Ep. 40: The Struggle to Change an HIV Narrative

Welcome to the reboot of the Undark Podcast, which will deliver — once a month from September to May — a feature-length exploration of a single topic at the intersection of science and society. In this episode, join radio producer and sound designer Alexander Charles Adams and podcast host Lydia Chain as they investigate the complex history of a destigmatizing message about HIV transmission, and how it is changing lives today.

Below is the full transcript of the podcast, lightly edited for clarity. You can also subscribe to The Undark Podcast at iTunes, Apple Podcasts, TuneIn, or Spotify.

Meta Smith-Davis: And of course you don’t want to really talk about it ’cause you’re not supposed to be having condomless sex. You’re living with HIV.

Meta Smith-Davis: My name is Meta Smith-Davis. I am the assistant director of prevention at HIV/AIDS Alliance for Region Two.

Alexander Charles Adams: Meta Smith-Davis works in a well-known HIV service organization here in Louisiana that handles a lot of patients who are entering or re-entering care. On any given day, she could do anything from administrative work to providing HIV testing and counseling. She works in Baton Rouge, which is one of the cities most heavily-impacted by the HIV epidemic.

Meta Smith-Davis: We are generally the first point of contact for folks. We start telling them about U=U while we’re signing ‘em up for case management. Because we know as folks living with HIV, we know what’s going on in ya’ mind: My sex life is over.

Lydia Chain: This is the Undark Podcast. I’m your host, Lydia Chain. That term Smith-Davis used — U=U — may be unfamiliar. U=U is the acronym for Undetectable Equals Untransmittable. What that means is there’s a path for people living with HIV to have zero risk of transmitting the virus from sex. But with complicated caveats, uneven messaging, and the sheer difficulty of changing a scientific narrative, the journey of U=U from controversial press release to established, destigmatizing fact is messy and ongoing. In today’s episode, reporter Alexander Charles Adams digs into the complex history of U=U and how it is shaping people’s lives today.

Alexander Charles Adams: So how did your career in HIV care start?

Meta Smith-Davis: I contracted HIV. [laughter]

Alexander Charles Adams: Like many people in the field, it took Meta Smith-Davis a long time to come to terms with having HIV, and it wasn’t a straight line. But it was always rooted in community.

Meta Smith-Davis: I didn’t know anything about HIV. I didn’t want to learn anything about HIV. The only reason I took the medicine as sick as it made me is because I didn’t want anybody to tell my grandchildren that their grandmother died from AIDS. I didn’t want that to be their legacy. So I took the medicine but that’s all I did and bleach. I took the medicine and bleached everything.

Alexander Charles Adams: Because Smith-Davis’s doctors didn’t give her the basic information around HIV transmission modes, she suffered from internalized stigma, and it wore down her mental health. So the idea of going beyond that, searching for love, intimacy, connection seemed impossible.

Meta Smith-Davis: And I realized that I had to do something about my mental health because living with HIV and the very thought of not being able to be intimate, not being able to have a husband, not being able to have great sex! It was just way, way too depressing. Way too depressing. Because I mean…I liked having sex.

Alexander Charles Adams: There is intense social pressure on people living with HIV to protect the HIV-negative people around them, even if it is to their own detriment. If someone living with HIV openly states their desire for condomless sex, they are often judged as reckless or immature. And due to social stigma, they often face persecution, violence, and even criminalization. In many states it’s illegal to potentially expose someone to HIV, even through actions that we know don’t transmit HIV, like spitting or protected sex. While these cases are often just used as a bludgeon to “out” or retaliate against someone living with HIV, people have ended up in jail.

Bruce Richman: There are hundreds and hundreds of thousands of people with HIV who are suffering right now in the United States because they and other people think they’re infectious.

Alexander Charles Adams: This is Bruce Richman. He’s the founding executive director of the HIV advocacy group the Prevention Access Campaign.

Bruce Richman: And they’re suffering from social rejection, from isolation, from depression, from suicide, from intimate partner violence, from prosecution, and from murder because the risk is still being exaggerated. It’s an emergency in the United States. It is a public health emergency.

Alexander Charles Adams: There are more than a million people living with HIV in the U.S. About 20,000 of them live in Louisiana. The Louisiana Department of Health and the cities of New Orleans and Baton Rouge recently endorsed the U=U message. This message makes a dramatic difference in quality of life for those people.

