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HST Blog

May 09
HIV ends with me – integrating U=U evidence into HIV service delivery

by Willemien Jansen and Judith King – Copy and Content Editors, and Siyabonga Gema – Communications Officer


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Being diagnosed as HIV-positive is no longer a death sentence.

In fact – with adherence to modern antiretroviral therapy (ART) – it is regarded as a chronic medical condition that can be well controlled, and it is possible for a person's viral load to be so low that HIV cannot be transmitted to someone else.

Based on several studies showing that there is no risk of HIV transmission from virally suppressed patients to HIV-negative partners, the global concept of sustained viral suppression is known as 'Undetectable = Untransmittable' or 'U=U'.

What is viral load?

Viral load is the amount of HIV found in a person's blood. This can be checked by doing a viral load test. Viral load is measured by testing the number of viral particles – or 'copies' ‒ in each millilitre (copies/ml) of a small sample of blood. Taking ART medication correctly every day lowers the viral load to the point where it cannot cause harm to the patient and it cannot be passed on to anyone else. This is known as viral load suppression.

What is undetectable?

When the results of two consecutive viral load tests taken over a period of six months show that a person has 50 copies/ml or less of HIV in their blood, their viral load is defined as undetectable. This can be achieved by taking one's treatment every day as prescribed, because the medication is so effective that the virus cannot reproduce to infect new cells in the body. It may take a little longer for some people to reach this level, but it is possible to achieve an undetectable viral load within six months.

It is important to remember that the virally suppressed person is still HIV-positive, as ART cannot cure HIV altogether. 'Resting' or latent HIV cells remain in the body, and the virus will begin to reproduce itself again if the person stops taking ART. This is why it is essential for a person living with HIV to remain on ART for life, so that sustained viral suppression keeps their immune system strong, and they can live as long as someone who is HIV-negative. 

What is 'untransmittable'?

'Untransmittable' means that virus cannot be passed on to another person or unborn baby through blood or sexual fluids. HIV is still present in a person's body, but there is too little of it for onward transmission.

Focusing on the proven option of treatment as prevention and the science of U=U can reduce HIV-related fear and stigma, make disclosure of one's HIV-positive status easier, and move us towards achieving HIV epidemic control.

HST's programming supports U=U as a public health campaign

Through the SA SURE PRO project and in partnership with the Department of Health, HST is supporting implementation of the U=U approach as a feature of all stages of HIV service provision and related technical assistance for case management.

Planning for this implementation began in mid-2021, and was built around the project's key objectives of ensuring optimal HIV case-finding and treatment enrolment, ART adherence, and continuity of care to achieve and maintain viral suppression.

At that point, data from the Ritshidze Project indicated that no more than 65% of patients understood the relevance of viral load suppression to HIV transmission, so the team also centred on ways to support patient and provider literacy, with healthcare workers using the U=U messaging as a powerful counselling tool to encourage treatment adherence and create demand for regular viral load monitoring among couples and individuals.

Based on diligent record-keeping and data analysis, and through collaboration with pharmacy staff and community caregivers, our teams working in facilities and communities are continuously tracking and tracing patients who have missed their clinical appointments and medication collection, which flags the risk of treatment interruption. Various return-to-care interventions ‒ such as the 'Welcome Back' strategy, enhanced adherence counselling, and intensified application of the Case Management Model II ‒ are deployed as needed.

Rigorous data reporting on sites needing urgent action for retention of patients on ART is undertaken to ensure that return-to-care targets are met in all four of the project's supported districts.

Our training and post-training mentorship programme, along with site support provided jointly by pharmacy, case management and clinic‒laboratory interface teams, incorporates multiple modules for every aspect of patient-centred HIV care.

SA SURE PRO project teams are partnering with civil society to actively disseminate accurate U=U information and contextually appropriate messaging. In so doing, they caution virally suppressed patients that although condomless sex will not result in HIV transmission, having an undetectable viral load does not provide protection from other sexually transmitted infections or pregnancy.

As a PEPFAR Implementing Partner, HST is committed to contributing to the rapid and widespread uptake of U=U, which has generated a new momentum for South Africa's HIV response and an improved quality of life for people living with HIV.

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Dr Thembisile Xulu – Chief Executive Officer of the South African National AIDS Council (SANAC) – reiterated at the national U=U launch that if an HIV-positive person adheres to treatment, they can achieve and maintain viral load suppression and not transmit the virus.

The National Minister of Health, Dr Joe Phaahla, led the official national U=U launch on Tuesday, 7 May 2024 in the uThukela District of KwaZulu-Natal. The launch saw representatives of national and provincial government, civil society organisations and the People Living with HIV sector come together to rally behind the science-based message that a person with HIV who adheres to treatment achieves an undetectable viral load and cannot transmit HIV sexually.

At the launch, the community of KwaDlamini in Ward 12 of Ntabamhlophe, Estcourt, interacted with health professionals from the Department of Health and non-governmental organisations who engaged them on the importance of knowing their HIV status, starting treatment if diagnosed as HIV-positive, and remaining on treatment.

In her address to the audience, Dr Xulu rebutted the popular notion that people who are HIV-positive are responsible for the spread of HIV. She explained that it is those who do not know their status, and are not aware that they need to be on HIV treatment, who run the risk of transmitting the virus through unprotected sex. Importantly, she pointed out that U=U is not only a tool to help lower the rate of HIV infections, but also to address the issue of stigma.

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A multisectoral response saw HST Outreach Teams joining other community-based providers offering HIV literacy, health education and HIV testing and counselling services at the launch.

Apart from encouraging community members to know their status, part of the launch engagement entailed educating the public that despite being on HIV treatment, people still need to use protection as a preventative measure for sexually transmitted infections (STIs).

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The U=U launch was preceded by the launch of 'Zikhala Kanjani' on 26 April 2024 in Richmond, uMgungundlovu District. This national communications campaign aims to increase the reach and quality of HIV prevention services for young people.



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 Content Editor