German NGO endorses treatment as prevention

Deutsche AIDS-Hilfe, the largest HIV voluntary sector organisation in Germany has issued a position paper on the role of treatment in HIV prevention which broadly echoes and supports last year’s landmark Swiss statement on the limited risk of a person taking effective HIV treatment passing on their infection.

Whereas the Swiss had stated in definitive terms that people on effective combination therapy and without any sexually transmitted infections cannot sexually transmit HIV, the German paper describes transmission in these circumstances as “unlikely”, and suggests that this approach is as effective as the use of condoms.

Moreover, the Germans stress the importance not only of sexually transmitted infections, but also of other health problems which can damage mucous membranes, and so increase the risk of HIV transmission.

January 2008’s statement from leading Swiss HIV doctors argued that HIV-positive people who were taking antiretroviral therapy with an undetectable viral load in their blood and no sexually transmitted infections could not pass on HIV to their sexual partners.

According to Deutsche AIDS-Hilfe, if the following conditions are met, the sexual transmission of HIV is unlikely:

• The HIV-positive partner’s viral load has been undetectable for at least six months.
• There is good adherence to antiretroviral treatment.
• There is no damage to mucous membranes.

They say that in these circumstances, the risk of HIV transmission is negligibly low, and is comparable to the transmission risk with 100% condom use. If an individual combines condom use with controlled viral load, then the transmission risk is described as close to zero.

Like the Swiss Federal Commission for HIV/AIDS, Deutsche AIDS-Hilfe consider that this information will be relevant to stable, long-term relationships where one partner has HIV. After a couple has made an informed and joint decision, they recommend viral load monitoring every three months and regular check-ups for sexually transmitted infections.

Sexually transmitted infections increase the risk of HIV transmission, either by raising viral load in the positive partner, or because sores and lesions damage mucous membranes and make it easier for HIV to enter the bloodstream. However Deutsche AIDS-Hilfe draw attention not only to sexually transmitted infections like syphilis and herpes, but also to other causes of damage to mucosal surfaces in the vagina, penis, anus and gut. Damage may also be caused by conditions which cause inflammation of the gut like ulcerative colitis and Crohn’s disease, or by fistulas (abnormal passages, for example between the vagina and the bladder).

The paper mentions cases where HIV has been detected in semen although it was undetectable in the same person’s blood, and also highlights the case of the German man who was reported last August to have transmitted HIV to his regular partner, although his viral load had been undetectable for some time and neither man reported any sexually transmitted infections.

Nonetheless Deutsche AIDS-Hilfe argue for a ‘realistic’ HIV prevention approach which recognises that individuals do not necessarily aim to completely eliminate all risks, but balance risk reduction against sexual desires. They emphasise that individuals will make their own decisions according to their own priorities.

Moreover, although they acknowledge that there is very little evidence available on the effect of viral load on infections between gay men, they suggest that such evidence is unlikely to be produced in the foreseeable future. They argue that it is logical to assume that gay men on effective treatment also experience dramatic reductions in their infectiousness.

The paper summarises the different advantages and disadvantages of condom use and of the ‘viral load method’. Before being used, condoms need a less involved discussion than the viral load method, and also protect against other sexually transmitted infections and unwanted pregnancy. On the other hand, they are less effective when they are not used correctly, or if they are used inconsistently.

The viral load approach is said to have the advantage that it will provide protection even during sexual practices like oral sex that are usually considered ‘low risk’ enough for condoms not to be used. Moreover, pregnancy can be achieved. Disadvantages of this approach are the lack of protection against other sexually transmitted infections, the complexity of the conditions for its use, and the possibility of an unnoticed increase in viral load as a result of treatment failure.