>> I think it's quite likely that at least one of these 5 people have... something in their body that could be transfected into another person's cells and cause an active HIV infection.
No, they definitely don't. It's well known[1] that people without detectable levels of HIV in their blood cannot transmit HIV to other people. That is true for people who are simply receiving normal treatments (see: https://www.nih.gov/news-events/news-releases/science-clear-...). It is certainly also true for these transplant recipients.
Edit:
[1]: Specifically, researchers have never observed transmission from someone with undetectable viral load, despite many large studies searching for such an event
What you've said is true, but I'd add that there are worrying number of HIV+ men that have stopped disclosing their status to sexual partners because they've heard that "undetectable = untransmissible." While that does seem to be true, there are a number of problems with this:
1. Not everyone takes their medications exactly as prescribed.
2. Lots of folks on antiretroviral therapy are not undetectable, or may move between undetectable and detectable over time.
It's important that people still disclose their status to sex partners.
A lot of misconceptions in this and other comments. To address the two most glaring ones:
> 1. Not everyone takes their medications exactly as prescribed.
That's irrelevant. Not only is there a fair amount of leeway in the standard dosing schedules (meaning that missing some doses does not actually cause a clinically meaningful impact), but the studies that demonstrate that U=U are based on real-world applications. Variability from adherence is already captured by the results.
> 2. Lots of folks on antiretroviral therapy are not undetectable, or may move between undetectable and detectable over time.
This is not true and based on an incorrect understanding of what "undetectable" signifies clinically. Once a person has durably achieved clinical undetectability under HAART, they do remain undetectable, as long as there is no prolonged disruption in treatment[0]. The most common reason for a disruption in treatment is an inability to access treatment - not something that happens without the person's full awareness.
People on Internet forums like HN like to get worked up about bogeymen like people intentionally not taking their medications, but actual clinical data shows that stuff is largely the realm of urban legends, not reality. And if you're that concerned about it, the answer is simple: PrEP prevents HIV with a near-100% efficacy, rendering the question "is this person undetectable?" moot.
[0] Emphasis on prolonged. Missing a few days, or even a week or two, does not cause HIV to become detectable again. These sorts of treatment interruptions are contraindicated, but for other unrelated clinical reasons, not because of the impact on viral load.
While you are right, I don't think any of this is an excuse for not sharing your status.
Yes we should remove the stigma around HIV and I am sympathetic towards those that have it and still deal with that stigma that very much exists within the gay community.
Myself I am on Prep, and while it is a near 100% it is not in fact 100%. And yes I know I can't get it from someone who is undetectable.
But I also know I had a situation where after hooking up with someone I found out they were undetectable. That made me feel uncomfortable, largely because he did not tell me. It immediately made me question, is this guy actually undetectable as he is claiming? Is he taking is medication properly? Is there something else he didn't tell me.
To be clear I have hooked up with people who have that information in their profile or they told me beforehand, but I have major issues with not being up front with that information if we are about to have sex. I would expect the same for any STD, testing positive for Covid, or any other thing that could have an impact on me.
> as long as there is no prolonged disruption in treatment
Which happens all the time. Treatment is significantly more burdensome and expensive than women taking birth control, for example, and we all know how accidents still happen.
Notice how you’re shifting the blame to the victim, who was knowingly put at risk. “It’s really your fault because you’re not on Prep.”
It’s just bizarre how worked up people get about not wanting to be honest with their sex partners. It’s basic human decency.
Birth control has way less leeway than the parent describes hiv treatment. Oral birth control fluctuates wildly and must be taken literally within the same hour or so every day. I don’t think birth control and hiv transmissibility are comparable cases here, because the potential for pregnancy and the potential for hiv infection don’t appear to work remotely similarly. I don’t personally have a horse in this race, I’m merely pointing out I think this comes off as not understanding pregnancy prevention, hiv treatment, or both.
No analogy is perfect. My point is that people go on and off HIV medication all the time for all sorts of reasons: costs, burden, side effects, etc. By comparison birth control is very easy. It’s an example how medicine can be effective, but still create risks in real life.
The parent poster says going off hiv medication doesn’t really happen outside of external circumstances and even when it does it takes weeks to cause a problem. This isn’t the same for birth control.
> there are worrying number of HIV+ men that have stopped disclosing their status to sexual partners because they've heard that "undetectable = untransmissible."
