How Does Treatment as Prevention Benefit My Patients with HIV?

Evidence from Three Landmark Studies

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Three landmark studies have shown that treatment prevents sexual transmission of HIV.^1-3 Across all three studies, no linked HIV transmissions were observed between mixed-HIV-status partners when the partner with HIV was virally suppressed (defined in these studies as having a plasma HIV RNA viral load less than either 200 or 400 copies/mL).

These data provide conclusive evidence of the power of viral suppression in preventing HIV transmission. Although statistically, a non-zero risk estimate can never be completely ruled out in a mathematical sense, despite the number of observations, the data tell us that the best estimate for the transmission risk is zero and that future HIV transmissions are not expected when people with HIV remain virally suppressed.

If taken as prescribed, antiretroviral therapy (ART) reduces the amount of HIV in the body (viral load) to a very low level, which keeps the immune system working and prevents illness. This is called viral suppression—defined as having less than 200 copies of HIV per milliliter of blood. HIV medicine can even make the viral load so low that a test can’t detect it. This is called an undetectable viral load.

Getting and keeping an undetectable viral load by taking ART is the best thing your patients with HIV can do to stay healthy and prevent transmission of HIV to others through sex. This is sometimes referred to as treatment as prevention (TasP). Your patients may also refer to treatment as prevention as Undetectable = Untransmittable or U=U. The U=U campaign was developed by members of the HIV community to increase awareness about the relationship between viral suppression and the prevention of sexual transmission of HIV.

There is strong evidence about treatment as prevention for preventing HIV transmission through sex, but more research is needed for other ways, including breast/chestfeeding and injection drug use.

Health care providers who treat patients with HIV have an important role in supporting HIV prevention. Talking to your patients with HIV about treatment as prevention is one of the best things you can do for their overall health and to stop HIV transmission. Because a patient’s needs may change over time, engage each patient in brief conversations at every visit to discuss the prevention steps they are taking and whether treatment as prevention is right for them. These conversations can help you become more familiar with each patient, including their adherence and transmission risk. In addition, these conversations can normalize discussions about factors that may affect your patients’ health, such as sex, substance use, and mental health disorders.

Use the following tips and conversation starters to support your patients with HIV:

• Share information with your patients about the research on treatment as prevention and then ask them open-ended questions to start the conversation.
• Talk about the benefits of achieving and maintaining an undetectable viral load, including not being able to sexually transmit HIV to others.
• Emphasize that while treatment as prevention is a highly effective prevention strategy, its success depends on achieving and maintaining an undetectable viral load. Note that if a patient’s viral load increases, so does their risk of transmitting HIV to their HIV-negative partners through sex.
• Discuss the prevention steps your patients are taking to help them adhere to their treatment regimen and maintain an undetectable viral load.
• Use the information your patients share with you to identify barriers they may have to adhering to ART and regular, ongoing care that may make it difficult for them to achieve and maintain viral suppression.

Your patients with HIV who use or want to use ART as their primary means of prevention may benefit from additional prevention methods if either partner desires added security for HIV protection or is concerned about sexually transmitted infections (STIs). These methods could include pre-exposure prophylaxis (PrEP) and/or condoms. Using multiple HIV prevention methods is especially important if the person with HIV has trouble with adhering to ART, has taken ART for less than 6 months, or has not yet achieved or maintained viral suppression.

To help all people with HIV and their partners get maximal benefit from treatment as prevention as an intervention strategy, it is important for providers, people with HIV, and their partners to have clear information regarding the benefits of and the challenges with achieving and maintaining viral suppression. Some challenges are further detailed in the text boxes below.