UequalsU Consensus Statement

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RISK OF SEXUAL TRANSMISSION OF HIV FROM A PERSON LIVING WITH HIV WHO HAS AN UNDETECTABLE VIRAL LOAD  

Messaging Primer & Consensus Statement 

There is now evidence-based confirmation that the risk of HIV transmission from a person living with HIV (PLHIV), who is on Antiretroviral Therapy (ART) and has achieved an undetectable viral load in their blood for at least 6 months is negligible to non-existent. While HIV is not always transmitted even with a detectable viral load, when the partner with HIV has an undetectable viral load this both protects their own health and prevents new HIV infections.[i]  

However, the majority of PLHIV, medical providers and those potentially at risk of acquiring HIV are not aware of the extent to which successful treatment prevents HIV transmission.[ii] Much of the messaging about HIV transmission risk is based on outdated research and is influenced by agency or funding restraints and politics which perpetuate sex-negativity, HIV-related stigma and discrimination.

The consensus statement below, addressing HIV transmission risk from PLHIV who have an undetectable viral load, is endorsed by principal investigators from each of the leading studies that examined this issue. It is important that PLHIV, their intimate partners and their healthcare providers have accurate information about risks of sexual transmission of HIV from those successfully on ART. 

 At the same time, it is important to recognize that many PLHIV may not be in a position to reach an undetectable status because of factors limiting treatment access (e.g., inadequate health systems, poverty, racism, denial, stigma, discrimination, and criminalization), pre-existing ART treatment resulting in resistance or ART toxicities. Some may choose not to be treated or may not be ready to start treatment.

 Understanding that successful ART prevents transmission can help reduce HIV-related stigma and encourage PLHIV to initiate and adhere to a successful treatment regimen.

 The following statement has been endorsed by:

  • Dr. Michael Brady – Medical Director of Terrence Higgins Trust and Consultant HIV Physician, London, UK

  • Dr. Myron Cohen – Principal Investigator, HPTN 052; Chief, Division of Infectious Diseases, UNC School of Medicine, North Carolina, USA

  • Dr. Demetre C. Daskalakis, MPH – Assistant Commissioner, Bureau of HIV/AIDS Prevention and Control New York City Department of Health and Mental Hygiene, New York, USA

  • Dr. Andrew Grulich – Principal Investigator, Opposites Attract; Head of HIV Epidemiology and Prevention Program, Kirby Institute, University of New South Wales, Australia

  • Dr. Jens Lundgren – Co-principal Investigator, PARTNER; Professor, Department of Infectious Diseases, Rigshospitalet, University of Copenhagen, Denmark

  • Dr. Julio Montaner – Director of the British Columbia Centre for Excellence in HIV/AIDS; Director of IDC and Physician Program Director for HIV/AIDS PHC, Vancouver BC, Canada

  • Dr. Pietro Vernazza – Executive Committee, PARTNER; Author, Swiss Statement 2008, Update 2016; Chief of the Infectious Disease Division, Cantonal Hospital in St. Gallen, Switzerland

Organizational endorsements include:

People living with HIV on ART with an undetectable viral load in their blood have a negligible risk of sexual transmission of HIV.  Depending on the drugs employed it may take as long as six months for the viral load to become undetectable. Continued and reliable HIV suppression requires selection of appropriate agents and excellent adherence to treatment. HIV viral suppression should be monitored to assure both personal health and public health benefits.

NOTE:   An undetectable HIV viral load only prevents HIV transmission to sexual partners. Condoms also help prevent HIV transmission as well as other STIs and pregnancy. The choice of HIV prevention method may be different depending upon a person’s sexual practices, circumstances and relationships. For instance, if someone is having sex with multiple partners or in a non-monogamous relationship, they might consider using condoms to prevent other STIs.

 “NEGLIGIBLE” = so small or unimportant as to be not worth considering; insignificant. 

