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

Messaging About HIV Transmission Risk When Viral Load Is Undetectable: Reactions and Perceived Accuracy Among US Sexual Minority Men

BACKGROUND

Scientific evidence indicates that HIV viral suppression to an undetectable level eliminates sexual transmission risk ("Undetectable=Untransmittable" or "U=U"). However, U=U messaging has been met with skepticism among sexual minority men (SMM) and others. In this survey-based experiment, we manipulated messaging about HIV risk and examined reactions and perceived message accuracy among US SMM.

METHODS

SMM living with HIV (n = 106) and HIV-negative/status-unknown SMM (n = 351) participated in an online survey (2019-2020). Participants were randomly assigned to 1 of 3 messaging conditions, which varied by level of HIV sexual transmission risk associated with an undetectable viral load (No Risk [U=U]/Low Risk/Control). Participants reported reactions, message accuracy, and reasons for perceiving inaccuracy. We coded open-response data (reactions and reasons) into conceptual categories (eg, "Enthusiasm"). We compared reactions, accuracy ratings, and reasons by condition and serostatus.

RESULTS

In the No Risk Condition, common reactions were Enthusiasm (40.0%), Skepticism/Disagreement (20.0%), and Agreement (19.4%), reactions common to comparison conditions. A higher percentage of HIV-negative/status-unknown participants (24.1%) expressed Skepticism/Disagreement in the No Risk Condition compared with other conditions (3.2%-9.7%). Participants living with HIV were more likely than HIV-negative/status-unknown participants to perceive the message as accurate in all conditions. In the No Risk Condition, common reasons for perceiving inaccuracy were Risk Misstated (46.1%), Oversimplified/Caveats Needed (17.1%), and Personal Unfamiliarity/Uncertainty (14.5%), reasons common to comparison conditions. Across conditions, 10.3% of participants attributed message inaccuracy to undetectable being misdefined.

CONCLUSION

Most SMM reacted favorably to U=U messaging. However, many-especially HIV-negative/status-unknown SMM-expressed skepticism. Interventions are needed to enhance U=U understanding and acceptance.

2023 Undetectable = Untransmittable global policy roundtable report: a multistakeholder perspective on Undetectable = Untransmittable research and policy priorities

Background Launched in 2016 by Prevention Access Campaign, the 'Undetectable=Untransmittable' (U=U) campaign empowers people living with HIV to live full social, sexual and reproductive lives, dismantle stigma, promote increased treatment access, and advocate for updated HIV guidelines. Methods Key priorities for promoting improvements to community-centred, evidence-informed U=U policy and research were the focus of a half-day global roundtable held in 2023 alongside the 12th International AIDS Society Conference in Brisbane, Australia. After a series of presentations, experts in U=U research, policymaking, advocacy and HIV clinical care participated in facilitated discussions, and detailed notes were taken on issues related to advancing U=U policy and research. Results Expert participants shared that knowledge and trust in U=U remains uneven, and is largely concentrated among people living with HIV, particularly those connected to gay and bisexual networks. It was agreed that there is a need to ensure all members of priority populations are explicitly included in U=U policies that promote U=U. Participants also identified a need for policymakers, healthcare professionals, advocates and researchers to work closely with community-based organisations to ensure the U=U message is relevant, useful, and utilised in the HIV response. Adopting language, such as 'zero risk', was identified as crucial when describing undetectable viral load as an effective HIV prevention strategy. Conclusion U=U can have significant benefits for the mental and physical wellbeing of people living with HIV. There is an urgent need to address the structural barriers to HIV care and treatment access to ensure the full benefits of U=U are realised.

Behavior Change Among HIV-Negative Men Who Have Sex with Men Not Using PrEP in the United States

This study measures changes in condomless anal sex (CAS) among HIV-negative men who have sex with men (MSM) who are not taking pre-exposure prophylaxis (PrEP). It considers the 2014-2019 cycles of the American Men's Internet Survey, a serial, cross-sectional web-based survey of US cisgender MSM aged ≥ 15 years, in which ~ 10% of each year's sample is drawn from the previous year. Among those surveyed for 2 years who remained HIV-negative and off PrEP, reports of having any CAS and of CAS partner number were compared across years. We disaggregated by partner HIV status, and considered demographic predictors. The overall population saw a significant 2.2 percentage-point (pp) increase in reports of any CAS year-over-year. Sub-populations with the largest year-on-year increases were 15-24-year-olds (5.0-pp) and Hispanic respondents (5.1-pp), with interaction (young Hispanic respondents = 12.8-pp). On the relative scale, these numbers correspond to 3.2%, 7.2%, 7.3% and 18.7%, respectively. Absolute increases were concentrated among partners reported as HIV-negative. Multivariable analyses for CAS initiation found effects concentrated among Hispanic and White youth and residents of fringe counties of large metropolitan areas. CAS partner number increases were similarly predicted by Hispanic identity and young age. Although condom use remains more common than PrEP use, increasing CAS among MSM not on PrEP suggests potential new HIV transmission pathways. Concentration of increases among 18-24-year-old MSM portends future increases in the proportion of newly diagnosed HIV that occur among youth. Concentration among young Hispanic MSM will likely expand existing disparities. Although reducing barriers to PrEP remains vital, condom promotion for MSM remains a key public health practice and appears to be missing key audiences. LGBTQ+-inclusive sex education is one avenue for enhancing these efforts.

