Role of viral suppression in HIV treatment and prevention and its potential in addressing harmful laws and discrimination
Andy Seale
A * , Rachel Baggaley A , Lara Vojnov A and Meg Doherty A
+ Author Affiliations
- Author Affiliations
A Department of Global HIV, Viral Hepatitis and Sexually Transmitted Infections Programmes, WHO, Geneva, Switzerland.
Sexual Health - https://doi.org/10.1071/SH23048
Submitted: 5 April 2023 Accepted: 10 June 2023 Published online: 6 July 2023
© 2023 The Author(s) (or their employer(s)). Published by CSIRO Publishing. This is an open access article distributed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License (CC BY-NC-ND)
Abstract
The World Health Organization’s (WHO) global public health mandate includes a focus on expanding access to HIV testing, antiretroviral therapy (ART) and treatment monitoring to improve the clinical management of HIV, achieve sustained viral suppression, and prevent HIV-related incidence, morbidity, and mortality. This article documents key moments in research and WHO policies that have informed how ART is applied within HIV programs, including as a prevention tool with the potential to support efforts to address HIV-related discrimination. For more than 20 years, WHO has promoted the benefits of HIV treatment including as part of the approach to prevent the mother-to-child transmission (vertical transmission) of HIV. WHO guidance has followed, and continues to follow, the evolving evidence. In 2023, WHO continues to clarify that there is zero risk of sexual HIV transmission when a person living with HIV has an undetectable viral load and an almost zero or negligible risk of sexual transmission when a person living with HIV has a viral load of ≤1000 copies/mL – helping to evolve the focus of community campaigns and health worker training to include a focus on ‘virally suppressed’ while also continuing to emphasise the ultimate goal of achieving an undetectable viral load. This evolution does two things: first, it strongly reasserts the evidence around there being no chance of transmission if a person has an undetectable viral load; and second, it provides an extremely strong degree of confidence that, similarly, individuals who are virally suppressed will not pass on the virus sexually. WHO is now encouraging positive and clear messaging to highlight that the consistent use of ART prevents onwards HIV transmission.
Keywords: community interventions, HIV prevention, HIV/AIDS, human rights, legislation, patients’ views, policy, public health, stigma and discrimination, viral suppression.
References
[1] World Health Organization. Who we are. WHO website; 2023. Available at https://www.who.int/about/who-we-are [accessed 24 January 2023].[2] World Health Organization. HIV global situation and trends. Global Health Observatory; 2022. Available at https://www.who.int/data/gho/data/themes/hiv-aids#:~:text=Since%20the%20beginning%20of%20the,at%20the%20end%20of%202021 [accessed 24 January 2023].
[3] World Health Organization. Why the HIV epidemic is not over. 2018. Available at https://www.who.int/news-room/spotlight/why-the-hiv-epidemic-is-not-over [accessed 24 January 2023].
[4] World Health Organization. WHO Advisory Group of Women Living with HIV to meet in Geneva. 2019. Available at https://www.who.int/news/item/04-10-2019-who-advisory-group-of-women-living-with-hiv-to-meet-in-geneva [accessed 24 January 2023].
[5] World Health Organization. PMTCT STRATEGIC VISION 2010–2015. Preventing mother-to-child transmission of HIV to reach the UNGASS and Millennium Development Goals. 2010. Available at https://apps.who.int/iris/bitstream/handle/10665/44268/9789241599030_eng.pdf?sequence=1 [accessed 24 January 2023].
[6] Quinn TC, Wawer MJ, Sewankambo N, Serwadda D, Li C, Wabwire-Mangen F, Meehan MO, Lutalo T, Gray RH, Rakai Project Study Group Viral load and heterosexual transmission of human immunodeficiency virus type 1. N Engl J Med 2000; 342 921–9.
| Viral load and heterosexual transmission of human immunodeficiency virus type 1.Crossref | GoogleScholarGoogle Scholar |
[7] United Nations General Assembly 26th Special Session. Declaration of Commitment on HIV/AIDS. Resolution A/RES/S-26/2 adopted by the General Assembly. 2001. Available at https://digitallibrary.un.org/record/443771#record-files-collapse-header [accessed 03 March 2023].
