This article first appeared on the CATIE website here.

Une version française est disponible ici. 

Summary

HIV viral load is the amount of HIV (or number of virus) in the bodily fluids of someone living with HIV. It is measured in the blood as part of routine clinical care. A higher viral load is associated with a higher risk of HIV transmission. Research shows that successful HIV treatment can reduce the viral load to “undetectable” levels and this can reduce the risk of HIV transmission. However, HIV transmission may be possible when the viral load is undetectable because there is still virus present in the blood and other bodily fluids. The risk of HIV transmission when taking antiretroviral treatment may increase if sexually transmitted infections (STIs) are present, doses of medications are missed, or drug resistance develops. This risk may also be higher for anal sex than for vaginal sex.

What is viral load and how is it affected by HIV treatment?

HIV viral load is the number of copies of HIV in the bodily fluids of someone living with HIV. It is measured as the number of copies of the virus in one millilitre of fluid (copies/ml). Viral load is measured in the blood and is used to monitor the progression of HIV infection and the success of HIV treatment. It is not commonly measured in other bodily fluids, such as semen, vaginal fluid or rectal fluid.

HIV treatment consists of a combination of at least three drugs that are normally taken daily. The goal of HIV treatment is to reduce the production (also called replication) of HIV, raise levels of CD4 T-cells, and slow disease progression. HIV treatment is also called highly active antiretroviral treatment (HAART) or antiretroviral therapy (ART).

With successful HIV treatment, the viral load can become very low or “undetectable” in the blood and other bodily fluids.

What is a “normal” viral load?

There is no such thing as a “normal” viral load. The viral load in the bodily fluids can change as a result of several factors, such as the stage of HIV infection and HIV treatment.

During the first few weeks after becoming infected with HIV, the viral load in the blood and other bodily fluids is very high. This stage of HIV infection is known as the acute infection stage and at this time the viral load can reach levels higher than 1 million copies/ml.

The acute HIV infection stage only lasts for a few weeks and then the chronic stage of HIV infection begins. During the chronic stage, the viral load begins to decrease and – after a few months – the viral load stabilizes at a lower level.

If HIV treatment is started, the viral load can be reduced to “undetectable” levels in the bodily fluids within a few months. However, if doses of medications are missed or HIV develops resistance to treatment, then the viral load will increase.What does it mean to have an “undetectable” blood viral load?

“Undetectable” means that the number of virus in the blood is below the limit that viral load tests can detect. Viral load tests used in Canada cannot detect HIV in the blood if there are less than 40–50 copies/ml. Therefore, an undetectable viral load means the amount of virus in the blood is too low to detect, it does not mean that there is no virus present.

Is the viral load in the blood associated with a person’s risk of transmitting HIV?

Research shows that a lower amount of virus in the blood is usually associated with a lower risk of transmitting HIV to others, and a higher viral load is associated with a higher risk.

The amount of virus in the blood is usually correlated with the viral load in the semen, vaginal fluid, and rectal fluid (the fluids commonly involved in the sexual transmission of HIV). This means that when the viral load in the blood decreases, it generally also decreases in the other fluids.

However, the viral load in the different bodily fluids is never exactly the same. For example, the viral load in the semen, vaginal fluid or rectal fluid can sometimes be higher than the viral load in the blood.

Does HIV treatment reduce the risk of sexual transmission of HIV?

Successful antiretroviral treatment can lower the viral load in the blood and other bodily fluids to undetectable levels and this can reduce the risk of sexual HIV transmission.

A randomized controlled study known as HPTN 052 found that HIV treatment reduced the risk of HIV transmission between serodiscordant heterosexual couples by 96% (equivalent to a 26-fold reduction in risk). A serodiscordant couple is where one partner is HIV-positive and the other is HIV-negative.

Couples in the HPTN 052 study were mostly heterosexual, mostly reported having vaginal sex, and were provided with regular adherence counselling, viral load tests, testing and treatment for sexually transmitted infections (STIs), and prevention counselling and free condoms. Therefore, this study demonstrated the effectiveness of treatment in reducing the risk of HIV transmission through vaginal sex when pills are taken regularly, drug resistance is monitored, and STIs are managed. Antiretroviral treatment may be much less effective than 96% when these conditions are not met.

