Switch On Your HIV Smarts.

Who knows about U=U? Awareness that undetectable individuals do not transmit HIV increasing, says new study

, by Emily Land

About eight years ago, Jimmy Gale’s doctor told him about treatment as HIV prevention. He explained that by taking antiretroviral medications, Gale’s viral load would likely become undetectable, and then it would not be possible to transmit HIV to partners.

Jimmy Gale

Jimmy Gale, manager of HIV-positive services at San Francisco AIDS Foundation

“Leading up to that, I was afraid to date, afraid to meet anyone,” said Gale. “Then, for the first time, I felt in control of my sexual health.”

Although Gale, who is now the manager of HIV-positive services at San Francisco AIDS Foundation, learned about treatment as prevention, or TasP, many years ago, understanding of treatment as prevention has not yet fully permeated public awareness.

“I think it’s about 50/50, the percentage of people who understand what treatment as prevention is, and what it means,” said Gale, who talks to people everywhere from cab rides, to the grocery store, to clients at work about HIV and what it means to be undetectable. “This is not a new message, but in some communities there’s still mistrust.”

What does the research show?

Recent research, conducted in Vancouver, British Columbia with HIV-positive and HIV-negative men who have sex with men, found that awareness of treatment as prevention is increasing, but still unevenly distributed with HIV-negative men and men with lower social capital less likely to be aware or accepting of treatment as prevention information.

Kiffer Card

Kiffer Card

“With an increasing number of biomedical options available to gay and bi men, including PrEP, we were interested in looking at who in our population was aware of these prevention strategies, and how social norms and cultural influences might impact acceptability or trust in these strategies,” said lead researcher Kiffer Card, from Simon Fraser University.

A total of 556 HIV-negative (or HIV status unknown) men and 218 HIV-positive men in Vancouver participated in the study. Between 2012 and 2016, people completed interviews and lab testing (HIV, CD4, viral load, hepatitis C and syphilis testing) every six months. The median age was 34, and most (85%) of the sample identified as gay.

Based on answers to questions about awareness of treatment as prevention, participation in viral load sorting (selecting partners with undetectable viral loads), and certainty of treatment as prevention benefits, people were classified as being “Unaware,” “Skeptical,” or “Believing.”

  • Men classified as “Unaware” had not heard of treatment as prevention, did not engage in viral load sorting, and were generally skeptical of the preventive benefits of treatment as prevention.
  • Men classified as “Skeptical” were in the middle. For example, they had may have heard that people with undetectable viral loads could not pass on the virus, but disagreed with statements about whether it was “safe” to have sex without a condom in these instances.
  • Men classified as “Believing” had the most awareness of treatment as prevention. They believed that treatment as prevention lowered HIV risk “a lot,” engaged in condomless viral load sorting with serodiscordant partners, and agreed with statements about the benefits of treatment as prevention.

When people started the study (between 2012 and 2014):

  • Nearly 3 in 4 (74%) HIV-negative/unknown men and one-third (33%) of HIV-positive men were “Unaware” of treatment as prevention; and,
  • 44% of HIV-positive men were “Believing,” while only 4% of HIV-negative men were “Believing.”

Over the course of the study, the proportion of HIV-positive men classified as “Unaware,” “Skeptical,” and “Believing” was relatively stable: About half of HIV-positive men were “Believing” in treatment as prevention at the start and end of the study.

There was a discernable shift, however, among HIV-negative men. The proportion of HIV-negative men who were “Unaware” of treatment as prevention decreased from 74% at the start of the study to 33% by the end of the study.

“I think of most interest—epidemiologically but also from a community standpoint—was that there certainly is an increasing awareness and support of treatment as prevention among HIV-negative guys,” said Card.

Card also explained that people with less “social capital” were less likely to show an increasing awareness of treatment as prevention. That is, men with less education, who were not employed, who did not have a regular partner, who identified as bisexual or straight, who used drugs, or were not connected to the gay community were less likely to be aware of treatment as prevention or show an increased understanding of treatment as prevention over time. This finding has particular implications for public health and community education efforts.

Why is treatment as prevention important?

“When I was diagnosed with HIV in 2003, I felt like I was a walking infection. I was terrified about passing HIV on to someone that I love,” said Bruce Richman, HIV activist and founder of the U=U campaign. “I didn’t start treatment because taking a pill every day would remind me that I was infectious, every day. After I started treatment in 2012, when my health started to deteriorate, I learned from my doctor that because I was undetectable, I couldn’t transmit HIV. I couldn’t pass it on. I was elated.”

Treatment as prevention is vital for public health: HIV transmissions would drop to zero if everyone living with HIV were on antiretrovirals and had undetectable viral loads.

Understanding treatment as prevention—and what it means to have an undetectable viral load—is important for both HIV-negative and HIV-positive people so they can make accurate, informed decisions about the types of sexual activity they enjoy with their partners, said Card.

“We’re not out to tell people who and who not to have sex with, of course—people should explore what is comfortable and feels safe for them—but certainly we want people to be informed about the benefits of treatment,” said Card.

The message of treatment as prevention is also valuable in its own right to HIV activists like Richman, who explains that the “undetectable” message empowers people living with HIV and decreases HIV stigma. (Read more about the Undetectable = Untransmittable messaging campaign by Prevention Access Campaign.)

“I tell everyone I meet about Undetectable = Untransmittable (U=U)—regardless of their status,” said Gale. Social media has played a huge role in getting this message out. Even dating apps are displaying ads about U=U and encouraging folks to educate themselves. It’s really exciting.”

U=U is just the start

Personally, Gale said he sees the U=U message as just the start to a larger understanding of HIV health and people living with HIV.

“Undetectable is so much more than untransmittable. It is freedom. It is peace of mind. And it provides long-term health benefits. People living with HIV are more than just their lab results, and our value isn’t dictated by our viral load. Achieving an undetectable viral load is important, but not just because it protects our sexual partners.”

Read BETA articles by Dr. Joanna Eveland about why it’s important for people living with HIV to start, and stay on, HIV treatment and about the impact of HIV stigma. Find out more about what it means to be undetectable and have a suppressed viral load, and read more about the U=U campaign by Prevention Access Campaign.

People living in the San Francisco Bay Area are welcome to find out more and join services offered by San Francisco AIDS Foundation, which includes navigation to HIV care and treatment, one-on-one and group support, educational events, social support, and more.


Card, K.G. and colleagues. Belief in Treatment as Prevention and Its Relationship to HIV Status and Behavioral Risk. JAIDS, January, 2018.


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