Awareness and Acceptability of Undetectable = Untransmittable Among a U.S. National Sample of HIV-Negative Sexual and Gender Minorities

Awareness of U = U among Sexual and Gender Minorities in Brazil, Mexico, and Peru: Differences According to Self-reported HIV Status

The slogan Undetectable equals Untransmittable (U = U) communicates that people living with HIV (PLHIV) who are on antiretroviral therapy (ART) will not transmit HIV to their sexual partners. We describe awareness of U = U among sexual and gender minorities (SGM) living in Brazil, Mexico, and Peru by self-reported HIV status (PLHIV, negative, unknown) during 2021 using an online survey. We estimated two models using Poisson regression for each population group: Model A including socio-demographic factors (country, gender, age, race, education, and income), and then Model B including taking ART (for PLHIV) or risk behavior, ever-taking PrEP, and HIV risk perception (for HIV-negative or of unknown HIV status). A total of 21,590 respondents were included (Brazil: 61%, Mexico: 30%, Peru: 9%). Among HIV-negative (74%) and unknown status (12%), 13% ever used PrEP. Among PLHIV (13%), 93% reported current use of ART. Awareness of U = U was 89% in both Brazil and Mexico, which was higher than in Peru 64%. Awareness of U = U was higher among PLHIV (96%) than HIV-negative (88%) and HIV-unknown (70%). In multivariate models, PLHIV with lower education were less aware of U = U, while those taking ART were more aware. Among HIV-negative, non-cisgender, lower income, and those with lower education had lower awareness of U = U, while individuals ever using PrEP had higher awareness. In conclusion, awareness of U = U varied by HIV status, socio-demographic characteristics, and HIV risk behavior. The concept of U = U should be disseminated through educational strategies and include a focus on SGM to combat HIV stigma.

Perceived Accuracy Around Undetectable = Untransmitable Among Sexual and Gender Minorities Using Smartphones in India

Sexual and gender minorities (SGM) using online venues in India are usually not reached by government HIV interventions, remaining an understudied yet important population. We investigated sociodemographic characteristics, sexual behaviours along with familiarity, knowledge, and correlated factors around perceived accuracy of the Undetectable = Untransmittable (U = U) slogan. Grindr users in India completed an online, cross-sectional survey in May-June 2022. We included individuals ≥ 18 years old who reported sex with men (excluding those who were born female and or identified as cis-gender female). Associations with perceived U = U accuracy were estimated using adjusted prevalence odds ratios (aPOR) with 95% confidence intervals (95% CI). The survey was completed by 3,126 eligible participants. The median age was 28 years and most participants lived in urban areas and had graduate or postgraduate education. HIV prevalence was 3.1%. Only 14% reported familiarity with the U = U slogan and after an explanation was provided, 25% perceived it as completely accurate. This was associated with knowing their HIV status (HIV Negative aPOR 1.37 [95%CI 1.1, 1.71], HIV Positive aPOR 3.39 [95%CI 2.11, 5.46]), having heard of PrEP (aPOR1.58 [95%CI 1.29,1.92]) or have used PrEP (aPOR1.56 [95%CI 1.15, 2.12]) along with use of party drugs (aPOR1.51 [95%CI 1.0 2.10]), being in touch with NGOs (aPOR 1.61 [95%CI 1.27, 2.02], p < .001) and having attended LGBTQIA + events (aPOR1.38 [95%CI 1.1, 1.73]). SGMs in India had low familiarity and low perceived accuracy around U = U. Education about U = U and innovating new strategies to reach this hidden population could reduce stigma around HIV in India.

Message Framing Strategies to Promote the Uptake of PrEP: Results from Formative Research with Diverse Adult Populations in the United States

There are no evidence-based recommendations for communicating about pre-exposure prophylaxis (PrEP) as part of a broader HIV-prevention messaging approach. To inform future message development related to PrEP uptake, we interviewed 235 individuals across ten locations in the U.S. to explore their understanding and perceptions of draft HIV prevention messages and assess their overall preferences for a broad or PrEP-focused messaging approach. Participants responded favorably to and related to both draft messages. Participants who were not aware of PrEP were more likely to say the broad HIV-prevention message was personally relevant than those aware of PrEP. There were no significant differences in perceived personal relevance for the PrEP-focused message. Qualitative findings suggest that HIV prevention messages should use specific well-defined terms, include links to additional information, and use choice-enhancing language that emphasizes personal agency and frames the call to action as an informed decision among an array of effective prevention options.

