BHIVA preconference: U=U and HIV and immigration detention
This year the conference pre-meeting focused on the importance that BHIVA gives to raising awareness that having an undetectable viral load prevents sexual HIV transmission (U=U).
The programme also included an excellent talk on the current care for HIV positive people held in detention centres.
Dr Nadi Gupta from Rotherham NHS Foundation Trust presented results from a BHIVA membership questionnaire in October 2018, that had been prompted by very low awareness of U=U amongst her patients. 
The anonymous online survey was answered by 270 doctors with 20% having heard about U=U from colleagues and only three people never having heard of U=U.
Most doctors reported discussing U=U routinely (70%), on diagnosis (70%), when starting ART (55%) or when becoming undetectable (48%) but a small percentage only discussed U=U when asked (3%, n=7) or don’t usually discuss it (3%, n=6).
Using direct language when discussing U=U is also important part of U=U but only 37% of doctors in the survey were explicit about U=U having a zero risk. Use of evasive language was still common to describe the risk and these less-direct words actually undermine confidence in U=U: for example, using extremely low (8%), next to zero (21%), virtually impossible (10%) or negligible (11%).
Discussions commonly included reviewing the evidence with their patients in order for the patients to understand the results. However, more than 30% of clinics had no information about U=U in the waiting room.
A majority of doctors (70%) were aware that U=U doesn’t cover breastfeeding.
In response to this survey, BHIVA issued a statement supporting U=U (for World AIDS Day on 1 December 2018). 
The statement emphasised:
- The importance of using zero risk or no risk in U=U discussion.
- That explaining the data supporting this statement is often important for patients to be convinced.
- Using free U=U resources – such as the posters, post-cards and leaflets produced by i-Base to raise awareness in the clinic. 
U=U founder Bruce Richman then talked about the history of U=U as a global campaign. 
The chance to have sex without fear has been such a transformative experience that this is needed globally, not just in high-income countries. The scale-up of community mobilisation has seen the campaign endorsed by more than 850 organisations in 97 countries.
An important context that has developed more recently is that having an undetectable viral load should not itself be attached to any moral value. Adopting U=U should always be a personal decision and not a public health initiative.
Examples from the US PEPFAR/USAID-funded Linkages programme included resources for 30 countries. These included the importance of wider access to viral load tests that have a lower threshold of 200 copies/mL.
Two further talks were included in this workshop.
Professor Matthew Wait from the University of Portsmouth gave an overview about how U=U affects HIV and the law in England and Wales. 
This focused on implications for reckless transmission and on whether or not HIV positive people need to tell their sexual partners about their HIV status if viral load is undetectable. Prosecution requires proof of transmission, that the intention to transmit was deliberate and that the previously negative partner did not consent to any risk.
The considerable stigma – fueled by transmission cases in the mainstream news media – was highlighted as driving the continued fear of HIV and the related discrimination.
Although not strictly linked to U=U, the final talk by Kat Smithson from National AIDS Trust provided an impressive and comprehensive review of the multiple ongoing concerns about HIV care in immigration detention and removal centres. 
During 2017 more than 27,000 people were held in detention centres, just over half of whom were later released back to stay in the UK. There are currently no data on HIV rates in these people but as they disproportionally come from sub-Saharan Africa (20%) or Eastern Europe (20%) rates are likely to be higher than general UK population.
The talk expanded on key issues in the new BHIVA/NAT report on these issues (that is also available online). 
- Access to healthcare.
- Stigma and discrimination.
- Detention of vulnerable people.
- Public health.
Importantly, it also provides practical advice for doctors and other health workers whose patients are involved at any stage of the detention process.
Part of the discussions about U=U included the question of how long a person needs to have an undetectable viral load before their partners are protected.
The new consensus seems to be that U=U starts when HIV first becomes undetectable as long as this is in the context of good adherence.
Although initial guidelines (including BHIVA) took a cautious approach and recommended waiting for six-months, there is little data to inform this question. In practice, protection is now commonly taken form the first undetectable viral load result and there is little need to make people wait an additional six months.
Unless stated otherwise, all references are to the programme and abstracts of the 25th Annual BHIVA Conference (BHIVA 2019), 2 – 5 April 2019, Bournemouth.
- BHIVA Pre-conference Meeting: Important Challenges. 2 April 2019
https://www.bhiva.org/AnnualConference2019Presentations (web page)
- Gupta N. BHIVA’s position on U=U an update. BHIVA 2019, preconference workshop.
- HIV i-Base. U=U free resources. Free to order online.
- Richman B. U=U in resource limited countries. BHIVA 2019, preconference workshop.
- Weait M. U=U the legal context. BHIVA 2019, preconference workshop.
- Smithson K. HIV care in immigration detention and removal. BHIVA 2019, preconference workshop.
- BHIVA/NAT. Immigration detention and HIV Advice for healthcare and operational staff. (March 2019).