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Konda KA, Qquellon J, Torres TS, Vega-Ramirez EH, Elorreaga O, Guillén-Díaz-Barriga C, Diaz-Sosa D, Hoagland B, Guanira JV, Benedetti M, Pimenta C, Vermandere H, Bautista-Arredondo S, Veloso VG, Grinsztejn B, Caceres CF. Awareness of U = U among Sexual and Gender Minorities in Brazil, Mexico, and Peru: Differences According to Self-reported HIV Status. AIDS Behav 2024; 28:2391-2402. [PMID: 38662277 PMCID: PMC11199300 DOI: 10.1007/s10461-024-04336-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2024] [Indexed: 04/26/2024]
Abstract
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.
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Affiliation(s)
- K A Konda
- Keck School of Medicine, University of Southern California, 1845 N Soto St, Los Angeles, CA, 90032, USA.
- Centro de Investigación Interdisciplinaria en Sexualidad, Universidad Peruana Cayetano Heredia, SIDA y Sociedad, Lima, Peru.
| | - J Qquellon
- Centro de Investigación Interdisciplinaria en Sexualidad, Universidad Peruana Cayetano Heredia, SIDA y Sociedad, Lima, Peru
| | - T S Torres
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (INI-Fiocruz), Rio de Janeiro, Brazil
| | - E H Vega-Ramirez
- Instituto Nacional de Psiquiatria Ramon de la Fuente Muñiz, Mexico City, Mexico
| | - O Elorreaga
- Centro de Investigación Interdisciplinaria en Sexualidad, Universidad Peruana Cayetano Heredia, SIDA y Sociedad, Lima, Peru
| | - C Guillén-Díaz-Barriga
- Facultad de Estudios Superiores Iztacala, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | - D Diaz-Sosa
- Instituto Nacional de Psiquiatria Ramon de la Fuente Muñiz, Mexico City, Mexico
| | - B Hoagland
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (INI-Fiocruz), Rio de Janeiro, Brazil
| | - J V Guanira
- Centro de Investigación Interdisciplinaria en Sexualidad, Universidad Peruana Cayetano Heredia, SIDA y Sociedad, Lima, Peru
| | - M Benedetti
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (INI-Fiocruz), Rio de Janeiro, Brazil
| | - C Pimenta
- Departmento de Doenças de Condições Crônicas e Infecções Sexualmente Transmissiveis, Brazilian Ministry of Health, Rio de Janeiro, Brazil
| | - H Vermandere
- Instituto Nacional de Salud Pública (INSP), Mexico City, Mexico
| | | | - V G Veloso
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (INI-Fiocruz), Rio de Janeiro, Brazil
| | - B Grinsztejn
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (INI-Fiocruz), Rio de Janeiro, Brazil
| | - C F Caceres
- Centro de Investigación Interdisciplinaria en Sexualidad, Universidad Peruana Cayetano Heredia, SIDA y Sociedad, Lima, Peru
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Agarwal H, Yeatts K, Chung SR, Harrison-Quintana J, Torres TS. Perceived Accuracy Around Undetectable = Untransmitable Among Sexual and Gender Minorities Using Smartphones in India. AIDS Behav 2024; 28:1039-1046. [PMID: 37861923 DOI: 10.1007/s10461-023-04212-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2023] [Indexed: 10/21/2023]
Abstract
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.
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Affiliation(s)
- Harsh Agarwal
- UNC Gillings School of Global Public Health, Chapel Hill, NC, 27599, USA.
| | - Karin Yeatts
- UNC Gillings School of Global Public Health, Chapel Hill, NC, 27599, USA
| | - Stephanie R Chung
- UNC Gillings School of Global Public Health, Chapel Hill, NC, 27599, USA
| | | | - Thiago S Torres
- Instituto Nacional de Infectología Evandro Chagas, Fundação Oswaldo Cruz (INI-Fiocruz), Rio de Janeiro, Brazil
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Calabrese SK, Kalwicz DA, Zaheer MA, Dovidio JF, Garner A, Zea MC, Treloar C, Holt M, Smith AKJ, MacGibbon J, Modrakovic DX, Rao S, Eaton LA. The Potential Role of Undetectable = Untransmittable (U = U) in Reducing HIV Stigma among Sexual Minority Men in the US. AIDS Behav 2024; 28:741-757. [PMID: 38285293 PMCID: PMC11043859 DOI: 10.1007/s10461-023-04263-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/26/2023] [Indexed: 01/30/2024]
Abstract
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.
