Prevention

Viral load refers to the amount of HIV virus present in the blood of a person living with HIV. If a person’s viral load is “undetectable,” it means that the virus is still present, but below the level that tests can detect.

In recent years, an overwhelming body of clinical evidence has firmly established the HIV Undetectable=Untransmittable ( U=U) concept as scientifically sound. U=U means that people living with  HIV who achieve and maintain an undetectable viral load by taking antiretroviral therapy (ART) daily as prescribed cannot sexually transmit the virus to others. HIV treatment is a powerful HIV prevention tool, however, people’s viral load can also increase without any clear symptoms.

If you are having sex with somebody who has a different HIV status than you, here are some things to keep in mind about undetectable viral load:

• Viral load can and does fluctuate for some people – a single “undetectable” viral load test result does not mean that HIV will be undetectable in the future, so regular testing is important. An undetectable viral load sustained over six months greatly reduces the risk of HIV transmission.
• Adherence to HIV medications (i.e., taking them as prescribed) is key to maintaining an undetectable viral load.
• Having an undetectable viral load does not reduce the risk of transmitting other sexually transmitted infections (STIs), and it is possible that having STIs increases the risk of transmitting HIV. If you are having sex without a condom because you have a low viral load, it is important to test for other STIs regularly.
• People living with HIV have to disclose their HIV status to partners before sexual activity that poses “a realistic possibility” of HIV transmission. Ontario has recognized that having a low enough viral load could, on its own, mean there is no realistic possibility of transmission. For more information on the criminalization of HIV non-disclosure, go to the DISCLOSURE AND CRIMINALIZATION For up-to-date and emerging information on viral load and other HIV prevention strategies, please visit CATIE. For more information on HIV and Criminalization visit Legal Clinic Ontario (HALCO).

Having sex with people who are of the same HIV status as you, whether positive or negative, can help reduce the risk of HIV transmission. This is sometimes called “serosorting”.

The idea behind this strategy is that if people living with HIV are only having sex with other people living with HIV, and HIV-negative people are only having sex with HIV-negative people, then HIV-negative people are not going to be exposed to HIV. While it seems simple in concept, there are factors that can make it more complicated in real life. In fact, some organizations recommend serosorting for HIV-positive people and discourage it for HIV-negative people as it can be more difficult to be sure of an HIV-negative status. If you are considering serosorting as an HIV prevention strategy, there are some things to consider:

For HIV-negative people: You cannot be sure your partner is HIV-negative. They might not know their status: According to national HIV estimates, 8,300 people were living with HIV but didn’t know it (undiagnosed) at the end of 2018. They might have had sex without condoms or used another HIV prevention strategy (like PrEP) since their last HIV test, or they might have been infected within the window period before their last HIV test (up to 12 weeks). They might not understand how testing works, or assume they are HIV-negative because they have no symptoms. If you are going to have sex without a condom with other people you think are HIV-negative, here are some strategies to consider:

• Get tested for HIV and other sexually transmitted infections (STIs) on a regular basis.
• Talk to your sexual partner(s) about their HIV status, and do not make assumptions. If they are a regular partner, do not assume their status or sexual health has not changed since the last time you discussed this with them
• If you cannot have an open and honest conversation, or cannot be sure of their HIV status, consider what information you do not know and whether you are comfortable with having sex without a condom in this situation.

For HIV-positive people: There is still the possibility of getting or passing on other STIs, like syphilis and hepatitis C. If you are going to have sex without a condom with other people living with HIV, here are some strategies to consider:

• Get tested for STIs and hepatitis C on a regular basis.
• Talk to your partner about their HIV status, STIs, and sexual health strategies. If they are a regular partner, do not assume their status or sexual health has not changed since the last time you discussed this with them. For tips and strategies, click here.