Clockwise from left, Dr. Steven Klemow, Dr. John T. Carlo
North Texas HIV specialists, activist say results prove need for HIV testing
DAVID TAFFET | Senior Staff Writer
In a new study including almost 1,000 sero-discordant couples in Europe, there was no transmission of HIV from a positive, non-detectable partner to an HIV-negative partner despite more than 76,000 exposures, proving that “undetectable equals untransmittable.”
The study was conducted over eight years at 75 sites across 14 European countries and published last week in the medical journal The Lancet.
A separate study among heterosexual couples, came to the same conclusion.
Dr. Steven Klemow, an HIV specialist at Methodist Hospital in Dallas, said the results prove the necessity for HIV testing. “With this confirmatory and incontrovertible evidence available to us now, it is our first priority, and an extremely urgent one, to test as many people as possible,” Klemow said.
Klemow said this is information that’s been known in HIV circles for about three years. What makes this study so valuable is that there were absolutely no transmissions between partners.
“There’s zero risk of transmission,” he said. “That makes this one of the rare finds in medicine — an absolute.”
In addition, when referring to “non-detectable” in the U.S., the standard is 20 copies or less of HIV found in a sample.
In this latest European study, 200 copies rather than 20 was the criterion used. Yet at 10 times the viral load used to define undetectable, there still were no transmissions from a positive to a negative partner.
That should have a number of repercussions, Klemow said, including squashing the practice of criminalization that has spread in recent years. In some jurisdictions, a sexual partner who doesn’t disclose his or her HIV status can be charged with assault with a deadly weapon for possibly transmitting the disease. Likewise, an HIV-positive person who spits on a police officer could be charged, even though that’s not a method of transmission.
If someone is undetectable, Klemow said, it’s unreasonable for there to be any criminal repercussions.
Klemow said the study results are not surprising, because a number of studies have been done that already confirmed this information. But this study is significant because it was conducted among gay couples only. And the 76,000 exposures counted were anal intercourse, the most common way HIV has spread among gay men.
Of the almost 1,000 couples studied, there actually were 15 new infections among the negative partners. But those were confirmed through DNA testing to have happened when the negative partner in a study couple had unprotected sex with someone other than his partner who was not undetectable.
Klemow explained that the U=U approach to ending AIDS is like having herd immunity. If enough people had vaccinated against the measles, the disease would have been permanently eradicated. The measles flare-ups we’ve seen have happened in communities that didn’t have enough people vaccinated, a situation complicated by the anit-vaxx trend based on a debunked study and bad science.
With HIV, if there weren’t many people infected and untreated, the likelihood of it spreading would be greatly reduced. But that will take a concentrated effort to increase HIV testing and getting people into treatment.
“At Methodist,” Klemow said, “we’re in discussion about universal testing.”
That would include routinely testing anyone who came to the emergency room, was admitted to the hospital or had an appointment with any doctor throughout the hospital system.
Klemow said that most estimates indicate 18 percent of people infected with HIV in the U.S. don’t know they have it, and some studies estimate as many as 25 percent of people with HIV are undiagnosed.
With new treatments, keeping the viral load under control is easier than ever. A new two-drug regimen has recently been approved, and newer drugs are showing less toxicity than ever.
Klemow said the results of this study also change who is indicated for PrEP, or pre-exposure prophylaxis. Negative partners in sero-discordant couples were the first group of people doctors suggested should go on the preventive medication. Now, if the positive partner is undetectable, the negative partner isn’t indicated for PrEP, Klemow said.
“PrEP has been successful, but has only been available to a certain segment,” he said. “There’s a stigma around women being offered PrEP.”
Resource Center President and CEO Cece Cox called the data compelling. On a community-wide basis, she said, “keeping the viral load low individually keeps it low collectively.”
She said she favors everyone getting tested with consent, adding, “Too many people still think it’s a gay disease.”
Although HIV testing is included at no charge under the Affordable Care Act, too many doctors are not testing their patients for HIV, Cox said, because of misconceptions and stigma. But this study can lessen stigma.
“They don’t need to be stigmatized because of fear of passing on the virus,” Cox said.
Dr. John Carlo, president and CEO of Prism Health North Texas, said this new study “continues to affirm what we’ve seen from previous studies,” adding that to him, one of the most important uses for this study is as the basis for explaining to patients that they can live with HIV, have a healthy sex life and be safe.
An important distinction about this being a European study, Carlo said, is that testing is routine there, and with the
European system’s universal healthcare, medication is affordable.
Carlo said if everyone was tested in this country, there would be less stigma, and if undetectable really means untransmittable, a barrier to testing would be removed.
As for PrEP, Carlo said for sero-discordant couples, a more individualized approach is appropriate. While it might not be indicated for monogamous couples, it was still important for negative spouses in non-monogamous relationships to protect themselves, he stressed.