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Calabrese SK, Zaheer MA, Flores JJ, Kalwicz DA, Modrakovic DX, Rao S, Dovidio JF, Zea MC, Eaton LA. Messaging About HIV Transmission Risk When Viral Load Is Undetectable: Reactions and Perceived Accuracy Among US Sexual Minority Men. J Acquir Immune Defic Syndr 2024; 96:270-279. [PMID: 38905477 PMCID: PMC11196007 DOI: 10.1097/qai.0000000000003417] [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] [Received: 09/15/2023] [Accepted: 02/29/2024] [Indexed: 06/23/2024]
Abstract
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.
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Affiliation(s)
- Sarah K. Calabrese
- Department of Psychological and Brain Sciences, George Washington University, Washington, DC, USA
- Department of Prevention and Community Health, George Washington University, Washington, DC, USA
| | - Myra A. Zaheer
- Department of Psychological and Brain Sciences, George Washington University, Washington, DC, USA
- School of Medicine and Health Sciences, George Washington University, Washington, DC, USA
| | - Justino J. Flores
- Department of Psychological and Brain Sciences, George Washington University, Washington, DC, USA
| | - David A. Kalwicz
- Department of Psychological and Brain Sciences, George Washington University, Washington, DC, USA
| | - Djordje X. Modrakovic
- Department of Psychological and Brain Sciences, George Washington University, Washington, DC, USA
| | - Sharanya Rao
- Department of Psychological and Brain Sciences, George Washington University, Washington, DC, USA
| | - John F. Dovidio
- Department of Psychology, Yale University, New Haven, CT, USA
| | - Maria Cecilia Zea
- Department of Psychological and Brain Sciences, George Washington University, Washington, DC, USA
| | - Lisa A. Eaton
- Department of Human Development and Family Sciences, University of Connecticut, Storrs, CT, USA
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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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Bor J, Fischer C, Modi M, Richman B, Kinker C, King R, Calabrese SK, Mokhele I, Sineke T, Zuma T, Rosen S, Bärnighausen T, Mayer KH, Onoya D. Changing Knowledge and Attitudes Towards HIV Treatment-as-Prevention and "Undetectable = Untransmittable": A Systematic Review. AIDS Behav 2021; 25:4209-4224. [PMID: 34036459 PMCID: PMC8147591 DOI: 10.1007/s10461-021-03296-8] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2021] [Indexed: 12/12/2022]
Abstract
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
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Affiliation(s)
- Jacob Bor
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Boston, MA, 02119, USA.
- Health Economics and Epidemiology Research Office, Wits Health Consortium, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, GP, South Africa.
| | - Charlie Fischer
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Boston, MA, 02119, USA
| | - Mirva Modi
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Boston, MA, 02119, USA
| | | | | | - Rachel King
- UCSF Institute for Global Health Sciences, University of California, San Francisco, 550 16th Street, San Francisco, CA, 94158, USA
| | | | - Idah Mokhele
- Health Economics and Epidemiology Research Office, Wits Health Consortium, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, GP, South Africa
| | - Tembeka Sineke
- Health Economics and Epidemiology Research Office, Wits Health Consortium, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, GP, South Africa
| | - Thembelihle Zuma
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- University of KwaZulu-Natal, Durban, South Africa
- Division of Infection and Immunity, University College London, London, UK
| | - Sydney Rosen
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Boston, MA, 02119, USA
- Health Economics and Epidemiology Research Office, Wits Health Consortium, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, GP, South Africa
| | - Till Bärnighausen
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
| | - Kenneth H Mayer
- Fenway Health Institute, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Dorina Onoya
- Health Economics and Epidemiology Research Office, Wits Health Consortium, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, GP, South Africa
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Calabrese SK, Mayer KH, Marcus JL. Prioritising pleasure and correcting misinformation in the era of U=U. Lancet HIV 2021; 8:e175-e180. [PMID: 33662266 DOI: 10.1016/s2352-3018(20)30341-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 12/05/2020] [Accepted: 12/10/2020] [Indexed: 10/22/2022]
Abstract
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.
