Paul Dalton and Alan McCord

In January 2008, the Swiss AIDS Commission issued a controversial Statement on the transmission of HIV in heterosexual mixed status couples. It stated that HIV is not likely to be passed on when the positive partner fully adhered to a potent HIV regimen, had undetectable viral load for at least six months, and did not have any other sexually transmitted infection (STI) during that time, even despite sex without condoms.

What ensued has been tumultuous community discourse and opinion pieces worldwide. Some have denounced the Swiss Government as irresponsible. Others responded with “no comment”. Few others, like Project Inform, invited this as a way to discuss issues faced by people living with and affected by HIV.

This outcry stems from the perception that the Swiss Government was saying that people who take effective HIV drugs can stop having safer sex or abandon their condom use without infecting their partners. The panelists were clear: this is not their message. Some have criticized other aspects of the Statement, arguing it failed to address other issues, such men who have sex with men.

The Sunday afternoon session, HIV Transmission under ART, provided a forum to discuss this Statement. Seven panelists attempted to clarify the persistent questions that have lingered ever since to a crowd of about 300. Project Inform believes the conversations the Statement has spurred can help inform discussions formany people living with HIV, as detailed below. Understand this statement in its context.

At various points throughout this epidemic, many medical, social and behavioral issues have emerged. We have grappled with the risks of casual transmission and oral sex — each without definitive research. In these cases, observations and an understanding of the mechanics of HIV transmission helped mold recommendations that have stood the test of time. A study called HPTN 052 is currently enrolling, designed to answer the risks of transmission under HAART. The results likely won’t be available until 2016, at which point we may look back and wonder what the commotion was all about. We also might ask ourselves, how many new infections could have been prevented in the meantime?

Understand the limitations of the statement.
Too often critics of the Swiss Statement have used its limitations to dismiss the it entirely. This is both scientifically and ethically unsound. Science works best when studies and reports are examined honestly, taking into account both their strengths and weaknesses. Some have said it’s premature to talk about these data until such time that there are more mature and definitive results. One panelist reminded the audience of the experience of male circumcision where 17 years elapsed between the emergence of supportive circumstantial evidence in reducing HIV infection rates, and the definitive results from prospective, randomized studies.

It is possible to encourage conversations with couples on issues that they can do something about. This includes encouraging each partner to disclose his/her status, to discuss their fears, or to even start engaging in safer sex, among many others. In some parts of the world, health care systems are overburdened and cannot accommodate these discussions. For many, viral load or STI tests are unavailable. For others, medical infrastructures barely exist. Though the world has reacted to this Statement, it may very well not apply to most of the planet.

A weakness of the Statement is that the data came from studies of heterosexual sex. In the US, the CDC estimates about half of new HIV infections are among MSM, reinforcing the importance of studying the impact of treatment on prevention among this group. Provide accurate information.

The Statement provides a good deal of applicable data, much buried beneath the vocal backlash. Physicians, community workers and others who interact with HIV-positive people and their partners can and must provide information clearly and accurately. The basic model of fully informed decision-making that has defined Project Inform’s approach to HIV treatment decisions is just as applicable to this situation.

Get regular health care.
One undeniable take-home message is the critical importance of having accurate medical information to make informed decisions. Vast inequalities in access to things like viral load tests and STI screening must be accounted for in settings worldwide. Some panelists felt that these differences render the Statement largely meaningless to most people with HIV. Project Inform sees it differently. It is much like the early data on combination therapy: information that might have only applied to few people at that time can have profound implications for far more people down the line. As seasoned AIDS activist Heidi Nass puts it, ‘progress in progress.’

Use this as a tool.
Project Inform encourages sophisticated conversations among mixed status couples and others. After nearly three decades of the epidemic, a great deal is known about how HIV is and is not passed. Each partner, along with their doctors, can be encouraged to discuss these issues. These data, when discussed alongside a person’s needs for true sexual intimacy, can lead to fuller and more honest discussions between sexual partners.

As we have stated in our March 2008 response to the Swiss Statement, we encourage all sexually active individuals to learn their status by regularly testing for HIV; we encourage treating HIV as early as individuals are ready to start and the medical information suggests; we encourage adhering to HIV treatment while practicing safer sex; and we encourage the honest conversations between partners and their providers on the medical and behavioral issues of transmission.

Practice safer sex.
The Swiss Statement does not suggest individuals abandon using condoms or other safer sex practices. In fact, it spotlights the necessity for a couple’s continued diligence in this area. One panelist argued that condom use without treatment is about as protective as treatment without condoms. The Statement argues that the best possible prevention comes from combining treatment and condoms. Accurate information on transmission risk should drive these decisions.

Also worth pointing out is how little attention has been paid to issues of pleasure, intimacy and stigma facing people with HIV throughout these public debates. While researchers might not place much emphasis on these issues, they’re of great importance to people living with HIV. They have profound implications for their emotional and sexual well being.

Push this discussion to test for HIV.
The Statement underscores the need to reach those who are undiagnosed or untested. These discussions can only work when people know their HIV status. Most estimates show about 1 in 4 Americans with HIV do not know they have HIV. Project Inform encourages testing as a way to take control of one’s life.

Explore ways to prevent HIV.
The Statement highlights the role that effective treatment plays in preventing new infections. Project Inform recently revised its mission statement to include biomedical prevention to help reduce new infections. This includes interventions such as Pre-Exposure Prophylaxis (PrEP), vaginal and rectal microbicides, and male circumcision, among others. These alternate methods should be considered as being additive and synergistic to behavioral interventions such as condom use. Therefore, no one method should preclude the others. The more choices one has, the better. The better the data are, the more confidence people can have in their choices.

The “asymmetry of risk”.
One interesting point raised by a panelist was the asymmetry of risk. If you say something is dangerous, and it turns out not to be so, there’s usually little consequence. However, if you claim something is not risky and it turns out to cause harm, the repercussions can be catastrophic. This can lead groups to be overly conservative in protecting their own interests. Looked at in this light, the Swiss Statement is remarkable.

Raise new research questions.
Much new data need to be uncovered to more fully answer the concerns raised by the community. How do STIs play a role in transmission and at what level? Do different strains of HIV affect its transmission? Do different classes of HIV drugs affect the levels of HIV in genital secretions differently? How do viral load blips affect transmission? How much do we know about HIV transmission through oral, vaginal or anal sex? Pursuing these and other questions are critical to help better inform those faced with these decisions.

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