Thursday, February 5, 2015

Understanding Undetectable Viral Load and Reducing HIV Transmission in 2015

by the CDPHE's Regina Charter and Nancy Wolff

Since the mainstream discovery of HIV in 1981, the Centers for Disease Control (CDC) has made huge strides in understanding the treatment, testing and prevention of HIV. Since 1987, Regina and I have worked at the Colorado Department of Public Health and Environment (CDPHE) in the Sexually Transmitted Infection (STI)/HIV/Viral Hepatitis Branch providing prevention services to people infected and affected by HIV. We’ve witnessed and experienced the evolution of the HIV epidemic. HIV has changed from being a terminal illness to a chronic infection. A big reason for the medical advancement of care and treatment for HIV is the increasing number of People Living with HIV/AIDS (PLWHA) who are accessing care. Treatment with HIV medication generally leads to maintaining an undetectable viral load (UND VL). This creates healthier individuals and healthier communities. The scientific breakthroughs are to be celebrated!

The current research on HIV transmission and new medical interventions are exciting and promise big changes in HIV prevention, but the information can be confusing and leave us wondering how to guide clients. Due to that, some case managers and social workers serving PLWHA have requested guidance and clarification on the current research and how to speak to clients about Undetectable Viral Load test interpretation and HIV transmission. This article is intended for providers serving people infected and affected by HIV.

For the first time in decades, medical science has a new type of protection to offer. Drug therapies prescribed for PreExposure Prophylaxis (PrEP) and Non-Occupational Post-Exposure Prophylaxis (nPEP) have been researched and discussed for years, but now these HIV prevention options are quickly becoming more widely available. nPEP is a combination of potent HIV meds to be administered within 72 hrs of exposure to HIV and are taken for one month. Due to side effects, many people do not tolerate nPEP well. PrEP, on the other hand, is well-tolerated, has fewer side effects and needs to be taken regularly before potential exposure to HIV. It is very exciting to offer additional options to those at risk for HIV.

In addition, promising research, such as the PARTNER Study, indicates that PLWHA, who are on antiretroviral therapy and maintaining UND VL are less likely to transmit the virus to their HIV negative partners. The preliminary news is very good, but it is just that, preliminary. While we all want to embrace good news, to do so in this case would be preemptive and not in anyone’s best interest.

The following is our status update, review and clarification on the PARTNER study preliminary results.

The PARTNER Study- 

Our status update, review and clarification on the PARTER study preliminary results. 
  • The study has not yet concluded. The critical details from this research will not be completed for several more years. Currently, only preliminary data is available. This study is just two years into the research that is predicted to take nearly 10 years to complete. The study has not reached its own validity standards, and therefore, the initial results cannot be generalized.
  • Nearly 800 couples are currently enrolled in this study, which includes an unprecedented number of men who have sex with men (MSM) couples. However, as the population at highest risk for acquiring HIV in the US, MSM couples only comprise about a third of the total couples enrolled. More couples will continue to be enrolled and hopefully the proportion of MSM couples will increase so that study results can be generally applied to this population.
  • An UND VL is not a static destination, but rather a dynamic process that requires careful maintenance with help from medical professionals. The PARTNER study’s authors acknowledge that the study participants receive ample support and monitoring to maintain an UND VL, which is not typical of most clinical settings. Because of this, the study participant outcomes do not necessarily equal what real life couples experience.
  • PARTNER study authors acknowledge that HIV transmission has occurred in the study. The details of those cases have not yet been made available. At this time, no study has identified the specific conditions that increase the risk of HIV transmission despite an UND VL. Potential transmission variables for HIV positive to negative partners are still being researched. These may include concurrent STI infection, other health conditions or infections, medication interactions, HIV reservoirs, multiple sex partners and periodic discrepancies in blood VL compared to seminal or vaginal fluid VL.
  • It is not yet known what elements are necessary to protect negative partners from acquiring HIV. Some of the questions the research is asking:
    • Is maintaining an UND VL enough to prevent transmission, or must it be in conjunction with other forms of protection?
    • Are condoms still necessary in certain circumstances, during certain types of sex?
  • The PARTNER study does not state that there is zero chance of HIV transmission when the HIV + partner has an UND VL. While the current data supports that an UND VL significantly lowers the chances of infection, the study expects that HIV transmission will occur between some of the couples by the end of the study.
The PARTNER study and others like it are promising and hopeful. However, as public health representatives, we must provide information that is accurate and protects everyone. HIV is a complex infection on many levels - medical, emotional and societal to name a few. Overusing simplistic “treatment is prevention” messages is inadequate.