 ADDITIONAL EXPERT QUOTES, SOURCES, AND EXPLANATIONS [iii]

1. “If you are durably virologically suppressed you will not transmit to your partner… I’ll say this again, for somebody who is in a discordant couple, if the person [with HIV] is virologically suppressed, ‘durably’ –there is no virus in their system, hasn’t been for several months —  your chance of acquiring HIV from that person is ZERO. Let’s be clear about that: ZERO.  If that person the next day stops therapy for two weeks and rebounds, your chance goes up. That’s why we talk about ‘durable’ viral suppression…You’re as durably virologically suppressed as good as your adherence”.  Dr. Carl Dieffenbach, Director of the Division of AIDS, NIH.  NIH Video interview (November 11, 2016)

 2. “When an HIV positive person first starts on treatment, it takes a few months before viral growth is completely suppressed. During that short window of time, the couple should use condoms. Alternatively, the HIV negative partner might use antiretroviral agents as pre-exposure prophylaxis [PrEP].” Dr. Myron Cohen Chief, Division of Infectious Diseases, UNC School of Medicine, North Carolina, USA; Principal Investigator, HPTN 052. POZ magazine (September 26, 2016)

 3. Suppressing the viral load of a person living with HIV to undetectable levels “not only saves their lives but prevents them from infecting others.  So the higher percentage of people who are on treatment, in care and get their viral loads to undetectable, the closer you get to literally ending the epidemic.” Dr. Anthony Fauci, Director of NAID, NIH. NIH Video Interview  (August, 2016)

4. “..Once you begin therapy, you stay on therapy, with full virologic suppression you not only have protection from your own HIV….. but you also are not capable of transmitting HIV to a sexual partner. With successful antiretroviral treatment, that individual is no longer infectious.”  Dr. Carl Dieffenbach, Director of the Division of AIDS, National Institutes of Health. NIH Videointerview (August, 2016)

5. “We can now say with confidence that if you are taking HIV medication as prescribed, and have had an undetectable viral load for over six months, you cannot pass on HIV with or without a condom.” Dr. Michael Brady, Medical Director, Terrence Higgins Trust, London, England (July 2016)

6. “The force of evidence in both real world and clinical trial experience confirms that individuals with suppressed viral loads have a negligible risk of transmitting HIV. Treatment as prevention, pre-exposure prophylaxis, and traditional prevention measures, like condoms, make up an HIV prevention toolkit based in harm-reduction that allows individuals to make personalized and enlightened decisions to both maintain their health and prevent HIV and STI transmission.” Dr. Demetre C Daskalakis, MPH – Assistant Commissioner, Bureau of HIV/AIDS Prevention and Control New York City Department of Health and Mental Hygiene (July 2016)

 7. “Does this work over a long period of time for people who are anxious to be suppressed? The answer is absolutely yes, we now have 10,000 person years (of follow-up) with zero transmissions from people who are suppressed.” Dr. Myron Cohen. Medpage; NEJM. (July 2016)

8. “Among serodifferent heterosexual and MSM couples in which the HIV-positive partner was using suppressive ART and who reported condomless sex…there were no documented cases of within-couple HIV transmission” among 58,000 condomless sex acts.  Reporting on PARTNER study  Dr. Alison Rodger, et al. JAMA. (July 2016)

9. “These results are simple to understand – zero transmissions from over 58,000 individual times that people had sex without condoms…[PARTNER study] provides the strongest estimate of actual risk of HIV transmission when an HIV positive person has undetectable viral load – and that this risk is effectively zero.“ Simon Collins, Steering Committee, PARTNER, i-BASE (July 2016)

10. “The [Swiss] statement [was the first position statement that] addressed the infectiousness of an HIV-positive person once the virus was stably suppressed for at least 6 months with ART. [T]he [Swiss Federal Commission for AIDS-related Issues] felt, based on an expert evaluation of HIV transmission risk under therapy, that the risk of HIV transmission in such a situation was negligible.” Dr. Pietro Vernazza, chief of the Infectious Disease Division, Cantonal Hospital in St. Gallen, Switzerland; Executive Committee, PARTNER  Swiss Medical Weekly  (Jan. 2016, confirming the original 2008 Swiss statement)’