I thought that was the entire point of the “undetectable = untransmissible” campaign — freeing people from worrying about passing it to others and having to live with a scarlet letter, which is an incentive to get treated
> It’s important that people still disclose their status
Nobody is saying you should live with a scarlet letter. But you should disclose to people you're having sex with your status and let them make an informed decision.
Untreated HIV (usually) takes years to cause AIDS, and then takes months to years for you to die from it. Before you have AIDS, you can still start treatment, and can still enjoy a long life afterwards. That being said though, the earlier you start treatment, the better.
So yes, there are still strong incentives to get tested, but people still don't get tested when having HIV is criminalized.
Yes okay, so you should have a scarlet letter only visible to people with whom you have a class of relationship that is particularly fundamental for human happiness.
If you’re having consensual sex, you should be able to discuss the risks with your sex partner. It isn’t a scarlet letter to discuss the fact that you have a disease which is understood to be currently noncommunicable. It’s discussed openly in communities with high risk factors. Keeping known risk factors from your partners is a betrayal of their trust effectively on par with violation of their consent. It denies them the possibility to even determine whether they understand the risks they’re taking. It further denies them the ability to evaluate that risk over time as their partners’ input to that risk might evolve.
None of this is specific to HIV! This is basic interpersonal responsibility as taught to middle school children basically everywhere that doesn’t have a severely toxic anti-sex culture. Clear and honest communication about risk of disease is essential to healthy, consensual sex. And that’s been known since at least when I was a teenager well back into the last century.
This is a perfect counterexample for the flawed logic of the argument put forth by another commenter above, which appears in marketing materials for drug companies in American media, frighteningly.
In the first year after achieving VL undetectability, 354/1386 (25.5%) patients experienced low-level VL rebound, the remaining patients maintained consistent undetectability. Low-level rebound occurred less commonly with non-nucleoside reverse transcriptase inhibitor (NNRTI)-based HAART than with other regimens (P = 0.01). Over median 2.2 (range 0.0-7.4) years of subsequent follow-up, 86 (6.2%) patients experienced virological failure, corresponding to 2.30 failures per 100 person-years (95% confidence interval [CI] 1.82-2.79). Independent predictors of virological failure included low-level rebound during the first year after achieving undetectability relative to consistent undetectability (rate ratio [RR] 2.18, 95%0 CI 1.15-4.10), female gender (RR 1.79, 95% CI 1.12-2.85) and receiving a ritonavir-boosted protease inhibitor (Pl/r) relative to NNRTI-based HAART (RR 1.88, 95% CI 1.02-3.46).
> In the first year after achieving VL undetectability...
I'm gathering from your comments that you don't have a clinical background in HIV research (because if you did, you would not be posting this as a reply).
Not only does your link not prove what you think it does, but it actually says the exact opposite: once a patient has durably achieved clinical undetectability under HAART, they do remain undetectable, even when using older generations of drugs that are no longer first-line treatments. It even states that in the conclusion: " Patients on first-line HAART who maintain consistent VL undetectability for 1 year have a low risk of subsequent virological failure."
To spell it out: the mistake you're making is that you're looking at a paper that studies treatment-naive patients and whether or not they durably achieve undetectability, whereas what we're talking about is patients who have already durably achieved undetectability.
So the paper you linked isn't particularly relevant to our conversation, because it's studying a completely unrelated endpoint, but by coincidence, it does actually corroborate the point I was making.
What you quoted does not support your point. “have a low risk of subsequent virological failure"
Low risk is not zero risk. Also the actual population of people who durably achieved undetectability is effectively a true Scotsman argument in that you reject people who seemed to achieve it who then became detectable again. We don’t have long term data saying all people who are undetectable for N years are undetectable for 40 years because the treatments aren’t that old. All we can do is extrapolate and people who are undetectable for even 4 years have become detectable.
Newer treatments look promising but they have even less long term data to extrapolate from. And of course things look even worse when people stop taking treatment for various reasons.
If you’re trying to use it as a scientific term then actually apply the term correctly. They specifically mention failures in such people in the actual paper though do indicate it’s a low risk for that population:
They note risk factors for increased viral load include include illness or vaccination etc. The intent may be to remove people who have regular failures but the definition isn’t purely based on their underlying medical condition. With that 1 year as a benchmark you’re excluding people who happened to experience such risk factors while excluding people who have yet to experience them.
