Disclosure. Speakers are required to disclose any commercial relationships before today s presentation. MidAtlantic AIDS Education and Training Center

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1 Disclosure The does not endorse or recommend any commercial products, processes, or services. The representations and opinions expressed in this presentation are solely those of the author(s) and do not represent the views or policies of MA AETC, the University of Pittsburgh, or its funding agencies. Speakers are required to disclose any commercial relationships before today s presentation.

2 U=U Understanding the Concept and Using It Effectively Rashaad Banks HIV Health Educator Inova Juniper Program

3 U=U

4 Objectives Discuss the concept, background and stipulations of U=U Discuss why folks find U=U controversial Highlight many frequently asked questions and debunk myths Dive into ways to educate & spread the word to clients and staff

5 What is U=U Undetectable equals Untransmittable. Officially launched in 2016 A person is on treatment and are virally suppressed can not transmit the virus to their partners Treatment as Prevention (TasP) It s another tool in the toolbox, just like condoms and PrEP are a tool Still discussing condoms (STIs, pregnancy) and PrEP

6 What is U=U There are currently over 450 organizations in about 60 countries are onboard

7 U=U Works with Stipulations Strictly sexual transmission only A PLWH on meds needs to have an undetectable viral load (<50 copies/ml) Can take a month to a few months to be undetectable, so not right away Stay undetectable for at least 6 months Take meds daily See your healthcare provider regularly (actually showing up for their appointments) to monitor their results Communicate any concerns or issues with their provider

8 Why is U=U Important? Improve the lives of those with HIV Gives individuals normalcy again; they can have relationships and babies without fear and stigma Dismantles HIV stigmas Affects policies, criminalization, personal feelings, etc. Incentivizes folks to get tested, go on treatment and stay on treatment Which reduces transmission in the community

9 History of U=U 1998: San Francisco Cohort Mother-to-child transmission was reduced to approaching zero 2006: TasP (Treatment as Prevention) concept Get people on treatment and they have a low chance of transmitting the virus 2008: Swiss Statement- People with HIV are not infectious as long as the HIV positive person is on ART consistently, has a undetectable viral load for 6 months and does not have any STIs 2011: HPTN 052 Study Over 1,800 serodiscordant couples (one person is HIV positive and one not). The study showed a 96% reduction of HIV transmission 2014: PARTNER Study Over 1,110 serodiscordant couples and not one HIV transmissions through sexual contact with their partner* 2015: Opposites Attract Over 340 serodiscordant gay couples, not a single case of HIV transmission** 2015: ETAG (European AIDS Treatment Group) Statement that the risk of transmission from an HIVpositive person who takes treatment and has an undetectable viral load may be so low as to be unmeasurable, and that s equivalent to saying they are uninfectious.

10 History cont d 2016: Canadian Consensus Statement and statements from main the principal investigators from the main studies; PARTNER, Opposites Attract and HPTN 052 and author of SWISS Statement Prevention Access Campaign discussed with heads of HIV clinics, heads of medical associations and prominent HIV doctors. Met with Dr. Demetre Daskalakis, Deputy Commissioner of NYC Department of Health and Mental Hygiene; and they signed onto the campaign Brought it NYC, Terrence Higgins Trust, NASTAD, Housing Works, San Francisco AIDS Foundation, CATIE and IAS, AIDSMap, AIDS United all signed on 250 organizations, 24 countries and 11 languages at this time CDC (Center for Disease Control) released their official statement in 2017 Now to disseminate the message to as many agencies, providers, clients and the general public as possible

