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Test and Treat was one of the few sessions I was ‘kind of able’ to follow at the latest British HIV Association (BHIVA) conference in London at the beginning of the month. In spite of all my ‘activism’ when I listen to very scientific presentations my brain switches off and most of the information passes over my head.

Anyway here is a very simplified version.

In the past few years it has become clear that an undetectable viral load does reduce infectiousness immensely. This is why, for example, preventing mother to child transmission is so successful once women have an undetectable viral load.  And this is also why the Swiss Doctors released the controversial ‘Swiss Statement’ giving the green light to unprotected sex to monogamous, heterosexual, sero-discordant couples on effective treatment.

This topic is crucial to the world of public health not because the grey suits really want us who live with HIV to have guiltless and condomless sex, or ‘Nyama Kwa Nyama’,   doing it flesh to flesh,  as my Swahili speaking friends say with starry eyes.  What really matters to policy makers is finding a shortcut to prevention. World Health Organisation (WHO) believes that if with undetectable viral load you can stop sexual transmission of HIV we can treat our way out of the epidemic. All it is needed is: testing everybody on the planet every year (!) and putting them on ARVs straight away, regardless of CD4 count, for the rest of their life.

Professor Myron Cohen, from the University of North Carolina, who opened the session, highlighted three major concerns clouding the picture:

  • Transmission of resistant viral strains

  • The contribution of patients with acute and early HIV (subjects who are not likely to be detected routinely but contribute substantially to the spread of HIV)
  • The practicality of the idea.

Prof Myron also gave us the example of a recent study in China among 1927 sero-discordant couples on treatment. This study reported around 4% transmission among couples where the HIV positive partner was on ARVs. This study was not considered conclusive because they didn’t use viral load monitoring.  However it provides a real life example of some of the problems of ‘Test and Treat’.

The second presentation of the session, by  Dr Steve Taylor from University of Birmingham,  looked more in-depth to the scientific side of preventing HIV transmission. In order to reduce sexual HIV transmission it is crucial to understand better how HIV works once it is inside the body. Some drugs can  penetrate the genital tract  and stay there at a good level,  thus protecting us from passing the virus.  But not all the drugs work the same way and the collection of samples of genital fluids for research has its challenges!

What I find really exciting is that the criteria of reducing sexual infectiousness will be paramount in developing new drugs and  better combining the drugs we already have.  Personally I was really relieved and felt immediately less infectious just  by knowing that the drugs I am using score really well in the genital tract!

A poster presentation by Dr Taylor and the team he works with, including more information on how different drugs penetrate the genital tract is available here.

As a person with HIV I am definitely very excited at the idea that one day I may  not be considered a viral threat to the world. I think that if sexual infectiousness could really be eradicated this would play an important role in decreasing stigma.

However, I think there are several problems with the ‘Test and Treat’ approach. Firstly an ethical one: is it right to give  somebody potentially toxic treatment in the name of prevention? And could this lead to human right abuses in which vulnerable and stigmatized populations, such as sex workers and drug users are forced to be tested by the police?

Secondly an economic and political one:  in a time in which we can not even test and offer treatment to millions of people who are dying of AIDS around the world, because of lack of money and political will, discussing the ‘Test and Treat’ model seems a  purely academic exercise.

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8 thoughts on “Test and Treat

  1. Great post Silvia – explains it well in a way I can understand as so often the technicalities of the ins and outs of HIV issues and testing and meds go over my head as it is often so complicated.

    Personally, due to my experience of my having HIV for some years and not knowing ( as I am someone who prefers to know my health status even if the news is not good and whatever it is. And therefore always be in control of my health and treatment as far as I am able ) and my husband nearly dieing of AIDs/PCP etc as he did not know he was HIV+ until he got ill and his health being far more undermined than it may have been had he – and I – found out we had HIV sooner, I still er on the side of universal ‘opt-out testing for all in the UK to save lives.

    I also feel that if everyone routinely was tested for HIV in the UK, the same as women in the UK have smear tests or HPV tests and breast screening for over 50s, or even like routine blood tests for iron etc it would lessen the stigma of HIVsignificantly.

    One the stigma of going for an HIV test in the first place and also the stigma of finding you are in fact HIV+.

    So on while on balance, right now, I am still on the side of universal HIV testing, and at least for a start in his country i.e HIV testing as a routine part of any health check without you having to request it, I do thanks to your article above understand more of the arguments against this and will give them further consideration.

  2. I also wanted to add that while of course I do not comment on every post you make I very much appreciate and admire your blog.

    As opposed to my own blog that I am fully aware is for me only and consists of my very subjective ramblings and is used mostly as part of my own personal way of coping with the distress of being over 50 and finding you are HIV+ ( a distress I do not believe will ever go for me ) and somewhere for me to offload and indeed rant in public!!