No studies have been completed among populations who mostly have anal sex, such as some gay men or other men who have sex with men (MSM). However, a working group meeting hosted by the World Health Organization in 2011 concluded that “there is reason to believe that early initiation of ART for HIV prevention will benefit MSM, transgender women, and others who have anal intercourse, although the magnitude of the effect may be different from that observed in serodiscordant heterosexual couples.” In other words, HIV treatment reduces the risk of HIV transmission for gay men and other MSM, but it may or may not be as effective as for heterosexual couples in the HPTN 052 study.

There are ongoing studies that are trying to get a better idea of how well HIV treatment can reduce the risk of HIV transmission among gay men and other MSM.

Is HIV transmission possible when the viral load in the blood is undetectable?

Although the risk of sexual HIV transmission is reduced when the viral load is undetectable, the risk of HIV transmission may not be eliminated.

Many people who have an undetectable viral load in the blood also have an undetectable viral load in other bodily fluids. However, undetectable does not mean that there is no virus, only that the amount of virus is below the limits that tests can detect. Therefore, HIV transmission may still be possible because there is still virus present.

Also, it is possible for people who have an undetectable viral load in the blood to sometimes have detectable (although lowered) levels of virus in their other bodily fluids. A higher level of HIV in the semen, vaginal fluid, and rectal fluid may increase the risk of transmission when the blood viral load is undetectable. However, it is unclear how often this happens and how significant it is in terms of HIV transmission. Research shows it may be more common if a person has an STI, but can also happen in the absence of STIs.

What is the risk of HIV transmission when the blood viral load is undetectable?

Although we know having an undetectable blood viral load can greatly reduce the risk of HIV transmission, it is unclear exactly what this risk is reduced to.

In the research conducted so far, there have been no recorded HIV transmissions among heterosexual couples where the HIV-positive partner is on treatment and their blood viral load is undetectable. However, this does not mean the risk through condomless sex is zero. All of the couples studied to date have also reported using condoms often. This makes it difficult to determine the risk of HIV transmission when no condom is used.

Although there have been no studies among gay men and other MSM, there has been one report of HIV transmission occurring between two men when the HIV-positive partner had an undetectable viral load.

Also, the risk of HIV transmission when the viral load is undetectable may not be the same for all types of sex. This risk may be higher for anal sex than for vaginal sex, particularly if the HIV-negative partner is the receptive partner (bottom) during anal sex. This is because receptive anal sex generally carries a higher baseline HIV risk than other types of sex.

There are ongoing studies following serodiscordant heterosexual and same-sex couples who are taking HIV treatment, have an undetectable viral load, and do not always use condoms. These studies will provide a better understanding of the risk of HIV transmission when the viral load is undetectable and no condom is used.

What does this all mean for people who want to use HIV treatment to prevent HIV transmission?

There are no simple answers on viral load, HIV treatment and their relationship to HIV transmission and prevention. However, there are key messages for those who want to use HIV treatment to reduce their risk of HIV transmission:

• Check to make sure the blood viral load is undetectable before starting this approach and get frequent viral load tests to ensure it remains undetectable while using this strategy. It is generally recommended that the viral load be undetectable for 6 months before using this approach.
• Take pills exactly as prescribed. Adherence to treatment is critical to keep the viral load undetectable in the blood and prevent the development of drug resistance.
• Get tested regularly for STIs (including, syphilis, gonorrhea, chlamydia, and herpes). STIs can increase the risk an HIV-positive person transmits HIV and an HIV-negative person becomes infected with HIV. If either partner has an STI, start treatment immediately and try to avoid condomless sex during this time.
• Ask your doctor about vaccinations for hepatitis A, hepatitis B, and human papilloma virus (HPV).
• Using other HIV prevention strategies as much as possible – particularly condoms and lube – will help reduce the overall risk of HIV transmission.

References

Wawer MJ, Gray RH, Sewankambo NK et al. Rates of HIV-1 Transmission per Coital Act, by Stage of HIV-1 Infection, in Rakai, Uganda. Journal of Infectious Diseases. 2005 May 1;191(9):1403 –1409.

Baeten JM, Kahle E, Lingappa JR et al. Genital HIV-1 RNA predicts risk of heterosexual HIV-1 transmission. Science Translational Medicine. 2011 Apr 6;3(77):77ra29.