"I Don't Believe That One": A Qualitative Study of Undetectable = Untransmittable Views Among Older Adults Living With HIV in South Carolina

ABSTRACT

Undetectable = Untransmittable (U = U) means that people with HIV who achieve and maintain an undetectable viral load have effectively zero risk of sexually transmitting the virus to others. However, research on how U = U is perceived by older adults living with HIV (OAH) is currently lacking. This study explored U = U views among OAH. From October 2019 to February 2020, we conducted open-ended interviews with 24 OAH recruited at an HIV clinic in South Carolina. Interviews were audio-recorded and transcribed. We employed thematic analysis in this study. Three themes emerged from the analysis: (a) Conflicting beliefs in U = U; (b) Use condoms regardless; and (c) Fear of HIV reinfection. Despite strong scientific evidence supporting U = U, some OAH do not believe in U = U. This lack of belief could deprive OAH of the benefits U = U offers. Therefore, it is vital to educate OAH about U = U to enhance their understanding and belief in U = U.

Knowledge of Sexually Transmitted Infections and HIV among People Living with HIV: Should We Be Concerned?

Poor knowledge of sexually transmitted infections (STIs) and HIV among people with HIV (PLHIV) could worsen life quality. We aimed to investigate their STI and HIV knowledge, disclosure and undetectable = untransmittable (U=U). We proposed an anonymous questionnaire regarding STI and HIV to PLHIV attending ten Italian outpatient infectious diseases clinics. Moreover, disclosure and U=U were investigated. The calculated sample size was 178 people. Considering a missing response of 10%, the final sample size was 196. We enrolled 200 PLHIV (73.5% males), with a median age of 52.5 (IQR 41-59) years. The mean score was 7.61 ± 1.22 with no difference by gender, education, and employment. Significant statistical difference was observed by sexual orientation; bisexuals and those who preferred not to answer had a lower score than heterosexuals and MSM (p = 0.0032). PLHIV showed poor knowledge about HIV transmission (25% appropriately answered). Nearly 30% responded that virologically suppressed PLHIV could transmit the infection. Finally, 137 (68.5%) and 158 (79.0%) disclosed to the general practitioner and family and friends, respectively. Nearly 52.0% knew the meaning of U=U, and 83.6% highlighted its positive rebound. In conclusion, important knowledge gaps are present among PLHIV regarding U=U, and its implications are little-known. Improving PLHIVs' awareness will undermine self-stigma and enhance life quality.

The Implications of PrEP Use, Condom Use, and Partner Viral Load Status for Openness to Serodifferent Partnering Among US Sexual Minority Men (SMM)

PrEP has been reported to facilitate openness to serodifferent sexual partnerships among sexual minority men (SMM). However, other aspects of a sexual scenario likely come into play, including whether or not condoms are used and whether or not the partner living with HIV has an undetectable viral load. This online survey study evaluated the association between PrEP status and openness to serodifferent partnering, as well as the effects of various sexual scenario variables (condom use and partner's viral load) among 268 HIV-negative SMM in the US. Each participant reported their PrEP status and rated their openness to serodifferent partnering in four sexual scenarios, which varied by condom use (with/without) and partner viral load status (detectable/undetectable). Analyses of covariance (ANCOVAs) were conducted to assess differences in openness to serodifferent partnering by PrEP status in each scenario, adjusting for background characteristics. A two-way repeated measures ANCOVA and a three-way mixed factorial ANCOVA, including PrEP status as a between-subjects variable, were also performed to assess the effects of condom use and partner viral load status on openness. Across all scenarios, current PrEP users expressed significantly greater openness to serodifferent partnering compared to participants who had never used PrEP. Current PrEP users were also more likely than former PrEP users to consider partnering with someone with an undetectable viral load without using condoms. Both PrEP users and PrEP-inexperienced individuals had greater openness to serodifferent partnering with a partner having an undetectable (vs. detectable) viral load, which was magnified by condom use among the latter.