Meta Smith-Davis: It gave us the opportunity to take off that stigmatizing coat that says you can’t have condomless sex. You just can’t do it. I’m sorry. And for, uh; one of the women in my group was a particularly young woman of childbearing year, and she was just over the moon. She has a new baby now. She has a new baby now.

Alexander Charles Adams: In Smith-Davis’s work as an assistant prevention director, there’s a noticeable shift in how she conducts new diagnoses and testing appointments.

Meta Smith-Davis: It’s freein’. It’s mind blowin’ that you can walk away with a case manager. Most of the time they have my phone number. You have another person that is living with HIV that you can call, and you can still have sex when you become virally suppressed? Have some fun.

Alexander Charles Adams: HIV treatment works by suppressing replication of the virus, which lowers the overall amount of the virus in the body. It can drop so low tests cannot measure it — we call that “undetectable.” And since undetectable equals untransmittable, that person is incapable of passing HIV to a sexual partner. U=U applies to people living with HIV who are on treatment and who have been undetectable for 6 months. And it only applies to sex, not breastfeeding or other transmission modes. We’re only at the opening of this story, and you’ve probably already noticed there are a lot of qualifications, jargon, and in general a lot of information that could get confused. Even the words undetectable and untransmittable are a mouthful. That particular language comes from an international coalition, the Prevention Access Campaign or PAC, which we mentioned earlier. The PAC, a collection of advocates and researchers, pored over using right language to get this movement to take off.

Alexander Charles Adams: The PAC formed to spread this particular message in 2015 and, in 2016, released their U=U Consensus Statement, a short document stating that undetectable viral load means there is negligible sexual risk. It was later revisited to say “no risk.” It was co-authored by preeminent HIV researchers specializing in transmission. Again, Bruce Richman from Prevention Access:

Bruce Richman: We just got the experts together and said, “Look your science isn’t getting out to the public. You know, all your, your studies are all showing that this is true, but no one’s talking about it.”

Alexander Charles Adams: And actually it’s this long, long history of studies, sub-studies, and risk assessments of those studies where the story gets interesting. The Consensus Statement document itself is pretty dense, and is aimed at healthcare providers rather than the community. And this reflects how this whole discussion has mostly happened at the level of health organizations.

This revolutionary science actually first became available over a decade ago. It’s only recently, in the past two years, that most regional and national health organizations began to support a U=U message. The struggle to get that message to the people who need it the most has been complex, and it’s ongoing work.

If you scroll down the U=U Consensus Statement, you’ll see over 60 endorsements from various HIV orgs. Under that, there’s a list of endorsements from major HIV scientists and comments on new studies. As you get to the bottom of the page, the years start rapidly going backwards landing in 2011, way before the PAC but back when the science around this got big. We’ll get back to that, but first I want to take you to a moment even earlier.

Pietro Vernazza: All these couples were so anxious — they, they were afraid of transmitting the virus if they would have sex without a condom. And I know there is no risk so this doesn’t go together.

Alexander Charles Adams: This is Dr. Pietro Vernazza. In the early 2000s, his research pioneered advancements in sperm washing technologies to help people living with HIV conceive children. In studying how the virus operates in semen both from patients on and off treatment, he noticed something huge.

Pietro Vernazza: And I saw that there was absolutely no virus in the semen detectable. So we already know that if you have no virus in the semen it’s almost impossible that you transmit the virus. And we felt ethically obliged to inform these patients about the non-existence of any risk.

Alexander Charles Adams: In 2008 while he was the President of the Swiss Federal Commission for HIV/AIDS, he and his colleagues wrote a document later known as the Swiss Statement. Right across the top of this statement is: HIV-positive individuals not suffering from any other STD and adhering to an effective antiretroviral treatment do not transmit HIV sexually. Dense, but powerful.

The data Vernazza and his colleagues used to support the Swiss Statement was a combination of studies ranging from 2007 all the way back to the late-90s. In some, researchers confirmed that when people were virally suppressed, they didn’t have HIV in their genital excretions. And in two studies of about 400 people each, there were no transmissions between people who were undetectable and their negative partners. But the Swiss Statement was rejected by the HIV care establishment, specifically health organizations like the WHO, CDC, and NIH.

David Purcell: I don’t, I don’t think the, the Swiss Statement was widely accepted when it came out.