Cohen MS, Chen YQ, McCauley M, Gamble T, Hosseinipour MC, Kumarasamy N, et al. Prevention of HIV-1 infection with early antiretroviral therapy. New England Journal of Medicine. 2011 Aug 11;365(6):493–505.

World Health Organization. WHO and U.S. NIH Working Group Meeting on Treatment for HIV Prevention among MSM: What Additional Evidence is Required. Geneva; 2011 Nov.

Sheth PM, Kovacs C, Kemal KS et al. Persistent HIV RNA shedding in semen despite effective antiretroviral therapy. AIDS. 2009 Sep 24;23(15):2050–4.

Stürmer M, Doerr HW, Berger A, Gute P. Is transmission of HIV-1 in non-viraemic serodiscordant couples possible? Antiviral Therapy. 2008;13(5):729–32.

Galvin SR, Cohen MS. The role of sexually transmitted diseases in HIV transmission. Nature Reviews Microbiology. 2004 Jan;2(1):33–42.

Loutfy MR, Wu W, Letchumanan M et al. Systematic Review of HIV Transmission between Heterosexual Serodiscordant Couples where the HIV-Positive Partner Is Fully Suppressed on Antiretroviral Therapy. PLoS ONE. 2013 Feb 13;8(2):e55747.

Let’s be clear from the start. My history is one of being an opponent of treatment as prevention (TasP) - and a vocal one at that. But that was then and this is now, a time where the arguments of yore are no longer at all persuasive. So I’ve changed my mind and I now fully support TasP.

To be honest, mine is not a popular stance in Eastern Canada, but I’m in good company elsewhere. I’m referring to endorsement of TasP by the  World Health Organization, the International AIDS Society, the Joint United Nations Programme on HIV/AIDS (UNAIDS), the British Columbia Centre for Excellence in HIV/AIDS, (BC-CfE), the Terrence Higgins Trust, not to mention luminaries like Barack Obama, Hillary Clinton, Bill Clinton and Canada’s own Stephen Lewis.

But those names in themselves do not stir me.  It’s the opportunity that TasP, particularly in the absence of any other current strategy to see an end to AIDS in our lifetime, while improving the health of those with the virus. As Stephen Lewis has said utilizing TasP has become a “moral imperative”, a matter of ethics and of human rights. “What is urgently needed is for the Canadian government to do the right thing and that is to expand HIV testing and treatment nationwide.”

Leading treatment as prevention researcher/advocate Dr. Julio Montaner, a former head of the International AIDS Society, echoes his words, saying  “It is imperative for the Canadian government to mobilize political will and funds to nationally expand testing, treatment and support to people living with HIV/AIDS. This is the moral thing to do if we want to end AIDS and secure the health of our future generations.”

They are both right, of course

All of which leads me to say I was delighted to respond to the British Columbia Centre for Excellence in HIV/AIDS' invitation to endorse their efforts to secure a national AIDS strategy for Canada incorporating TasP.  You’ll find my words quoted in their press release below.

*************************

New study reinforces effect of antiretroviral treatment on prevention of HIV and calls for national action

Study stresses need for political will and funding to implement the made-in-Canada Treatment as Prevention strategy to save lives and prevent new infections 

Vancouver, B.C. [May 14, 2013] — A new study from the BC Centre for Excellence in HIV/AIDS (BC-CfE) and University of British Columbia shows there is strong and consistent evidence that expanded use of highly active antiretroviral therapy (HAART) decreases HIV transmission across a variety of geographical regions and sub populations. 

Researchers reviewed scientific evidence published in peer-reviewed journals about the benefit of HAART among HIV-positive individuals in preventing HIV transmission. Their analysis of existing literature reinforced the strong relationship between use of HAART and reduced transmission among not only stable heterosexual serodiscordant (where one partner is HIV positive) population, but also high-risk groups such as men who have sex with men (MSM) and injection drugs users (IDU).

“There is no doubt HIV Treatment as Prevention is a game changer,” said Dr. Julio Montaner, director of the BC-CfE and senior author of the study. “It is imperative for the Canadian government to mobilize political will and funds to nationally expand testing, treatment and support to people living with HIV/AIDS. This is the moral thing to do if we want to end AIDS and secure the health of our future generations.”

