of the Swiss Statement have used its
limitations to dismiss the it entirely. This is both scientifically
and ethically unsound. Science works best when studies and reports
are examined honestly, taking into account both their strengths
and weaknesses. Some have said it’s premature to talk about
these data until such time that there are more mature and definitive
results. One panelist reminded the audience of the experience of
male circumcision where 17 years elapsed between the emergence
of supportive circumstantial evidence in reducing HIV infection
rates, and the definitive results from prospective, randomized
studies.
It is possible to encourage conversations with couples
on issues that they can do something about. This includes encouraging
each partner to disclose his/her status, to discuss their fears,
or to even start engaging in safer sex, among many others. In some
parts of the world, health care systems are overburdened and cannot
accommodate these discussions. For many, viral load or STI tests
are unavailable. For others, medical infrastructures barely exist.
Though the world has reacted to this Statement, it may very well
not apply to most of the planet.
A weakness of the Statement is
that the data came from studies of heterosexual sex. In the US,
the CDC estimates about half of new HIV infections are among MSM,
reinforcing the importance of studying the impact of treatment
on prevention among this group.
Provide accurate information.
The Statement provides a good deal
of applicable data, much buried beneath the vocal backlash. Physicians,
community workers and others who interact with HIV-positive people
and their partners can and must provide information clearly and
accurately. The basic model of fully informed decision-making that
has defined Project Inform’s
approach to HIV treatment decisions is just as applicable to this
situation.
Get regular health care.
One undeniable take-home message is the critical importance
of having accurate medical information to make informed decisions.
Vast inequalities in access to things like viral load tests and
STI screening must be accounted for in settings worldwide. Some
panelists felt that these differences render the Statement largely
meaningless to most people with HIV. Project Inform sees it differently.
It is much like the early data on combination therapy: information
that might have only applied to few people at that time can have
profound implications for far more people down the line. As seasoned
AIDS activist Heidi Nass puts it, ‘progress in progress.’
Use
this as a tool.
Project Inform encourages sophisticated conversations
among mixed status couples and others. After nearly three decades
of the epidemic, a great deal is known about how HIV is and is
not passed. Each partner, along with their doctors, can be encouraged
to discuss these issues. These data, when discussed alongside a
person’s
needs for true sexual intimacy, can lead to fuller and more honest
discussions between sexual partners.
As we have stated in our March
2008 response to the Swiss Statement, we encourage all sexually
active individuals to learn their status by regularly testing for
HIV; we encourage treating HIV as early as individuals are ready
to start and the medical information suggests; we encourage adhering
to HIV treatment while practicing safer sex; and we encourage the
honest conversations between partners and their providers on the
medical and behavioral issues of transmission.
Practice safer sex.
The Swiss Statement does not suggest individuals abandon
using condoms or other safer sex practices. In fact, it spotlights
the necessity for a couple’s continued diligence in this
area. One panelist argued that condom use without treatment is
about as protective as treatment without condoms. The Statement
argues that the best possible prevention comes from combining treatment
and condoms. Accurate information on transmission risk should drive
these decisions.
Also worth pointing out is how little attention
has been paid to issues of pleasure, intimacy and stigma facing
people with HIV throughout these public debates. While researchers
might not place much emphasis on these issues, they’re of
great importance to people living with HIV. They have profound
implications for their emotional and sexual well being.
Push this
discussion to test for HIV.
The Statement underscores the need to reach those who
are undiagnosed or untested. These discussions can only work when
people know their HIV status. Most estimates show about 1 in 4
Americans with HIV do not know they have HIV. Project Inform encourages
testing as a way to take control of one’s life.
Explore ways
to prevent HIV.
The Statement highlights the role that
effective treatment plays in preventing new infections. Project
Inform recently revised its mission statement to include biomedical
prevention to help reduce new infections. This includes interventions
such as Pre-Exposure Prophylaxis (PrEP), vaginal and rectal microbicides,
and male circumcision, among others. These alternate methods should
be considered as being additive and synergistic to behavioral interventions
such as condom use. Therefore, no one method should preclude the
others. The more choices one has, the better. The better the data
are, the more confidence people can have in their choices.
The “asymmetry
of risk”.
One interesting point raised by a panelist was the asymmetry
of risk. If you say something is dangerous, and it turns out not
to be so, there’s usually little consequence. However, if
you claim something is not risky and it turns out to cause harm,
the repercussions can be catastrophic. This can lead groups to
be overly conservative in protecting their own interests. Looked
at in this light, the Swiss Statement is remarkable.
Raise new research
questions.
Much new data need to be uncovered to more fully answer the concerns
raised by the community. How do STIs play a role in transmission
and at what level? Do different strains of HIV affect its transmission?
Do different classes of HIV drugs affect the levels of HIV in genital
secretions differently? How do viral load blips affect transmission?
How much do we know about HIV transmission through oral, vaginal
or anal sex? Pursuing these and other questions are critical to
help better inform those faced with these decisions.
NEXT