When the immune system of a HIV+ person has been weakened by the virus to a critical level, the HIV specialist will prescribe supervised and regular anti-retroviral therapy (HAART).
Over time, the person’s immune system will strengthen, even to the stage when the viral load inside the body becomes undetectable. Does this mean that the person is no longer infectious and can abandon safer sex practices and condom usage?
Swiss Federal Commission for AIDS-related Issues (SFCAI)
In February 2008, the SFCAI published a communication in the Bulletin of Swiss Medicine, stating that "HIV-positive individuals without additional sexually transmitted diseases (STD) and on effective anti-retroviral therapy are sexually non-infectious".
This sparked an intensive international debate on the matter, with different institutions and experts taking opposing stands. A Closed Hearing was then held in Geneva in June, where scientific researchers and public authorities gathered under one roof in a bid to reach a common understanding on this controversial issue.
XVII International AIDS Conference
During the conference held in Mexico City in August 2008, the following public health implications were highlighted:
- In heterosexual partnerships, the risk of HIV transmission is low in the presence of effective HAART. However, the risk is not zero.
- In male same-sex partnerships, HIV transmission risk gets higher with repeated exposure.
- The presence of other STDs increases HIV transmission risks – STDs have an epidemiologic synergy with HIV and will increase the genital viral load in a HIV+ person. Conversely, a person who is HIV- but already has other STDs is actually more susceptible to HIV infection.
It has been found that the use of HAART alone has limited application as a strategy for individuals. As a population strategy, the treatment has real synergies with condom use, and has the potential to reduce HIV epidemics if consistent condom use is maintained. Otherwise, there is a huge potential for doing more harm than good.
The conclusion was that if the SFCAL claim were to be widely accepted, resulting in reduced condom usage, modeling projections indicated that there will potentially be substantial increases in HIV incidence.
Safety under HAART
Following from the conclusion, communication about safer sex practices when under HAART must be kept concise and targeted. Specifically, the messages are:
- Do not issue any advice against the use of condoms even when the viral load becomes undetectable. Rather, patients should be advised and encouraged to continue with consistent condom usage and safer sex practices.
- The basic principles on prevention of HIV transmission remains the same. Related educational and outreach messages should not be changed.
HAART and Pregnancies
Safety issue aside, what about serodiscordant heterosexual couples who wish to plan for safer pregnancies? Will HAART prevent the transmission of HIV from one partner to the other?
- If the female is HIV+ while the male is HIV-, it has been found that HAART can be used to achieve undetectable viral load, making it safe for the female to conceive without infecting the male. Alternatively, the couple can opt for mechanical insemination.
- On the other hand, if the male is HIV + while the female is HIV-, sperm washing is generally not a viable option to consider due to high costs and lack of accessibility to this highly-specialized procedure. The best alternative is to use HAART to achieve undetectable viral load in the male before attempting to conceive. For additional protection against HIV transmission, pre-exposure prophylaxis can be considered for the female.
