In the JournalsPerspective

Canadian review: ‘Negligible’ risk for HIV from virally suppressed patients on ART

Rachel Rodin, MD
Rachel Rodin

There is a “negligible” risk that a patient with HIV who is on antiretroviral therapy and maintains viral suppression at a certain level will transmit HIV during sex, according to findings from a systemic review published in the Canadian Medical Association Journal.

The review was undertaken as part of the Canadian government’s examination of HIV nondisclosure laws.

“Under current criminal law in Canada, a person who is aware that they are HIV positive can be convicted for not disclosing their infection to sexual partners,” Rachel Rodin, MD, scientific director at the Public Health Agency of Canada’s Centre for Communicable Diseases and Infection Control, told Infectious Disease News. “The 2012 Supreme Court of Canada Mabior ruling requires disclosure of HIV infection before sex acts that ‘pose a realistic possibility of HIV transmission.’”

Last year, the Department of Justice Canada released a report highlighting what it called the country’s “overcriminalization of HIV nondisclosure.” In their review, Rodin and colleagues sought evidence of the transmission risk for HIV during sex between serodiscordant partners.

They searched MEDLINE and other databases for systemic reviews of HIV sexual transmission risk, as well as any new studies that had not been included in previous reviews. Only reviews that focused on the absolute risk for sexual transmission between partners with differing HIV-status were included, according to the study.

They identified 12 reviews eligible for inclusion in the analysis. They used one review to estimate the risk for HIV transmission associated with condom use without ART, which was low (1.14 transmissions/100 person-years; 95% CI, 0.56-2.04). The other 11 studies included in the meta-analyses estimated HIV transmission among patients on ART. They included 23 transmissions over 10,511 person-years, also translating to a low risk (0.22 transmissions/100 person-years; 95% CI, 0.14-0.33), according to Rodin and colleagues.

No study included a transmission event with a patient on ART and a viral load of less than 200 copies/mL assessed across consecutive measurements 4 to 6 months apart (0 transmissions/100 person-years, 95% CI 0-0.28), demonstrating a “negligible” risk for HIV transmission among serodiscordant partners under these circumstances, Rodin and colleagues said, and supporting the notion that “Undetectable equals untransmittable.”

In a related editorial, Richard Elliott, LLB, LLM, executive director at Canadian HIV/AIDS Legal Network, warned that risk is categorized differently in public health and criminal courts and that the conclusions presented by Rodin and colleagues “may overstate to the criminal justice system the riskiness of various acts.”
“In an analysis intended to inform the criminal justice system, [the authors’] qualitative assessments of transmission risk apply risk categories originally developed 30 years ago to enable public education about safer sex and health risk reduction in general,” Elliott wrote. “These categories reflect the relative riskiness of different activities. But they should not be transposed into a system tasked with determining criminal liability based on risk associated with a single act.”

The Canadian justice department already used the findings from this review to help guide its 2017 report on HIV nondisclosure. Rodin and colleagues said the research “may inform the responses of other justice systems.”

“Based on our findings, relevant case law and other factors, Justice Canada concluded that the criminal law should not apply to people living with HIV who maintain a suppressed viral load of less than 200 copies of the virus per millilitre of blood because the realistic possibility of transmission test is not met in these circumstances,” said Rodin. – by Marley Ghizzone

Disclosures: The authors report no relevant financial disclosures.

Rachel Rodin, MD
Rachel Rodin

There is a “negligible” risk that a patient with HIV who is on antiretroviral therapy and maintains viral suppression at a certain level will transmit HIV during sex, according to findings from a systemic review published in the Canadian Medical Association Journal.

The review was undertaken as part of the Canadian government’s examination of HIV nondisclosure laws.

“Under current criminal law in Canada, a person who is aware that they are HIV positive can be convicted for not disclosing their infection to sexual partners,” Rachel Rodin, MD, scientific director at the Public Health Agency of Canada’s Centre for Communicable Diseases and Infection Control, told Infectious Disease News. “The 2012 Supreme Court of Canada Mabior ruling requires disclosure of HIV infection before sex acts that ‘pose a realistic possibility of HIV transmission.’”

Last year, the Department of Justice Canada released a report highlighting what it called the country’s “overcriminalization of HIV nondisclosure.” In their review, Rodin and colleagues sought evidence of the transmission risk for HIV during sex between serodiscordant partners.

They searched MEDLINE and other databases for systemic reviews of HIV sexual transmission risk, as well as any new studies that had not been included in previous reviews. Only reviews that focused on the absolute risk for sexual transmission between partners with differing HIV-status were included, according to the study.

They identified 12 reviews eligible for inclusion in the analysis. They used one review to estimate the risk for HIV transmission associated with condom use without ART, which was low (1.14 transmissions/100 person-years; 95% CI, 0.56-2.04). The other 11 studies included in the meta-analyses estimated HIV transmission among patients on ART. They included 23 transmissions over 10,511 person-years, also translating to a low risk (0.22 transmissions/100 person-years; 95% CI, 0.14-0.33), according to Rodin and colleagues.

No study included a transmission event with a patient on ART and a viral load of less than 200 copies/mL assessed across consecutive measurements 4 to 6 months apart (0 transmissions/100 person-years, 95% CI 0-0.28), demonstrating a “negligible” risk for HIV transmission among serodiscordant partners under these circumstances, Rodin and colleagues said, and supporting the notion that “Undetectable equals untransmittable.”

In a related editorial, Richard Elliott, LLB, LLM, executive director at Canadian HIV/AIDS Legal Network, warned that risk is categorized differently in public health and criminal courts and that the conclusions presented by Rodin and colleagues “may overstate to the criminal justice system the riskiness of various acts.”
“In an analysis intended to inform the criminal justice system, [the authors’] qualitative assessments of transmission risk apply risk categories originally developed 30 years ago to enable public education about safer sex and health risk reduction in general,” Elliott wrote. “These categories reflect the relative riskiness of different activities. But they should not be transposed into a system tasked with determining criminal liability based on risk associated with a single act.”

The Canadian justice department already used the findings from this review to help guide its 2017 report on HIV nondisclosure. Rodin and colleagues said the research “may inform the responses of other justice systems.”

“Based on our findings, relevant case law and other factors, Justice Canada concluded that the criminal law should not apply to people living with HIV who maintain a suppressed viral load of less than 200 copies of the virus per millilitre of blood because the realistic possibility of transmission test is not met in these circumstances,” said Rodin. – by Marley Ghizzone

Disclosures: The authors report no relevant financial disclosures.

    Perspective

    Photo of Abimbola Farinde

    The requirement to disclose HIV status to potential sexual partners is not a practice that is adopted in many nations, so Canada is unique in its approach of prosecuting those who do not disclose their status when engaging in sexual activity. The potential for prosecution is believed to be a method of deterrence, increasing self-awareness and reporting, and reducing the possibility of HIV transmission across the society. The systemic review conducted by LeMessurier and colleagues demonstrates the potential for diminished risk for HIV transmission with the appropriate adherence to ART, condom use and reduction of viral load to less than 200 copies/mL. Although risk was found to be low, there is still the chance of an associated risk, so precautions should always be taken. These key factors, as well as other relevant considerations, are believed to be critical to informing public health polices and the response that the justice system has toward disclosure of HIV status not only in Canada but may also shape the polices that will ultimately be adopted by other nations.

    Abimbola Farinde, PhD

    Professor, Columbia Southern University

    Disclosure: Farinde reports no relevant financial disclosures.