The debate on Undetectable = Untransmittable (U=U): will it work in Africa?

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What happens when there is clear science supporting a specific health intervention, but large-scale program implementation raises questions about its application? This was the core question during a debate on Undetectable = Untransmittable (U=U) at the Southern African HIV Clinicians Society 2018 conference held in Johannesburg, South Africa, from October 24-27, 2018.

Yes: U=U is appropriate for Africa

Dr. Annemarie Wensing from the University Medical Center Utrecht took the “yes” position and reviewed the evidence on U=U. This includes four clinical studies which found no HIV transmissions after more than 150,000 condomless sex acts among serodiscordant couples where the HIV-positive partner was virally suppressed. Having an undetectable viral load does imply regular viral load monitoring, she said, and it is important to be clear about the threshold for an undetectable viral load (the studies used viral loads of between 50-200 copies/mL).

U=U is appropriate for Africa, Dr. Wensing said. “It empowers people living with HIV and takes away the fear of infecting other people. It restores the human right of stress-free sexual intercourse and supports the right to care, the right to knowledge, and the right to sex.”

Dr. Wensing made a call to three specific groups, requesting healthcare workers to diminish the fear of HIV and lower stigma by providing information to people living with HIV and their partners about U=U and to act on viral load results, health officials to ensure regular and reliable viral load monitoring, and people living with HIV to be activists, demanding viral load testing and knowing their viral load status.

No: U=U is too simplistic for a southern African context

Dr. Graeme Meintjes from the University of Cape Town took the “no” position on U=U. He also reviewed the evidence on U=U and agreed with Dr. Wensing that the evidence is clear regarding virtually no risk of HIV transmission when people living with HIV are virally suppressed. The studies show that U=U is appropriate messaging for individuals with good adherence and frequent viral load monitoring, he said.

However, Dr. Meintjes stated that U=U is not so simple in a complex context such as South Africa’s large-scale ART program, with four million people on treatment and plans to reach all eight million people living with HIV in the country. He raised a number of challenges related to client behavior and program implementation, using evidence from ART program implementation in Khayelitsha in South Africa. These include:

  • Client disengagement from care: Over two years, 25% of ART program clients in Khayelitsha disengaged from care for six months or more and later re-engaged in care
  • Inadequate viral load testing and delays in the use of results: South African guidelines provide for annual viral load testing and there are significant delays in the use of viral load results: one study revealed that it took an average of six months to switch clients to second-line treatment after it was indicated by viral load results
  • ART supply interruptions, which has been termed a national crisis and prompted the formation of Stop Stockouts to monitor and provide advocacy on this issue

Client disengagement from care and ARV stockouts increase the risk of resistance, adding complexity to the messaging that should be provided, Dr. Meintjes said. “Sharing information on U=U should be on an individual level based on assessment of a client’s treatment history and a couple’s risk.”

Q&A and comments from the audience

The Q&A session following the presentations from each perspective raised issues such as:

  • What are the ethics of HIV disclosure to sexual partners in light of U=U?
  • How do we resolve the intersection of clinical recommendations regarding more frequent viral load testing with the financial cost of implementation among four million people on ART?
  • How do we combine our messaging on U=U with messaging on dual protection to prevent sexually-transmitted infections and unwanted pregnancies?

There are no easy answers to these questions, but the willingness to tackle tough issues and engage in discussion based on evidence and program experience bode well for the upcoming three days of the conference.

Undetectable = Untransmittable (U=U), Southern African HIV Clinicians Society, SAHCS Conference 2018, program implementation, viral suppression, treatment, adherence, undetectable viral load, virally suppressed