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Affiliation(s)
- Sarah K Calabrese
- Department of Psychological and Brain Sciences, and Department of Prevention and Community Health, George Washington University, Washington, DC, USA.
| | - Kenneth H Mayer
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; The Fenway Institute, Fenway Health, Boston, MA, USA
| | - Julia L Marcus
- Department of Population Medicine, Harvard Medical School, Boston, MA, USA; The Fenway Institute, Fenway Health, Boston, MA, USA
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Ngure K, Ongolly F, Dolla A, Awour M, Mugwanya KK, Irungu E, Mugo N, Bukusi EA, Morton J, Odoyo J, Wamoni E, Barnabee G, Peebles K, O'Malley G, Baeten JM. "I just believe there is a risk" understanding of undetectable equals untransmissible (U = U) among health providers and HIV-negative partners in serodiscordant relationships in Kenya. J Int AIDS Soc 2020; 23:e25466. [PMID: 32144888 PMCID: PMC7060133 DOI: 10.1002/jia2.25466] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Accepted: 02/05/2020] [Indexed: 11/11/2022] Open
Abstract
Introduction Sustained HIV viral suppression resulting from antiretroviral therapy (ART) eliminates the risk of HIV transmission, a concept popularly framed as Undetectable = Untransmittable (U = U). We explored knowledge and acceptance of information around the elimination of HIV transmission risk with ART (U = U) in Kenya. Methods Our qualitative study was conducted within a project evaluating the use of pre‐exposure prophylaxis (PrEP) integrated into ART care for HIV serodiscordant couples in public clinics in Kenya (the Partners Scale Up Project). From February 2017 to April 2019, we conducted semi‐structured key informant interviews with 83 health providers and in‐depth interviews with 61 HIV‐negative people in serodiscordant relationships receiving PrEP services. Transcripts were coded using thematic analysis. Results Health providers reported being aware of reduced risk of HIV transmission as a result of consistent ART use and used words such as “very low,” “minimal” and “like zero” to describe HIV transmission risk after viral suppression. Providers reported finding viral load results helpful when counselling clients about the risk of HIV transmission. Many lacked confidence in U = U and counselled on consistent condom use even after viral suppression while some expressed concerns that communicating this message to people living with HIV (PLHIV) would lead them to engage in multiple sexual relationships. Other providers reported that they did not counsel about the reduced risk of HIV transmission after viral suppression for fear of being blamed if HIV transmission occurred. HIV‐negative partners reported being informed about U = U by providers but they did not believe nor trust the message. Even after their partners achieved viral suppression, some HIV‐negative partners were unwilling to stop PrEP, while others indicated that they would use condoms if they stopped PrEP to be sure that they were protected from HIV. Conclusions Despite awareness that effective ART use eliminates HIV transmission risk, there is both a lack of in‐depth knowledge and conviction about the strategy among health providers and HIV‐negative partners in serodiscordant relationships. New strategies that go beyond communicating the science of U = U to consider the local social and clinical environments could maximize the effectiveness of U = U.
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Affiliation(s)
- Kenneth Ngure
- Department of Community Health, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya.,Department of Global Health, University of Washington, Seattle, WA, USA
| | - Fernandos Ongolly
- Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Annabell Dolla
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Merceline Awour
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Elizabeth Irungu
- Department of Community Health, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | - Nelly Mugo
- Department of Global Health, University of Washington, Seattle, WA, USA.,Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Elizabeth A Bukusi
- Department of Global Health, University of Washington, Seattle, WA, USA.,Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Jennifer Morton
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Josephine Odoyo
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Elizabeth Wamoni
- Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Gena Barnabee
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Kathryn Peebles
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | | | - Jared M Baeten
- Department of Global Health, University of Washington, Seattle, WA, USA.,Department of Epidemiology, University of Washington, Seattle, WA, USA.,Department of Medicine, University of Washington, Seattle, WA, USA
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