Providers should discuss U=U with all patients living with HIV

Calabrese, Sarah K.; Mayer, Kenneth H.

doi:10.1016/s2352-3018(19)30030-x

Cited by 69 publications

(50 citation statements)

References 8 publications

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“…Health providers play a key role in communicating new health interventions, including U = U and PrEP [23,24]. The U = U knowledge gap has been reported in a recent global survey of clinicians [23]. Consistent with other studies, there is therefore a need to support health providers on the science behind U = U so that they can effectively communicate U = U in a believable way [23,25].…”

Section: Discussionmentioning

confidence: 80%

“I just believe there is a risk” understanding of undetectable equals untransmissible (U = U) among health providers and HIV‐negative partners in serodiscordant relationships in Kenya

et al. 2020

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Introduction Sustained HIV viral suppression resulting from antiretroviral therapy (ART) eliminates the risk of HIV transmission, a concept popularly framed as Undetectable = Untransmittable (U = U). We explored knowledge and acceptance of information around the elimination of HIV transmission risk with ART (U = U) in Kenya. Methods Our qualitative study was conducted within a project evaluating the use of pre‐exposure prophylaxis (PrEP) integrated into ART care for HIV serodiscordant couples in public clinics in Kenya (the Partners Scale Up Project). From February 2017 to April 2019, we conducted semi‐structured key informant interviews with 83 health providers and in‐depth interviews with 61 HIV‐negative people in serodiscordant relationships receiving PrEP services. Transcripts were coded using thematic analysis. Results Health providers reported being aware of reduced risk of HIV transmission as a result of consistent ART use and used words such as “very low,” “minimal” and “like zero” to describe HIV transmission risk after viral suppression. Providers reported finding viral load results helpful when counselling clients about the risk of HIV transmission. Many lacked confidence in U = U and counselled on consistent condom use even after viral suppression while some expressed concerns that communicating this message to people living with HIV (PLHIV) would lead them to engage in multiple sexual relationships. Other providers reported that they did not counsel about the reduced risk of HIV transmission after viral suppression for fear of being blamed if HIV transmission occurred. HIV‐negative partners reported being informed about U = U by providers but they did not believe nor trust the message. Even after their partners achieved viral suppression, some HIV‐negative partners were unwilling to stop PrEP, while others indicated that they would use condoms if they stopped PrEP to be sure that they were protected from HIV. Conclusions Despite awareness that effective ART use eliminates HIV transmission risk, there is both a lack of in‐depth knowledge and conviction about the strategy among health providers and HIV‐negative partners in serodiscordant relationships. New strategies that go beyond communicating the science of U = U to consider the local social and clinical environments could maximize the effectiveness of U = U.

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Section: Discussionmentioning

confidence: 80%

“I just believe there is a risk” understanding of undetectable equals untransmissible (U = U) among health providers and HIV‐negative partners in serodiscordant relationships in Kenya

et al. 2020

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“…Moreover, when thinking specifically about serodiscordant couples, recent results from Opposites Attract suggest that PrEP might be useful in the initial months of a relationship or during the first months of ART initiation, after which ARTinduced viral suppression is likely sufficient [50]. Here, the need to disseminate the knowledge that U=U (undetectable = untransmissible) should be emphasized [51]. As suggested in a recent review of HIV epidemiology in Latin America [4], U=U knowledge "empowers people living with HIV, improves adherence and decreases selfstigma" and it may also improve intimate relationships by decreasing fear of transmission.…”

Section: Discussionmentioning

confidence: 99%

How heterogeneous are MSM from Brazilian cities? An analysis of sexual behavior and perceived risk and a description of trends in awareness and willingness to use pre-exposure prophylaxis