Alexander Charles Adams: This is David Purcell, the Deputy Director of Behavior and Social Science for the CDC’s Division of HIV Prevention. Purcell spearheaded development of the CDC’s clinic-standard HIV risk assessment tool.

David Purcell: I think if you read, read from back in that time there wasn’t widespread acceptance. I wasn’t, you know, focused on this at that time, but I don’t think if you look back at like news reports and other things, I don’t think that was widely embraced.

Alexander Charles Adams: In an article with Time magazine, the CDC and WHO responded promptly to the Swiss Statement re-affirming that all HIV positive patients must use condoms in every sexual encounter. The CDC comment to Time also called Vernazza’s statements premature and expressed uncertainty if there’d ever be a time people living with HIV would be non-infectious. These organization’s arguments centered on questions about the confidence of viral load testing and the stability of undetectability. Essentially, are we sure the tests are right, and if you’re suppressed on Tuesday, are you also Friday? Thing is, both of these questions were already answered in the literature before the Swiss Statement. Yes, the tests are right, and yes, they are stable.

The Swiss Statement did not achieve international consensus, but I asked Vernazza how the issue of getting U=U known played out in Switzerland. It went pretty smoothly, he said.

Pietro Vernazza: As physicians working in Switzerland, the whole problem for us was not so important anymore. So we tried to do our work for our patients in Switzerland. We felt we did the right thing and, and we are proud of having done it.

Alexander Charles Adams: Even though the Swiss Statement didn’t receive wide acceptance, researchers dove deeper into the question of transmission on treatment. Studies across the globe sprung up searching for a more definitive answer to this question. Remember the study I said we’d come back to? Here we are. In 2011, a landmark study was published in the New England Journal of Medicine called HPTN 052. Now, 052 reported that HIV meds reduced the risk of transmission by 96 percent. The study’s results were so astounding, the ethics board observing the trial called for an immediate release of the data and for the participants not on treatment to begin taking meds immediately. Upon presentation of 052, Anthony Fauci, head of the National Institute of Allergy and Infectious Diseases, considered the foremost HIV scholar in the world said, “Now we have absolute, confirmed data…treatment is prevention.” But we didn’t get all the way to U=U in 2011.

On the ground, HIV care did experience a shift. The CDC pushed and funded a Treatment as Prevention initiative, or TasP, with the goal of getting more people living with HIV on treatment to achieve a lowered transmission risk. TasP was innovative, in that it was a large, federally-funded initiative that brought together the previously separate public health concepts of treatment and prevention. Yet in messaging from the CDC and its partners, the way to get from a lowered risk to no risk, was condoms. And as we heard from Smith-Davis, that’s not the life-giving message she was looking for. Health orgs like the CDC said they could not back a zero-risk statement following 052 because they needed more data. I asked Vernazza about this in our interview.

Pietro Vernazza: The CDC didn’t say OK for, for heterosexuals it’s true. No, they said we just don’t have enough evidence. And to me that was just not justified.

Alexander Charles Adams, on tape: Not to ask a sappy question but how did that make you feel?

Pietro Vernazza: Oh, I was frustrated. I was frustrated. I mean we did come up with all that evidence and…and the fact that the CDC and other organizations did not inform their at least heterosexual couples there’s no risk. The fact that they did not make the statement tells you that they didn’t want the people to start having sex without [a] condom. That is the point that I felt is just unacceptable.

Alexander Charles Adams: I asked Purcell about this and this was his response:

David Purcell: I mean, Dr. Vernazza’s welcome to make whatever claims he wants. I think that’s fine. Um, I don’t think it’s necessarily accurate, in this case.

Alexander Charles Adams: The CDC stayed in the “we need more data” camp from 2008 to 2017 while research gathered. Richman was very direct about the ways people in many public health organizations talk about condoms and HIV:

Bruce Richman: People say to me in public health, “this is going to give people with HIV a license to have condomless sex.” And I remember so many times I’ve, uh, I heard the word a “license” to have condomless sex. And I said “do we need a license to have condomless sex?” Because like first where do I get one? And then also like, who gives you permission to make that decision for us?

Alexander Charles Adams: The relationship between STI risk and transmission, in general, is actually not if you do or don’t use condoms. It’s how many partners you have. Data from as early as the 90s shows that young adults who report “always using condoms” actually had almost identical STI incident rates as those who reported “never using condoms.” And it’s been replicated in a number of forms, not just testing for STIs but actual evidence of use of condoms versus reporting using condoms. What we’ve found is people who self-report always using condoms, simply aren’t. So while the CDC’s message after the Swiss Statement was that people living with HIV should be using condoms in every sexual encounter, they were just having condomless sex and feeling bad about it instead.