Study authors noted the effectiveness of abstinence promotion, condom use and needle exchange programs have been limited. In 2010 there were 2.5 million new infections, 1.8 million AIDS-related deaths and 390,000 children infected globally, with disproportionate representation in low-income countries. Only 54 per cent of HIV-infected individuals with severe immunodeficiency are on HAART, and only 20 per cent of people with HIV know their status.

Over the years, scientific evidence has mounted nationally and internationally in favour of HAART’s impact on reducing disease progression to AIDS and death and secondarily decreasing HIV transmission. In B.C., between 1996 and 2009, the number of individuals receiving HAART increased from 837 to 5,413 and the number of new HIV diagnoses fell from 702 to 338 per year (52 per cent decrease). The rates of HIV testing increased throughout the study period. In addition, in 2011, the HIV Prevention Trials Network (HPTN) reported that HAART led to a 96 per cent reduction in HIV transmission among serodiscordant couples.

“I am living proof of the long-term benefits of HIV treatment,” said Bob Leahy, editor of PositiveLite.com, Canada’s online HIV magazine, and someone who has lived with HIV for 20 years. “HAART has allowed me to live a normal and productive lifestyle and this is nothing short of a miracle for people like myself who have been given a second chance. It makes so much sense, and is the right and ethical thing to do, to ensure we quickly scale up testing across Canada so that every HIV-positive person has access to HAART, both to improve their own health and to very significantly reduce the risk of transmission.”

The Joint United Nations Programme on HIV/AIDS (UNAIDS) recently reported a 10 per cent drop in HIV/AIDS funding from 2009 to 2010 to support the Universal Access pledge. The U.S.’ budgeted contribution to the Global Health Initiative is projected to fall 10.8 per cent for 2013.

“We have the tools to end HIV/AIDS, and B.C. is a shining example of what can be achieved through universal implementation of Treatment as Prevention,” said Stephen Lewis, co-director of AIDS-Free World and renowned HIV/AIDS activist. “We are talking about human lives and the future health of Canadians. We cannot afford any further debate or more expensive clinical trials to prove what we already know. What is urgently needed is for the Canadian government to do the right thing and that is to expand HIV testing and treatment nationwide.”

The B.C. pioneered Treatment as Prevention strategy has led to the widespread expansion of HAART coverage in British Columbia. It has demonstrated a marked decrease in morbidity, mortality and new HIV cases. As the only province to implement the Treatment as Prevention strategy, B.C. stands alone as the sole province to show a consistent decline in new HIV diagnoses since 1996.

“While expansion of Treatment as Prevention will no doubt be lifesaving, evidence shows the long-term financial benefits can be tremendous,” said Dr. Bohdan Nosyk, lead author of the study and health economist at the BC-CfE. “HAART has evolved beyond individual health benefits to the HIV-positive person to secondary preventive benefits for the community at large. Failing to expand HIV funding can reverse the gains made against the epidemic and undermine the promise of HIV Treatment as Prevention.”

Research by the Canadian AIDS Society suggests the lifetime economic cost of each HIV infection is over $425,000, including health care costs and lost productivity.

Every year, 3,300 men and women in Canada are diagnosed with HIV infection and it is estimated more than 71,000 Canadians are now living with HIV.

The full study authored by several renowned HIV/AIDS experts and published in AIDS, official journal of the International AIDS Society, can be found here.

What is Treatment as Prevention?

The Treatment as Prevention strategy has been pioneered by BC-CfE’s Dr. Julio Montaner. It involves widespread HIV testing and immediate provision of anti-HIV drugs known as HAART to medically eligible people with HIV. The BC-CfE has demonstrated that the benefits of early HAART treatment are twofold: it reduces the level of HIV in the blood to undetectable levels thus improving the health of people with HIV, and decreases the level of HIV in sexual fluids to undetectable levels thus reducing the likelihood of HIV transmission by more than 95 per cent. In 2009, the BC government invested $48 million over four years in the BC-CfE-led Seek and Treat for Optimal Prevention of HIV/AIDS (STOP HIV/AIDS) pilot project. The intent of the pilot is to expand HIV testing and treatment among hard-to-reach populations such as injection drug users in Vancouver’s inner city and Prince George.