The Potential Role of Undetectable = Untransmittable (U = U) in Reducing HIV Stigma among Sexual Minority Men in the US

The Undetectable = Untransmittable (U = U) message and its scientific underpinnings have been widely suggested to reduce HIV stigma. However, misunderstanding and skepticism about U = U may prevent this destigmatizing potential from being fully realized. This cross-sectional study examined associations between U = U belief (belief that someone with a sustained undetectable viral load has zero risk of sexually transmitting HIV) and HIV stigma among US sexual minority men. Differences by serostatus and effects of brief informational messaging were also explored. The survey was completed online by 106 men living with HIV and 351 HIV-negative/status-unknown men (2019-2020). Participants were 18-83 years old (M[SD] = 41[13.0]). Most were non-Hispanic White (70.0%) and gay (82.9%). Although nearly all participants (95.6%) were aware of U = U, only 41.1% believed U = U. A greater percentage of participants living with HIV (66.0%) believed U = U compared with HIV-negative/status-unknown participants (33.6%). Among participants living with HIV, U = U belief was not significantly associated with perceived, internalized, or experienced HIV stigma or with viral load prejudice (prejudice against people who have a detectable HIV viral load). Among HIV-negative/status-unknown participants, U = U belief was associated with less frequently enacted HIV discrimination, more positive feelings toward people with an undetectable viral load, and lower personal endorsement of stigmatizing beliefs. Brief informational messaging about U = U did not affect most stigma dimensions and did not favorably affect any. Interventions are needed to correct commonly held, outdated misconceptions about HIV transmission risk. Such initiatives must not only engage people living with HIV but also engage HIV-negative/status-unknown people to maximize the destigmatizing potential of U = U.

Attitudes Toward and Beliefs in the Effectiveness of Biomedical HIV Prevention Strategies Among Emerging and Young Adult Sexual Minority Men

BACKGROUND

Pre-exposure prophylaxis (PrEP) and HIV treatment as prevention, which underlies the Undetectable = Untransmittable (U = U) campaign, are two effective biomedical approaches for HIV prevention among sexual minority men (SMM). Attitudes toward PrEP and U = U may differ between SMM emerging adults (EA: 18-24 years old) and young adults (YA: 25-29 years old) to drive differences in sexual behavior. However, to date, few studies assessed the degree to which YAs and EAs differ in their beliefs in the effectiveness of PrEP and U = U.

METHOD

A national sample of 80 SMM in the USA (Mage = 25.1 years; 53.7% racial/ethnic minority; 38.8% EA; 61.3% YA) participated in a 6-month mHealth intervention for PrEP adherence. Non-parametric tests assessed differences in sexual behaviors and attitudes toward the effectiveness of PrEP and U = U between EAs and YAs using baseline data.

RESULTS

Compared to EAs, higher proportions of YAs trusted PrEP's effectiveness and considered condom use unnecessary after taking PrEP. More YAs than EAs were willing to engage in sexual behaviors that they felt too risky before learning about U = U and were more comfortable having condomless sex with HIV-positive partners. Conversely, a greater proportion of EAs than YAs preferred to use condoms even when their partners are on anti-HIV medications.

CONCLUSION

Overall, YAs trusted the effectiveness of U = U and PrEP more than EAs, underscoring developmental differences in SMM's perspectives on biomedical HIV prevention tools. Our findings underscore the importance of tailoring messages on biomedical HIV prevention options differently for EAs and YAs to optimize uptake.

Attitudes and Beliefs About HIV Treatment as Prevention Among People Who are Not Engaged in HIV Care, 2018-2019

Treatment as prevention (TasP) is an effective HIV prevention strategy. Our objectives were to explore TasP attitudes and beliefs among people with HIV (PWH) who are not engaged in care and to examine attitudes and beliefs by selected characteristics. We sampled PWH who had participated in the Medical Monitoring Project (MMP), a structured interview survey, from June 2018-May 2019 to participate in 60-minute semi-structured telephone interviews. We obtained sociodemographic and behavioral quantitative data from the MMP structured interview. We used applied thematic analysis to analyze the qualitative data and integrated the qualitative and quantitative data during analysis. Negative attitudes and beliefs, especially skepticism and mistrust, about TasP were pervasive. Only one participant who identified as female, was not sexually active, and had not heard of TasP held positive attitudes and beliefs about TasP. TasP messages should use clear and unambiguous language, address mistrust, and reach people who are not engaged in medical care.