Bruce Richman: You know, people would also say that “we agree with U=U 100 percent. But what happens if someone living with HIV stops taking their medication?”

Alexander Charles Adams, on tape: Yeah.

Bruce Richman: “And that means they’re going to be detectable again. And what if they don’t know? And then that means,” and then I’ll just say to them, “do you think that we’re stupid? Can’t you just educate them?” Educate us. Don’t lie to us. Give us the information. Tell us that medicine only works if you take it.

Alexander Charles Adams, on tape: Yeah

Bruce Richman: Duh! Like you know? Right? So these were excuses that people gave because they were uncomfortable with the idea of people living with HIV having sex without condoms.

Alexander Charles Adams: There are barriers to getting people living with HIV in treatment and undetectable. Studies show it’s stigma, the structure of our health care system, poverty, and other forms of oppression. It is not the medications. The medications today work very well, are easier to access, have fewer side effects, and it’s hard to blow a regimen or make it ineffective. Meds today are so powerful, missing one or two doses a month doesn’t impact overall viral suppression. U=U only applies if you are adherent. When linked to care and costs are manageable, people living with HIV are adherent. Also, since people receive regular viral load testing with their care, we don’t have the same reporting issue as with condoms. There is an objective measurement.

So beyond cautious world health leaders or dogma around condom usage, why couldn’t 052 blow it out of the water? Right off the top, a 96 percent reduction in risk is not a hundred, so this does not get us to zero risk.

Later sub-studies demonstrated the infections that gave us that missing 4 percent must have occurred before the participants reached full viral suppression. But that clarity about the data wasn’t the only weak point. HPTN 052 lacked homosexual participants. It was also crafted to ask if early treatment affected sexual transmission risk, not the absolute risk of condomless sex while undetectable. The call for more data grew more intense.

A massive study called PARTNER was presented in 2014. The study followed nearly 900 couples through tens of thousands of condomless vaginal and anal sex acts over multiple years. It reported zero in-couple HIV transmissions. And PARTNER set out to ask the specific question other studies had not: What is the absolute HIV transmission risk for condomless sex, both vaginal and anal. PARTNER’s conclusion confirmed that 2008 Swiss Statement: there was effectively no sexual transmission risk.

PARTNER didn’t have quite enough data on homosexual sex acts, so the team extended the study with PARTNER2 and exclusively gay male participants. The final results would not be published until 2018.

In the summer of 2016, the Prevention Access Campaign released their Consensus Statement as a call to action for the world to recognize that people with undetectable viral loads of HIV could not sexually transmit the virus. That U does equal U. The PAC says that the groundswell of evidence going back to the late 90s on HIV in semen all the way up to contemporary studies like PARTNER were consistent enough to confidently form this conclusion in 2016.

Richman says, before the PAC there was no community organization amongst people living with HIV to push this message. Richman believes this, along with slow governments and condom dogma, takes some blame in the lengthy delay for U=U acceptance.

Bruce Richman: It’s too radical. The government’s not radical. What’s radical are the activists and the community. We can be radical. And then we push the government. We pressure the government and things move. But it, it didn’t work that way with this.

This is a field that has become corporatized. It’s become AIDS Inc. Even the activists. I mean, granted there are some really good ones that I work with, but they write, people write statements. They go to conferences. And they do leadership trainings, and they do more statements and more conferences. And they argue with each other. In the meantime, the risk between all- about all of us was being exaggerated. And some of us knew…Most of them didn’t do anything. I mean, that’s, that’s why I’m not so popular among some of these positive leaders.

And as soon as we organized in 2016, in the summer, the government responded to us in one year. Can you imagine if people had organized years earlier and tried to push the — Nobody!…Nobody paid attention, Alexander. No one.

Alexander Charles Adams: The Consensus Statement got its first U.S. endorsements from the New York City Department of Health and NASTAD — the National Alliance of State and Territorial AIDS Directors. I spoke to the board chair of NASTAD from that time, DeAnn Gruber.