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.

Designing effective U = U communication strategies considering the needs of PLHIV, their partners, and healthcare worker constraints in South African clinics

INTRODUCTION

We sought to understand the Undetectable = Untransmittable (U = U) communication needs of persons living with HIV (PLHIV) and barriers to U = U communication among healthcare providers (HCPs) in South Africa.

METHODS

We conducted five focus group discussions (FGDs) with HCPs (N = 42) including nurses and counsellors from primary healthcare clinics (PHCs) in the Gauteng and Free State Provinces of South Africa, three FGDs (N = 27) with PLHIV recruited by snowball sampling from civil society organizations, and 27 in-depth interviews (IDIs) with recently diagnosed PLHIV in Johannesburg. IDIs and FGDs were audio recorded, transcribed, translated to English, and analysed thematically.

RESULTS

PLHIV were largely unaware and sceptical of U = U as the message appeared to contradict the mainstream HIV prevention clinical guidance. The low viral load (VL) knowledge further reduced confidence in U = U. PLHIV need support and guidance on the best approaches for sharing U = U information and disclosing their VL status to their partners, highlighting the central role of community understanding of U = U and VL to mediate the desired stigma reduction, social acceptance and emotional benefits of U = U for PLHIV. HCPs were uneasy about sharing U = U due to concerns about risk compensation and ART non-adherence and worried about enabling any ensuing HIV transmission. HCPs also need a simple, unambiguous, and consistent narrative for U = U, integrated with other HIV prevention messages. PLHIV and HCPs alike recommended a patient-centred approach to communicating U = U, focusing primarily on attaining viral suppression and emphasizing that condomless sex is only safe during periods of ART adherence.

CONCLUSIONS

These data highlight the need for simple U = U communication support targeting both HCP and PLHIV. Culturally appropriate communication materials, with training and ongoing mentorship of the clinic staff, are essential to improve patient-centred U = U communication in clinics.

The Perils of Overly Sensitive Viral Load Testing for Persons With Human Immunodeficiency Virus

The concept of "undetectable = untransmittable (U = U)" has been revolutionary in both the prevention and treatment of persons with human immunodeficiency virus (HIV). Most studies proving the concept of U = U used an HIV RNA (viral load [VL]) cutoff of 200 copies/mL to define being undetectable. Since then, increasingly sensitive commercial VL assays, sometimes down to a lower limit of detection (LLD) of 20 copies/mL, lead to confusion about the definition of "undetectable" and when someone is truly considered untransmittable. VLs between the LLD and 200 copies/mL have been associated with future virologic failure; however, no data exist to suggest that intervening in those patients leads to any meaningful benefits. In the absence of a demonstrable benefit of reporting such low VLs, we view this practice as harmful. We suggest recommendations for adjusting VL reporting and improving provider counseling, and call for research designs to mitigate the harms of overly sensitive VL testing.

"They test my blood to know how much blood is in my body": the untapped potential of promoting viral load literacy to support adherence and viral suppression among adolescents living with HIV

INTRODUCTION

Achieving sustained HIV viral suppression is a key strategy to optimize the health and wellbeing of those living with HIV. Sub-optimal adherence to antiretroviral therapy (ART) in adolescents and young people living with HIV (AYPLHIV) in Southern Africa, due to a range of social and contextual factors, including poor mental health, has presented a substantial challenge to meeting targets aimed towards improving treatment outcomes and reducing transmission. With the increasing availability of viral load (VL) testing in Southern Africa, there is an opportunity to better understand the relationship between VL literacy, wellbeing and adherence among adolescents.

METHODS

We conducted qualitative interviews with 45 AYPLHIV aged 10-24 years in three districts (urban, peri-urban and rural) in Zimbabwe between March and August 2021. The sample was purposively selected to represent a range of experiences related to HIV status disclosure, gender, marital status and treatment experience. Separate workshops were conducted with 18 healthcare workers (HCWs) and 20 caregivers to better understand existing support mechanisms to AYPLHIV accessing ART. We used thematic analysis to examine adolescent VL literacy, treatment support networks, experiences of clinic interactions, VL testing procedures and barriers to adherence.

RESULTS

VL literacy was consistently under-developed among participants. Comprehension of phrases commonly heard during clinic visits, such as TND (target not detected) and "high" and "low" VL, were better understood by older participants. VL testing was predominantly understood as a clinical procedure that enables HCWs to monitor treatment adherence. Absent throughout the interviews were descriptions of how viral suppression improves health and quality of life, likely fosters wellbeing and enhances self-esteem, enables participation in education and social activities, and eliminates the risk of onward transmission.