Treatment as Prevention is internationally recognized by organizations such as the World Health Organization, International AIDS Society and the Joint United Nations Programme on HIV/AIDS (UNAIDS). Treatment as Prevention has been endorsed by U.S. President Barack Obama, Secretary of State Hillary Clinton and former U.S. President Bill Clinton as an effective strategy in the fight against HIV/AIDS.

“I’ve been told that I can look forward to a tremendous reduction in stress and anxiety about seroconverting. I look forward to that. We’ll see. “ 

On April 5, 2013 I took my first dose of Truvada as pre-exposure prophylaxis (PrEP). I won’t deny it. I’ve been feeling very conflicted about starting PrEP.  

Why do I have access to Truvada when the majority of people who need antiretroviral medication to stay alive don’t have access? I got my hands on this bottle relatively easily. The social injustice is not lost on me. I don’t have relatively easy access to this medication because I deserve it more than anyone else.

So what HAVE I done to deserve access to PrEP? Well, a lot of it is sheer luck, actually.

•    Nearly every time I see the news, I am amazed at how lucky I am. I was born in Canada. Talk about winning the lottery. Out of 7 billion people, I am one of only 34 million people living in Canada. Trust me, it’s a great place to live!

•    I’ve been working in HIV for 20 years, including the last 10 years focussed on tracking biomedical HIV prevention research. This provides me with ongoing access to the latest information.

•    I make a good living. I can access healthcare relatively easily and generally for free or at a cost that has little impact on my standard of living.

•    I have a doctor. He’s young (My age. That’s young. Shut up.), gay, and sees a lot of people living with HIV in his practice. So talking to him about my sex life and about PrEP was not difficult. He keeps up to date on research. After a good discussion, he agreed to prescribe PrEP.

•    Not only do I live in Canada, but I live in Québec, the only province to have a universal public drug plan. As long as the drugs my doctor prescribes are on the provincial drug formulary, I am covered for most of the cost. I pay $500 into the drug plan annually, and PrEP will cost me less than $1,000/year on top of that. And if I ever need other drugs for any reason, I will not pay for them. Because $992/year ($82.66/month to be precise) is the most I would have to pay for all my drugs combined.

I’m not trying to be disingenuous. I know that beyond being lucky and privileged, I have access to PrEP because I’ve taken some very concrete steps as well. I did lots of introspection. I tried to reduce my risk as much as possible through other means. I did a lot of research. I actively sought out access. I make sure I’m very diligent about taking my pills.

I always have been very diligent about that. I take all my antibiotics when I need them. I take vitamins daily. When I was on antidepressants, I never missed a dose in 1.5 years. I follow advice from medical professionals to the letter. Case in point: I’ve needed physiotherapy twice. Both times, the conversation during my second visit went something like this:

Physiotherapist: Wow, you’re made remarkable progress in one week. I’ve never seen anyone progress so quickly with this type of injury. Which exercises did you do?

Me: All of them, like you showed me.

PT: You did ALL the exercise I gave you?! How often?

Me: Every day, like you told me.

PT: You did ALL your exercise EVERY day?! How many times a day?

Me: Twice, like you told me.

PT: You did ALL your exercises, EVERY day, TWICE a day?! I’ve never seen this in all my years of practice! No wonder you’re doing so well!

*SLAP* You’re at risk of HIV!

I might make jokes, but I don’t take this lightly.

Every morning when I wake up it’s the first thing I think about. That might stop after a while. But two weeks into taking PrEP, it’s the same thing. I wake up, and as I ponder about whether I want to go back to sleep again for a little longer, I can’t do it. I immediately think: when I get up I have to take my Truvada pill. Because I’m at risk of HIV.

Each and every time I open the cupboard and grab the bottle, I think: how is it possible that I am so lucky to have such easy access to this medication when millions of people who need it to stay alive don’t have access?

Who needs a coffee? I get a slap in my face every morning. Two of them in fact.

*SLAP* You’re at risk of HIV and STIs!

*SLAP* You’re one of the lucky few who has access to this medication and to this prevention option!