11. “[T]he HPTN 052 study saw only cases of transmission during ART that occurred shortly (days) after the initiation of therapy. If only transmissions after the first six months of ART are considered (as stipulated in the Swiss statement) the efficacy would have been 100% with a transmission risk of zero.”  Dr. Pietro VernazzaSwiss Medical Weekly  (Jan. 2016)

12. “We have…rigorous confirmation that treatment prevents the spread of HIV and improves the health of infected people.”  Dr. Thomas R. Frieden, Center for Disease Control Director, USA New England Journal of Medicine sourcing HPTN 052 & PARTNER studies (Dec. 2015)

13. “If people are taking their pills reliably and they’re taking them for some period of time, the probability of transmission in this study is actually zero.” Dr. Myron Cohen, Chief, Division of Infectious Diseases, UNC School of Medicine, North Carolina, USA; Principal Investigator, HPTN 052 Interview with plus (August, 2015)

 14. “[People with HIV] will not pass on the infection, if the virus is undetectable, to their partners…” Professor David Cooper – Director of the Kirby Institute for Infection and Immunity in Society. University of NSW, Australia; ABC AU interview (May 2015)

15. “When you treat a person who is HIV infected you render them no longer contagious. Over a period of years that benefit is further realized… Sexual relationships can be much safer because [treatment] suppresses transmission. There is a societal benefit, a public health benefit, an altruistic benefit. ” Dr. Myron Cohen, Chief, Division of Infectious Diseases, UNC School of Medicine, North Carolina, USA; Principal Investigator, HPTN 052 At IAS Meeting,  (2015)

16. When asked what the study tells us about the chance of someone with an undetectable viral load transmitting HIV, presenter Alison Rodger said: “Our best estimate is it’s zero.” Reporting on PARTNER study interim results. Dr. Alison Rodger, University College London, United Kingdom; Lead Author PARTNER,  NAM -AIDSMap (March, 2014)

17. People living with HIV “are leading lives that are normal in quality and length. With effective treatment, they are not infectious.”  Health care workers on effective HIV treatment are “totally safe.” Professor Dame Sally Davies, Chief Medical Officer, England. The Telegraph (Aug. 2013)

 18.“In reality, if you give the treatment the opportunity to get on with its work, you will have zero transmission”. Dr. Julio Montaner,  Director of the British Columbia Centre for Excellence in HIV/AIDS; Director of IDC and Physician Program Director for HIV/AIDS PHC:  TED Talk referring to HPTN 052 (Nov. 2011).

[i] Much of the current prevention messaging refers to this as Treatment as Prevention or TasP.  As of the writing of this primer, there have been no confirmed cases of HIV transmission from a person with an undetectable viral load in any studies. The official cut-off point for an undetectable viral load as defined by the WHO ranges from <50 copies/ml in high income countries to <1,000 copies/ml in low to middle-income countries. For the purposes of this statement, an undetectable viral load is defined as under <200 copies/ml.

[ii] Only a small proportion of HIV-positive people in a large US treatment study regarded themselves as non-infectious after up to three years on antiretroviral therapy (ART), and a third of participants regarded their chance of infecting a partner as still ‘high’, even though only 10% of participants actually had a detectable viral load.” NAM- AIDSMap (2016)

[iii] Acknowledgements: In addition to PAC’s Founding Task Force, Professor Carrie Foote (Indiana University-Indianapolis) and Edwin Bernard (HIV Justice Network), reviewed and provided valuable input on the Primer.

President-Elect Donald J. Trump: An HIV-Positive Born-Again Christian’s Perspective

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It’s now well known across the world that the United States recently elected Donald J. Trump to be its 45th president. Emotions are running high, not only within the HIV community, but also within communities across the globe, as we grapple what the future holds for our country. His presidency came as a surprise to many, especially in light of polls that overwhelmingly favored his opponent, democratic nominee Hillary Clinton, as the projected winner.

I’ll be the first to say that Trump was not my preferred choice for president from either the stance of a born-again Christian or someone living with HIV. This, however, was not the consensus of the Electoral College or of many white evangelical Christians. In fact, white evangelicals make up 25% of the United States population and over 80% voted in favor of the Republican ticket.