DeAnn Gruber: This is actually now coming back to me; and it was when I was the chair of NASTAD…The director of NASTAD Murray Penner had reached out to me and he said, “DeAnn, I really think it’s important that NASTAD sign on to the proclamation statement about U=U.” And the board agreed.

Alexander Charles Adams: To be a part of NASTAD, you have to be directing a state or territory-level HIV program, so DeAnn’s involvement was based on her work in the Louisiana Department of Health as the leader of the State HIV and Hepatitis C Program. But the Louisiana Department of health didn’t sign on when NASTAD did.

Alexander Charles Adams, on tape: So there — was there anything stopping LDH from approving or supporting this message before the CDC did?

DeAnn Gruber: I do know that you know there are certainly times as being state government and also receiving a lot of federal funding to support this program…We will recommend something, and yes you know the administration may say what do our funders think about this. And are they ones who are also endorsing something like this.

And it is true we take a lot of lead from CDC and from others, you know, of statements that come out as being public health officials that you know there…there wasn’t…there, it was just there was a hesitation. There was a hesitation.

Alexander Charles Adams: But other international and national support for U=U snowballed. The U.S. Southern AIDS Coalition endorsed in February 2017, then Germany’s AIDS Support in June, and AIDS Center Moscow in October. Endorsements kept rolling out leading to September 2017 when the CDC endorsed the science of U=U. This moment sticks out in the memory of many people living with HIV in America. For Smith-Davis, back in Louisiana, she remembers it vividly.

Meta Smith-Davis: Finally we were free to talk about it openly. It made us feel stronger. It made us feel empowered. It really did. It changed the way we talked about sex. It changed the way we engaged in sex. It freed us.

Alexander Charles Adams: With the long road to U.S. government endorsement ended, the next step was getting this information in the hands of people living with HIV, their providers, and their communities. In my home state of Louisiana, our state health department — along with the cities of Baton Rouge and New Orleans — officially endorsed the U=U campaign this year.

DeAnn Gruber: So I reached out to our assistant secretary, who is Dr. Alexander Billioux…basically bringing this forward and saying “look, I think that this would be really valuable and it would be great for the state to kind of step up and do something like this.”

Alexander Charles Adams: In July, the Louisiana Department of Health launched their U=U website, which is well-sourced and laid out, and they have these cute “U=U Louisiana” buttons and stickers. LDH is currently developing U=U specific training modules with Bruce Richman from the PAC, so it’s a small world. They’re moving forward, but there’s also something to say here about how messy public health messaging can be.

David Purcell: First you got to get the science. Then you got to figure out like “well how do we communicate this to people who’ve been scared of HIV positive people for 35 years?” So some of I think what you’re capturing, and I think your, your, your, your inquiry is interesting is that it’s, it’s not easy to change a narrative, a scientific narrative, um, in a, fairly long-established and quite scary disease for many people, particularly those of us who’ve been around for 40 years.

Alexander Charles Adams: So what do we know in public health changes narratives? One example is funding. Now, the CDC normally makes its endorsements and agendas known via what initiatives it funds, and what requirements it has to receive funding. Here’s Gruber:

DeAnn Gruber: Whenever our new five-year funding cycles come out from CDC they then at times will emphasize different priorities. And so it’s true that in the, in the 2012 funding opportunity treatment as prevention was one of those pillars that was within the CDC funding.

Alexander Charles Adams: I asked Purcell if U=U is something that would make it into funding opportunities.

David Purcell: U=U would not be in a funding announcement.

Alexander Charles Adams: He said that’s because it’s mostly a communication. It’s a message, and one that he says should be left up to local health care providers to determine the best way to deliver. Richman disagrees. He says that not only should U=U receive direct funding, but it should be a requirement in funding applications. But there’s been some confusion at that local level about what health departments and providers are allowed to say. Richman has run into people who thought U=U was trademarked and that they couldn’t use it. Which, it’s not. And it was just this August, almost a full two years after the CDC backed the science behind U=U, that it emailed out a memo to all its TasP grantees giving them the express permission to tell their communities that there was no risk of sexual transmission.

In public health, good data is often hard to get and difficult to share with everyone who needs it. It took a decade for U=U to go from observation, to early studies, to a properly designed study that asked the right questions and included the right people. And as evidence gathered, every player in the system, be they researchers, public health experts, community activists, or even patients, had to assess the relative risks and benefits — the ethical pressures of deciding to act, and if so, how fast. They all ended up accepting that scientifically, U=U. It’s just that some took longer than others. And through all of that time, people living with HIV didn’t get to enjoy the peace of mind and relief that U=U brings.

