









































Communication, Society and Media 
ISSN 2576-5388 (Print) ISSN 2576-5396 (Online) 

Vol. 2, No. 2, 2019 
www.scholink.org/ojs/index.php/csm 

61 
 

Original Paper 

The Science of Undetectable Equals Un-Transmittable Plays out 

in Real Life a Clinical Case Report 
Alycia T. Dickens1* 

1 Hampton Veterans Affairs Medical Center, Department of Medicine, Division of Infectious Disease, 

Hampton, Virginia, USA 
* Alycia T. Dickens, Hampton Veterans Affairs Medical Center, Department of Medicine, Division of 

Infectious Disease, Hampton, Virginia, USA 

 

Received: February 19, 2019      Accepted: March 14, 2019      Online Published: April 12, 2019 

doi:10.22158/csm.v2n2p61                      URL: http://dx.doi.org/10.22158/csm.v2n2p61 

 

Abstract 

66-year-old African American man presented to the Infectious Disease Clinic for evaluation and 

treatment of Hepatitis C. Risk for Hepatitis C was Intravenous Drug Use (IVDU) 20 years earlier. 

Patient was referred to the Infectious Disease (ID) Clinic by primary care provider. Medical work-up, 

done by primary care provider, included HIV testing and the patient tested HIV+. Further testing by 

Infectious Disease Provider showed a cd4 643 @38% and a HIV RNA or HIV Viral Load of 43 

copies/ml. Interestingly, this patient was unaware of his HIV (+) status and he is also newly married 

less than 2 years. 

Keywords 

long term non-progressor, elite controller, un-detectable equals un-transmittable (u=u), Treatment as 

Prevention (TasP), Pre-Exposure Prophylaxis for HIV (PrEP) 
 

1. Introduction 

66-year-old African American man presented to the Infectious Disease (ID) Clinic for evaluation and 

treatment of Hepatitis C. Risk for Hepatitis C was Intravenous Drug Use (IVDU) 20 years prior. Patient 

also reported a history of being incarcerated x 6 years. The patient was previously treated for Syphilis 

and had a titer of 1:1. Patient was referred to the Infectious Disease Clinic by primary care provider. 

Patient was also noted to have a positive Quantiferon tuberculosis (TB) result. He stated he was never 

treated for tuberculosis (TB) or Latent TB. Primary care work-up included HIV testing and he tested 

HIV+. Unfortunately, he had never been informed or counseled about the HIV+ diagnosis. Upon 

arrival in the ID Clinic, he was subsequently informed of the HIV diagnosis and further testing by 



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Infectious Disease Provider showed a cd4 683 @ 36% and a HIV RNA of 58 copies/ml. Interestingly, 

patient was newly married less than 2 years. 

1.1 Definitions 

1) Long Term non-progressor and/or Elite Controller-HIV infected people who are symptom free with a 

CD4 count above 500 cells/mm without the aid of antiretroviral therapy for a minimum of eight years.  

2) Undetectable=Un-transmittable (U=U)—The concept that HIV infected individuals who are virally 

suppressed cannot transmit the HIV virus.  

3) Treatment as Prevention (TasP)—HIV that is controlled with antiretroviral therapy that reduces the 

amount of virus in the body which helps to prevent HIV transmission to others via sex, needle sharing 

or from mother to child-to-child via pregnancy, birth or breastfeeding. 

4) CD4 Count-CD4 cells are a type of white blood cell. They are sometimes also called T-cells, 

T-lymphocytes, or helper cells. They work by activating an immune response. One of the fundamental 

issues with HIV is that the cells meant to initiate an immune defense are the very same cells targeted 

for infection by Human Immunodeficiency Virus (HIV). Your CD4 cell count is the number of blood 

cells in a cubic millimeter of blood. It is not a count of all the CD4 cells in your body. A higher number 

indicates a stronger immune system. A normal or a CD4 cell count of a person who does not have HIV 

can be anything between 500 and 1500. 

5) HIV (Human Immunodeficiency Virus). There is no cure for HIV but with effective medical care it 

can be controlled. HIV attacks the body’s immune system, specifically the CD4 cells (T cells), which 

help the immune system fight off infections. Untreated, HIV decreases the number of CD4 cells (T 

cells) in the body, making the person more likely to get other infections or infection-related cancers. 

6) Pre-exposure Prophylaxis (PrEP)—Pre-exposure prophylaxis for HIV is an HIV prevention tool 

used for people who are HIV negative but who are at substantial risk for HIV acquisition. The mainstay 

of PrEP is taking a daily pill, Truvada, to prevent HIV infection. PrEP is more than 90% effective in 

preventing HIV transmission especially when used with condoms and other STD/STI prevention 

methods.  

7) HIIV Viral Load (VL) or HIV RNA PCR—A Viral load test quantifies the amount of HIV’s genetic 

material in a blood sample. The results of a viral load test are described as the number of copies of HIV 

RNA in a milliliter of blood. The higher the number the more HIV there is in your blood, then the faster 

your CD4 cell count will drop which equates to increased risk of becoming ill because of HIV.  

8) The Joint Nations Programme on HIV/AIDS (UNAIDS)—The main global advocate for coordinated 

and comprehensive for action against the HIV/AIDS pandemic. 

9) UNAIDS Goal/Target of 90-90-90 (for all countries)—90% of people living with HIV will be 

diagnosed by 2020.  

90% of people diagnosed with HIV will be on antiretroviral therapy by 2020. 



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90% of people on antiretroviral therapy will have viral suppression by 2020. 