Potential impact of doxycycline post-exposure prophylaxis prescribing strategies on incidence of bacterial sexually transmitted infections

BACKGROUND

Doxycycline post-exposure prophylaxis (doxyPEP) reduces bacterial sexually transmitted infection (STI) incidence in people with HIV (PWH) or using HIV preexposure prophylaxis (PrEP). Given concerns about widespread antibiotic use, we identified doxyPEP prescribing strategies to minimize use while maximizing impact on STIs.

METHODS

We used electronic health records of gay and bisexual men (GBM), transgender women, and non-binary people assigned male sex at birth with ≥2 STI tests (chlamydia, gonorrhea, syphilis) at an LGBTQ-focused health center during 2015-2020. We defined 10 hypothetical doxyPEP prescribing strategies based on PrEP use, HIV status, or STI history. We estimated doxyPEP use and STI diagnoses averted in counterfactual scenarios in which people meeting prescribing criteria received doxyPEP, assuming STI rates during use would have been reduced by clinical trial efficacy estimates.

RESULTS

Among 10,546 individuals (94% GBM), rate of any STI was 35.9/100 person-years. Prescribing doxyPEP to all individuals would have averted 71% of STI diagnoses (number needed to treat for one year to avert one STI diagnosis, NNT = 3.9); prescribing to PrEP users/PWH (52%/12% of individuals) would have averted 60% of STI diagnoses (NNT = 2.9). Prescribing doxyPEP for 12 months after STI diagnosis would have reduced the proportion using doxyPEP to 38% and averted 39% of STI diagnoses (NNT = 2.4). Prescribing after concurrent or repeated STIs would have maximized efficiency (lowest NNTs) but prevented fewer STIs.

CONCLUSIONS

Prescribing doxyPEP to individuals with STIs, particularly concurrent or repeated STIs, could avert a substantial proportion of all STI diagnoses. The most efficient prescribing strategies are based on STI history rather than HIV status or PrEP use.

Investigating the Content of #UequalsU on Twitter

Undetectable = Untransmittable (U = U) is the scientific fact that HIV cannot be transmitted when an individual is virally suppressed. This breakthrough discovery has the potential to greatly reduce HIV stigma and its negative effects. However, U = U is not widely known. Given that Twitter has the potential to raise awareness of health issues, the purpose of this study was to analyze the content of the #UequalsU on Twitter. The results showed that mentioning sex and mentioning love were strong predictors that a tweet would be liked and retweeted. This information could help to spread the message of U = U more widely and potentially lessen HIV stigma.

Barriers to Treatment as Prevention Adoption Among Sexual and Gender Minority Individuals Who Have Sex with Men in the United States

The discovery that people with an undetectable HIV viral load are unable to transmit the virus to sex partners (U = U) has ushered in a new era in HIV care. As a result of this discovery, treatment as prevention (TasP) has become a powerful tool toward ending the epidemic. However, despite its sound scientific basis, many communities affected by HIV face barriers toward adopting TasP as a complete HIV prevention strategy. In addition, most research to date has only focused on TasP in the context of committed monogamous partnerships. To identify barriers to TasP adoption among some of those most affected by HIV, we conducted in-depth qualitative interviews with 62 sexual and gender minority individuals of varying serostatuses. Participants were identified from the results of an online survey, where those who indicated at least some awareness of TasP were invited to partake in a follow-up interview. Interviews were thematically coded to identify emergent themes relating to TasP adoption. Seven primary barriers emerged from data analysis pertaining to TasP science, internalized beliefs about HIV safety, and interactional dynamics between partners: (1) unfamiliarity with TasP science, (2) perceived limitations of TasP science, (3) difficulty changing understanding of "safe sex," (4) unwillingness to rely on partners' reports of being undetectable, (5) persistent HIV stigma, (6) less difficulty finding serosimilar partners, and (7) difficulty incorporating TasP into casual encounters. Together, these barriers confirm the existing findings about TasP adoption, and extend the literature by identifying barriers beyond a lack of education and outside of monogamous contexts.

