Patients with Undetectable HIV Do Not Pose Transmission Risk

People infected with HIV whose viral load is undetectable — thanks to antiretroviral therapy (ART) — are at effectively no risk of transmitting the virus, according to a new letter from the Centers for Disease Control and Prevention (CDC).

The acknowledgement, included in a “Dear Colleague” letter sent to healthcare professionals late last month, marks a major moment for patients and brings the CDC in line with other public health organizations around the world.

Bruce Richman, executive director of the Prevention Access Campaign, said the news will have a major impact on people with HIV, and is a welcome affirmation of a trove of scientific research.

The Prevention Access Campaign has long been pushing for such declarations from the CDC and other health agencies, launching a campaign called “Undetectable=Untransmittable,” or U=U.

Richman told MD Magazine the review process leading to the declaration began a year ago, when he met to discuss U=U with Richard J. Wolitski, PhD, director of the Office of HIV/AIDS and Infectious Disease Policy at the US Department of Health and Human Services.

That review culminated Sept. 27, when the CDC said patients whose viral load is less than 200 copies/ml are at virtually no risk of passing the disease on to someone else.

“Across 3 different studies, including thousands of couples and many thousand acts of sex without a condom or pre-exposure prophylaxis (PrEP), no HIV transmissions to an HIV-negative partner were observed when the HIV-positive person was virally suppressed,” the CDC wrote. “This means that people who take ART daily as prescribed and achieve and maintain an undetectable viral load have effectively no risk of sexually transmitting the virus to an HIV-negative partner.”

The CDC letter was signed by Eugene McCray, MD, the director of the CDC’s Division of HIV/AIDS Prevention, and Jonathan Mermin, MD, MPH, director of the CDC’s National Center for HIV/AIDS, Viral Hepatitis, Sexually Transmitted Disease, and Tuberculosis Prevention.

In making that statement, the CDC joins more than 400 organizations in 58 countries. Some in the patient advocacy community have been frustrated that the CDC did not act sooner, but Richman noted that the review involved analysis of game-changing research and required buy-in across all federal health departments during a time of presidential transition. Given that task, he said 1 year is a reasonable amount of time.

“I can understand the frustration because we work with public health agencies, research organizations, and AIDS organizations in the US and other parts the world that have moved faster, but as someone who was integrally involved in the review process, I’m satisfied with the pace.”

Regardless of the timing, Richman said the decision is a major milestone. The declaration should help expand the public’s understanding of the virus, and of the medical advancements that have eliminated the transmission risk for many patients. However, he said the import of the statement isn’t just about public perception — it’s also about how HIV/AIDS patients see themselves.

“In 1996 we learned effective treatment would save our lives,” he said. “Now we know that it will prevent us from passing HIV on to our partners. This news dismantles the internalized stigma, fear, and shame that people with HIV have lived and died with for over 35 years.”

Richman said that internalized stigma can lead to a number of side effects, including depression, self-harm and suicide. The stigma can also diminish patients’ willingness to start or continue with treatment, he said, despite the high effectiveness of HIV/AIDS drugs.

Now, as public health organizations like the CDC join the effort to promote the U=U science, many HIV/AIDS patients will be able to live fuller, less fearful lives.

“We’ve heard from many folks since the beginning of the campaign that the news has given them hope, a new lease on life, the chance to love and be intimate again, and the opportunity to conceive children without alternative and expensive means of insemination,” he said.