The PARTNER study, a licence to bareback?
Absence of evidence is not evidence of absence. Does the PARTNER study signal the death of condoms or should we curb our enthusiasm, and carry on pretending we use them?
The preliminary results of the PARTNER study were one of the most talked about data presented at the CROI 2014 conference held in Boston this year. This multicentre study conducted across 75 centres in the EU was and still is looking at the risks of HIV transmission within couples where one partner is HIV-negative and the other is HIV-positive on treatment.
So far, the study has enrolled over 1,100 couples and based on an interim analysis including 16,400 occasions of sex in gay men and 28,000 in heterosexuals couple, no case of HIV transmission has been observed between an HIV positive person with a viral load below 200 copies/ml and their HIV negative partner (Read the Aidsmap report for more details and watch a video about the study).
Does this mean that gay men can finally ditch condoms with their HIV positive sexual partners on treatment? Well, it is not that simple.
We need to acknowledge that the results of the PARTNER study are preliminary but also that they are another stepping stone in a series of studies demonstrating that antiretroviral treatment can reduce the risk of HIV transmission, otherwise known as Treatment as/for Prevention (TasP). Before PARTNER, the HPTN 052 study conducted among heterosexual couples in Sub-Saharan Africa had already shown a 96% reduction in the risk of transmission. Other studies in KwaZulu Natal and Malawi have also showed reduced risk of HIV transmission even with limited treatment coverage. Further back in time, the 2008 Swiss Statement had already indicated that within specific circumstances, HIV infected individual could be considered as not infectious.
As always, it takes time for scientific results to diffuse from the scientific community to the public, and when it does, one can be sure it will trigger all kind of debates and arguments more than often entrenched in beliefs and prejudices than facts.
One of the key facts in the PARTNER study is that being on treatment is not good enough to prevent HIV transmission. Viral load of the HIV infected must be below 200 copies/ml, and the statistical analysis leading to the much publicised conclusion actually specifically excluded people with a viral load above 200 copies/ml, as were couples in which HIV-negative partners took PEP or PrEP or couples in which people did not attend follow-up visits. It also showed that infections could happen and often be attributable to sexual encounters outside an established relationship.
Nevertheless, taken together, existing study results support a conclusion that the Swiss Statement suggested 5 years ago. So what to make of it?
Whilst most of the community welcomed the news for its potential to affect the course of the epidemic, other have adopted a more prudent and critical approach. Kristian Johns, writing for GMFA is one of those for whom being on treatment for HIV is not a licence to bareback (He is not alone and his column for FS is only used here as a case in point).
“Lads, lads, lads. Let’s just rein in our penises and hold fire on the condom-burning for a cotton-picking second. No transmissions doesn’t mean there’s a zero risk of transmitting HIV, it just means there were no transmissions. Granted, it’s encouraging, but only as encouraging as playing Russian Roulette with a loaded gun and getting away with your head intact after multiple tries. There’s still a bullet in the gun, my friends. ” write Johns in the issue 141 of FS magazine.
Kristian raised here the very valid point that no observed transmission does not mean no transmission at all and later that viral load must be controlled and that some people did become infected by people outside their relationship, finally adding that “until we have a cure for HIV, or at the very least, a vaccine, there is no ‘new negative’.”
There aren’t, but there are HIV positive people who are very closed to be “new negative” and some sexual intercourses much closer to no risk of transmission than anything else abstinence or condom can offer. Data from clinical trials not only prove it but epidemiological records also confirm it.
What optimism and its counter-reaction (much less publicised and Kristian Johns can be praised for voicing his concerns, as should GMFA for printing them) indicate, is that facts and all the facts needs and must be explained because gay men can decide, based on an informed choice (which is something I believe FS stands for) to ditch or not condoms or to no longer feel guilty for not using condoms with some of their partners (and why not, start to enjoy sex again).
The reality is that, as individual, with a minimum of educational intent and effort, we can take control of our sexual life, and relax those clenched cheeks that make us looks like an uptight condom brigade Janissary.
If condoms work for you then carry on with using them, but as fellow writer Gus Cairns wrote “[the PARTNER study] confirms that we gay men have to change our ideas about infectiousness and HIV radically if we are to stand a chance of reducing HIV infection in our community.”
The message of the PARTNER study is not to ditch condoms but to change our understanding and beliefs about our risk of getting infected by HIV. Whilst serosorting, seropositioning and negotiated safety have failed to show real effectiveness, whilst PrEP is not available in the UK, whilst PEP is underused, whilst condom use is on the decline, treatment as/for prevention has shown a string of successes in reducing HIV transmission.
What the PARTNER study should forces us to do is to rethink our relationship with HIV status; it should forces us to question our preferences for sexual partners with an alleged or declared HIV negative status and our discriminatory attitude toward those HIV positive (until we become one of them).
What PARTNER, HPTN 052 and other treatment as/for prevention studies should do is not to lead us to react against the possibility of an HIV-free generation but to revisit our HIV prevention messages and beyond our HIV prevention strategies.
What the PARTNER study should not do is to throw us back into dualist and outdated debates about HIV prevention.
Institutionalised HIV prevention tends to be monolithic, and why bother with it if “Bareback feels good and there’s no amount of health promotion that’s going to convince penis-owners of anything else”, as wrote Kristian. That statement is in need of qualification. True, most people, whether they are gay or not, whether it is about HIV or not, will remain impervious to prevention messages of all sorts as long as they do not feel they are at risk. Look at 48-year-old Rachel Dilley, who recalls finding out she was HIV positive and never thought she could be at risk because she believed HIV only affected Black people in Africa.
For organisations involved in messaging prevention it is also a strong signal that they should get up to date with the science, that they should be wary of engaging in partisan debate, that they should built on evidence, engage with the research at much earlier stage of development and work hard(er) to make complex information intelligible facts.
There is no doubt that HIV transmission could occur from those on treatment with a perfect, undetectable viral load, even if we have not seen it yet. But an upfront dismissal of is neither justified nor justifiable. It only shows an inability to move along with clinical developments. It deprives men, particularly those who do not use condoms, of a prevention choice that could protect them from becoming infected, as long as they understand the limitations of treatment as/for prevention. It stigmatises HIV positive gay men who do not need to be reminded that they still have HIV as the pill(s) they take everyday does that for them.
Treatment for prevention is not a magic bullet. Until there is a HIV vaccine, there is no magic bullet, not even in that gun that some use to play “Russian Roulette” with; but there are guns that jam and TasP is the first prevention intervention to actually jam that gun.
~rjt
Edit 30/03: clarifications and (some) typos.
Just one brief comment: the name of the study is “PARTNER”, not “PARTNERS”.
Thx for spotting it, a lapse of attention in part caused by the Partners PrEP Study. Too many studies with similar names! (when you think I went to PARTNER to get the link…)