Integrated Care as a Model for Interprofessional Disease Management and the Benefits for People Living with HIV/AIDS

INTRODUCTION

Today, antiretroviral therapy (ART) is effectively used as a lifelong therapy to treat people living with HIV (PLWH) to suppress viral replication. Moreover, PLWH need an adequate care strategy in an interprofessional, networked setting of health care professionals from different disciplines. HIV/AIDS poses challenges to both patients and health care professionals within the framework of care due to frequent visits to physicians, avoidable hospitalizations, comorbidities, complications, and the resulting polypharmacy. The concepts of integrated care (IC) represent sustainable approaches to solving the complex care situation of PLWH.

AIMS

This study aimed to describe the national and international models of integrated care and their benefits regarding PLWH as complex, chronically ill patients in the health care system.

METHODS

We conducted a narrative review of the current national and international innovative models and approaches to integrated care for people with HIV/AIDS. The literature search covered the period between March and November 2022 and was conducted in the databases Cinahl, Cochrane, and Pubmed. Quantitative and qualitative studies, meta-analyses, and reviews were included.

RESULTS

The main findings are the benefits of integrated care (IC) as an interconnected, guideline- and pathway-based multiprofessional, multidisciplinary, patient-centered treatment for PLWH with complex chronic HIV/AIDS. This includes the evidence-based continuity of care with decreased hospitalization, reductions in costly and burdensome duplicate testing, and the saving of overall health care costs. Furthermore, it includes motivation for adherence, the prevention of HIV transmission through unrestricted access to ART, the reduction and timely treatment of comorbidities, the reduction of multimorbidity and polypharmacy, palliative care, and the treatment of chronic pain. IC is initiated, implemented, and financed by health policy in the form of integrated health care, managed care, case and care management, primary care, and general practitioner-centered concepts for the care of PLWH. Integrated care was originally founded in the United States of America. The complexity of HIV/AIDS intensifies as the disease progresses.

CONCLUSIONS

Integrated care focuses on the holistic view of PLWH, considering medical, nursing, psychosocial, and psychiatric needs, as well as the various interactions among them. A comprehensive expansion of integrated care in primary health care settings will not only relieve the burden on hospitals but also significantly improve the patient situation and the outcome of treatment.

People Living with HIV and AIDS: Experiences towards Antiretroviral Therapy, Paradigm Changes, Coping, Stigma, and Discrimination-A Grounded Theory Study

BACKGROUND

The experiences in coping with HIV/AIDS from people living with HIV (PLWH) in Austria, Munich, and Berlin regarding adherence, antiretroviral therapy (ART), stigmatization, and discrimination were the main focus of this study. Therapy adherence is the cornerstone for PLWH to reduce disease progression and increase life expectancy combined with a high quality of life. The experience of stigmatization and discrimination in different life situations and settings is still experienced today.

AIMS

We aimed to examine the subjective perspective of PLWH concerning living with, coping with, and managing HIV/AIDS in daily life.

METHODS

Grounded Theory Methodology (GTM) was used. Data collection was conducted with semi-structured face-to-face interviews with 25 participants. Data analysis was performed in three steps, open, axial, and selective coding.

RESULTS

Five categories emerged, which included the following: (1) fast coping with diagnosis, (2) psychosocial burden due to HIV, (3) ART as a necessity, (4) building trust in HIV disclosure, (5) stigmatization and discrimination are still existing.

CONCLUSION

In conclusion, it can be said that it is not the disease itself that causes the greatest stress, but the process of coping with the diagnosis. Therapy, as well as lifelong adherence, is hardly worth mentioning today. Much more significant is currently still the burden of discrimination and stigmatization.