11 Released Statements New York Consensus Statement There is now evidence-based confirmation that the risk of HIV transmission from a person living with HIV (PLHIV), who is on Antiretroviral Therapy (ART) and has achieved an undetectable viral load in their blood for at least 6 months is negligible to non-existent. While HIV is not always transmitted even with a detectable viral load, when the partner with HIV has an undetectable viral load this both protects their own health and prevents new HIV infections. Issued: July 21, 2016 Endorsements: Updated January 28, 2018 CDC Statement When [antiretroviral treatment] results in viral suppression, defined as less than 200 copies/ml or undetectable levels, it prevents sexual HIV transmission. Across three different studies, including thousands of couples and many thousand acts of sex without a condom or pre-exposure prophylaxis (PrEP), no HIV transmissions to an HIV-negative partner were observed when the HIV-positive person was virally suppressed. This means that people who take ART daily as prescribed and achieve and maintain an undetectable viral load have effectively no risk of sexually transmitting the virus to an HIV-negative partner. Issued: September 26, 2017

12 Why Folks Find it Controversial Status quo/fear of change Intersecting stigma & phobias Disagreement with science Low science literacy Fear of doing harm Dangerous for community Blips in viral load Reckless behaviors Won t think condoms or PrEP are important It s not zero but there is no zero in science No problem with science, but more of a social issue Science proves this works!

13 FAQs

14 FAQ: What About Viral Blips Viral blips are normal, even in undetectable individuals but not enough to transmit HIV Studies have shown the blips aren t high enough to increase HIV transmission and will go back to normal Blips will raise the load to about 75 or 100 or even 200. A person needs over 1,000 to transmit

15 FAQ: What If Someone Is Undetectable Now But Stops Their Meds and Viral Load Rises They run a risk of having a detectable viral load and U=U won t apply anymore Provide the patient with education and discuss the importance of meds Build a strong patient/provider relationship Discuss condoms and PrEP But remember you can t make someone take their meds

16 FAQ: Breastfeeding (TasP) Treatment as Prevention uses ART to decrease the risk of HIV transmission. ART reduces the HIV viral load in the blood, semen, vaginal fluid and rectal fluid. It also lowers the risk of breastfeeding, but not enough studies done yet on breastfeeding So breastfeeding is still not allowed

17 FAQ: What About Needle Sharing U=U does not apply to HIV transmission through needle sharing. There is not yet enough research to draw a conclusion So ire on the side of caution and say there is a risk for needle sharing

18 FAQ: What About STIs Having a STI is not significant to HIV transmission when the partner with HIV has an undetectable viral load However, an STI in the presence of a detectable viral load may increase the risk of HIV transmission

19 FAQ: Detectable HIV in Genital Fluids Scientists have found that HIV treatment that leads to an undetectable viral load in the blood also normally leads to an undetectable viral load in semen, vaginal, and rectal fluids Occasionally people with an undetectable viral load in the blood have HIV RNA and DNA in semen, vaginal and rectal fluids but this has not been found to increase transmission risk HIV RNA and DNA are only particles of HIV, the whole virus is required to be infectious HIV

20 FAQ: Do We Tell Folks to Stop Using Condoms or PrEP No, we tell folks that condoms and PrEP are proven risk reduction methods. Give your clients all the information and allow them to make decisions that are best for them Condoms (if used correctly) are the only method that helps prevent HIV, STIs, and pregnancy PrEP (if used correctly) reduces a person risk of HIV up to 90% Having an undetectable viral load, using PrEP and using condoms are all HIV prevention strategies that people can choose to use alone or in combination

21 FAQ: How Do I Respond When Someone Ask So Can I Still Spread HIV? Be honest with them and give them accurate facts, statistics and allow them to make decisions for themselves If a person is undetectable and has been undetectable for at least 6 months, they can not transmit HIV during sex. Now that can change if a person stop taking their meds and their viral load rises, then they can transmit HIV Encourage them to talk to their partners, get tested, used condoms and PrEP in combination with TasP if they choose Can I still spread HIV? Um?...