[8] Baggaley RF, Ferguson NM, Garnett GP. The epidemiological impact of antiretroviral use predicted by mathematical models: a review. Emerg Themes Epidemiol 2005; 2 9
| The epidemiological impact of antiretroviral use predicted by mathematical models: a review.Crossref | GoogleScholarGoogle Scholar |
[9] Taylor M, Newman L, Ishikawa N, Laverty M, Hayashi C, et al. Elimination of mother-to-child transmission of HIV and Syphilis (EMTCT): Process, progress, and program integration. PLOS Med 2017; 14 e1002329
| Elimination of mother-to-child transmission of HIV and Syphilis (EMTCT): Process, progress, and program integration.Crossref | GoogleScholarGoogle Scholar |
[10] World Health Organization. Elimination of mother-to-child transmission of HIV, syphilis and hepatitis B. 2022. Available at https://www.who.int/initiatives/triple-elimination-initiative-of-mother-to-child-transmission-of-hiv-syphilis-and-hepatitis-b [accessed 24 January 2022].
[11] i-base. The Swiss Statement. 2008 (updated in 2019). Available at https://i-base.info/qa/factsheets/the-swiss-statement [accessed 24 January 2022].
[12] Cohen MS, Chen YQ, McCauley M, Gamble T, Hosseinipour MC, Kumarasamy N, et al. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med 2011; 365 493–505.
| Prevention of HIV-1 infection with early antiretroviral therapy.Crossref | GoogleScholarGoogle Scholar |
[13] World Health Organization. Guidance on couples HIV testing and counselling including antiretroviral therapy for treatment and prevention in serodiscordant couples. Recommendations for a public health approach. 2012. Available at https://apps.who.int/iris/bitstream/handle/10665/44646/9789241501972_eng.pdf?sequence=1&isAllowed=y [accessed 25 January 2023].
[14] Bavinton BR, Prestage GP, Jin F, et al. Strategies used by gay male HIV serodiscordant couples to reduce the risk of HIV transmission from anal intercourse in three countries. J Int AIDS Soc 2019; 22 e25277
| Strategies used by gay male HIV serodiscordant couples to reduce the risk of HIV transmission from anal intercourse in three countries.Crossref | GoogleScholarGoogle Scholar |
[15] Rodger AJ, Cambiano V, Bruun T, et al. Sexual activity without condoms and risk of HIV transmission in serodifferent couples when the HIV-positive partner is using suppressive antiretroviral therapy. JAMA 2016; 316 171–81.
| Sexual activity without condoms and risk of HIV transmission in serodifferent couples when the HIV-positive partner is using suppressive antiretroviral therapy.Crossref | GoogleScholarGoogle Scholar |
[16] World Health Organization. Treat all people living with HIV, offer antiretrovirals as additional prevention choice for people at “substantial” risk, news release. 2015. Available at https://apps.who.int/mediacentre/news/releases/2015/hiv-treat-all-recommendation/en/index.html [accessed 24 January 2022].
[17] Coates A, Allotey P. Global health, sexual and reproductive health and rights, and gender: square pegs, round holes. BMJ Glob Health 2023; 8 e011710
| Global health, sexual and reproductive health and rights, and gender: square pegs, round holes.Crossref | GoogleScholarGoogle Scholar |
[18] Seale A, Broutet N, Narasimhan M. Assessing process, content, and politics in developing the global health sector strategy on sexually transmitted infections 2016–2021: implementation opportunities for policymakers. PLoS Med 2017; 14 e1002330
| Assessing process, content, and politics in developing the global health sector strategy on sexually transmitted infections 2016–2021: implementation opportunities for policymakers.Crossref | GoogleScholarGoogle Scholar |
[19] Barré-Sinoussi F, Abdool Karim SS, Albert J, Bekker L-G, Beyrer C, Cahn P, Calmy A, Grinsztejn B, Grulich A, Kamarulzaman A, Kumarasamy N, Loutfy MR, El Filali KM, Mboup S, Montaner JSG, Munderi P, Pokrovsky V, Vandamme A-M, Young B, Godfrey-Faussett P. Expert consensus statement on the science of HIV in the context of criminal law. J Int AIDS Soc 2018; 21 e25161
| Expert consensus statement on the science of HIV in the context of criminal law.Crossref | GoogleScholarGoogle Scholar |
[20] The Lancet HIV U=U taking off in 2017. Lancet HIV 2017; 4 e475
| U=U taking off in 2017.Crossref | GoogleScholarGoogle Scholar |
[21] Prevention Access Campaign. Our history. The evolution of U=U. 2022. Available at https://preventionaccess.org/about/ [accessed on 24 January 2022].