CONCLUSIONS

It is imperative that we reconsider how routine VL monitoring is communicated to and understood by AYPLHIV. Reframing ART, including VL test results, in terms of the psychosocial benefits that viral suppression can generate is likely to be crucial to motivating AYPLHIV to maintain optimal treatment engagement and develop self-management approaches as they move into adulthood. Access to accurate information tailored to individual concerns and circumstances can support AYPLHIV to achieve wellbeing.

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.

Let's talk about U=U: seizing a valuable opportunity to better support adolescents living with HIV

The clinical knowledge that people living with HIV who maintain an undetectable viral load and therefore cannot transmit HIV sexually, known as Undetectable equals Untransmittable (U=U), has reached a critical mass of adults, but it is relatively silenced within adolescent HIV care and support. We argue that understanding the full range of opportunities enabled by viral suppression, including the elimination of transmission risk, could transform adolescents' understanding of living with HIV, incentivise optimal treatment engagement and support and sustain their positive mental health. However, the reluctance to discuss U=U with adolescents means that we are not providing them with adequate access to the information and tools that would help them to succeed. We need to recognise, value, and invest in the mediating role of building viral load literacy, illustrated by conveying U=U in ways that are meaningful for adolescents, to accelerate viral suppression. Rather than protect, rationing access to information on U=U only increases their vulnerability and risk to poor HIV and mental health outcomes.

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.

Desires for Individual- and Interpersonal-Level Patient Portal Use for HIV Prevention Among Urban Sexual Minority Men: Cross-sectional Study

BACKGROUND

Gay, bisexual, and other sexual minority men have expressed the acceptability of patient portals as tools for supporting HIV prevention behaviors, including facilitating disclosure of HIV and other sexually transmitted infection (STI/HIV) laboratory test results to sex partners. However, these studies, in which Black or African American sexual minority men were undersampled, failed to determine the relationship of reported history of discussing HIV results with sex partners and anticipated willingness to disclose web-based STI/HIV test results using a patient portal.

OBJECTIVE

Among a sample of predominantly Black sexual minority men, this study aimed to (1) determine preferences for patient portal use for HIV prevention and (2) test the associations between reported history of discussing HIV results and anticipated willingness to disclose web-based STI/HIV test results with most recent main and nonmain partners using patient portals.

METHODS

Data come from audio-computer self-assisted interview survey data collected during the 3-month visit of a longitudinal cohort study. Univariate analysis assessed patient portal preferences by measuring the valuation rankings of several portal features. Multiple Poisson regression models with robust error variance determined the associations between history of discussing HIV results and willingness to disclose those results using web-based portals by partner type, and to examine criterion validity of the enhancing dyadic communication (EDC) scale to anticipated willingness.

RESULTS

Of the 245 participants, 71% (n=174) were Black and 22% (n=53) were White. Most participants indicated a willingness to share web-based STI/HIV test results with their most recent main partner. Slightly fewer, nonetheless a majority, indicated a willingness to share web-based test results with their most recent nonmain partner. All but 2 patient portal features were valued as high or moderately high priority by >80% of participants. Specifically, tools to help manage HIV (n=183, 75%) and information about pre- and postexposure prophylaxis (both 71%, n=173 and n=175, respectively) were the top-valuated features to include in patient portals for HIV prevention. Discussing HIV test results was significantly associated with increased prevalence of willingness to disclose web-based test results with main (adjusted prevalence ratio [aPR] 1.46, 95% CI 1.21-1.75) and nonmain partners (aPR 1.54, 95% CI 1.23-1.93).

CONCLUSIONS

Our findings indicate what features Black sexual minority men envision may be included in the patient portal's design to optimize HIV prevention, further supporting the criterion validity of the EDC scale. Efforts should be made to support Black sexual minority men's willingness to disclose STI/HIV testing history and status with partners overall as it is associated significantly with a willingness to disclose testing results digitally via patient portals. Future studies should consider discussion behaviors regarding past HIV test results with partners when tailoring interventions that leverage patient portals in disclosure events.

Rapid qualitative analysis approach to stakeholder and client interviews to inform mobile-based HIV testing in the U.S. Deep South

BACKGROUND

The severity of the HIV epidemic in the United States' rural South highlights geographic, socioeconomic, and racial disparities that disproportionately affect poor Black Americans. Approximately 16% of Alabamians living with HIV remain undiagnosed and just 37% of rural Alabamians have ever been tested for HIV.

METHODS

We conducted in-depth interviews with 22 key stakeholders involved in HIV prevention, testing, treatment, or community health initiatives, and 10 adults living in rural communities across Alabama to explore HIV testing challenges and opportunities. We utilized a rapid qualitative analysis approach and engaged community partners for feedback and discussion. This analysis will inform the implementation of a mobile HIV testing service in rural Alabama.

