Is U=U true? 15 questions and answers that you care about most

U=U is an abbreviation for the following phrase: Undetectable viral load = Unable to transmit the virus

This means that if a person living with HIV achieves an undetectable HIV viral load through antiretroviral therapy (ART), they will not transmit HIV even if they do not use condoms or take preventive medication (PrEP).

The protection achieved through treatment (ART) depends on the following factors:

ART treatment was continued stably for several months.
The viral load remained undetectable for several months – guidelines recommend six months.
Take your medicine on time every day.

Simply put, when the HIV viral load is undetectable, there are too few viruses to cause infection.

Although people receiving ART remain HIV positive, HIV transmission no longer poses a risk.

Most infections require a certain amount or concentration of virus to occur. For example, the viral load may need to be above 500, 1000 or 1500 copies per milliliter to be infectious. The actual upper limit is unknown, but an undetectable viral load means the virus is too low to pose a risk of infection.

HIV itself is a relatively difficult virus to contract, but ART treatment reduces this risk to zero.

Yes. The PARTNER study included both gay and lesbian and heterosexual couples.

In some heterosexual couples, the man is HIV positive, while in others, the woman is HIV positive.

About a third of the 900 couples in the PARTNER 1 study were gay men. The PARTNER 2 study included 1,000 gay couples.

In PARTNER 1, couples had unprotected sex more than 58,000 times. In PARTNER 2, the number was 77,000 times. There were no cases of HIV transmission associated with either study.

Yes. The specific drug combination is not important. U=U only requires that the viral load is undetectable. All ART treatments that achieve this mean U=U.

Yes. The PARTNER study collected information about the different types of sexual behaviors people had. For example, how many times people had oral, vaginal, or anal sex. The study also asked whether the HIV-negative partner was the active or passive partner. The study also covered whether ejaculation occurred.

The PARTNER report showed zero transmissions in all situations. This included the highest risk of HIV transmission, which is being the passive partner in anal sex.

Whether or not to use condoms is a personal choice. Or hopefully, it’s a decision you make with your partner. Condoms are highly effective in protecting against many sexually transmitted infections (STIs) and are an effective form of birth control to prevent pregnancy.

But if HIV is the only concern, then in the context of U=U there is no reason to continue using condoms.

Your partner must decide for themselves what is right for them.

They may want to use condoms for other reasons. Or they may still be concerned about HIV transmission. Sometimes it takes time for people to accept new evidence. Especially if they have been using condoms for years.

If one or both parties unknowingly have an STI, U=U still applies.

The PARTNER study included couples with reported STI incidence, usually in the context of open relationships. Despite the importance of routine STI testing and treatment if necessary, there were no cases of HIV transmission.

The risk of HIV transmission increases only if either partner is infected with an STI when ART is not used.

Guidelines recommend that viral load should be undetectable for six months before relying on U=U to provide 100% protection.

However, this is a cautious approach and is why the guidelines refer to “stable ART treatment”.

The guidelines say that viral load can become undetectable in up to three months, depending on the drug you choose. If you have a very high viral load when you start ART, it can sometimes take longer for the viral load to become undetectable. But using an integrase inhibitor in combination therapy can usually make the viral load undetectable within a month.

Occasional missed doses do not change U=U because the viral load will still be undetectable.

Good adherence is important, but you may need to miss 2-3 consecutive days of HIV medication before your viral load becomes detectable.

If you do miss a few days of ART in a row, it is important to check that your viral load is still undetectable before relying on U=U again. This is also important to avoid drug resistance. Good

adherence is essential with U=U. U=U depends on not missing HIV medicines too often.

Sometimes the viral load result will be over 50 and return to undetectable levels without a change in treatment. Any result less than 200 copies per milliliter will not affect U=U. In the PARTNER study, undetectable viral load was defined as less than 200 copies per milliliter.

With good compliance, viral load will not rebound.

Once your viral load has been undetectable for more than six months, your medications will continue to work as long as you take them. Good adherence is essential.

Interactions with HIV medicines may increase your risk of viral load rebound. This means checking with your pharmacist or doctor to make sure any new medicines or supplements (including over-the-counter medicines) will not interact with your ART.

Among people on stable ART treatment, less than 5% experience a rebound in viral load each year, and these rebound cases are almost all related to low compliance.

In the case of U=U, the distinction between “zero risk” and “minimal risk” is a technical detail that is not important in practice.

Technically, it is impossible to prove that something will not happen, even if the risk is truly zero. Instead, the scientific approach is to define a possible risk, no matter how small. For example, one in a million. For low-risk activities, this is easy to do, but for zero-risk activities, there is nothing to measure.

In these cases, a very small theoretical risk is effectively zero. That’s why scientists are happy to say that the risk of U=U is now zero. The risk is not “greatly reduced” or “negligible.” The risk is simply zero.

In the more than a decade since the 2007 Swiss statement, there have been no confirmed case reports of HIV transmission while the viral load was undetectable.

Even if a case were reported in the future, the absolute risk would be so low that it would still be effectively zero.

When people are on ART and their viral load is undetectable, the risk of other modes of HIV transmission is also reduced.

However, it does not reduce other risks to zero. For example, a baby can still be infected with HIV through breastfeeding even if the mother has an undetectable viral load. The risk of HIV transmission from sharing injection drug equipment is higher than sexual transmission. There is no evidence to support this risk being zero.

1. What is U=U?

2. What are the conditions for achieving U=U?

3. How can a person not be contagious?

4. Is U=U suitable for everyone?

5. Are all anti-HIV drugs applicable?

6. Does U=U apply to all types of sexual behaviors?

7. Does this mean I can stop using condoms?

8. My partner is HIV positive/negative but still wants to use condoms?

9. Do STIs (sexually transmitted infections) affect zero risk?

10. How long does it take to measure the viral load?

11. What should I do if I forget to take my medicine one day?

12. What about viral load fluctuations?

13. Will the viral load rebound to a higher level?

14. What is the difference between “zero” and “very low” risk?

15. Does U=U apply to other modes of HIV transmission, such as blood transmission and mother-to-child transmission?

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Is U=U true? 15 questions and answers that you care about most