[22] World Health Organization. Viral suppression for HIV treatment success and prevention of sexual transmission of HIV. 2018. Available at https://www.who.int/news/item/20-07-2018-viral-suppression-for-hiv-treatment-success-and-prevention-of-sexual-transmission-of-hiv [accessed 24 January 2022].
[23] Ministry of Public Health of Thailand, WHO Regional Office for South-East Asia, UNAIDS. Statement: people living with HIV with an undetectable viral load cannot transmit HIV sexually. 2020. Available at https://www.who.int/docs/default-source/searo/hiv-hepatitis/joint-moph-unaids-who-uu.pdf?sfvrsn=8378cd0_2 [accessed 24 January 2023].
[24] World Health Organization. Consolidated guidelines on HIV, viral hepatitis and STI prevention, diagnosis, treatment and care for key populations. 2022. Available at https://www.who.int/publications/i/item/9789240052390 [accessed 24 January 2023].
[25] World Health Organization. HIV fact sheet. 2022. Available at https://www.who.int/news-room/fact-sheets/detail/hiv-aids [accessed 24 January 2023].
[26] GNP+, The Global Network of People Living with HIV. Statement in response to adoption of 2021 political declaration on HIV/AIDS. 2021. Available at https://gnpplus.net/latest/news/statement-in-response-to-adoption-of-2021-political-declaration-on-hiv-aids/ [accessed 25 January 2023].
[27] United Nations General Assembly. Political declaration on HIV and AIDS: ending inequalities and getting on track to end AIDS by 2030. 75th Session, A/75/L.95. 2021. Available at https://www.who.int/news/item/11-06-2021-new-hiv-aids-political-declaration-seeks-to-end-inequalities-and-get-on-track-to-end-aids-by-2030 [accessed 25 January 2022].
[28] World Health Organization. Global health sector strategies on, respectively, HIV, viral hepatitis, and sexually transmitted infections for the period 2022–2030. 2022. Available at https://www.who.int/publications/i/item/9789240053779 [accessed 25 January 2022].
[29] World Health Organization. Seventy-fifth World Health Assembly. Resolution WHA75.20. 2022. Available at https://apps.who.int/gb/ebwha/pdf_files/WHA75/A75_R20-en.pdf [accessed 25 January 2022].
[30] Hasen N. U=U: This World AIDS Day, let’s start telling people living with HIV the truth. 2021. Available at https://www.psi.org/2021/11/this-world-aids-day-lets-start-telling-people-living-with-hiv-the-truth/ [accessed 24 January 2022].
[31] Nunes NN, Vasconcelos R, Cortez AL, et al. Is U=U consistently known and implemented? A survey among different medical specialists in Brazil. Int J STD AIDS 2023; 34 395–401.
| Is U=U consistently known and implemented? A survey among different medical specialists in Brazil.Crossref | GoogleScholarGoogle Scholar |
[32] Broyles L, Luo R, Boeras D, Vojnov L. Lack of risk for sexual transmission of HIV at lower levels of HIV viremia: a systematic review. Lancet 2023;
| Lack of risk for sexual transmission of HIV at lower levels of HIV viremia: a systematic review.Crossref | GoogleScholarGoogle Scholar |
[33] World Health Organization The role of HIV viral suppression in improving individual health and reducing transmission. 2023; https://www.who.int/teams/global-hiv-hepatitis-and-stis-programmes/hiv/treatment
[34] Caswell G, Dubula V, Baptiste S, et al. The continuing role of communities affected by HIV in sustained engagement in health and rights. J Int AIDS Soc 2021; 24 e25724
| The continuing role of communities affected by HIV in sustained engagement in health and rights.Crossref | GoogleScholarGoogle Scholar |
[35] UNAIDS. Global AIDS strategy 2021-2026 — end inequalities. End AIDS. 2021. Available at https://www.unaids.org/en/resources/documents/2021/2021-2026-global-AIDS-strategy