RESULTS

The following themes were identified: (1) Cultural norms, racism, poverty, and rurality impair access to healthcare. (2) Lack of sex education, low knowledge of HIV and perception of risk reinforce stigmas. (3) Messaging about "Undetectable = Untransmissible" (U = U) is not well understood in communities. (4) Community involvement may promote communication and trust between communities and testing advocates. (5) Novel testing strategies are acceptable and may diminish barriers.

CONCLUSIONS

Working with community "gatekeepers" may be a key strategy to understand and promote acceptability of interventions new to rural Alabama and ameliorate stigma within communities. The implementation of new HIV testing strategies requires building and maintaining relationships with advocates, especially faith-based leaders, who engage people across many demographics.

Antiretroviral Therapy Use, Viral Detectability and Fear of Onward Transmission Among People Living with HIV in Australia: Changes Between 1997 and 2018

This paper examines how antiretroviral therapy (ART) use and fears towards the onward transmission of HIV have changed among people living with HIV (PLHIV) in Australia between 1997 and 2018. Participants were recruited as part of the HIV Futures study, a large cross-sectional survey of PLHIV in Australia, in 1997, 2003, 2012 and 2018 (total n = 3889). ART use, viral load detectability, and fear of onward HIV transmission were compared between years. Predictors of onward transmission fear were assessed among the 2018 subsample. While ART use within our sample decreased between 1997 and 2003, it subsequently increased to 97% in 2018. Self-reported viral load undetectability steadily increased over time, up to 88% in 2018. Notably, fewer PLHIV reported being fearful of transmitting HIV in 2018 compared to all other years. Being unfamiliar with the undetectable = untransmissible health movement, and having a detectable or uncertain viral load at last test, were significant predictors of being fearful of onward HIV transmission. Beyond the immediate medical considerations of HIV treatment, these results suggest that the undetectable = untransmissible movement may play a critical role in attenuating burdens experienced by PLHIV in Australia and that such messaging, in tandem with early and consistent ART use, should remain a salient feature of heath messaging among this population.

The ethical imperative to reduce HIV stigma through community-engaged, status-neutral interventions designed with and for transgender women of colour in the United States

INTRODUCTION

In the era of biomedical HIV prevention and treatment technologies, such as treatment as prevention (TasP) and pre-exposure prophylaxis (PrEP), there is momentum to develop and rigorously evaluate interventions focused on PrEP among those at risk for HIV acquisition and antiretroviral therapy (ART) adherence among people living with HIV. While HIV status-specific interventions focused on PrEP or ART provide valuable information, status-segregated interventions can create, perpetuate, and even increase HIV stigma among transgender women of colour and other marginalized communities in the United States (US).

DISCUSSION

Due largely to community advocacy, discourses that support status-neutral approaches have emerged in the scientific literature. Although US-based funding mechanisms have typically designated awards focused on a specific HIV status, intervention developers and implementing agencies find creative ways to design and implement status-neutral programmes despite such restrictions. We present our experience with intervention research in New York, Detroit, New Orleans, Puerto Rico and the San Francisco Bay Area, all Ending the HIV Epidemic (EHE) priority jurisdictions. Kickin it with the Gurlz' was developed to be status-neutral through two grants due to community demands for a unifying approach. The Transgender Women Engagement and Entry to (TWEET) Care Project was designed to improve HIV care engagement for transgender women living with HIV, but developers realized the importance of including participants of any HIV status. Healthy Divas was designed for transgender women living with HIV but subsequent implementing agencies prioritized adapting it to be status-neutral. These examples support the urgency of designing, implementing and evaluating status-neutral interventions.

CONCLUSIONS

Community-based organizations strive for inclusivity in their programming and are rightly often reluctant to segregate services based on the HIV status of their clients. As researchers, we have an ethical imperative to work to reduce HIV stigma and respond to the needs of those most impacted by HIV, including transgender women of colour. As such, we call upon funders to develop mechanisms that support the development and testing of HIV status-neutral interventions to reduce HIV stigma and support community building, thereby increasing the possibility of fully realizing the benefits of biomedical HIV prevention and treatment technologies for all.

