U=U – A Foundation for Ending the HIV Epidemic

By: Murray Penner, Executive Director, North America, Prevention Access Campaign

What many have thought for nearly 20 years is now an undeniable fact:  People living with HIV (PLWH) on effective treatment cannot transmit the virus to their sexual partners. This is the basis for Undetectable = Untransmittable, or U=U. You may know it, but in the United States, many PLWH, providers, policy makers, and the general public still don’t. This fact can transform lives and the field when communicated properly and represents a significant opportunity to help end the HIV epidemic.

There is an abundance of research supporting U=U, including PARTNER 1, in which both straight and gay couples had more than 58,000 condomless sex acts and PARTNER 2, in which gay male couples had more than 77,000 condomless sex acts. Both studies had zero linked HIV transmissions. Other research includes the Rakai, HPTN 052, and Opposites Attract studies, as well as the Swiss Statement that first published information about the risk of transmission being zero in 2008. This and other evidence is discussed in an online article at www.i-base.info/htb/32308.

Prevention Access Campaign (PAC) launched the U=U campaign through its consensus statement in July of 2016 and within three short years has achieved support from nearly 900 organizations in 98 countries. PAC is a community of people living with HIV, researchers, organizations, and other allies who share the common goals to end the dual epidemics of HIV and HIV-related stigma by empowering people with accurate and meaningful information.

Sharing the U=U message provides an unprecedented opportunity to improve the lives of people living with HIV and to dismantle HIV stigma. It has far-reaching public health implications for engagement across each stage of the treatment cascade and for expanding access to universal treatment and care to all people living with HIV so that they can benefit from viral suppression.
The basics rules of U=U are not complex.  It's about TLC:

1. Treatment – stay on Treatment as prescribed 
2. Labs – get Labs done regularly 
3. Connection – stay Connected to Care 

Words matter. In conveying the message that U=U, it is critical to be clear and definitive, which inspires confidence and doesn’t promote unnecessary doubts or fear. PAC recommends using easy to understand phrases such as “can’t pass it on,” “cannot transmit,” and “no risk." You can even say “zero risk.” Avoid phrases that may suggest even a slight risk like “nearly impossible,” “extremely low, “essentially no,” and “virtually impossible.” Any perceived window of risk, no matter how slight, may be considered “still a risk.” If you hear or see such ambiguous phrases being used, please speak out!

The U=U message is not copyrighted.  It belongs to everyone and is based on the science of treatment as prevention, pioneered in 2007 by Dr. Julio Montaner, who was also one of the earliest signatories to the U=U consensus statement. The phrase “Undetectable = Untransmittable (U=U)” was created by the community and researchers to easily convey the TasP science in a more definitive and empowering way.

As you create statements, videos, speeches, and/or newsletters, please keep in mind that millions of people don’t know about or believe U=U. Every communication is an opportunity for change. Make the information prominent so it has the best chance of being seen, not buried or near the end of a video where it could go unnoticed. U=U can be utilized in many messages:

• HIV stigma – U=U is the greatest opportunity we’ve had to dismantle it. 
• HIV treatment – U=U is an added incentive to start and adhere to treatment & to stay engaged in care. 
• Sexual and reproductive health – U=U means PLWH can have sex and conceive children without fear of transmission or alternative and expensive means of insemination. 
• Mental health – U=U reduces the fear and shame of transmission which has lifted people with HIV out of depression and social isolation. 
• HIV prevention – An undetectable HIV viral load only prevents HIV transmission to sexual partners. PrEP for HIV-negative individuals also prevents it. But these HIV-prevention tools do not prevent STIs and pregnancy. Using condoms helps prevent HIV transmission as well as other STIs and pregnancy. Choices for prevention methods may be different depending upon a person’s sexual practices, circumstances and relationships. For instance, if someone is having sex with multiple partners or is in a non-monogamous relationship, they might consider using condoms to prevent other STIs, while two individuals in a monogamous, sero-different relationship may choose U=U.
• Access to treatment and services – U=U is the public health argument for access. Everyone deserves to benefit from treatment. But people who do not achieve viral suppression must not be shamed or stigmatized either. Structural inequalities and social determinants of health make it difficult or impossible for far too many to reach viral suppression.   
• HIV criminalization – U=U is an important part of the modernization toolbox. 

Other items to keep in mind:

• Undetectable, synonymous with viral suppression, is under 200 copies/ml. 
• Achieving an undetectable viral load can take several months of ART. Once achieved, continued adherence is required. 
• U=U only applies to sexual transmission; there is not yet evidence about breastfeeding or needle sharing, although the U=U message should still be considered. 
• U=U may not exempt people with HIV from disclosure laws, which are unjust and bad for public health regardless of viral load. 

For more information on U=U or the Prevention Access Campaign, visit www.uequalsu.org.



Disclaimer: Guest blogs do not necessarily reflect the views of the ADAP Advocacy Association, but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about public health-related issues and updates.