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Affiliation(s)
- Sarah K Calabrese
- Department of Psychological and Brain Sciences, George Washington University, 2013 H Street NW, Washington, DC, 20006, USA.
- Department of Prevention and Community Health, George Washington University, Washington, DC, USA.
- Centre for Social Research in Health, University of New South Wales, Sydney, Australia.
| | - David A Kalwicz
- Department of Psychological and Brain Sciences, George Washington University, 2013 H Street NW, Washington, DC, 20006, USA
| | - Myra A Zaheer
- Department of Psychological and Brain Sciences, George Washington University, 2013 H Street NW, Washington, DC, 20006, USA
- School of Medicine and Health Sciences, George Washington University, Washington, DC, USA
| | - John F Dovidio
- Department of Psychology, Yale University, New Haven, CT, USA
| | - Alex Garner
- Hornet Gay Social Network, Los Angeles, CA, USA
- MPact Global Action for Gay Men's Health and Rights, West Hollywood, CA, USA
| | - Maria Cecilia Zea
- Department of Psychological and Brain Sciences, George Washington University, 2013 H Street NW, Washington, DC, 20006, USA
| | - Carla Treloar
- Centre for Social Research in Health, University of New South Wales, Sydney, Australia
| | - Martin Holt
- Centre for Social Research in Health, University of New South Wales, Sydney, Australia
| | - Anthony K J Smith
- Centre for Social Research in Health, University of New South Wales, Sydney, Australia
| | - James MacGibbon
- Centre for Social Research in Health, University of New South Wales, Sydney, Australia
| | - Djordje X Modrakovic
- Department of Psychological and Brain Sciences, George Washington University, 2013 H Street NW, Washington, DC, 20006, USA
| | - Sharanya Rao
- Department of Psychological and Brain Sciences, George Washington University, 2013 H Street NW, Washington, DC, 20006, USA
| | - Lisa A Eaton
- Department of Human Development and Family Sciences, University of Connecticut, Storrs, CT, USA
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Borsa A, Siegel K. Barriers to Treatment as Prevention Adoption Among Sexual and Gender Minority Individuals Who Have Sex with Men in the United States. AIDS Patient Care STDS 2023; 37:268-277. [PMID: 37155966 PMCID: PMC10171941 DOI: 10.1089/apc.2023.0001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023] Open
Abstract
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.
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Affiliation(s)
- Alexander Borsa
- Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University Irving Medical Center, New York, New York, USA
| | - Karolynn Siegel
- Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University Irving Medical Center, New York, New York, USA
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Card KG, Shen T, Barath J, Sang J, Lal A, Moore DM, Lachowsky NJ. Patterns of Event-Level Concurrent Substance Use During Sex Among Gay, Bisexual, and Other Men Who Have Sex with Men in Metro Vancouver. AIDS Behav 2023:10.1007/s10461-023-04036-w. [PMID: 36943600 DOI: 10.1007/s10461-023-04036-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2023] [Indexed: 03/23/2023]
Abstract
This study identified patterns of sexualized substance use among gay, bisexual, and other men who have sex with men (gbMSM) and examined associated risk factors for sexually transmitted and blood borne infections (STBBI). Data were from a longitudinal cohort recruited using respondent-driven sampling between Feb-2017 and Feb-2019. Participants reported on events with up to five of their most recent sexual partners. Latent class analysis examined patterns of concurrent substance use 2 h prior to or during sex. Multinomial regression identified demographic, partner-level, and event-level factors associated across 11,877 sexual events reported by 757 participants. Most combinations of substance use were rare, but most drugs were frequently combined with other drugs when they were used prior to or during a sexual event. Six latent classes of concurrent event-level substance use were identified. The referent class (58.8% of events) was characterized by limited use of any drugs. The Common Drug Use class (12.1%) was characterized by use of alcohol, cannabis, and poppers and the Licit Drug Use class (21.6%) was characterized by use of alcohol alone. The Party 'N' Play (PnP) class (2.3%) was characterized by use of crystal methamphetamine GHB, Poppers, and Erectile Drugs; The Multi-use (3.5%) class was characterized by the PnP substances plus alcohol and ecstasy; and the Cannabis + class was characterized by use of Cannabis, Erectile Drugs, and Ecstasy. Relative to the referent class, all other classes were associated with events with more behavioural and network risk factors for STBBIs-highlighting the need for harm reduction interventions for gbMSM who use these drugs.
