Editor’s Note:
The 12th International AIDS Society Conference on HIV Science (IAS 2023) began on July 23, 2023, in Brisbane, Australia. At the conference, experts from the World Health Organization (WHO) introduced important updates to the HIV guidelines, emphasizing the importance of “HIV viral suppression for improved individual health and reduced transmission.” On the eve of the conference, The Lancet published a systematic review showing that the risk of HIV transmission with low-level viral load is almost zero.
From “U=U” to “Traffic Lights”
Since 1998, clinical observational data from studies like PARTNER and HPTN 052 have supported the “U=U” concept, meaning “Undetectable = Untransmittable.” This idea has been recognized by authoritative organizations such as UNAIDS, WHO, CDC USA, and the International AIDS Society. A systematic review published in The Lancet during the IAS conference included 8 studies and analyzed 7,762 couples, one of the two is serologically positive, from 25 countries. It found that with a viral load of less than 1000 copies/mL, the risk of sexual transmission of HIV is nearly zero. These powerful data contribute positively to eradicating the stigma around HIV carriers and improving treatment adherence.
WHO experts have effectively categorized the HIV transmission risk into three levels:
– Green Light: Undetectable virus, zero sexual transmission risk, and the lowest mother-to-child transmission risk.
– Yellow Light: Viral load <1000 copies/mL; due to treatment interruptions, just starting treatment, or drug resistance, some virus replication is present. The sexual transmission risk is almost zero or negligible.
– Red Light: Viral load >1000 copies/mL; due to treatment interruptions, just starting treatment, or drug resistance, some virus replication is present, posing a high risk for both sexual and mother-to-child transmission.
However, WHO’s ultimate goal is to achieve an undetectable viral load level for all HIV carriers, consistent with WHO’s 2030 goal of ending the HIV epidemic with three “95%” targets.
As per WHO, by the end of 2022, out of 39 million global HIV carriers, 29.8 million (76%) were receiving ART treatment. Nearly three-quarters (71%) of HIV carriers achieved viral suppression, but only 46% of child HIV carriers did, highlighting an urgent area of concern.
Other Updates from WHO Guidelines
– Half of all Monkeypox patients worldwide are co-infected with HIV: WHO disclosed global monitoring data, analyzing over 32,000 out of 82,000 Monkeypox patients with HIV test information. It showed that 52% of Monkeypox patients carried HIV, with the majority being MSM (Men who have Sex with Men). Over 80% reported acquiring Monkeypox through sexual contact. Among 16,000 patients diagnosed with both HIV and MPVX infection, about 25% were in the late stage of AIDS or immunosuppressed.
– The risk of death from COVID-19 is 142 times higher for HIV carriers than the general population: WHO’s global clinical platform data for COVID-19 showed that, during the waves of Delta, pre-Delta, and Omicron variants, the overall hospital death risk for HIV carriers with COVID-19 was between 20% to 24%. For non-HIV-infected individuals, the death risk during the Omicron wave decreased by 53%-55%, while for HIV carriers it only decreased by 16%-19%. This disparity meant that during the Omicron wave, the risk of death for HIV carriers was 142 times higher than for non-HIV carriers.
– Optimizing HIV Testing Services by Expanding Test Choices and Simplifying Service Delivery: With the update in HIV testing recommendations, WHO is urging countries to expand the use of HIV self-testing and promote HIV testing coverage in sexual activities and social networks, especially in areas with high burdens and significant testing gaps.
– Primary Health Care (PHC) for HIV: The new policy framework for PHC and HIV will assist policymakers in optimizing ongoing efforts and collaboration in response to PHC and specific diseases, including HIV. In the second year of its implementation, the “Global Health Sector Strategy on HIV, Viral Hepatitis, and Sexually Transmitted Infections, 2022-2030” actively advocates for synergy within the Universal Health Coverage and PHC framework.
Which countries are close to the 95-95-95 target?
WHO noted that the aforementioned latest studies and guidelines were proposed when the COVID-19 pandemic was ending and there was a global lag in progress towards ending the HIV epidemic. However, some countries responded swiftly with strategies to end HIV, including Australia, Botswana, Eswatini, Rwanda, The United Republic of Tanzania, Zimbabwe, and 16 other nations nearing the global 95-95-95 target: 95% of patients aware of their HIV status, 95% of diagnosed patients receiving continuous treatment, and 95% of those on treatment achieving viral suppression.
References:
1.Laura N Broyles, et al. The risk of sexual transmission of HIV in individuals with low-level HIV viraemia: a systematic review.The Lancet .Published:July 22, 2023. DOI:https://doi.org/10.1016/S0140-6736(23)00877-2
2.What’s new in WHO guidelines: innovations, treatmentintegration, and monitoring. IAS 2023.
3.New WHO guidance on HIV viral suppression and scientific updates released at IAS 2023.https://www.who.int/news/item/23-07-2023-new-who-guidance-on-hiv-viral-suppression-and-scientific-updates-released-at-ias-2023
TAG: IAS 2023, Commentary, HIV/AIDS, Guidelines
