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Shout It From the Rooftops: Undetectable = Untransmittable!

Jemma Alarcón, MD, MPH

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October 08, 2021

U=U, tell everybody!

They are walking at night, Dontae is wearing a black leather jacket and Troy a brown one. Their path in the park is well lit, surrounded by trees. They are about to kiss, but Dontae stops him, Troy asks, "What's the matter?" Dontae responds, "There is something we should talk about." The mood becomes tense.

Dontae seems nervous, eyes tearful, "I am undetectable…HIV positive."

Troy becomes upset. Dontae pleads, "I never put you at risk, we used a condom — I am undetectable." Troy repeats, "You should have told me. You took away my choice." Dontae responds. "I took my meds. By taking my meds, I made sure that you couldn't catch it." Troy, visibly upset, walks away from Dontae leaving him alone.

Alone — how many folks living with HIV still feel.

Designated Survivor, a Netflix show that unfortunately was cancelled (I would watch a fourth season, for what is worth), introduced the audience to what must be a very common situation: the HIV-positive partner, in this case a man, sharing his status with his partner. A few episodes later, Dontae tells Troy that he acted like a bigot because U=U (undetectable = untransmittable).

Although disclosing your status, especially when it has to do with sexually transmitted infections, to a partner you hope to be intimate with is the right thing to do (ideally before any sexual encounter) Dontae is right that U=U. If you are living with HIV and taking your HIV medication every day, if your viral load is undetectable (meaning that a PCR test cannot replicate any virus because too little is to be found in your blood), you cannot transmit HIV.

In the 40 years since HIV/AIDS was first discovered, we have come a long way. The life expectancy of folks living with HIV is now comparable to the general population.

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As a family medicine resident, I have the opportunity to care for folks with HIV. I tell my patients that our advances in treating it are so great that your family doctor can treat it, just like we treat hypertension and diabetes.

Despite this, the stigma is well and alive — Silence = Death continues to be fitting. New HIV cases are diagnosed every day, and many will not know until they have AIDS.

A classic teaching is that some individuals with new HIV will experience flulike illness soon after transmission. Patients with AIDS (defined as a CD4 cell count < 200 and/or presenting with an AIDS-defining condition) will often present with significant weight loss, decreased appetite, and diarrhea.

Many still see HIV as a life sentence and will suffer from depression and often not tell anyone, even their therapist, that they have it.

We, as a society, have to step up. If the viral load is null, not enough virus around to be detected, then the person will not be able to transmit the virus.

Dontae was probably afraid of being stigmatized and with good reason. Until we all see it as the preventable, treatable, untransmittable disease, silence will continue to equal death.

In a later episode, Troy shares with Dontae that his doctor agreed that U=U and apologized for his strong reaction. Physicians have the opportunity to help their patients understand this concept as well.

Even if you are not treating their HIV, you can remind them that if their viral load is undetectable, they are unlikely to transmit the virus and can lead longer, healthier lives. You can also ask what their understanding of the disease is and share the good news.

For more information, the National Institute of Health looks at the science evidence of U=U.

PS: Here is a link on how to become HIV certified as a family doc: https://aahivm.org/credentialing/

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About Dr Jemma Alarcón
Jemma Alarcón, MD, MPH, was born in South Texas and grew up in Northern Mexico. She completed her undergraduate degree in public health studies at Johns Hopkins University. She graduated from UC Irvine's PRIME-LC, a 5-year MD/master's program designed to foster physician-activists who serve the Latino community. She also completed a master's in public health at Johns Hopkins Bloomberg School of Public Health. She is currently a third-year family medicine resident at Ventura County Medical Center.

Please note that writings represent the author's views and do not reflect the views of the Healthcare Agency or County of Ventura Government.

Connect with her on Twitter: @jalarcon

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