Changing every doubtful provider or worried patient’s mind will still take some time, and there’s ongoing conversations to be had about what parts of this messy system could go faster, or make better use of resources. The goal now is to connect patients to care and support systems with accurate information.

Meta Smith-Davis: That’s so sad that this knowledge was out there all that time. Hm…But it’s here now. We gotta get everybody signed on to U=U. Not just for folks that are living with HIV but for the folks that love them. For the folks in their community. For the folks in their synagogues and churches and whatever else where’s they, they worship. We gotta get this message out where it’s normalized.

Talk. Learn. And when you learn it, transmit those lessons into something. Don’t take what you learn from us and keep it.

Lydia Chain: Alexander, thank you so much for bringing us this story, and also for joining me here on the show.

Alexander Charles Adams: Thanks for having me.

Lydia Chain: Could you walk us through a clinic setting? What tools does a provider have to help someone navigate that HIV risk? Say they are HIV negative, and they have a sexual partner living with HIV who is at that undetectable level. What does that look like?

Alexander Charles Adams: Yeah, so a great tool that people are able to use…Providers can use the CDC risk assessment tool that was developed by the HIV/AIDS division. David Purcell, one of the people that we featured in the documentary, spearheaded that development. And what this tool does is it allows you to sit down with a patient as a provider and plug in: Ok, if you are HIV negative and let’s say you’re having anal sex, and you’re the receptive partner, and you can put in that your partner is HIV positive and is on anti-retroviral treatment. There is not a selection to say if they’re virally suppressed or undetectable. You plug that in and it’ll spit out a number. Now, based on everything we talked about in the documentary, we know that what it should spit out is effectively no risk, or no risk, or something about U=U. Right now it doesn’t do that. It says you have a six in ten thousand chance of contracting HIV. Right down at the bottom of the sliding scale you have whenever you put in this information, there is a little to no risk section, and there are no markers there. You can’t actually put in anything into the tool to reach that area.

Lydia Chain: If this tool is saying there’s essentially no way to get to no risk with an HIV positive partner, that’s not the right message.

Alexander Charles Adams: It’s not the message that patients are looking for, it’s not the message providers feel like will be effective, and it’s not the accurate message either.

Lydia Chain: Are there other players in this field, be it health organizations or HIV advocacy organizations that are still not effectively incorporating U=U into its message?

Alexander Charles Adams: Well there are certainly organizations, HIV focused organizations here in the United States that do not promote or include U=U the same way they include pre-exposure prophylaxis or post exposure prophylaxis…

Lydia Chain: And that’s PrEP, and PEP, correct?

Alexander Charles Adams: Yes, so those are things people can take either before a risk event or immediately after a risk event in order to prevent contracting HIV. And both of those situations are geared towards negative people. So what I am saying here is we have HIV organizations in the United States that gear more towards people who are negative than people who are positive in a world where we have something like U=U that kind of levels the playing field of treatment and prevention. So an example of that, where the implementation is uneven between things that are geared towards people who are negative and people who are positive…Bruce Richman, the founding executive of PAC who we spoke to in the piece, told me that when an activist Maria Mejia was asked to do a video interview for AmFar, The Foundation for AIDS Research, had all of the content that she shared about her life that revolved around sex, that revolved around U=U, and cut all that away from the final edit of the interview and only left it in a text-based blog post.

Lydia Chain: That really changes the message.

Alexander Charles Adams: Yeah, absolutely. It definitely affects who hears it, and how many people hear it, and practically, how many times they hear it.

Lydia Chain: So there’s still work to be done on making sure that information on U=U gets to the people that really need it.

Alexander Charles Adams: I think a key in finding that path is focusing more on the people who are living with HIV in order to have conversations about both treatment and prevention.

Lydia Chain: That was Alexander Charles Adams reporting from Baton Rouge, Louisiana. Our theme music is produced by the Undark Team, and additional music in today’s episode was created by Night Owl (Broke for Free), Monplaisir (Evol, Theme Song, There is no place like home), and Komiku (Un desert). I’m your host, Lydia Chain. See you next month.

UPDATE: A previous version of this podcast incorrectly stated that U=U does not apply to virally suppressed people who have other STIs. The podcast audio and transcript have been updated to remove this error.