Here are some sample question and answers with the recommended language and messages that providers can give to PLWHA that align with the national goal of Getting to ZERO new HIV infections:

What does my UND VL test result mean?

  • UND VL is great news for YOU about the course of your HIV infection. It does not mean the VL is ‘zero.’ There is no such thing as a ‘zero VL’.
  • This test result only refers to the VL on the day your blood was drawn. VL can fluctuate (go up/down) day to day and be at different levels in different bodily fluids. Reasons for fluctuations are not completely known or understood. Unfortunately, there is no current way to test all bodily fluids for VL in the moment.
  • As your body and life changes over time, so will your viral load. These results are only accurate for right now. Expect to keep doing these tests to monitor your viral load over time. Assume that they can fluctuate at any time without visible symptoms or changes in your day to day health. Changes in your viral load do not necessarily mean there is anything wrong with your health, but monitoring these test results helps us take better care of you.
  • STIs such as Chlamydia, gonorrhea and syphilis can increase viral load and keep it raised for up to three weeks after STI treatment.
  • An UND VL reduces probability of HIV transmission, but does not eliminate the possibility of transmission to your sex partners. Although you are less likely to transmit HIV to your sex partners, all of the conditions and situations in which HIV transmission can occur are still being researched.
  • It is not impossible to infect a sex partner with HIV when you have UND VL. It is still possible to infect a sex partner. Obtaining and maintaining an UND VL is one component in reducing risk and should not be solely relied upon to avoid HIV transmission.
What can I do to keep my partners safer and maintain my UND VL?
  • PrEP for your partner is another strategy to ensure they won’t get HIV from you or anyone else.
  • Condoms will protect you from other STIs such as gonorrhea, Chlamydia, syphilis and herpes.
  • Many STIs are curable, but are becoming increasingly difficult to treat. Reducing your risk of acquiring a new STI is an important part of maintaining a healthy immune system.
  • It is still necessary to consider all risk reduction measures that can work for you and your partners, such as condom use and not sharing needles, etc.
Is disclosing my HIV status necessary if I have an UND VL?
  • If you thought that there was a chance of transmitting HIV, how might that influence your decision to disclose or to use a condom?
  • Developing a personal HIV disclosure plan lowers anxiety and supports health goals. Having at least one confidant who you talk to about your HIV status is a good start and can make a difference in your overall health. Who in your life knows your status? When and how do you disclose to sex partners? What support do you need to empower yourself to feel a sense of control and to build confidence when disclosing your HIV status?
  • Research supports that HIV disclosure and open communication with supportive people (such as friends, family, community) are key to maintaining a healthy emotional outlook and physical well-being.
HIV disclosure and discussion with potential sex partners is still important for informed consent and to prevent new infections. How important is disclosure to you? How comfortable are you with disclosing your HIV status to potential sex partners? Most new HIV infections are not intentional. Accidents happen. Misinformation happens. As providers you have the ability to assist your clients in being the most informed, empowered and skilled. Brainstorm with them about the many possible resources available to protect themselves and others.

This is the first in a series of posts that Regina and I want to share with you. Through this forum, we hope to continue to celebrate the successes and discuss the current HIV landscape. We are all striving to preserve the progress made in HIV treatment and prevention. The goal is to support our HIV positive clients and their partners in making well informed decisions about their health.

Your thoughts and feedback are welcome!

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