I’ve been told that I can look forward to a tremendous reduction in stress and anxiety about seroconverting. I look forward to that. We’ll see. I’m not there yet by any stretch. But at least I get some measure of comfort from knowing that I’m putting chances on my side by reducing my risk as much as I can in my current situation. Doing my best to stay healthy seems like the right thing to do to honour those who don’t have access to this drug.

About the author: Marc-André LeBlanc has worked in the community-based HIV/AIDS movement for 20 years.He does community engagement, capacity-building and policy work related to biomedical HIV prevention research, both in Canada and globally. He is a co-founder of International Rectal Microbicide Advocates (IRMA), serves as secretary on their steering committee, has authored two reports on the global state of rectal microbicide efforts, and leads IRMA’s global efforts to ensure the safety of sexual lubricants. Marc-André loves movies. He got a film studies degree while working full-time, just for the sheer fun of it. He is now leading advocacy efforts to get ice cream and popcorn recognised as new basic food groups in Canada’s Food Guide

This article originally appeared on My PrEP Experience here. 

This article was originally published in TheBody.com here

An undetectable viral load: the point at which HIV, though still present, cannot be found in a person's blood with the most sensitive tests available. It's a powerful concept with profound implications to the life of a person living with HIV (and his or her partner). However, according to CDC's treatment cascade, for a host of complex reasons, 75 percent of people living with HIV in the U.S. have not reached the point of viral suppression. (Among some specific groups in the U.S., that number is even larger.) For many of those that have, reaching that point was a major milestone in their lives. We asked people living with HIV to contribute thoughts and stories about getting their own viral loads to undetectable.

Minister Rob Newells, Oakland, Calif.; Diagnosed in 2005

Reaching undetectable never seemed like a significant milestone to me. I waited for my CD4-cell count to drop below 400 (about 18 months after my initial diagnosis) before I made the decision to begin antiretroviral therapy. My viral load, which was never extremely high, has been undetectable on every test since I started HIV meds in 2006.

For a long time, I thought viral suppression was a normal result of taking the medications. I expected nothing less. The HIV treatment cascade was a visual wake-up call that I am in the 25 percent minority. Clearly, we have much more work to do to increase retention in care and adherence to the medications that both improve the health of people living with HIV/AIDS and help to prevent transmission of the virus.

Meta Smith, Baton Rouge, La.; Diagnosed in 2001

At the time I was told I was HIV positive, I was placed on meds and did not have any idea how being undetectable would help me. When I had been on the meds for at least three months I returned to the doctor after lab work and was told I was undetectable. I knew I was feeling better after the meds; but after being told what undetectable was and how it would affect my life, I need to say I was on TOP OF THE WORLD and have stayed that way since then. It meant the world to me and changed my life, for the better. I got busy living.

Nelson Vergel, Houston, Texas; Diagnosed in 1986

I'm on the last combination I can try. I take a lot of pills. ... There's a part of me that's been very frustrated, extremely frustrated, with the fact that I've had it really hard when it comes to HIV. I've never had an undetectable viral load until three years ago ... Twenty-six years with virus in my blood, no matter what I did, no matter how many conferences I went to, no matter how many papers I read ... I felt like a loser, like a failure -- really, they call us "failure patients."

Watch Nelson's full "Day in the Life" video.

Bernadette Berzoza, Denver, Colo.; Diagnosed in 1989 

Over the past few years I have really fought and struggled to get my viral load down. It's been 23 years that I have been positive, and in the beginning it was just keeping your T cells up. Then the viral load was added. I was so freaked out when they told me my viral load was in the millions and we needed to change my meds to get it to undetectable. I did what was recommended but it wasn't working for me as they thought it would.

Read Bernadette's full story of getting her viral load down after many years.

Joe Ohmer, Bronx, N.Y.; Diagnosed in 2002

Eight months after I was diagnosed with HIV, my gastroenterologist that was taking care of my liver issues did some blood work, and my HIV viral load was undetectable without any medication. I didn't realize that that was anything significant or insignificant at the time, until maybe eight or 10 years later when my GI doctor mentioned it to me. I went on a regimen of Epivir (lamivudine -- also used to treat HIV, in different combinations with a higher dose) and Hepsera (adefovir) for my hepatitis B, which since I've been on it has been undetectable as well. Except for one blip, my HIV viral load has been undetectable.