It seems that many Christians have forgotten words spoken by Paul in Titus 1:7-8, “Since an overseer manages God’s household, he must be blameless — not overbearing, not quick tempered, not given to drunkenness, not violent, not pursuing dishonest gain. Rather, he must be hospitable, one who loves what is good, who is self-controlled, upright, holy and disciplined.”

We’ve heard over and over this election season that this was bigger than any one candidate but rather about the values we stand for as Americans. As a Christian, I must ask myself, does Donald Trump represent the above-stated values? Many Christians simply vote on one core issue: abortion. While I myself do not agree with abortion except in unique and rare circumstances, I feel that there are many more issues that one must take into account.

The old saying “WWJD” or “what would Jesus do” leaves me shaking my head anytime I hear Trump talk about anything from immigration to poverty. Christians have put nation before kingdom, and that is a big reason why Trump will be our 45th president. I will follow the bible verse in Matthew 22:21 that says, “Render to Caesar the things that are Caesar’s and to God the things that are God’s,” however, I will also hold Trump accountable for his actions.

From another perspective, as someone living with HIV, it’s frightening this man will be leading our country. It’s really like a blind coin toss with the outcome unknown, as he has not elaborated his views on the subject. With the recent passing of 2016 World AIDS Day, I was hoping to get a glimmer of hope, some shimmer of light that would tell me, “OK Josh, things are going to be all right.” But that didn’t happen.

Instead, we got more of the same response surrounding an issue that personally affects my life: silence. We my as well have heard crickets from the president-elect as, instead of recognizing such an important date, he spent it touring the country on a “thank you” tour that only served to boost his ego. I wasn’t expecting huge recognition. Heck, I would have settled for a simple two-to-three-minute message. The fact is, over 1.2 million in the United States are living with HIV, and your telling me in the last year he couldn’t find the time to mention us even once? Instead of thanking the voters who elected him, how about thanking the long-term survivors who in many cases gave their lives so that I and others living with the virus have the opportunity to live.

Unlike other issues, HIV has lives at stake if he doesn’t get it right. This isn’t a plan that he is simply going to be able to “wing” or piggyback off current strategy. We need a leader who has a clear and concise plan that will address all aspects of the pandemic, both nationally and globally.

We’ve fought too hard to increase funding for prevention and awareness to turn back the wheels of time. While we can’t be certain what the future holds, the silence from the Trump administration and past conservative stances on the issue are unsettling at best. This may not be the nation’s top priority, but it’s my top priority, and I will make sure that the Trump administration, Congress and the Senate know it. These are our lives and we will continue to speak up to ensure the progress we’ve made is not undone.

I urge all Americans to remain vigilant during this presidency. We must not grow complacent or allow yesterday’s news to detour us from our mission for today. While I’m willing to follow the advice of Hillary Clinton and give him a chance, that does not go without limits. It’s going to be a long road ahead of us; however, we must remember the words of Frederick Douglass, who said:

If there is no struggle, there is no progress. Those who profess to favor freedom and yet depreciate agitation are men who want crops without plowing up the ground. They want rain without thunder and lightning. They want the ocean without the awful roar of its many waters. This struggle may be a moral one, or it may be a physical one, and it may be both moral and physical, but it must be a struggle. Power concedes nothing without a demand. It never did and it never will.

God Bless America and may he give us all the wisdom and strength to move forward in the years that follow.

Si Se Puede: Speaking Up as Allies to Latinx Communities

“Si se puede” or “yes, one can,” a term coined by Dolores Huerta, could be heard in speeches by Cesar Chavez and the United Farm Workers in the early 1970s. It’s a slogan that not only served to unify Latinx people, namely Mexican Americans, but also raised awareness around the plight of farm workers. It is still used almost 40 years later for various causes. Little did we know that a decade after the saying became popular, the world would face a health epidemic — HIV/AIDS — it had never seen before, and Hispanics would become a disproportionately affected group.

For the past twelve years, my life has largely centered on this very group, even though I myself am not Hispanic. At 14 years old, I began to take food and clothes down to a local orphanage in Tijuana, Mexico, through missionary work with my church. Almost immediately, it was apparent that I needed to learn the language if I wanted to be effective. I learned formal Spanish including reading and writing in school, while I learned what we call “street” Spanish from monthly visits to Mexico.

