Who’s talking about untransmissible HIV?

4 minute read

One in four GPs are unaware or sceptical of U=U, leaving patients potentially in the dark about this latest advance.

Only one third of GPs have discussed the message that undetectable HIV viral load equals untransmissible (U=U), new research suggests. 

The results of an anonymous survey of 407 GPs across Australia show that 74% of GPs were aware of and “agreed” with U=U. 

The researchers also found that 26% of GPs were “neutral” or “disagreed with” U=U, suggesting that HIV patients might not up to date with this latest advance. 

“The messages from doctors regarding HIV have been about using condoms since the 1980s, and this is entrenched, so it is difficult for GPs, especially with no training on the most updated science of HIV transmission, to believe in the accuracy of U=U,” they wrote in Sexual Health.   

The research comes as a systematic review in The Lancet of 7700 serodiscordant couples found that in three studies there were no cases of HIV transmission when the partner with HIV had a viral load less than 200 copies of the virus per mL.  

Another four studies found more than 300 cases of HIV transmission, but none were in patients considered stably suppressed on antiretroviral therapy.  

 Among all studies, there were two cases of transmission when the individual with previously diagnosed HIV had a viral load of less than 1000 copies per mL, known as a suppressed viral load.  

“However, interpretation of both cases was complicated by long intervals (ie, 50 days and 53 days) between the transmission date and the most recent index viral load result,” they said.  

The researchers said it was generally accepted that HIV viral loads of less than 200 copies per mL were associated with zero risk of sexual transmission, the risk at virus levels higher than 200 has so far been controversial. 

The Australian study in Sexual Health found that when GPs “agreed” with U=U they were five times more likely to discuss the topic.  

Doctors were more likely to agree with U=U and discuss the topic if they were younger and had extra training in sexual health, the researchers said. 

“The most effective way to increase the proportion of GPs discussing U=U might be to increase their confidence in the evidence of U=U.”  

“The concept that an undetectable viral load equals untransmissible HIV infection (U=U) is supported by robust evidence from several large studies,” they said.  

“This is clear evidence that U=U, and this messaging of 100% efficacy should not be replaced with doubt-provoking comments such as ‘next to zero’ or ‘extremely low’ risk.” 

The researchers said U=U had the potential to improve health outcomes for people living with HIV.  

They referred to international study of 718 people living with HIV in 25 countries that showed the odds of suboptimal adherence to medications were 40% lower in those who discussed U=U with their healthcare provider.  

They also had 50% higher odds of reporting optimal sexual health and were twice as likely to disclose their HIV status with other people in their life compared to people living with HIV who were unaware of U=U.  

The Australian researchers also found that 60% of the surveyed GPs could not identify a resource to help with conversations of U=U. 

“This evidence suggests an urgent need for further training on U=U for all Australian GPs,” they said. 

The researchers said the main barriers to having the U=U conversation were due to a perceived lack of exposure to clients living with HIV and a lack of understanding of U=U.  

They also found that the main barriers to discussing U=U were a lack of relevant client presentations (48%), lack of understanding about U=U (40%) and difficulty identifying those who would benefit from U=U (6%). 

“It is possible that GPs have a narrow view of which client groups would be suitable for a U=U conversation,” they said.   

“For the U=U message to be the most effective, it should be shared with all clients; however, this may not be practical in a busy GP setting. So, at the minimum, it should be shared with all clients living with HIV and clients with a partner living with HIV.”  

The researchers said a public health campaign reducing stigma would encourage more clients to disclose their HIV status with a GP.  

“Clinics could place posters with inclusive language and positive messages regarding HIV to help encourage clients to initiate these discussions.”  

Sexual Health 2023, online 12 March 

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