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Affiliation(s)
- Kiffer G Card
- Faculty of Health Sciences, Simon Fraser University, 8888 University Drive, Burnaby, BC, V5A 1S6, Canada.
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, Canada.
| | - Tian Shen
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, Canada
| | - Justin Barath
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, Canada
| | - Jordan Sang
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, Canada
- British Columbia Centre on Substance Use, Vancouver, Canada
| | - Allan Lal
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, Canada
| | - David M Moore
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, Canada
- Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Nathan J Lachowsky
- School of Public Health and Social Policy, University of Victoria, Victoria, Canada
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Challenges to communicating the Undetectable equals Untransmittable (U=U) HIV prevention message: Healthcare provider perspectives. PLoS One 2022; 17:e0271607. [PMID: 35862361 PMCID: PMC9302742 DOI: 10.1371/journal.pone.0271607] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 07/01/2022] [Indexed: 11/19/2022] Open
Abstract
“Undetectable equals Untransmittable”, or U=U, is a public health message designed to reduce HIV stigma and help communicate the scientific consensus that HIV cannot be sexually transmitted when a person living with HIV has an undetectable viral load. Between October 2020-February 2021 we conducted 11 in-depth interviews and 3 focus groups with diverse HIV/STI service providers (nurses, public health workers, physicians, frontline providers, and sexual health educators) in Ontario, Canada (n = 18). Our objective was to understand how U=U was communicated to sexual health service users in healthcare interactions. Interview questions were embedded in a larger study focused on improving access to HIV/STI testing. Transcripts were transcribed verbatim and analysed following grounded theory. Most providers emphasized the significance of U=U as a biomedical advancement in HIV prevention but had some challenges communicating U=U in everyday practice. We discovered four interrelated barriers when communicating the U=U message: (1) provider-perceived challenges with “zero risk” messaging (e.g., wanting to “leave a margin” of HIV risk); (2) service users not interested in receiving sexual health information (e.g., in order to provide “client centered care” some providers do not share U=U messages if service users are only interested in HIV/STI testing or if other discussions must be prioritized); (3) skepticism and HIV stigma from service users (e.g., providers explained how the hesitancy of some service users accepting the U=U message was shaped by a legacy of HIV prevention messages and persistent HIV stigma); and (4) need for more culturally appropriate resources (e.g., communities other than sexual and gender minority men; non-English speaking service users; that account for broader legal context). We discuss ways to overcome barriers to communicating the U=U message as well as the limitations and potential unintended consequences of U=U framings in the context of unequal access to HIV prevention and treatment.
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Kalichman SC, Kalichman MO, Eaton LA. Undisclosed HIV Status to Sex Partners and Its Unintended Consequences in the Era of Undetectable = Untransmittable. J Acquir Immune Defic Syndr 2021; 88:149-156. [PMID: 34267054 DOI: 10.1097/qai.0000000000002762] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 07/01/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Adherence to antiretroviral therapy (ART) and sustained HIV suppression virtually eliminate HIV transmission, eg, having an undetectable viral load renders HIV untransmittable (U=U). Owing to the greatly reduced likelihood of HIV transmission when viral load is undetectable, we studied one behavioral ramification of adopting a U=U prevention strategy-not disclosing HIV status to sex partners. SETTING Cisgender men recruited through community outreach in the state of Georgia, USA. METHODS We examined HIV status disclosure to sex partners among 345 young (median age = 29 years) men receiving ART. Data were collected using computerized interviews, daily sexual behavior surveys over 28 days, unannounced pill counts for ART adherence, urine tests for drug use and urogenital health, and blood samples for HIV viral load. RESULTS One in 3 participants (34%) engaged in condomless anal/vaginal intercourse with an HIV-negative/unknown HIV status partner over 28 days. Average ART adherence was 76%, and one in 5 men had detectable HIV viral loads. Men who engaged in condomless sex with undisclosed partners demonstrated significantly less HIV disclosure to family and friends and had fewer enacted stigma experiences. Hierarchical regression models showed that endorsing U=U as a personal HIV prevention strategy predicted undisclosed condomless sex over and above substance use, HIV stigma experiences, disclosure to family and friends, ART adherence, and HIV viral load. CONCLUSIONS Interventions are needed to improve ART adherence and assist men living with HIV in their decisions to disclose HIV status to sex partners.
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Affiliation(s)
- Seth C Kalichman
- Institute for Collaboration on Health, Intervention and Policy, University of Connecticut, Storrs, CT
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