Talking about HIV status when you are undetectable – HIV update, 28 September 2022

Talking about HIV status when you are undetectable

Over the years, a lot of researchers have asked people with HIV about their decisions to talk about (or not talk about) having HIV with sexual partners. But not many of those studies have been done since it’s become well known that Undetectable = Untransmittable (U=U), in other words that people who have an undetectable viral load can’t pass on HIV to their sexual partners.

US researchers recently asked 20 undetectable gay men about discussing their HIV status with men they have sex with (or men they might have sex with).

Some men felt that partners ‘deserved to know’, especially if they were going to have anal sex. Most men believed that if there was the potential for a romantic relationship, mentioning HIV was the ‘authentic’ and ‘honest’ thing to do.

But many others didn’t feel this was the case because of U=U. "I just don’t see how there has to be a conversation had, if the person who’s undetectable knows they’re undetectable, knows they can’t transmit,” one man told the researchers.

Many participants disclosed when asked, but did not make the information readily available. They thought that partners not asking meant they are willing to assume the risk (which in their case is non-existent).

“I would say since [I’m] undetectable, it should be up to the other person to ask the question… you don’t necessarily have to [disclose] since the danger isn’t there so to speak, right?” said one man. “So if the other person wants to ask the question, it should be up to them to ask the question.”

Other interviewees said that by making their HIV status clear on their hook-up app profiles, they avoided ‘awkward conversations’ – they did not know when they were rejected due to HIV, which protected their emotional wellbeing.

Trials of new anti-HIV drug restart after setback

Last December, there was a major setback for the development of a new, long-acting HIV medication called islatravir. Some people taking part in clinical trials had falls in CD4 cells and other types of white blood cells. As a result, the studies were put on hold while the problem was investigated.

Last week, the pharmaceutical company developing islatravir announced that US drug regulators have given it permission to restart some studies of the drug for use as HIV treatment.

A daily pill and a weekly pill will be investigated. Both will be in lower doses than before – it is thought that these are less likely to have safety problems. The daily pill will be tested in combination with doravirine, another daily pill that has been available since 2018. The weekly pill will be tested in combination with lenacapavir, a twice-yearly injection that was approved by European and UK drug regulators in August.

But there has been no announcement about development of injections or implants under the skin. One of the hopes with islatravir was that it might be potent enough for formulations like these to work for several months at a time, but this now looks uncertain. And we know for sure that development of islatravir pills for prevention (PrEP) will not be taken forward.

HIV treatment in pregnancy

HIV treatment guidelines around the world give different advice on the best anti-HIV medications to take during pregnancy. But a new study from the US suggests that dolutegravir should be used in preference to atazanavir/ritonavir or raltegravir, with darunavir/ritonavir as an alternative if dolutegravir is not feasible.

The findings are likely to be taken into account by experts updating treatment guidelines in the UK, Europe and US. Their current guidelines are not in line with the outcomes of the study which tracked over 1200 pregnancies in people with HIV.

The researchers assessed how many people who started HIV treatment before or during pregnancy had an undetectable viral load at the time of delivery. This is crucial for preventing HIV from being passed on.

Whereas 96% of those taking dolutegravir had an undetectable viral load at the time of delivery, the percentage of women who were virally suppressed was lower for several other regimens (atazanavir/ritonavir 84%, darunavir/ritonavir 90%, raltegravir 89%, elvitegravir/cobicistat 90%). Results for rilpivirine were comparable with those for dolutegravir.

There were no clear differences in terms of adverse birth outcomes like babies being born early or underweight.

And, as we reported in the last HIV update, the latest data from other studies show that dolutegravir is not linked with birth defects.

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