Awareness and Willingness to use Condoms and Preexposure Prophylaxis among Gay, Bisexual, and Other Cisgendered Men who Have sex with men in Slum Communities in Ghana. BSGH-004

Introduction: Research has begun to examine human immunodeficiency virus (HIV) prevention strategies within the Ghanaian context. Still, little is known about specific populations such as gay, bisexual, and other cisgender men who have sex with men (GBMSM) living in slum communities. We studied HIV prevention strategies such as condoms and preexposure prophylaxis (PrEP) in slum communities and the awareness and willingness to use these choices among GBMSM. This qualitative study examines HIV prevention strategies, specifically examining PrEP and condom use behaviors among GBMSM in Ghana. Methods: We conducted in-depth face-to-face interviews among 12 GBMSM from slums in Accra and Kumasi cities in Ghana. Data were analyzed through a summative content analysis with multiple reviewers to develop codes. Data were collected from participants in January 2022. Results: We found the fear and perceived risk of infection were motivators for consistent condom use, especially during anal sex. GBMSM living with HIV receiving antiretroviral therapy were more inclined to use condoms. We found motivations for using PrEP were influenced by the type of sexual activity and a history of negative HIV status. Also, the barriers to PrEP for GBMSM included limited access to healthcare facilities and the distance to these facilities. Conclusions: To improve condom and PrEP access and uptake, we recommend addressing structural barriers by increasing the number of health facilities and implementing targeted interventions to address the lack of information on HIV awareness and prevention. Involving peer educators may also effectively promote HIV prevention strategies, especially in communities with limited access to healthcare such as slums. Overcoming these access constraints could significantly enhance awareness and prevention of HIV, leading to improved health outcomes for GBMSM living in slum communities.

Reproductive Desire in Women Living with HIV/AIDS with Serodiscordant Partners

OBJECTIVE

To estimate the prevalence and factors associated with reproductive desire in a sample of women living with HIV/AIDS (WLHA) with serodiscordant partners.

STUDY DESIGN

Between September 2015 and August 2016, a cross-sectional study was conducted among 110 WLHA from HIV/AIDS treatment services and non-governmental organizations. An interview was conducted using a structured questionnaire to collect sociodemographic data, reproductive desire, and potential predictor variables. Poisson regression was used to analyze the factors associated with reproductive desire in the sample.

RESULTS

The prevalence of reproductive desire was 32.7% (95% Confidence Interval: % CI: 24.7-42.0%). In regression analysis, we observed an association between reproductive desire and the following variables: age < 30 years; relationship time < 2 years; reproductive desire for the partner; and absence of children.

CONCLUSIONS

The prevalence of reproductive desire in the investigated sample was relatively high. Young age and reproductive desire for the partner were the main associated factors.

HIV knowledge and its correlation with the Undetectable = Untransmittable slogan in Brazil

Knowledge about HIV transmission and prevention is a necessary step for adopting preventive behaviors. We assessed HIV knowledge and its correlation with the perceived accuracy of the "Undetectable = Untransmittable" (U=U) slogan in an online sample with 401 adult Brazilians. Overall, 28% of participants showed high HIV knowledge level. The perceived accuracy of the U=U slogan significantly correlated with HIV knowledge. Younger participants, those reporting lower income or lower education, or who had never tested for HIV showed poorer HIV knowledge. Filling gaps of knowledge among specific populations is urgent in order to increase preventive behaviors and decrease HIV stigma.

LGBTQ+ Affirming Care May Increase Awareness and Understanding of Undetectable = Untransmittable among Midlife and Older Gay and Bisexual Men in the US South

One of the most significant innovations in HIV prevention is the use of HIV treatment to prevent HIV transmission. This information has been disseminated as the "Undetectable = Untransmittable" (U = U) message. Despite evidence of effectiveness, U = U awareness, belief, and understanding remains limited in some communities. In this study, we examine whether having an LGBTQ affirming healthcare provider increases U = U awareness, belief, and understanding among midlife and older gay and bisexual men in the US south, an understudied and underserved population and region where new HIV infections are increasing. We used data from the Vanderbilt University Social Networks Aging and Policy Study (VUSNAPS) on sexual minority men aged 50 to 76 from four southern US states collected in 2020-2021. We found that only one in four men reported prior awareness of U = U, but awareness was higher among men who have an LGBTQ affirming provider. Among HIV negative men, those with an affirming provider were more likely to believe and understand U = U, have more accurate risk perception, and have ever tested for HIV. Improving access to LGBTQ affirming healthcare may improve U = U awareness, belief, and understanding, which could help to curb HIV transmission in the US south.

