U=U Talking Points
Undetectable = Untransmittable
- Can a person with HIV on treatment who has an undetectable viral load sexually transmit HIV?
No. A person living with HIV on antiretroviral therapy (ART) with an undetectable HIV viral load that is maintained over time and monitored every 4-6 months cannot transmit HIV through sex. The National Institutes of Health and the CDC have signed on to this concept.
- What is the evidence?
In short, the science has validated that someone with HIV with an undetectable viral load cannot sexually transmit the virus. Three large multinational studies involving couples in which one partner was living with HIV and other who was not – HPTN 052, PARTNER, and Opposites Attract – observed no HIV transmission to the HIV-negative partner when the partner with HIV had an undetectable viral load. These studies included thousands of condomless sex acts, both men and women, gay and straight couples. Since the advent of combination therapy, there have been no confirmed reports of anyone with an undetectable viral load sexually transmitting HIV.
- What is “viral load suppression” and what is an “undetectable viral load”?
Viral Suppression: Viral suppression means a person’s HIV viral load is less than 200 copies/mL of blood. This is also how the term is defined by the Health Resources and Services Administration (HRSA), which administers the Ryan White Program and the Bureau of Primary Health Care), and understood by those providing medical and support services to people living with HIV in Iowa.
Undetectable Viral Load: An undetectable viral load means the amount of HIV in the blood is below the limits of a laboratory test. The patient still has HIV; however, very little virus is circulating in the blood. For the purposes of the U=U campaign, the term “undetectable” is used synonymously with the term “virally suppressed.”
- So U=U means a person with HIV with an undetectable viral load cannot transmit the virus sexually. Does U=U apply to breastfeeding or the sharing of injection drug equipment?
Studies demonstrate that antiretroviral treatment greatly reduces the risk of HIV transmission from individuals who breastfeed their babies or who share equipment while injecting drugs. However, more research is needed to establish that these individuals do not transmit HIV. The “U=U” message is limited to sexual transmission at this time.
- What does ‘Treatment as Prevention’ mean?
Treatment as prevention (TasP) refers to any HIV prevention method that uses treatment with ART to decrease the risk of HIV transmission to a sexual or needle-sharing partner, or from mother to infant. ART reduces the HIV viral load in the blood, semen, vaginal fluid, and rectal fluid to very low levels, and as a result reduces HIV transmission risk to negligible levels. TasP is the foundation for U=U. U=U refers to the point when the virus in the blood is reduced to undetectable levels and there is effectively no risk of transmitting HIV sexually.
- After a person begins HIV treatment, how long does it take for the risk of sexually transmitting HIV to become effectively zero?
There is effectively no risk of sexual transmission of HIV when the partner living with HIV has achieved an undetectable viral load and then maintained it for at least six months. Most people living with HIV who start taking antiretroviral therapy daily as prescribed achieve an undetectable viral load within one to six months after beginning treatment.
- Does everyone who starts HIV treatment become and remain undetectable?
Almost everyone who starts ART finds a drug regimen that works within six months. About one out of six people will need additional time to find the right treatment due to side effects or adherence issues. Nearly everyone who starts HIV treatment can become and remain undetectable.
- Do viral “blips” increase the chance of transmission?
Viral blips have not been shown to increase the transmission of HIV. Small, transient increases in viral load (between 50 and 1000 copies), known as ‘blips,’ sometimes occur even when people on ART take their medications as prescribed. Typically,the amount of virus returns to undetectable levels without any change in treatment. Unless the viral blips start to increase in frequency, they do not mean treatment isn’t working and they are normally not of concern to providers.
- Does being undetectable mean that the virus has left the body?
Even when the viral load is undetectable, HIV is still present in the body. When therapy is interrupted because someone misses doses, takes a “treatment holiday,” or stops treatment completely, the virus emerges and begins to multiply, becoming detectable in the blood again. It is essential to take every pill every day as prescribed to achieve and maintain an undetectable status.
- What happens if a person stops taking antiretroviral therapy?