> If you’re trying to use it as a scientific term then actually apply the term correctly.
Your comments in this thread are a very good example of the aphorism "a little knowledge is a dangerous thing". As I mentioned above, it's pretty clear that you don't have a clinical background in HIV, because you're mixing up terms that have precise clinical definitions and drawing conclusions that are not only not warranted, but actively contradicted by the data.
There are a lot of incorrect statements or mistaken assumptions that you're building on here. I've pointed out a few of them already, but without the contextual domain knowledge, it would be difficult to correct them all in a way that's accessible to a lay audience. It certainly would not be possible in the scope of an HN comment.
As a general note: it's okay not to be an expert in a given field, but in that case, please keep that in mind when discussing it. The ability to find information which appears intelligible does not in se imply the necessary knowledge to contextualize and interpret that information correctly. That's particularly true when talking about information written for an incredibly specialized audience - even most clinicians would not be expected to read a paper on this topic, because HIV is a fairly unique subfield that requires a lot of domain-specific knowledge.
I have done professional work with HIV, not in the last 4 years but I doubt much has changed.
You’re repeatedly ignoring data showing you are wrong and in this case dangerously wrong. Read the damn paper I linked or any of several others which show the same thing. HAART is good but not perfect.
That's rather vague wording, so I'm not really sure what I'm supposed to make of that.
As I've pointed out multiple times, your comments include rather basic mistakes in terminology which demonstrate a lack of clinical familiarity with the topic at hand. Those misunderstandings are causing you to make make inferences that are not valid. You're reading this as "ignoring data showing [I am] wrong", but in reality, it's that the data simply doesn't say what you think it does.
If that isn't convincing, you can look at it from the other end entirely: the original claim you made (that "it’s important that people still disclose their status" because "having undetectable levels on day 1 doesn’t mean you have undetectable levels on day X and people don’t test every single day") is a conclusion that is soundly rejected by both public health experts and epidemiologists who specialize in HIV treatment and prevention.
As a rule of thumb: if you're citing orthodox methodology and research to make extremely heterodox claims, that's a good sign that you've made a mistake somewhere along the line.
That's as much time as I'm really going to spend discussing on a comment thread that I now see is inaccessible because the original comment is now flagged dead (and, frankly, for good reason).
I guess there’s a difference between a mathematical proof and practical, real life truth. Multiple studies have looked for transmission across tens of thousands of unprotected penetrative sex acts. There’s also a solid theoretical backing to the concept - it lines up with how we think HIV transmission works.
So it’s a bit like saying maybe there’s Bigfoot out there. Sure, maybe, but we have a pretty good reason to think there isn’t. For practical purposes no one should assume big foot is out there.
I'm not saying they could transmit though sex, I'm saying they could be caused to transmit through what is essentially viral cloning, by taking either a cell (or probably many cells, because the recipient has an immune system) containing proviral DNA (i.e. the DNA created by HIV's reverse transcription mechanism), and putting it into the recipient, or by taking the HIV proviral DNA from that cell and transfecting cells of the recipient with it, similar to how you can clone a polio virus by transfecting a cell with the DNA of polio, even though polio is an RNA virus. This has been done by Vincent Racaniello using early DNA sequencing techniques, and could be tested in an animal because of the Gain of Function'd mouse model he made. I can't remember anyone being able to create an animal model for HIV though...
Well in that case I hope no one is out there transplanting cells from these people into other people. I can’t imagine why anyone would do that. It seems to me like this should still count as curing someone.
Well, I think being precise in virology is a good thing. For example being infected with SARS-CoV-2 and having the disease COVID-19 are not exactly the same thing, and matter quite a bit when writing a prescription for Paxlovid. You can't (or aren't supposed to) write off-label prescriptions for EUA drugs, so it does matter. Apparently they changed the EUA recently though, and Internet rules lawyers think they can prescribe it to people who don't have COVID-19 at all, so it might not matter at this point.
No, they definitely don't. It's well known[1] that people without detectable levels of HIV in their blood cannot transmit HIV to other people. That is true for people who are simply receiving normal treatments (see: https://www.nih.gov/news-events/news-releases/science-clear-...). It is certainly also true for these transplant recipients.
Edit: [1]: Specifically, researchers have never observed transmission from someone with undetectable viral load, despite many large studies searching for such an event