Awareness, Understanding and HIV Stigma in Response to Undetectable = Untransmittable Messages: Findings from a Nationally Representative Sample in the United Kingdom

'Undetectable = Untransmittable', or 'U = U', is a message which communicates the scientific consensus that people living with HIV who maintain an undetectable viral load cannot sexually transmit HIV to others. This research aimed to empirically test whether a protection-framed U = U message is more effective at decreasing HIV stigma and increasing perceived accuracy of U = U than a risk-framed message. A nationally representative UK sample (N = 707) completed an online experiment. Participants viewed one of two U = U messages (protection-framed or risk-framed) and completed an online questionnaire. No evidence of a difference in HIV stigma at post-test or in perceived accuracy of U = U was found between the two message frame conditions. A minority of participants were aware of U = U prior to participation. Post-intervention, the majority of participants rated U = U as at least somewhat accurate. Higher understanding of U = U was associated with lower post-test stigma following a protection-framed message. Following a brief intervention, among a sample predominantly unaware of U = U previously, there was an overall favourable rating of U = U. No evidence was found for an effect of message framing on HIV stigma or perceived accuracy of U = U, but participants who completed a pre-test measure of stigma rated U = U as less accurate.

How Little Do We Know about HIV and STIs Prevention? Results from a Web-Based Survey among the General Population

Background: Prevention campaigns have led to a significant decrease in new HIV diagnoses in Western Europe, while other sexual transmitted infections (STIs) have shown an opposite trend. Several educational programs are promoted among young students, whereas informational campaigns addressing the general population are scarce. We aimed to investigate the level of awareness regarding STIs among the general population. Methods: We proposed a questionnaire regarding STIs and HIV to the general population in Italy. We assigned 1 point to correct, 0.5 point to partially correct, and 0 point to wrong answers. We collected data about age, sex, region of origin, level of education and whether they were health workers. Results: Overall, 2183 people answered the questionnaire, of which 555 aged over 50 years old. Being male, older than 50 years old, retired or unemployed, not educated, and no regular use of condoms were associated with lower scores. Only 16% of participants knew the Undetectable = Untransmittable (U = U) campaign. Overall, 2131 (97.6%) people think more educational campaigns should be offered. Of interest, 80% said the questionnaire led them to learn more about HIV and STIs. Conclusion: Our study reveals several gaps in general population awareness about HIV and STIs, especially among people aged over 50 years old. Most participants stated that the questionnaire was a learning opportunity. These data suggest that improvement of knowledge could start from easy-to-dispose medium, such as surveys and questionnaires delivered through social media. Furthermore, particular attention should be paid to population segmentation and campaign tailoring to enhance interventions effectiveness. Our data reinforce the need for more informational and educational campaigns tailored to the specific segments of the population.

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.

"It's how we get to know each other": Substance use, connectedness, and sexual activity among men who have sex with men who are living with HIV

BACKGROUND

Among MSM, substance use increases risk for acquiring HIV and is associated with sub-optimal engagement in HIV-related care. Most research related to substance use and sexual activity among MSM focuses on identifying and reducing risk of HIV acquisition and transmission rather than pleasure and agency. However, substance use may also facilitate sexual pleasure and build community, which could be particularly meaningful for individuals who cope with intersecting stigmas related to the disease, sexual identity, and drug use.

METHODS

To explore the ways in which substance use both promotes and hinders positive sexual expression and healthy sexual relationships, we conducted a secondary analysis of 33 semi-structured qualitative interviews with MSM living with HIV who were poorly engaged in care and reported recent substance use.

RESULTS

Thematic analysis revealed that substance use was perceived as: (1) a potential pathway to intimacy and enhanced sexual experiences; (2) a tool to help access partners and gain entry to a community; and (3) a source of empowerment, though some noted that it sometimes came at the cost of sexual disempowerment and unbalanced relationships.

CONCLUSIONS

Clinically, our results suggest that the complex motivations for substance use during sexual activity need to be carefully considered and discussed with patients, especially when attempting to decrease problematic use as a pathway to improved HIV self-care.

African American Clergy Recommendations to Enhance the Federal Plan to End the HIV Epidemic: A Qualitative Study

African Americans in the southern United States continue to be disproportionately affected by HIV. Although faith-based organizations (FBOs) play important roles in the social fabric of African American communities, few HIV screening, care, and PrEP promotion efforts harness the power of FBOs. We conducted 11 focus groups among 57 prominent African American clergy from Arkansas, Mississippi, and Alabama. We explored clergy knowledge about the Ending the HIV Epidemic: A Plan for America (EHE); normative recommendations for how clergy can contribute to EHE; and how clergy can enhance the HIV care continua and PrEP. We explored how clergy have responded to the COVID-19 crisis, and lessons learned from pandemic experiences that are relevant for HIV programs. Clergy reported a moral obligation to participate in the response to the HIV epidemic and were willing to support efforts to expand HIV screening, treatment, PrEP and HIV care. Few clergy were familiar with EHE, U = U and TasP. Many suggested developing culturally tailored messages and were willing to lend their voices to social marketing efforts to destigmatize HIV and promote uptake of biomedical interventions. Nearly all clergy believed technical assistance with biomedical HIV prevention and care interventions would enhance their ability to create partnerships with local community health centers. Partnering with FBOs presents important and unique opportunities to reduce HIV disparities. Clergy want to participate in the EHE movement and need federal resources and technical assistance to support their efforts to bridge community activities with biomedical prevention and care programs related to HIV. The COVID-19 pandemic presents opportunities to build important infrastructure related to these goals.