When therapy is stopped, viral load rebounds, and the risk of transmitting HIV to a sexual partner in the absence of other prevention methods returns. Taking antiretroviral treatment daily as directed to achieve and maintain undetectable status stops HIV infection from progressing. This helps people living with HIV to stay healthy and live longer while offering the benefit of preventing sexual transmission.
- Why do some people have detectable viral loads?
Access to adequate healthcare, treatment, and viral load testing are serious barriers in many parts of the world. Some people living with HIV start treatment but have challenges with adherence for a variety of reasons such as stigma, mental health challenges, substance abuse, unstable housing, difficulty paying for medications, hostile environments, drug resistance, and/or intolerable side effects. Some people who have access to treatment may choose not to be treated or may not be ready to start treatment. For people living with HIV who are not virally suppressed, there are highly effective prevention options, including condoms and PrEP, that can be used individually or in combination to prevent HIV. Everyone living with HIV, regardless of viral load, has the right to full and healthy social, sexual, and reproductive lives. See The Third U: Unequal.
- How often does a person living with HIV need to be tested to confirm they are undetectable?
For a person wanting to use U=U as their transmission prevention strategy, viral load should be monitored at least every 4-6 months, and more frequently for those who are new to antiretroviral therapy or who are changing regimens.
- What if there is detectable HIV in semen, vaginal fluids, or rectal fluids, but not in the blood?
Scientists have found that HIV treatment that leads to an undetectable viral load in the blood also normally leads to an undetectable viral load in semen, vaginal fluids, and rectal fluids. Occasionally people with an undetectable viral load in the blood have HIV RNA and DNA in semen, vaginal fluids, and rectal fluids, but this has not been found to increase transmission risk. HIV RNA and DNA are only particles of HIV, and the whole virus is required for HIV to be infectious. Furthermore, studies show that HIV RNA and DNA are most common soon after starting HIV treatment and are hardly seen after a year or more of an undetectable viral load in the blood.
- Does a person need to disclose their HIV status to their sex partners if they are undetectable?
Iowa Code chapter 709D requires someone with HIV to take practical means to prevent transmission, including being on treatment and following behavioral recommendations. It does not require disclosure of HIV status as long as these practical means to prevent transmission are taken.
- Should a person who does not have HIV stop using condoms and/or PrEP if they are with someone who is undetectable?
Having an undetectable viral load, using PrEP, and using condoms are all HIV prevention strategies that people can choose to use alone or in combination. Some people may prefer to use several HIV prevention strategies for a variety of reasons, such as to reduce transmission-risk anxiety, to prevent other STDs, to prevent pregnancy, or to address inconsistent ART adherence by a partner. Condoms are the only method that also prevents exposure to other STDs and that prevents pregnancy.
- Does a person still need to worry about other sexually transmitted diseases?
Neither HIV treatment nor PrEP prevents exposure to other sexually transmitted diseases, or STDs. Ways to reduce the risk of STDs include having both partners frequently tested at all sites of exposure (rectal, oral/throat, and vaginal) – and by timely treatment when an infection is identified, limiting the number of sexual partners, and using condoms. Vaccines are available to prevent some STDs, including hepatitis B and human papillomavirus (HPV).
- Does having an STD affect the chance of HIV transmission when a person is undetectable?
Based on recent studies, having an STD does not increase the risk of HIV transmission when the partner with HIV has an undetectable viral load. In both the PARTNER and Opposite Attracts studies, STDs were reported by a number of enrolled couples and no linked transmissions occurred. To date, the risk of transmission of HIV when syphilis is present in a couple has not been assessed.
- What does U=U mean for people living with HIV and having children?
A person living with HIV who has an undetectable viral load that is maintained and monitored can impregnate their partner or can conceive a baby without using alternative insemination practices. The science behind U=U provides peace of mind that they will not transmit HIV to their uninfected partner during sex. An undetectable viral load also dramatically reduces the risk of mother-to-child transmission during pregnancy and at delivery.
This fact sheet was adopted with information from the Prevention Access Campaign and the Michigan Department of Health & Human Services