22 Talking to Clients Helping them understand that they still have HIV and still need to take their meds and take care of themselves, but tell them the science Sharing this information with clients This concept is a powerful encouragement for people with HIV to engage in care and adhere to treatment Engage them and have a conversation to get a sense of their feelings around

23 Tips For Adherence to Antiretrovirals Establish Readiness Psychosocial issues Active substance use/risk of lapse Low literacy level Lack of disclosure Skepticism about ART Insurance costs/co-pays Busy schedule Social support Strategies to Up Adherence Patient education Use simplified regimens Case management Substance abuse treatment Support groups Reminder devices/pill boxes Treat underlying mental illness Build trust with patient

24 Criminalization Laws What does U=U mean for HIV criminalization laws?...hopefully changes to these laws VA HIV Disclosure Laws Class 6 Felony Any person who, knowing he or she is infected with HIV, has sexual intercourse, cunnilingus, fellatio, analingus or anal intercourse with the intent to transmit the infection 1 to 5 years in prison and $2,500 fine Class 1 Misdemeanor Any person who, knowing he or she is infected with HIV, has sexual intercourse, cunnilingus, fellatio, analingus or anal intercourse without having previously disclosed the existence of his or her HIV infection to the other person 1 year in jail and $2,500 fine

25 Moving Forward Sharing this information with the community, colleagues and most importantly, your clients Your personal beliefs may not align with U=U, but it s a proven prevention method and it s your duty as a healthcare provider to give your clients accurate and scientifically proven information How you word things and the conversations you have is up to you Your agency taking a position on it Criminalization laws changing

26 Wrapping Up U=U is undetectable = Untransmittable and is for sexual transmission only Has caveats where a person living with HIV needs to have an undetectable viral load and stay undetectable for at least 6 months In addition to being a prevention method, U=U improves the lives of those with HIV, dismantles HIV stigma and incentivizes folks to get tested, go on treatment and stay on treatment, which reduces transmission in the community Can be controversial to some, but remember there is no problem with science, but more of a social issue. Science proves this works As providers it s our job to share this information with our clients and engage them to set a sense of their feelings, but essentially it s their decision to make. Also, working with them on their readiness and strategies for adherence

27 Any Questions

28 References AVERT, Treatment as Prevention (TASP) for HIV. AVERT, August 15, 2017, Carter, Michael. Most Viral Load Blips Are Short-Lasting and of No Significance. NAM: AIDSMAP, May 19, 2008, Caivano, Nicholas and Ka Hon Chu, Sandra. U=U and The Overly-Broad Criminalization of HIV Nondisclosure. European AIDS Treatment Group, September 6, 2017, CATIE. Bruce Richman: Undetectable Equals Untransmittable. CATIEinfo, January 29, 2018, Collins, Simon. The Evidence for U=U (Undetectable = Untransmittable): Why Negligible Risk Is Zero Risk. i-base, April 20, 2018, i- base.info/htb/32308 Koren, David. Use of Antiretroviral Therapy in Clinical Practice. HIV Medical Management: Didactic and Clinical Experience for Providers, May 7, 2018, Philadelphia, PA Lyall, H. Breastfeeding in HIV-Positive Women. British HIV Association Autumn Conference, November 16, 2017 Prevention Access Campaign, February 15, Retrieved from Rashbaum, Bruce, personal communication, May 2018 Richman, Bruce. U=U: The Backstory. CATIE, 10, December 2017, Minnesota Department of Health, Undetectable = Untransmittable (U=U). Minnesota Department of Health, May 1, 2018,

29 MidAtlantic AIDS Education and Training Center - Contact Information Regional Partner: Inova Juniper Program 2740 Prosperity Ave Suite 200 Fairfax, VA Headquarters: MidAtlantic AIDS Education and Training Center Department of Infectious Diseases and Microbiology, Graduate School of Public Health, University of Pittsburgh maaetc@pitt.edu Linda Rose Frank, PHD, MSN, ACRN, FAAN Principal Investigator and Program Director Associate Professor of Public Health, Medicine & Nursing University of Pittsburgh