Same-sex behavior disclosure to health care providers associated with greater awareness of pre-exposure prophylaxis

BACKGROUND

This study aimed to determine whether the disclosure of same-sex behavior to health care providers (HCPs) is associated with higher rates of prior human immunodeficiency virus (HIV) testing experience and greater awareness of immediate antiretroviral therapy (ART), Undetectable = Untransmittable (U=U), and pre-exposure prophylaxis (PrEP) among men who have sex with men (MSM).

METHODS

We conducted a cross-sectional survey among 689 adult males in Chengdu, China who self-reported having had anal intercourse with at least one man in the past 6 months. We measured same-sex behavior disclosure to three types of HCPs (hospital clinicians, community-based organization peer educators, and Center for Disease Control and Prevention public health specialists), and the awareness of immediate ART, U=U, and PrEP.

RESULTS

Of the 689 enrolled participants, 31.4% had disclosed their same-sex behavior to some or all of the clinicians, 83.9% had done so to the peer educators, and 56.8% had done so to the public health specialists. Approximately four in five (82.1%) of the participants had ever been tested for HIV. The awareness rate was 84.8% for immediate ART, 20.2% for U=U, and 50.7% for PrEP. After controlling for significant background variables, same-sex behavior disclosure to clinicians was associated with greater awareness of PrEP (adjusted odds ratio [AOR] = 1.64; 95% confidence interval [CI]: 1.08-2.48), but similar findings were not reported regarding disclosure to peer educators or public health specialist. Same-sex behavior disclosure to any types of HCPs was not associated with HIV testing experience, and awareness of immediate ART or U=U.

CONCLUSIONS

The rates of same-sex behavior disclosure varied with different types of HCPs. Disclosure to clinicians was associated with greater awareness of PrEP, but not awareness of immediate ART or U=U.

Health Beliefs Linked to HIV Pre-Exposure Prophylaxis Use Intention Among Young Men Who Have Sex with Men in Taiwan

Pre-exposure prophylaxis (PrEP) is an effective tool to prevent HIV and has recently been approved in Taiwan. However, more research regarding PrEP acceptability and effective PrEP implementation is needed in Taiwan. Little is known about the intention to use PrEP and salient psychosocial factors among men who have sex with men (MSM). The purpose of this study was to examine health beliefs linked to PrEP use intention among young MSM (YMSM) in Taiwan. Using the Health Belief Model (HBM) as a guiding framework, an anonymous online survey was used to collect data from participants who were recruited using multiple channels to ensure diversity. Multivariate logistic regression was performed to examine the health beliefs linked to high PrEP use intention. Data from 1329 HIV-negative YMSM were analyzed; 488 (36.7%) were classified as having high PrEP use intention, which was found to be associated with having high perceived susceptibility to HIV infection [adjusted odds ratio (AOR) = 2.11], high perceived benefits of PrEP use (AOR = 2.14), high self-efficacy in PrEP use (AOR = 4.19), and many cues to action concerning PrEP use (AOR = 1.49). YMSM with high perceived barriers to PrEP use (AOR = 0.64) had lower PrEP use intention. In addition, the effects of HBM constructs and specific health beliefs on PrEP use intention varied by preferred penile-anal sexual role. The study findings may inform efforts aimed at improving PrEP acceptability and optimizing PrEP implementation programs tailored for YMSM of different sexual roles.

Participatory Prototyping of a Tailored Undetectable Equals Untransmittable Message to Increase HIV Testing Among Men in Western Cape, South Africa

Daily antiretroviral therapy (ART) suppresses viral replication, rendering HIV undetectable through viral load (VL) testing. People living with HIV (PLWH) who have an undetectable VL cannot transmit HIV to sexual partners or through giving birth, a message commonly referred to as U = U (undetectable equals untransmittable). To increase knowledge and understanding of U = U among men, who have poorer HIV testing and treatment outcomes than women, we engaged men from high HIV burden communities in Cape Town in two interactive human-centered design cocreation workshops to develop local U = U messaging for men. Two trained workshop facilitators, explained the U = U message to 39 adult men (in two separate workshops), and asked them how to effectively communicate U = U to other men in the local language (isiXhosa). Participant-designed messages sought to inform men about U = U to help assuage fears of testing HIV positive (by removing the stigma of living with HIV and being a vector of disease), and to explain that ART enables PLWH to live normal healthy lives, making HIV "untransmittable" to sex partners. Participants' messages emphasized that when virally suppressed, "I cannot spread HIV to the other person" and "(the pill) keeps on killing the virus so I can live a normal life for the rest of my life." Men cocreated simple local U = U messages to address fears of testing HIV positive and emphasizing ART's positive effects. Cocreated tailored messaging may reduce stigma associated with living with HIV and improve the uptake of HIV testing and treatment among South African men. This study was registered at clinicaltrials.gov under NCT04364165.

