Dr. Julio Montaner is a UBC-Killam Professor of Medicine and the UBC-St. Paul's Hospital Foundation chair in AIDS Research. Dr. Kora DeBeck is an assistant professor at Simon Fraser University's School of Public Policy and research scientist at the BC Centre for Excellence in HIV/AIDS.
The emergence of the HIV/AIDS pandemic in the 1980s was a traumatizing and terrifying time in modern history. The first public and political reactions were exploited by elected officials, often for political gain and by homophobic groups to further stigmatize and marginalize the gay community.
We have come a long way in the last three decades. Public discourse is no longer driven by ignorance, lack of information, stigma and fear in our understanding of HIV/AIDS. Or is it?
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Recently, an Abbotsford, B.C., man was charged with aggravated assault for allegedly not disclosing his HIV status to sexual partners. Without all the details related to his health status – including whether he was on effective treatment – we cannot comment on that specific case. However, past cases and the accompanying media attention, public reaction, and social media response demonstrate that Canadians need more information on the actual risk of being infected with HIV by someone receiving treatment in 2017.
Current HIV treatments are so effective that when people living with HIV are on antiretroviral medication, the virus in their bodily fluids (for example, plasma, semen, cervico-vaginal fluids) falls to undetectable levels, ensuring they are no longer infectious, and allowing them to have a near normal lifespan. Last month, the global medical and scientific community at the forefront of HIV research and care came together in Paris for the ninth International AIDS Society Conference, where they announced – unequivocally – that an undetectable HIV viral load means HIV is untransmittable.
Simply put, HIV treatment suppresses the virus to undetectable levels. When the virus is undetectable, HIV cannot be passed on.
However, our laws criminalizing HIV non-disclosure take the same approach to those on treatment and those who are not, without considering the vastly different risk of HIV transmission. The resulting fear of criminalization may keep people from getting tested. If a person doesn't know their HIV status they can't go on treatment, which is critical for suppressing the virus and preventing further transmissions.
Even when the risk of transmission is zero due to effective treatment, not disclosing your HIV status to sexual partners is considered a crime in Canada. This only furthers stigma, ignores science and prevents people from coming forward with their HIV status.
In the unusual case that someone is not on effective treatment and the viral load of an individual is not suppressed, there is a risk of HIV transmission. Under these conditions, disclosure of HIV status to sexual partners is required and other forms of protection are needed, including the use of condoms, pre-exposure prophylaxis (for HIV prevention), or post-exposure prophylaxis (after exposure). We do not make light of the fact that there is a risk of HIV transmission when someone is not on effective treatment and the viral load of an individual is not suppressed. Intentionally transmitting HIV to another person should remain a crime. The problem is that all too frequently the criminal law is used in cases where no risk of transmission was present.
The BC Centre for Excellence in HIV/AIDS pioneered the concept of Treatment as Prevention – engaging HIV-positive individuals earlier into treatment, sustaining them on care, and ensuring the virus is undetectable in blood and sexual fluids. We demonstrated that HIV treatment fully prevents progression of HIV infection to AIDS and premature death, as well as HIV transmission. This has been validated by numerous clinical research studies across the world, and serves as the basis for the United Nations' new strategy to end the AIDS pandemic by 2030.
However, for this strategy to be effective it is critical that people feel safe getting tested for HIV and engaging with HIV treatment. Stigma and discrimination directly undermines our ability to achieve these objectives.
Laws and policies need to catch up to the unequivocal research that shows individuals who have an undetectable viral load pose no risk for HIV transmission.
In our misguided attempts to protect the public by criminalizing HIV non-disclosure and splashing the names, images and locations of people living with HIV all over broadcast news and social media, we continue to stigmatize those living with HIV and make our communities feel less safe and more fearful. This is not only devastating for individuals accused of not disclosing their HIV status, but it also risks undermining broader HIV prevention efforts that depend on having people feel safe to get tested for HIV and engage with treatment.
We know that in the context of HIV infection, undetectable does equal untransmittable and therefore criminalizing HIV non-disclosure – and stigmatizing those living with it – is simply wrong.