et al. 2019

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Background: Brazil has the largest population of individuals living with HIV/AIDS in Latin America, with a disproportional prevalence of infection among gays, bisexuals and other men who have sex with men (MSM). Of relevance to prevention and treatment efforts, Brazilian MSM from different regions may differ in behaviors and risk perception related to HIV. Methods: We report on MSM living in 29 different cities: 26 Brazilian state capitals, the Federal District and two large cities in São Paulo state assessed in three web-based surveys (2016-2018) advertised on Grindr, Hornet and Facebook. Using logistic regression models, we assessed the association of risk behavior with HIV perceived risk as well as factors associated with high-risk behavior. Results: A total of 16,667 MSM completed the survey. Overall, MSM from the North and Northeast were younger, more black/mixed-black, of lower income and lower education compared to MSM from the South, Southeast and Central-west. Though 17% had never tested for HIV (with higher percentages in the North and Northeast), condomless receptive anal sex (previous 6 months) and high-risk behavior as per HIV Incidence Risk scale for MSM were observed for 41 and 64%, respectively. Sexual behavior and HIV perceived risk had low variability by city and high-risk behavior was strongly associated with high HIV perceived risk. Younger age, being gay/homosexual, having a steady partner, binge drinking, report of sexually transmitted infection (STI) and ever testing for HIV were associated with increased odds of high-risk behavior. Awareness and willingness to use PrEP increased from 2016 to 2018 in most cities. Conclusions: Overall, MSM socio-demographic characteristics were heterogeneous among Brazilian cities, but similarities were noted among the cities from the same administrative region with a marked exception of the Federal District not following the patterns for the Central-West. Combination HIV prevention is most needed among young men who self-identify as gay/homosexual, report binge drinking or prior STI.

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“…The finding that there is no viral transmission between sero-different couples when the HIV-positive partner has HIV RNA levels below the threshold of 200 copies/mL [5] has led to the undetectable = untransmittable (U=U) campaign [6], which has reduced the stigma associated with HIV infection and promoted the retention in care of PLWHAs [7]. It is also well known that factors such as bacterial infections, influenza vaccinations and poor adherence to ART can cause a transient viral rebound that may not require a change in antiretroviral regimen: interestingly, Kolber et al found that seven of their 34 patients experienced a viral rebound after an influenza vaccination, two of whom showed RT and PR mutations [8][9][10][11], although it is not clear whether these were primary mutations or a spillover of previous archived mutations [10].…”

Section: Discussionmentioning

confidence: 99%

Multidrug-resistant HIV viral rebound during early syphilis: a case report

et al. 2020

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Background: Syphilis has been associated with an increase in HIV RNA and a temporary decline in CD4 T cell counts in people living with HIV who are not receiving antiretroviral treatment (ART), and may be associated with a transient HIV RNA rebound in those who are receiving ART. Our case is the first to highlight the risk of a multidrugresistant HIV viral rebound during the course of early syphilis even if antiretroviral drug concentrations are within the therapeutic range. Case presentation: This 50-year-old HIV-1-positive male patient with concomitant early syphilis presented with an HIV RNA rebound (8908 copies/mL) during a scheduled visit to our clinic. He was receiving a stable ART regimen consisting of darunavir/cobicistat plus dolutegravir, and had a 15-year history of viral suppression. Good short-term drug adherence could be inferred as liquid chromatography tandem mass spectrometry showed that his trough antiretroviral drug concentrations were within the therapeutic range: darunavir 2353 ng/mL (minimum effective concentration > 500 ng/mL) and dolutegravir 986 ng/mL (minimum effective concentration > 100 ng/mL). A plasma RNA genotype resistance test revealed wild-type virus in the integrase region and protease region (PR), but extensive resistance in the reverse transcriptase (RT) region (M41L, E44D, D67N, K70R, M184V, L210W and T215Y). Phylogenetic analysis of next-generation sequences (used to investigate the presence of minor viral variants), the PR and RT sequences from plasma HIV RNA and pro-viral DNA extracted from peripheral blood mononuclear cells during the viral rebound, and a Sanger sequence obtained during a previous virological failure suggested clonal viral expression because the previous PR resistance mutations had been lost or had not been archived in pro-viral DNA. Conclusions: This case shows that early syphilis may cause an HIV RNA rebound in patients under stable virological control with the potential of transmitting an extensively drug-resistant virus.

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Providers should discuss U=U with all patients living with HIV

Cited by 69 publications

References 8 publications

“I just believe there is a risk” understanding of undetectable equals untransmissible (U = U) among health providers and HIV‐negative partners in serodiscordant relationships in Kenya

“I just believe there is a risk” understanding of undetectable equals untransmissible (U = U) among health providers and HIV‐negative partners in serodiscordant relationships in Kenya

How heterogeneous are MSM from Brazilian cities? An analysis of sexual behavior and perceived risk and a description of trends in awareness and willingness to use pre-exposure prophylaxis

Multidrug-resistant HIV viral rebound during early syphilis: a case report

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