Later on, Tijuana would grow to become like a second home. It’s where I met my now ex-girlfriend and possibly the very place I contracted HIV. It was in this border town, a melting pot of both U.S. and Mexican culture, that I learned about life. The people, ways of life, and spirit of helping fellow humans I’ve seen in Tijuana has always inspired me. It’s also opened my eyes, educated me with real-life experiences on the plight of undocumented workers and given me a bird’s eye view on the rippling effects of poverty.

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Josh at the Mexican Cultural Institute in Washington D.C. September 2016

Although I am Caucasian, I have continually immersed myself in Mexican culture. Whether it is television, food or music, I am “Tijuanense” — Spanish slang for someone from TJ. I was given the Spanish nickname of “Juanito Perez” (a name I got after working as a painter in my early teens) among others such as “Miklo Velka” and “Güerro.” I may not be Mexican by blood but I often say I am at heart.
My love for the Spanish language and knowledge of the culture has served especially useful in my HIV advocacy. I help moderate the largest Spanish-speaking international support group on Facebook, Grupo Internacional para Personas con VIH/SIDA y las Personas Afectadas, founded by fellow HIV advocate Maria Mejia. With over 18,000 members from across Latinx America, the group has given me a unique perspective not only of HIV here in the United States, but also on the challenges faced by the Latinx community across the world. Whether it is antiretroviral shortages due to the political situation in Venezuela or a lack of one-pill-a-day treatment options in countries such as Mexico, change is necessary.

Culturally, this virus remains a highly stigmatized and hush-hush subject within the community. Far too often, the voices of Hispanics go unheard, in some cases due to fear of social rejection due to the simple act of being open about one’s status. As discussed in the group on Facebook and elsewhere, various factors that can contribute to the stigma, including male machismo, lack of education/awareness, religious beliefs, language barriers, immigration status and poverty. I have great regard for the power of these issues, informed by my personal experiences and my efforts to appreciate the diverse cultures the Latinx community. I am committed to being a strong ally.

To those of use who are not Latinx, I urge you to put the term “si se puede” to use by uniting with our Hispanic brothers and sisters to look beyond our differences and break the stigma. At a time when Hispanics make up almost one-third of new HIV infections and the alarming news that one in 36 Latinx men (and one-quarter of gay Latinx men) will become HIV positive if current trends continue, it’s more important to speak up now than ever. We must support the work of Latinx leaders to get information about treatment as prevention and pre-exposure prophylaxis (PrEP) out to the Hispanic community. By doing so, we are not only chipping away at the stigma, but also saving lives along the way.

A battle isn’t won with a single soldier but rather with an army, a team in which each person’s role contributes to the overall group goal. It’s my hope that as an ally I can continue to lend a voice to the voiceless and a helping hand to a community that often lives in silence, alienated from the HIV/AIDS conversation.

If you are a Latinx person living with HIV or know someone who is, I would encourage you to visit the HIV/AIDS Resource Center for Latinos at TheBody.com by clicking here. If you are in search of a Spanish support group online check out Grupo Internacional by clicking here.

**This article was originally written by Joshua Middleton for http://www.thebody.com. Permission to share published content should be obtained through the original author and or Thebody.com**

Original Article Link can be found by clicking here

Unexpected Tribulations: How HIV Changed Everything

My story as featured on TheBody. It has been an honor to begin blogging for them and I look forward to them sharing more of my life living with HIV. If you have never checked out TheBody make sure to take a couple moments to take a look at the website. It is a great resource for all PLWHA and has an abundance of information regarding HIV/AIDS. Wishing everyone a very happy holiday season filled with love and joy.

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The moment I heard the words that I thought I wouldn’t hear in a million years, “You are HIV Positive,” time itself seemed to have stopped.

Thoughts raced through my mind as my whole body shut down going into a state of shock that I can best describe as a thick fog. The words of my health care professional seemed to go in one ear and out the other. It was if I wasn’t there.