Awareness and perception of accuracy of the Undetectable=Untransmittable message (U=U) in Italy: results from a survey among PLWHA, infectious-diseases physicians and people having unprotected sex

Evidences on the absence of risk of sexual transmission of HIV by persons living with HIV/AIDS (PLWHA) with undetectable plasma HIV-RNA (HIV-RNA <200 copies/ml) led to the worldwide campaign "U = U" (undetectable = untransmittable). The purpose of this study was to evaluate the perceived accuracy of this message among PLWHA, HIV-negative people having unprotected sex (PHUS) and infectious diseases' (ID) physicians in Italy. A nationwide survey has been conducted using three different anonymous questionnaires (for ID physicians, PLWHA and PHUS). A total of 1121 participants filled the questionnaires: 397 PLWHA; 90 physicians; 634 PHUS. Awareness of U = U message has been reported in 74%, 92% and 47% of PLWHA, ID physicians and PHUS, respectively. The perception of accuracy of the U = U message among those aware was reported as high in 80.4%, 79.5% and 67.3% of PLWHA, ID physicians and PHUS, respectively. Physicians perceived that 11% of PLWHA have a high rate of perception of U = U, whereas among PLWHA, only 34% reported definitive positive messages from physicians. Discrepancies between awareness and perception of accuracy of the message U = U in PLWHA and physicians have been found, suggesting still low confidence in the community regarding the message itself.

HIV Serostatus Disclosure Among Men Who Have Sex with Men in China in the Era of U=U and PrEP

Given the recent evidence on "Undetectable = Untransmittable" (U=U) and pre-exposure prophylaxis (PrEP), the present study aimed to investigate HIV disclosure behaviors and their associations with sexual risk behaviors and U=U and PrEP awareness among men who have sex with men (MSM) in China. A cross-sectional survey was conducted among 689 MSM recruited through a gay-friendly non-governmental organization located in Chengdu, China in 2018-2019. Information was collected by a structured self-administrated questionnaire. The enrolled sample included 554 (80.4%) participants who were HIV-negative and 135 (19.6%) participants with an unknown HIV status. In terms of disclosure, 41.4% of participants informed all partners about their HIV status all the time (informing behavior), while 30.4% asked all partners about their HIV status all the time (asking behavior). Only one-fifth knew about U=U, but this was not statistically associated with either informing or asking behavior. Half (50.5%) had heard of PrEP but this was not statistically associated with either informing or asking behavior. Common barriers to informing and asking behaviors were lower risk perception of HIV infection, a history of sexually transmitted infections, engagement in receptive sex, and a history of sex with casual partners. We found that both U=U and PrEP awareness and HIV serostatus disclosure were infrequent and not associated in this study of Chinese MSM. These data indicate huge information gaps among MSM in China.

Attitudes Toward HIV-Positive Status Disclosure Among U=U-Aware Sexual and Gender Minority Individuals in the USA: a Consensual Qualitative Research Approach

Introduction

The U=U (i.e., undetectable equals untransmittable) campaign is founded upon biomedical advancements that have positioned HIV as a manageable condition with effectively zero risk of transmission. In spite of these developments, attitudes of sexual and gender minority populations regarding the necessity of seropositive status disclosure remain unexamined.

Methods

The current study analyzed qualitative data regarding the necessity of seropositive status disclosure from 62 sexual minority men as well as transgender and gender non-conforming individuals who have sex with men from 2020 to 2021.

Results

The majority of participants believed disclosure to be necessary and invoked several social and structural factors that informed their attitudes. Participants cited HIV criminalization laws, the ethics of non-disclosure, and disclosure as a means of educating sex partners when appraising the necessity of disclosure. Participants also presented concerns regarding U=U efficacy and HIV stigma.

Conclusions

Findings indicate that the disclosure of seropositive status to sex partners is still important to U=U-aware sexual and gender minority individuals. The majority of the study sample, irrespective of HIV status, believed seropositive status disclosure was necessary in advance of sex.

Policy Implications

Findings suggest opportunities for public health messaging to remediate concerns about U=U efficacy, combat misinformation, and clarify out-of-date information on HIV criminalization.

