Centring ‘being undetectable’ as the new face of HIV: Transforming subjectivities via the discursive practices of HIV treatment as prevention

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 Interventions are needed to correct commonly held, outdated misconceptions about HIV transmission risk.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.

'Test Now, Stop HIV': COVID-19 and the idealisation of quarantine as the 'end of HIV'

The emergence of COVID-19 precipitated varied responses from public health officials in London, England. In April 2020, clinicians at 56 Dean Street sexual health and advice clinic in central London described social isolation as 'a unique window of opportunity' to 'break the chain' in HIV transmission. This was followed by critical responses within HIV prevention circles. Drawing from these responses, this article examines the implications of the clinic's 'Test Now, Stop HIV' campaign by asking how has the early COVID-19 pandemic reshaped institutional responses and strategies to end HIV transmission in England? We assess how campaign messages developed between April and May 2020. We analyse materials related to the campaign, including the clinic's Twitter account, the campaign website, and journalism in mainstream media. Based on this information, we discuss three themes: testing and issues of access; the biopolitics of testing; and the idealism of quarantine. We draw on sociology, cultural theory and science and technology studies to describe how the 'end of HIV' was constructed through the link between COVID-19 and HIV. We suggest the campaign reinscribes historical perceptions of abstinence and quarantine as idealised HIV prevention strategies, and thus fails to address safer sex in the time of Coronavirus.

All the Other Stuff: Treatment as Prevention and the Embodiment of Undetectability

The "Treatment as Prevention (TasP)" campaign advocates extended undetectability-untransmissibility (U = U) as a means to "End the Epidemic" of HIV/AIDS. Drawing on ethnographic research in Buenos Aires (Argentina), I identify three issues that prevail in overly-optimistic discourses associated with TasP, which: overshadow the history of HIV and antiretrovirals; overlook the inherent dynamism of undetectability; and understand antiretrovirals as technical tools with predictable effects, regardless of context. I address how undetectability becomes embodied in the lives of pre-HAART survivors while underscoring the diversity of challenges faced in a Latin American country with universal and free-of-charge access to antiretroviral therapy.

Subordinated agency: Negotiating the biomedicalisation of masculinity among gay men living with HIV

Health practices are shaped by gender relations and constructs. Utilising qualitative data, this study explores a shift in medication practices among gay men living with HIV (GMLH) in light of changing HIV/AIDS responses in Taiwan. In the 1980s and 1990s, the mobilisation of moralising discourses forged a gender hierarchy that subordinated HIV-positive gay males. In the 2000s, new state programmes on HIV/AIDS were implemented to enhance patients' adherence to treatment, but GMLH often expressed ambivalence towards medication, which could lead to HIV disclosure and, consequently, social exclusions under the gender hierarchy. Starting in the 2010s, the knowledge of HIV 'treatment as prevention' and a policy on early treatment have offered a new path for GMLH to navigate gender power dynamics and to strive towards an inclusive social life by taking medicine and optimising health, which facilitates a biomedicalisation of subordinated masculinity. This study contributes to the scholarship on HIV/AIDS by underscoring the significance of biomedicine for configuring masculine identities and practices among a subordinated group of men, as well as by highlighting the gender power relations and everyday 'nonbiomedical' negotiating practices that legitimise biomedicalisation.

Situating adherence to medicines: The embodied practices and hinterlands of HIV antiretrovirals

Adherence to medicines tends to be envisaged as a matter of actors' reasoned actions, though there is increasing emphasis on situating adherence as a practice materialised in everyday routines. Drawing on the qualitative interview accounts of Black African women living with HIV in London, UK, we treat adherence to HIV medicines as not only situated in the practices of the immediate and everyday but also relating to a hinterland of historical and social relations. We move from accounts which situate adherence as an embodied matter of affect in the present, to accounts which locate adherence as a condition of precarity, which also trace to enactments of time and place in the past. Adherence is therefore envisaged as a multiple and fluid effect which is made-up in-the-now and in relation to a hinterland of practices which locate elsewhere.

Ambivalence and the biopolitics of HIV pre-exposure prophylaxis (PrEP) implementation

Ambivalence, the vacillation between conflicting feelings and thoughts, is a key characteristic of scientific knowledge production and emergent biomedical technology. Drawing from sociological theory on ambivalence, we have examined three areas of debate surrounding the early implementation of HIV pre-exposure prophylaxis, or PrEP, for gay, bisexual, queer, and other men who have sex with men in Canada, including epistemology and praxis, clinical and epidemiological implications, and sexual politics. These debates are not focused on the science or efficacy of PrEP to prevent HIV, but rather represent contradictory feelings and opinions about the biopolitics of PrEP and health inequities. Emphasizing how scientists and health practitioners may feel conflicted about the biopolitics of novel biomedical technologies opens up opportunities to consider how a scientific field is or is not adequately advancing issues of equity. Scientists ignoring their ambivalence over the state of their research field may be deemed necessary to achieve a specific implementation goal, but this emotion management work can lead to alienation. We argue that recognizing the emotional dimensions of doing HIV research is not a distraction from "real" science, but can instead be a reflexive site to develop pertinent lines of inquiry better suited at addressing health inequities.

Reassessing the Ethics of Molecular HIV Surveillance in the Era of Cluster Detection and Response: Toward HIV Data Justice

In the United States, clinical HIV data reported to surveillance systems operated by jurisdictional departments of public health are re-used for epidemiology and prevention. In 2018, all jurisdictions began using HIV genetic sequence data from clinical drug resistance tests to identify people living with HIV in "clusters" of others with genetically similar strains. This is called "molecular HIV surveillance" (MHS). In 2019, "cluster detection and response" (CDR) programs that re-use MHS data became the "fourth pillar" of the national HIV strategy. Public health re-uses of HIV data are done without consent and are a source of concern among stakeholders. This article presents three cases that illuminate bioethical challenges associated with re-uses of clinical HIV data for public health. We focus on evidence-base, risk-benefit ratio, determining directionality of HIV transmission, consent, and ethical re-use. The conclusion offers strategies for "HIV data justice." The essay contributes to a "bioethics of the oppressed."