Recently, my GI doctor, who's the same one who saw me initially, brought up that I was undetectable before I went on any regimen.

Read the rest of Joe's unusual story of being undetectable without medication.

Melissa Baker, Mechanicsville, Va.; Diagnosed in 2007

I was diagnosed August 2007. By January 2009, I made the count-dependent decision to start meds. It took me longer than three months to become undetectable. If it had taken me any longer my provider was going to change my regimen, fearing a possible resistance. The day I heard "undetectable" finally came before he had to, and my virus has remained undetectable since. :) I was ELATED!

Reggie Smith, Atlanta, Ga.; Diagnosed in 1984

After being sick in 2005, I have been taking the antiretroviral combination that has kept my virus at undetectable levels, and allowed me to enjoy really good health. With God's grace, and enough desire to live well, I have been able to adhere pretty well to this regimen. My oldest granddaughter was 2 years old at the time. Now she is 9, and I have two other granddaughters, a grandson, and a set of boy/girl twins! I play softball and golf, take flying lessons, I am of service to my community, and I am blessed to share my experience and hope with you.

Read Reggie's full story of coping with being tired of taking HIV meds.

Lillibeth G., New York City; Diagnosed in 1992

When I was told my viral load was undetectable I felt 100 pounds lighter. My greatest challenge was getting to an undetectable status. I had multidrug resistance so getting to undetectable was a milestone.

I was diagnosed in 1992 and it was difficult for me to adhere to my treatment since I was in denial and angry at myself (I should've been more selective of my partner). During one of my doctor visits he found a clinical trial I was able to join for both Isentress (raltegravir) and Intelence (etravirine). I was determined to bring my viral load to undetectable since I have so much to live for; I needed to live for my son, my mom (she was alive at the moment), myself most of all; I have things to do, people to educate. After a 17-year fight, I got the GOOD news: "I'm undetectable!" It makes me feel so alive.

I have a whole new look at life: I'm going to live; I have a fighting chance. Now I can talk to others about the importance of getting to that point -- it gives you hope. I'm always smiling and laughing; life is so different for me now -- I have HOPE.

Pastor Andrena Ingram, Philadelphia, Pa.; Diagnosed in 1989

THAT was another day, I remember with clarity. Waking up and dreading my doctor's appointment, because I knew I was going to get my blood-work results, and because I was about sick and tired of injecting myself. I was tired of Fuzeon (infuvirtide, T-20), I was tired of medication, I was just tired of it all.

I sat down in her office, and she pulled out my chart and looked at the labs, and smiled. I was like ... OK, what is my CD4? And it had been explained to me months before that they were beginning to look at this thing called "the viral load" ... and how that was more important than the CD4 count. She told me what my CD4 count was, which had peaked a bit ... but she was still smiling. And then she said: Guess what Andrena? Your viral load is under 50 copies! She was cheesin'! Grinning from ear to ear! I still didn't understand what that meant, until she stopped grinning long enough to tell me. That it meant that the virus in my body was undetectable …

Even though she explained it to me, I still didn't quite get it, until a few days later ... my mind had to process it. It meant that the Fuzeon was working. It meant that I was NOT gonna die (anytime soon). ....

I was ecstatic!

Read Pastor Ingram's full story of getting to undetectable.

Shannon Southall, Denver, Colo.; Diagnosed in 1992

February 1996, four years after being given my HIV diagnosis, I found myself lying in a hospital bed, and hearing that I now have AIDS. My CD4 count was 131. I needed to add more medication. When I was initially diagnosed in 1992, I had 896 CD4 and my first doctor put me on AZT monotherapy. After a friend found an infectious disease specialist I was switched to Zerit and Epivir.

Now lying in the hospital my doctor came in and said there was this new drug available called Crixivan and he strongly recommended that I add this to my current regime. My viral load was 159,000 and these new meds show that they can reduce the virus in my system, therefore prolonging my life. So of course I said yes. By August, my viral load was undetectable, less than 200, and my CD4 count was finally up over 200. ...

A few years ago I started to wonder about switching or stopping meds for a while. Then I met the man who would become my husband. He is HIV negative and I know that keeping my viral load down is crucial to maintaining a healthy sex life and reducing the risk of transmission to him.

Read Shannon's full story of 21 years on HIV meds.