Changing Knowledge and Attitudes Towards HIV Treatment-as-Prevention and "Undetectable = Untransmittable": A Systematic Review

People on HIV treatment with undetectable virus cannot transmit HIV sexually (Undetectable = Untransmittable, U = U). However, the science of treatment-as-prevention (TasP) may not be widely understood by people with and without HIV who could benefit from this information. We systematically reviewed the global literature on knowledge and attitudes related to TasP and interventions providing TasP or U = U information. We included studies of providers, patients, and communities from all regions of the world, published 2008–2020. We screened 885 papers and abstracts and identified 72 for inclusion. Studies in high-income settings reported high awareness of TasP but gaps in knowledge about the likelihood of transmission with undetectable HIV. Greater knowledge was associated with more positive attitudes towards TasP. Extant literature shows low awareness of TasP in Africa where 2 in 3 people with HIV live. The emerging evidence on interventions delivering information on TasP suggests beneficial impacts on knowledge, stigma, HIV testing, and viral suppression.

Review was pre-registered at PROSPERO: CRD42020153725

Prevalence of U = U Awareness and Its Association with Anticipated HIV Stigma Among Low-Income Heterosexually Active Black and Latino Adults in New York City, 2019

The fact that people with HIV (PWH) who have an undetectable viral load cannot sexually transmit HIV has been disseminated under the messaging "Undetectable = Untransmittable" (U = U). U = U messaging intends to destigmatize HIV by demonstrating that PWH can have healthy sexual lives. Among a sample of low-income heterosexually active Black and Latino adults, we aimed to (1) measure the prevalence of U = U awareness and (2) determine its association with anticipated HIV stigma. Low-income heterosexually active adults were recruited through respondent-driven sampling in New York City. Among Black and Latino participants who self-reported not having HIV, multiple linear regression was used to determine the association between U = U awareness with the following types of anticipated HIV stigma, as determined by principal component analyses: (1) general; (2) dating related; and (3) sex related. Of 485 participants, 35% were aware of U = U. Those who were aware reported less dating-related [adjusted B: -0.20; 95% confidence interval (CI): -0.37 to -0.03] and sex-related (adjusted B: -0.15; 95% CI: -0.29 to -0.002) anticipated HIV stigma. Although the prevalence of U = U awareness was much lower than reported in other populations (e.g., gender and sexual minorities and PWH), prevalence was moderate in our sample, given that awareness efforts have generally not focused on heterosexually active adults. Our findings provide preliminary evidence that U = U awareness may have an impact on anticipated HIV stigma related to dating and sex. Additional methods to disseminate U = U messaging and dismantle HIV stigma in this population should be explored.

Treatment Is More Than Prevention: Perceived Personal and Social Benefits of Undetectable = Untransmittable Messaging Among Sexual Minority Men Living with HIV

Research suggests that the science of undetectable viral load (VL) status and HIV transmission-conveyed with the slogan "Undetectable = Untransmittable" or "U = U"-has gaps in acceptance despite robust scientific evidence. Nonetheless, growing acceptance of U = U creates conditions for a shift in the sociopolitical and personal implications of viral suppression. We conducted an online survey over a 23-month period in 2018 and 2019 among 30,361 adolescent and adult (aged 13-99) sexual minority men living with HIV (SMM-LHIV) across the United States. We examined the impact of U = U on self-image, potential for changing societal HIV stigma, whether SMM-LHIV had ever spoken with a provider about viral suppression and HIV transmission, and primary sources of hearing about U = U. Approximately 80% of SMM-LHIV reported that U = U was beneficial for their self-image and societal HIV stigma, 58.6% reported it made them feel "much better" about their own HIV status, and 40.6% reporting it had the potential to make HIV stigma "much better." The most consistent factors associated with these beliefs centered around care engagement, particularly self-reported viral suppression and excellent antiretroviral therapy adherence. Two-thirds reported ever talking to a provider about VL and HIV transmission, although the primary sources for having heard about U = U were HIV and lesbian, gay, bisexual, transgender, and queer (LGBTQ) news media and personal profiles on networking apps. These findings demonstrate the significant personal and social importance of U = U for SMM-LHIV that go above-and-beyond the well-documented health benefits of viral suppression, suggesting that providers should consider routinely initiating conversations with patients around the multifaceted benefits (personal health, sexual safety and intimacy, increased self-image, and reduced social stigma) of viral suppression.