Undisclosed HIV Status to Sex Partners and Its Unintended Consequences in the Era of Undetectable = Untransmittable

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.

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.

Investigating the effect of undetectable = untransmittable message frames on HIV stigma: an online experiment

People living with HIV who maintain an undetectable viral load by adhering to antiretroviral therapy cannot transmit the virus to others. The present pre-registered study sought to investigate whether messages about this fact have the potential to decrease HIV stigma, drawing on the framework of the Elaboration Likelihood Model to test variations in message framing, and measuring issue involvement as a covariate. Participants (N = 314) were randomised to one of three conditions: control message, opinion-based message, and evidence-based message. Using a between-subjects one-way ANOVA, it was found that there was no significant effect of the U = U message on perceived risk or perceived accuracy of the message. When controlling for issue involvement, operationalised as the extent to which participants felt that they can empathise with people living with HIV, participants who received the evidence-based U = U message reported lower stigmatising attitudes than those who received the opinion-based message. These adjusted results suggested that evidence-based framing was more effective than opinion-based framing and an unrelated control message.

Longitudinal Associations of Syndemic Conditions with Antiretroviral Therapy Adherence and HIV Viral Suppression Among HIV-Infected Patients in Primary Care

Psychosocial syndemic conditions have received more attention regarding their deleterious effects on HIV acquisition risk than for their potential impact on HIV treatment and viral suppression. To examine syndemic conditions' impact on the HIV care continuum, we analyzed data collected from people living with HIV (N = 14,261) receiving care through The Centers for AIDS Research Network of Integrated Clinical Systems at seven sites from 2007 to 2017 who provided patient-reported outcomes ∼4-6 months apart. Syndemic condition count (depression, anxiety, substance use, and hazardous drinking), sexual risk group, and time in care were modeled to predict antiretroviral therapy (ART) adherence and viral suppression (HIV RNA <400 copies/mL) using multilevel logistic regression. Comparing patients with each other, odds of ART adherence were 61.6% lower per between-patient syndemic condition [adjusted odds ratio (AOR) = 0.384; 95% confidence interval (CI), 0.362-0.408]; comparing patients with themselves, odds of ART adherence were 36.4% lower per within-patient syndemic condition (AOR = 0.636 95% CI, 0.606-0.667). Odds of viral suppression were 29.3% lower per between-patient syndemic condition (AOR = 0.707; 95% CI, 0.644-0.778) and 27.7% lower per within-patient syndemic condition (AOR = 0.723; 95% CI, 0.671-0.780). Controlling for the effects of adherence (AOR = 5.522; 95% CI, 4.67-6.53), each additional clinic visit was associated with 1.296 times higher odds of viral suppression (AOR = 1.296; 95% CI, 1.22-1.38), but syndemic conditions were not significant. Deploying effective interventions within clinics to identify and treat syndemic conditions and bolster ART adherence and continued engagement in care can help control the HIV epidemic, even within academic medical settings in the era of increasingly potent ART.

Prioritising pleasure and correcting misinformation in the era of U=U

There is widespread unawareness and disbelief regarding the evidence-based conclusion that people who have a sustained undetectable HIV viral load cannot sexually transmit HIV-ie, undetectable=untransmittable (U=U). Long-standing, misguided fear about HIV transmission persists; consequently, so does the policing of sexual expression and the penalisation of pleasure faced by people with HIV. Many people with HIV with an undetectable viral load have unnecessarily abstained from condomless sex, avoided serodifferent partnering, and had anxiety about onward sexual transmission due to perceived HIV risk that is now known to be non-existent. Some health professionals have refrained from correcting this misinformation because of concerns that people with HIV will engage in more condomless sex or have more sexual partners upon learning of U=U. Withholding information about U=U is thus rooted in behavioural assumptions and is scientifically unfounded. Moreover, withholding such information violates medical ethics, perpetuates health inequities, and infringes on the sexual health and human rights of people with HIV. Health professionals and the broader public health community have an ethical responsibility to actively address misinformation about HIV transmission and disseminate the U=U message to all people.