A little history
Call it what you want, the Tasp (Treatment as prevention), “U = U” or its French variation “I = I”, the main thing is to know it and to make it known. And for that nothing better than science. This webinar was aptly entitled “Undetectability of HIV: when science advances faster than mentalities” and it was Professor Gilles Pialoux (head of the infectious and tropical diseases department, Hôpital Tenon, AP-HP, Paris) who opened the ball with a history lesson on the Tasp. For Professor Pialoux, the very first trace of this concept dates back to the prevention of HIV transmission from mother to child and he cites the ACTG 076 study which dates from 1994 and which had shown a 68% reduction in mother-to-child transmission on AZT. It will be necessary to wait until the year 2000 before the notion of the absence of HIV transmission thanks to an undetectable viral load makes its appearance (Rakai study on 415 serodiscordant heterosexual couples in Uganda). But the real Tasp revolution took place on January 30, 2008, when the famous Swiss opinion launched in the media by an interview with Professor Bernard Hirschel on the occasion of December 1, 2007, was published in the medical journal Bulletin of Swiss doctors. At the time, the message, supported by science, was a revolution in the lives of people living with HIV, but also for their caregivers. But the message sometimes has trouble getting through and many doubt…despite the scientific data.
Whether it is the people concerned to whom it has always been explained that the condom was the only possible protection tool, but also certain caregivers who are reluctant to communicate on the Tasp, or even who question it. In May 2011, a first important study confirms the effectiveness of Tasp, it is HPTN 052. But we have to wait until March 2014 to reach the global scientific consensus with the results of the study. Partner. Partner is an international cohort that followed serodiscordant heterosexual or gay couples for several years who practiced vaginal or anal penetration without a condom while the HIV-positive partner was taking anti-HIV treatment and had an undetectable viral load. In total, the study focused on 894 couples (586 heterosexual and 308 gay) who had, in total, more than 44,500 sexual relations without a condom, including 21,000 anal intercourse (with or without ejaculation). With these figures, it is estimated that there should have been 15 infections in heterosexual couples and 86 in gay couples, if the HIV-positive partner did not take anti-HIV treatment. But in the study, no transmission was observed. The study continued until 2018 with a second part (Partner 2) reserved for serodiscordant gay couples. The results published in The Lancet, May 3, 2019, confirm once and for all the effectiveness of Tasp. Out of 783 couples and nearly 75,000 sexual acts without condoms (and without Prep), no case of transmission was observed between the partners.
Professor Pialoux concluded on the need to update the recommendations of the Expert Report on the care of people living with HIV (the first chapters of which should be published in the spring of 2023) on subjects such as the effectiveness of Tasp in breastfeeding or the six-month period to wait to be considered “non-contaminating” while with new treatments, the viral load becomes undetectable in six weeks or even less.
A 70-copy blip, who cares!
The second speaker, Dr. Michel Ohayon (founder and director of 190, the first sexual health center opened in Paris) returned to the importance for caregivers of talking about Tasp with their patients, from the first consultation. HIV: “Many of our patients do not dare to raise this issue, probably fearing a negative reaction or judgment from the doctor. “It is important that the treatment be considered protective and not punitive”. The doctor recalls to what extent the fear of transmitting HIV is rooted in most PLHIV: “This concern about transmission is permanent, obsessive because it revives many old traumas”. Can we talk about zero risk under Tasp? “I was very happy when I attended the presentation of the results of the Partner study at the IAS in Amsterdam [en juillet 2018, ndlr], and that I finally heard someone say in front of thousands of people that zero risk exists and I think we can talk about zero risk (…). A report under Tasp is a protected report, at least in relation to HIV. You can’t compare gonorrhea with HIV infection or else I missed an episode! says Dr. Ohayon ironically. The doctor insists on an element that seems important to him: “The difficulty is to explain what an undetectable viral load is. The international consensus is a viral load of less than 50 copies/ml, but our laboratories produce results of less than 40, 30, 20 copies, etc. In Partner, the threshold is 200 copies, or ten times the undetectability threshold of most tests that are used routinely. Which means that if someone makes a blip at 70 copies because he got the cold at the time of the sample, who cares! »
A little later during the questions/answers, Pr Pialoux drives the point home: “I take up Michel Ohayon’s expression: Yes, zero risk exists! The precautionary principle of giving a condom to 50 copies does not make sense”. A speech that will reassure all those who experience mini blips (ups) in their viral load, from time to time. Finally, Michel Oyahon returns to what he calls “the prodigiously liberating effect” of Tasp: “The liberation of this permanent fear of transmitting a disease which remains fantasized as deadly and very serious whereas today it is managed as a chronic infection.
In custody because of HIV!
Bruno Lamothe, lawyer and member of the association Les Séropotes, returned to the impact of Tasp in the legal sphere. The lawyer begins with an important reminder: HIV is an infection that must be declared by health professionals, but not in a nominative (therefore anonymous) way. Bruno Lamothe continues on the long battles waged by associations fighting against HIV against discrimination related to certain prohibited professions as well as some wins like improving theaccess to borrowing.
What about the criminalization of HIV in France? It took until March 2019 for the Court of Cassation, the highest jurisdiction of the French judiciary, to recognize the Tasp and therefore the absence of an offense when the accused person has an undetectable viral load. The Court has, in fact, rejected the appeal of a woman who had unprotected sex with a man living with HIV. The plaintiff, who was not infected, sued her ex-partner on the count of administration of harmful substances. But there is still a long way to go… Proof of this is with a recent totally bewildering affair mentioned by Bruno Lamothe. In 2022, in France, a person living with HIV was arrested at his workplace by gendarmes and placed in police custody for nearly 48 hours following a denunciation by his spouse who accused him of having had sex without a condom when she knew she was HIV positive. The Seropote legal unit had to intervene to put an end to this police custody and remind the gendarmes of the case law of the Court of Cassation.
My sex life has always been linked to danger
Étienne Fouquay, screening project manager at AIDES, presented the various campaigns on Tasp over the years, emphasizing the need to make messages simple and accessible to all. Then the webinar ended by giving the floor to two people directly concerned by the Tasp. Thaïs, 47, who has been living with HIV since 1993 and Silouane, 31, HIV-negative, in a serodiscordant couple since 2018. Thaïs’ testimony showed, if it were still necessary, the importance for health professionals to clearly address the Tasp. It was while reading a leaflet from AIDES that Thaïs discovered the existence of Tasp: “When I broached the subject with my infectiologist, he was very cautious and insisted on the need to maintain the use of condoms. Suddenly, for several years, I found myself with a double discourse and it was complicated for me to have a clear discourse with my partners. At the slightest condom accident, I accompanied my partner to the emergency room to request a TPE when in reality there was no risk. I was really scared even with an HIV-positive spouse, I was told to put on a condom because I could “over-contaminate” him! “My sex life has always been linked to danger,” laments Thaïs. Silouane, for his part, discovered the Tasp by being a user of the 190 for the Prep. Himself a health professional, he raises the question of the prejudices still very present in the hospital environment.
In conclusion, a webinar which showed how important, fifteen years after the “Swiss opinion”, it was to hammer home the message “I = I” again and again because the Tasp revolution can only be done through knowledge and let it know. The webinar is on line on the Actions Treatments YouTube page.