In the news ... 2008

Project Inform’s position on the Swiss Government’s statement on HIV treatment as prevention

by Dana Van Gorder, September 17, 2008

In a discussion at the International AIDS Conference in Mexico City in August, HIV/AIDS agencies continued to have very different responses to a statement released by the Swiss AIDS Commission in February 2008 saying that HIV-positive individuals receiving effective antiretroviral treatment do not appear to be at significant risk of transmitting the virus to HIV-negative partners in the absence of condom use. The Commission reviewed data from four studies conducted among heterosexual couples. One study involving 393 couples of mixed HIV status concluded that when an HIV-positive individual adhered to treatment with approved HIV antiretrovirals, had an undetectable viral load for at least six months, and did not suffer from any other sexually transmitted infections, their HIV-negative partner did not become infected as a result of unprotected sexual intercourse. However, another study found that 6 out of 43 HIV-negative partners did become infected with HIV as a result of sexual activity; apparently because their HIV-positive partners were not completely adherent to an antiretroviral treatment regimen.

The Swiss AIDS Commission did not recommend that HIV-positive people who are on effective HIV treatment dispense with condoms or safe sex practices. By and large, however, AIDS prevention agencies globally have expressed enormous concern that the Commission’s statement might result in a reduction of condom use among HIV-positive people receiving treatment for HIV infection. Most prevention agencies have in effect said “don’t try this at home.”

Project Inform issued a statement about the Swiss report in March of 2008. As a treatment advocacy organization that recently began to advocate for biomedical HIV prevention as well, we took a broad view of the issue. Concerned that the response of many prevention agencies to the Commission statement discounted the importance of HIV treatment and its potential to reduce HIV infection rates, Project Inform welcomed the opportunity provided by the Swiss statement to address three key challenges in the domestic HIV/AIDS epidemic.

First is the need to increase levels of testing in response to the fact that 25 percent of HIV-positive Americans are estimated to be unaware of their HIV status. Second is the need to increase the number of HIV-positive people receiving care and treatment for their infection in response to estimates that 20 percent of HIV-positive people are not doing so. And third is the need to reduce HIV infection rates using an expanded set of prevention options, including biomedical options.

In its March statement, Project Inform refrained from expressing alarm that the Swiss statement could result in the abandonment of condom use by HIV-positive people taking antiretrovirals. Instead, we suggested that encouraging at-risk individuals to know their serostatus, encouraging HIV-positive individuals to consider taking HIV medications early in infection, and encouraging condom use might make it possible both to improve clinical outcomes for HIV-positive people and reduce HIV incidence.

Indeed, Project Inform is planning to convene a meeting in 2009 at which researchers, clinicians and AIDS service organizations consider the role of HIV treatment in prevention. Our goal is to determine what research exists or is needed to determine when HIV-positive people might consider the initiation of HIV treatment both to improve their clinical outcomes and, in conjunction with the practice of safe sex, benefit prevention.

In the August issue of Gentleman’s Quarterly (GQ), David France wrote an article titled We All Forgot the Condom, in which he said “The Swiss study went largely ignored in the media. What’s more, powerful AIDS groups rushed to condemn it. Project Inform, a national HIV clearinghouse, decried the findings as a threat to the condom code.” In response to a series of emails to him saying that he had mischaracterized Project Inform’s position, David stuck to his assertion that we had attacked the Swiss statement for being a threat to condom use. He repeated his assertion that our statement insists that HIV-positive people use condoms each and every time they have sex with other HIV-positive individuals. In fact, our statement says that “Project Inform encourages HIV-positive people to consider the use of condoms during intercourse with other HIV-positive people in order to avoid potential re-infection and, as importantly, to avoid receiving or transmitting sexually transmitted infections other than HIV during sexual intercourse.”

As the author of Project Inform’s statement on this issue, I know what we mean by it. The Swiss statement is not an attack on the “condom code.” It is a challenge to leaders in the fight against HIV/AIDS to consider the possibility that, if we want to take another major leap toward reducing persistently high rates of HIV infection in the United States and globally, then combining expanded HIV treatment with condom use might constitute the next generation in HIV prevention.