    So I do very much admire the how informative what you write is and how ‘sainly’ it presents the issues of women living with HIV in the UK. As women with HIV in the UK in my opinion have far less of a voice online than from many other countries and in many ways I feel it is generally forgotten that so many of us do live with HIV in the UK.
    And so few women in the UK are willing to go public about being HIV+, even less online, even with a pseudonym.
    And while I understand so much why and why so many women HIV+ are living in secret and often in fear in the UK , I feel that it will only be by those few that can going public – and online as this is the greatest form of communication known to humankind these days as it reaches so many people – that the stigma and discrimination and indeed the misinformation and misunderstanding about women and HIV , will be reduced.

  3. Hey Veritee,

    Thank you for your comments. I am all for expanding testing. Especially in the UK and at GP level. My concerns are about using treatment as a shortcut for prevention and how ethical it is to put somebody on a toxic treatment to benefit others. Increased testing should also address one of the greates barrier for people to know their staus: stigma. Anti-stigma capmaigns should go hand in and with testing promotion.

  4. Yes agree -Anti-stigma campaigns should go hand in and with testing promotion.
    I know I am a baby in this I am a baby in livng with HIV myself
    BUT !!I am not a baby at all in life – less of a baby than most who meet me really realist as I am humble and do not tell people what my life has really been about – if I was to I would have to write a book and cant be bothered to do this!! And I doubt anyone would believe it anyway!!
    But I am a baby in this i.e the issue of living with HIV myself .
    And would never want testing used as a short cut for prevention but do have a bit of a question about your statement re

    ‘put someone on toxic treatment to benefit others’

    As going on HIV ARV treatment is NEVER!! just about befitting others is ???- how can it be? As first an foremost if you are to survive being HIV you have to go on ARVs at some point don’t you?

    As you have no other choice once your CD4 s drop do you?? or am I wrong? do you not agree?

    As if you test positive for HIV the ‘treatment’ may be toxic, I accept this and certainly I would not want not be on it if there was any option……..
    but letting HIV run its course and getting AIDs is a LOT more toxic!!! isn’t it??

    So how would universal testing and putting anyone diagnosed HIV on ARV treatment just be first an foremost used as a preventative? To me it would first and foremost be used to save lives???

    Yes that – a preventative – may be a bi product – and good if this is a bi product – what is wrong with that??

    But I saw my husband nearly die of AIDs and while I may be new to this i.e new to having HIV my self have actually in my life known in my life 4 people die of AIDs……watched them die in fact!! Sure you did not knwo this as I never said as – I have never explained to you or any one at Pozfem – but this was so long before I EVER in a hundred years thought I would EVER have HIV myself!!!!! ……..3 I when I lived in London in the late 80s and one I knew died here in Cornwall, and before there was any real effective treatment that there is now Ihad friends with HIV and I watched them die
    So maybe I am still so very ignorant still in terms of living with it myself – but I am not at all ignorant in terms of knowing what this – having the HIV virus – is all about.

    So to me no ARVs = death and I have seen it
    So if prevention is a side effect of those who test HIV poz then in my view totally great great!!!
    But the main reason and purpose for me in introducing UK national HIV testing – hopefully via the GP, is to diagnose those with HIV early and to prevent deaths
    So now I have come clean Sivia – I was not always a married woman who just happened – by total coincidence to get HIV in my 50s myself –

    Many years ago I was a drug user – and I also worked as a prostitute at one point -but for me this over 30 years ago – but I am one that survived to change my life – but that does not mean I did not know those that did not and that I did not keep in touch with them for some years and see some die of AIDs

    There you have it – a confession –
    But this is why I feel that ‘opt out’ testing is the only way forward

    I am not as much as a beginner in this as maybe most seem to think

  5. Just ignore me – you are doing a good job – a fantastic job
    So I am SORRY for my outburst

    -I just do not think many know who I really am or what my life has been??
    My fault – I guess I did not want to tell you or anyone at Pozfem as it was for me so long ago

    So -to a degree I was still shamed about how I lived my life once
    As re the issues around HIV. I am sadly no begginer in this. Yes it was some years ago when there was no effective treatment that I knew those who had HIV and ………….. and ……..so ironically

    I only found I had HIV myself n my late 50s only a couple of years ago – but so ironically to me I have known many with HIV in my life since the 80s and 4 who died before HAART
    Which is why HIV it has now become my burning issue in life and why I am totally determined to be open and fight stigma

    I my own way…I do not have your clout – never will!!

    I live in a rural area and I am not fit enoguh to travel the world and do not have a paid job in HIV awareness and never will do …..but I will fight till I can not any more

  6. As a woman with HIV, I am of the view that if charities and medical bodies promoted the Swiss Statement it would drastically reduce stigma and discrimination against those of us living with HIV.

    It’s about sensible education around the Swiss Statement rather than taking the view held by those such as the THT that refuses to advocate the research, even in a sensible coherent conversation via their helplines.

    Educate the UK population about the negligiable transmission rates should one adhere to the Swiss Statement’s guidelines and watch the discrimination and stigma lessen. Personally, I will start to believe in HIV charities once they take this bold move. My clinic already advocates the Swiss Statement and now it is time for charities and educational bodies to do the same.

    Personally, I do not want to spend the next 30 years of my life living in fear. The Swiss Statement is once way to empower the HIV community and to educate the general population and journalists.

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