This morning’s first plenary speaker was Bernard Hirschel, who is a hero to many of us with HIV. His paper this morning was entitled "Anti-HIV Drugs for Prevention".
Two years ago he published a controversial piece which indicates that if people with HIV are stable on their anti-HIV medication, have an undetectable viral load, have a good CD4 count, if they and their partner have no other sexually transmitted conditions, then it can be safe not to use condoms, even if their partner is HIV-negative. Yes, that’s a long sentence and there are lots of “ifs” in it. But for those of us who are in stable relationships with an HIV-negative partner – or seeking one – that was total music to our ears. It was controversial – and still is – amongst the public health fraternity, because they feared this would open the flood gates to new transmission between “sero-discordant” couples as we are named. They advise huge caution still with this use of this information at the general level. But for those of us who are in or contemplating these relationships, it still means so much.
What did it mean for me though personally? Well, to be honest, to begin with I didn’t tell my partner the news. We had been using the female condom consistently since 1993, when it first appeared in the UK, in order for me to make sure that I would at all times protect him against this bug. It was bad enough coping with the possibility that the kids might be motherless. I certainly didn’t want them to be without him too. Nor would I ever want to live with the guilt of having passed this to him. Unfortunately, however, I talked about this in a speech I made last year and gave it him to read afterwards, without remembering that this was in it. Oops. So we talked about it. I explained my reluctance – HIV can be fully manageable physically now with medication – but I still didn’t – and don’t want to deal with the guilt of passing on anything to him. But, he reasoned, if this is what you are talking about publicly, in terms of reasons against criminalisation, how come you can’t deal with this personally? You take your meds religiously, you have had an undetectable viral load for years, you have a disgustingly healthy CD4 count of 750. What’s the problem? So I agreed to talk it through with my consultant. My consultant also reasoned that he counsels couples where one partner needs a kidney transplant and the other partner offers to donate one. The partner in need feels badly and fearful about the potential consequences for the donor. “But”, my consultant counsels them, “if your partner loves you enough to want to take this risk in order to keep you alive, how about accepting your partner’s love for you as something you deserve?”
So now we no longer use condoms, or female condoms – or anything. It’s taken time to feel OK about this, to believe in the science. But this morning’s plenary confirmed that the “circumstantial evidence” around this is ever-growing and that “treatment as prevention”, as it’s called, really could make a difference to us all – not just on an individual or couple basis, but on long-term reduction of the “infection pool” as we are also lovingly described. This means that there could, in the long term, be fewer people acquiring HIV, because there would be fewer of us at risk of passing it on. There would also be fewer people acquiring HIV because TB is acquired less easily if we have a higher CD4 count – and so a less damaged immune system.
There are hurdles to overcome – not least the huge human rights dangers of governments and policy makers then imposing testing and anti-HIV drugs on people before full care and support and medication are in place, and before they actually need the drugs. But Bernard Hirschel is himself all too aware of these pitfalls.
I, for one, hope that he finds the funds to conduct the clustered randomised trial he is planning, in order to confirm this “circumstantial evidence” once and for all.