 

2. Method 

2.1 Diagnostic Focus & Assessment 

1) HIV testing repeated, including repeating cd4 & HIV RNA. 

a) Repeat HIV test (+) 

b) CD4 683 @ 36% 

c) HIV RNA 58 copies  

d) Patient did not have any clinical symptoms of HIV 

e) He denied weight loss or major changes in weight/appetite, no diarrhea, no nausea, no vomiting, no 

sore throat, no skin lesions, no lymphadenopathy 

2) Wife got HIV tested for HIV & other Sexually Transmitted Diseases (STDs)/Sexually Transmitted 

Infections (STIs) she was also tested for TB. 

a) Wife had negative HIV test, Negative HIV Viral Load test, negative RPR, TB, 

chlamydia/gonorrhea/trichomoniasis tests 

3) Patient states HIV risk is from IVDA done 20 years ago in 1998 which is when he also had syphilis.  

4) Patient denies any other risk activities to include men who have sex with men (MSM) or 

heterosexual contact other than wife. 

5) Local Health Department notified & inquiry done to assess if previous or other HIV testing had been 

done/recorded within the state database—There was no other HIV testing information found in the 

database for this patient regarding HIV testing. Only the Syphilis testing which showed reactive with 

1:1 ratio and documentation of appropriate treatment. 

2.1.1 Therapeutic Focus & Assessment 

The patient was prescribed Biktarvy. Biktarvy is the newest single tablet, once-daily regimen that 

includes tenofovir alafenamide and emtricitabine (BIC/TAF/FTC). It is an Integrase Strand Inhibitor 

(INSTI) that was approved by the United States Food and Drug Administration in February 2018. 

Single tablet regimens are used when possible and especially for naïve patients for simplification 

purposes. This drug also has few drug-drug interactions, a higher barrier of resistance when compared 

to other antiviral medications and has few side effects. Also, the TAF agent, included in this drug, 

concentrates in the CD4 cell having 90% less exposure to bone and blood as compared to the Tenofovir 

Disoproxil Furmarate (TDF) agent and the TAF agent it works even with TDF resistance. This patient 

also received the first shot of the Twinrx vaccine series. Twinrix is a vaccine that provides active 

immunity against both the hepatitis A and hepatitis B viruses. It is recommended and administered for 

people who are HIV infected because providers want to take precautions against patients acquiring 

other infections. Unfortunately, the patient refused the Pneumonia and Influenza vaccines, for personal 

https://www.healthlinkbc.ca/health-topics/sti150879#sti150879-sec
https://www.healthlinkbc.ca/health-topics/sth149722#sth149722-sec
https://www.healthlinkbc.ca/health-topics/sth149741#sth149741-sec


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reasons. The patient’s wife is being treated at a local health department with Truvada for Pre-Exposure 

Prophylaxis (PrEP) for HIV. The plan is to also treat and cure the hepatitis c infection and then treat 

Latent tuberculosis infection for this patient. 

 

3. Result 

The couple is relieved that the wife is HIV negative. The wife is somewhat knowledgeable about HIV 

as she has a relative who is HIV (+) and therefore was not threatened or too overwhelmed by the 

diagnosis. The wife desires to be on PrEP and to also use condoms, especially for contraception (as she 

is in her late 40s) after being counselled by the Health Department representative. The patient is happy 

that he can tolerate Biktarvy without any adverse side effects. The patient is also happy about being on 

a single tablet regimen and that this diagnosis did not destroy his marriage. 

 

4. Discussion 

This case illustrates that the concept of U=U works. This patient had an un-detectable HIV Viral Load 

via, per our assessment, long term non-progressor status. He did not transmit HIV to his wife of less 

than 2 years, even though he was not on HIV therapy. Traditionally, patients who are considered Elite 

Controllers or Long Term Non-Progressors are not necessarily initiated on Antiretroviral Therapy 

(ARV). However, this thought process is changing in the age of TasP, single-tablet regimens and with 

the much-improved side-effect profile noted with nearly all the new ARVs currently on the market. 

This patient specifically was initiated on ARV mainly for cardiovascular health to decrease 

proinflammatory response and to further reduce the likelihood of HIV transmission to his wife. He has 

some compromised renal function which also makes a case for ARV therapy, especially one containing 

the new Tenofovir Alafenamide (TAF) product, which decreases the potential of adverse side-effects 

related to bone and renal function especially for this 66-year-old African American male. This case 

demonstrates the importance of and the increased need for thorough history taking and HIV testing for 

the general population, but, most notably for high-risk individuals. It also represents the success and the 

proven biology of the notion undetectable equals un-transmittable (U=U). This outcome for this couple 

could have been very different and usually is especially for African American women. 

African Americans represent 12% of the United States population but 44% of the new HIV infections. 

The message of U=U needs to be spread within the community at large to help decrease stigma and 

discrimination about HIV testing and treatment. Moreover, the eastern region of Virginia has the 

highest HIV prevalence (30%) in the state. Unfortunately, even with knowledge of these dire statistics, 

African American women, in particular, underestimate their risk for HIV acquisition. As clinicians and 

researchers need to continue to advocate for minorities with HIV and those at risk for HIV. We need to 



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draw substantial attention to the co-contributors of poverty, violence, gender oppression, substance 

abuse, mental illness, incarceration and educational disparities to reach the UNAIDS goal of 90-90-90. 

 

Acknowledgement 

My deepest gratitude goes to my mentor Barbara Cross-Jones, PhD, FNP-BC for her support, 

encouragement and technical assistance with this paper.  

 

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