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Commentary Sexual Health

A Breakthrough Strategy for Ending the HIV Epidemic

Dr. Oxiris Barbot & Dr. Demetre Daskalakis

The consistent and steady decline in HIV is related to the power of an increasingly better known, life-saving HIV treatment that has the wonderful side effect of preventing sexual transmission.

At the height of the AIDS epidemic, one of the defining characteristics of the crisis was the belief that condomless sex basically guaranteed transmission of HIV. Public health authorities offered condoms and abstinence as the only prevention options, but even in the darkest days of the crisis, they were not enough to stop new infections from climbing. Experiencing sexuality included feelings of fear, shame, and stigma.

Today, that fear is changing. New York City has achieved historic success in driving down the rates of HIV: New diagnoses have dropped by 64 percent since HIV case reporting began nearly two decades ago, from 5,900 to 2,157 per year. And newly acquired infections, a measure of recent HIV transmission, are on an even faster downward trajectory in the city.

The progress in New York City, most recently, is often traced to interventions like pre-exposure prophylaxis (PrEP), a safe and effective daily pill that greatly reduces the risk of HIV infection, and public health officials’ efforts to diagnose people with HIV earlier and link them to care.

But the consistent and steady decline in HIV is also related to the power of an increasingly better known, life-saving HIV treatment that has the wonderful side effect of preventing sexual transmission. This prevention method is also called “U=U,” or Undetectable Equals Untransmittable. U=U is a simple way to disseminate a scientific fact: People living with HIV on effective treatment do not sexually transmit HIV. This Pride Month, U=U is the subject of the New York City Health Department’s new sexual health marketing campaign.

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The city’s health department, where we work, became the first U.S. government agency to officially join the U=U movement three years ago. Today, more than 860 community partners from nearly 100 countries have signed on, and the Centers for Disease Control and Prevention has endorsed the science behind U=U.

When we talk about U=U, data, not dogma, should drive the conversation. Last month, a landmark study was published in the Lancet that followed nearly 800 eligible male couples where one partner was living with HIV and the other was not. In over 76,000 reports of condomless sex, not one person with HIV who was taking antiretrovirals—or medications to treat HIV—and had an undetectable viral load passed HIV to their sexual partner. The researchers concluded, “evidence for gay men, as for heterosexual couples … indicate that the risk of HIV transmission when HIV viral load is suppressed is effectively zero for both anal and vaginal sex.”

Other recent studies by the Kirby Institute and the HIV Prevention Trials Network arrived at  similar conclusions after following more than 2,000 couples in ten countries combined.

Sound, scientific research demonstrates that people with consistent viral suppression will not sexually transmit HIV. Naysayers argue that the virus will transmit in other ways—for example, through a detectable virus present in genital fluids despite an undetectable blood viral load. Others maintain that someone with an undetectable viral load who also has a sexually transmitted infection can transmit the virus.

None of these theoretical challenges to the power of U=U have been observed in any study. To stifle the U=U message because of theories not demonstrated in the data serves no one, especially not people living with HIV.

Adoption of U=U by public health officials and other scientific authorities reflects a data-driven embrace of the importance of treatment as a prevention strategy that supports, rather than opposes, human behavior and desire. Disseminating and normalizing this message are key strategies to eliminate the stigma that comes with the HIV divide and create a more neutral environment that levels the playing field of sex and love.

Whether someone’s sexual health plans include taking medication to achieve and maintain a suppressed viral load, using condoms, taking PrEP, frequent STI screening, or some combination of the above, we are committed to ensuring that services address the needs of the whole person. We are all more than the result of a single HIV test.

Our progress in New York City shows that a future without HIV is possible. In February, President Donald Trump made a bold pledge to end the HIV epidemic by 2030, and for the first time in history, we have a pathway to bring new HIV infections down to non-epidemic levels. This Pride Month, we hope our leaders in Washington, along with other local and state government officials, will join us in endorsing U=U and funding programs that support people living with HIV. We cannot let the fear of the past dictate a strategy for the future.

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