May 5th, 2019

Latest Published Study on HIV Treatment as Prevention Is Déjà Vu All Over Again, But Some News Is So Good It Never Gets Old

Yogi Berra, putative author of “déjà vu all over again” and other profundities.

Even if you’re not an ID or HIV specialist, there’s an excellent chance you’ve heard of the PARTNER2 study, just published in The Lancet.

If not, the title could not be more descriptive:

Risk of HIV transmission through condomless sex in serodifferent gay couples with the HIV-positive partner taking suppressive antiretroviral therapy

And, in case you’ve just awoken from a Rumpelstiltskin Rip Van Winkle-length sleep, here are the results:

The risk is essentially zero.

This is far from the first time we’ve heard this information, either from this or other (HPTN 052, Opposites Attract) studies.

The formal publication of PARTNER2 therefore has a déjà vu quality to it, one which prompted Myles Helfand, the indefatigable and entertaining Executive Editor of the terrific HIV resource TheBody, to post the following:

“Breaking” indeed. Ha. To Myles, and to many of us, this is old news. The publication of the paper after years of comparable findings from this and other studies may seem anticlimactic, no big deal.

He’d no doubt cite that even this particular study was presented first at the AIDS 2018 conference last summer in Amsterdam. That’s over 8 months ago! Ancient history!

But here’s another take from Claire Farel, an ID doctor from the University of North Carolina (and, full disclosure, a wonderful graduate of our ID fellowship program):

(For those not in our field, that “U=U” stands for “Undetectable = untransmittable.”)

First, I am in complete agreement that telling people with HIV that their treatment prevents viral transmission is a “gift,” leading to profound and anxiety-relieving responses. It’s just as good as informing patients that if they take their HIV meds, they will not die of AIDS — and both pieces of information are equally true.

Conveying this information elicits such relief that yes, tears of happiness are often part of the mix, if you’re wondering about that Kleenex reference.

Second, the publication of a study in a peer-reviewed journal still lends far greater authenticity to scientific data than conference presentations or abstracts. This is particularly true when the journal publishing the paper is a prestigious one, such as The Lancet.

(I have cleared it with the Editorial Office that we’re allowed here at NEJM Journal Watch to write that The Lancet is prestigious. Note I didn’t say MOST prestigious.)

Don’t get me wrong — I agree that conference presentations play a critical role in rapidly getting important new data into the public domain. But there’s still room for distribution the old-fashioned way, in a journal, which is why I posted both Myles’s and Claire’s responses to this publication.

Before we leave this study, we must linger for a moment on the most unintentionally amusing sentence from PARTNER2.

It’s this:

In total, couples reported having condomless anal sex approximately 76,088 times during eligible couple-years of follow-up.

Something about the precision of that estimate — are they sure it wasn’t 76,089? — makes me smile every time.

7 Responses to “Latest Published Study on HIV Treatment as Prevention Is Déjà Vu All Over Again, But Some News Is So Good It Never Gets Old”

  1. Louis M. Katz MD says:

    An interesting discussion has flourished in blood banking circles–whether U=U applies to the context of blood donation and transfusion–i.e. is a full unit of blood from a suppressed individual non-infectious. The data are not in, and we are struggling with whether to screen donors for their use of PrEP etc.

    • Paul Sax says:

      There is replication-competent virus in suppressed individuals, so this would be of concern.


  2. Grimm brothers says:

    Isn’t Rumpelstiltskin this mad little man dancing around? It was Dornröschen (“sleeping beauty”) sleeping for hundred years.
    Anyway, don’t worry, this can happen even in prestigious journals.

  3. Antonia Calvo Cano says:

    And what about recommending natural conception for heterosexual partners without fear of transmission, when the man has indetectable viral load under treatment and the woman is seronegative? It would be the next step I am looking forward to read in guidelines: another gift for using kleenex at the clinic!

  4. Ghassan Al Awar says:

    Dear Paul,
    This brings up a very important question about: HIV infection and procreation.
    So, can an infected person who is completely suppressed and compliant get married and have children? And maybe a normal family life??
    B rgds & appreciation, Gh A.

  5. Stephen Smith says:

    These confirmatory data raise the even more embarrassing question –
    Why is the HIV incidence in the US unchanged in the last several years?
    Year New Infections
    2013 38,900
    2014 39,100
    2015 39,000
    2016 38,700
    2017 38,739

    I think I know the answer –
    It is because American Medicine is stupid.
    We treat each demographic the same.
    We say take this pill, because it is good for and you will live longer, a lot longer.
    At the end of the office visit, we are marketers of healthcare.
    No marketing company would “sell” a product the same way to each demographic.
    We have supply side Medicine. While this approach has been effective, clearly, it has limitations. We reached those limitations over a decade ago.
    We have to start figuring out what it will take for our non-adherent pts to take their pill. Positive incentives have to be on the table.
    For reasons I don’t understand, American Medicine frowns upon positive incentives, yet, of course, living longer is a positive incentive, which has a limited effect.
    Positive incentives are used all the time to decrease the rate of tobacco use, as are negative incentives. These incentives work.
    Obviously, everything we do in life is for incentives, positive or negative.
    We just have to figure out what incentive(s) will motivate the non-adherent pts to take their daily pill.
    The definition of insanity quote is overused, but is very applicable to our approach to this epidemic, which, should be over.

    Stephen M. Smith, M.D.

HIV Information: Author Paul Sax, M.D.

Paul E. Sax, MD

Contributing Editor

NEJM Journal Watch
Infectious Diseases

Biography | Disclosures | Summaries

Learn more about HIV and ID Observations.