The challenge for the new Safe Sex 2.0 effort will be trying to capture the attention span of someone who lives life and thinks in 140 characters. In this Internet age, we in the HIV+ and HIV- community (basically that is everyone) have been given the dual-edged sword of the internet as a tool for advocacy and outreach.  The internet is definitely useful in finding the answer to almost anything, and it has exponentially increased the means by which information can be disseminated to the masses.  However, the internet has also created vast, huge, and deep canyons between us, where we are only as connected as our wi-fi signal allows us to be. 

Back in the “old days”, we in the older gay community used to go to gay bars.  At those gay bars there were bowls of free condoms.  They were right there on the bar or by the door so that they were always on hand. Back then, we cared about protecting our community.  Back then it was not as controversial or offensive to talk about or insinuate safe sex. Safe sex was viewed as a normal, healthy part of the greater gay conversation. 

At some point though, this changed. Bars are no longer the meeting places of gay men.  Grindr, Scruff, and Adam4Adam have taken their place. Face to face caring was replaced by the cold glow of a computer screen.  Our community became diffused and fragmented and it dispersed like smoke in the wind. There were always those that didn’t go to the gay bars, just as there are those who do not go online today, but they were in the minority I believe.  

Our sense of community has been replaced by a transactional approach, where one’s personal opinions seem to trump the collective wisdom that has been tempered by experience.  Collaboration and compromise have been thrown down the toilet, to be replaced by the louder squeaky wheel of personal, selfish freedoms.

Now, if you were to talk about safe/safer sex or condoms, a method that is clinically proven to reduce HIV and other STDs, you are yelled at, or someone posts a pages long diatribe about how out of touch you are, and how it is their God-given right to have unsafe sex. They pull one tenuous statistic (that successful HAART treatment prevents 96% of HIV transmissions) and they have built an amendment to the sexual constitution, much like gun proponents clutch onto the 2nd Amendment. They ignore the fact that an undetectable viral load in the blood is NOT equal to an undetectable viral load in semen or in anal fluids/tissues. 

And so, the uninformed and unwilling shun proven methods of safety: condoms, HIV testing, non-sexual forms of intimacy.  (Apparently in the age of Grindr, intimacy seems to be an outdated concept as well.)  And then when they contract HIV, they then have this sense of confusion and incredulity, knowing in the back of their mind that they knew their risk all along but chose to ignore it and live in the moment.  There is even a hashtag for that, #YOLO (You Only Live Once).  

Because one in five urban gay men do not even know their HIV status, it is imperative to again find a way to encourage HIV testing and to advocate condom use. People proceed with actions based upon their perception of risk, as opposed to the actual risk at stake.   Stigma is still very high and the pervasive HIV stigma within the gay community (as well as outside of the gay community) prohibits those at the highest risk for HIV from getting tested. When those at highest HIV risk continue to contract the virus year after year after year, there should be a more aggressive approach to HIV testing and condom use.   

It is ironic that studies have shown that when a person is diagnosed with HIV, that person’s sexual behavior becomes safer. They care more about not wanting to infect others. But on the flip side of that is the callous carelessness that pervades young gay men, who believe their greatest source of angst is over what to wear to a Lady Gaga concert.  These guys repel conversations about HIV/risk/safety like Teflon repels an egg.  If you try to mention HIV, they all the sudden stop texting you back, or they fade from your Facebook...they become silent and they disappear.  

I believe there needs to be a new call to action, one in which the new ways of the internet and the social media expertise of the young are merged with the proven, effective methods of prevention.  And through all of this we must figure out how to burn of the fog that has settled on everyone regarding HIV:  for the older people who are tired and exhausted from 30+ years of advocacy and for the young, know-it-all youth who live in ignorance and bliss.

I wish I had the answer on how to do that, because until that answer is figured out, I fear we will again see a rise in HIV infections.  I believe the coming storm will rival the pre-HAART era. Before HAART, people died because there was no medicine.  Now, I believe stigma and indifference has become just as deadly as those early days. 

About the author: I am 38, a gay male from Knoxville, TN who is not ashamed of my HIV+ status. I am optimism personified. I am strength realized. I am just me.

Website: embacingpozitivity.blogspot.com.Twitter @jjemcdonald