My physical appearance tried with all its might to stay strong; but despite its best efforts the crumbling interior eventually took over and the flood of emotions ensued.

That was June of 2012, when I was initially diagnosed with HIV.

My journey with health issues began in 2010 after cutting my foot on coral in the Pacific Ocean. I ended up contracting necrotizing fasciitis, the flesh eating bacteria, that has a reputation of being rare and killing quickly. After undergoing emergency surgery my body went into a septic shock where my kidneys began to shut down and my blood pressure was in the 20s.

As I looked death in the eye, an inner strength developed in me like never before, one of survival.

After being in the ICU for a couple weeks and completing an almost three-week hospital stay I was released. What I thought would be the end of my troubles had only just began a time of my life that would be plagued with hospitalizations. I was hospitalized more than thirty times throughout the next several years for recurring staph and MRSA infections in my left leg. I went from having no health issues to a mounting plethora of health problems within a matter of no time.

At the time I was dating a girl I had fell in love with down in Tijuana through doing orphanage work with my church. I thought it was the picket fence relationship, it ended up being quite the opposite.

What started as a beautiful connection between the both of us went down hill when I found out she had cheated the first time. I had never been faced with this sort of situation and through my own inexperience I tried to “fix” and “save” the relationship that had already been broken. Even though I would go down to see her on a weekly basis, sometimes multiple times a week, in all reality it was a long distance relationship which comes with its own unique obstacles. I began to think that if we had a kid together that would solve our problems in some way, obviously misguided thinking, but that’s how my risk began to surmise.

When I found out she had cheated the second time, that was it, I called it off. However even though I knew breaking up was the right thing to do, I didn’t know how to handle it. I began to go out and party much more than I ever had before, putting myself in several situations where one night stands became the norm. Using protection really didn’t cross my mind, especially when alcohol was involved.

I was regularly getting tested for HIV and other STDs so I should be fine I told myself, right?

Wrong …

Testing is great, however I was playing the luck of the draw when I wasn’t doing anything to change my risk.

I found out my status by coincidence I say, not expecting to receive the HIV test results when I did. I went in for a routine checkup with my infectious disease specialist regarding my leg but since my primary care physician is within the same network, my result from a prior HIV test the week before, became the subject of discussion. I was faced with the choice and two different paths of where my life was headed and I determined I would not let HIV define my life but rather use my experience to help others in hopes of preventing new infections.

I know I am not the typical story you are thinking right; I don’t fit that “category” that unfortunately this condition has been stereotyped with for far too long. I am a heterosexual male, a born-again Christian, someone who grew up in a rather conservative home, and not the typical party boy that lived my life going with a different girl every night of the week or using IV drugs.

I was simply someone who put myself in a period of high risk where my personal health did not matter to me to the extent that it should have. I am not 100 percent sure if I got HIV from my ex-girlfriend or relations after; however to me that doesn’t matter, what matters to me isn’t so much the past but the present and future.

After being diagnosed and overcoming the initial shock I began to tell everyone in my life. I told my parents, co-workers, and friends. I was very fortunate to receive nothing but love and support. I reached out to find others living with HIV online and found several HIV activists who now have become great friends. My desire to learn more about the new enemy I was facing engulfed me as I began to reach out for support and study more about HIV/AIDS.

Shortly after, I began HIV treatment and within a month of commencing ARV therapy, reached undetectable levels of the virus which I maintain to this day. My faith and spirituality have also grown as I battle something bigger than myself.

I began to educate my peers, speak out on social media, and play my part ensuring HIV stops with me. I help moderate a large international online Facebook support group both in English and Spanish with tens of thousands of members fighting the battle every day. Through my love of writing and passion for HIV prevention/awareness I started my personal blog pozitivehope.com.

My story serves as a reminder that this virus does not discriminate and neither should we. Regardless of how we reached this point in our lives we are all brothers and sisters in this battle. HIV is simply a small part of my life as I have many other passions including learning new languages/cultures, aviation, and law. I’ve been through a lot for someone only 25 years old but that’s okay because it has been a blessing in disguise and formed me into the man I am today.