Undetectable equals untransmittable (U = U): awareness and associations with health outcomes among people living with HIV in 25 countries

Abstract

Objectives: 'Undetectable equals Untransmittable' (U=U) is an empowering message that may enable people living with HIV (PLHIV) to reach and maintain undetectability. We estimated the percentage of PLHIV who ever discussed U=U with their main HIV care provider, and measured associations with health-related outcomes. Secondarily, we evaluated whether the impact of the U=U message varied between those who heard it from their healthcare provider (HCP) vs from elsewhere.

Methods: Data were from the 25-country 2019 Positive Perspectives Survey of PLHIV on treatment (n=2389). PLHIV were classified as having discussed U=U with their HCP if they indicated that their HCP had ever told them about U=U. Those who had not discussed U=U with their HCP but were nonetheless aware that 'My HIV medication prevents me from passing on HIV to others' were classified as being made aware of U=U from non-HCP sources. Multivariable logistic regression was used to measure associations between exposure to U=U messages and health outcomes.

Results: Overall, 66.5% reported ever discussing U=U with their HCP, from 38.0% (South Korea) to 87.3% (Switzerland). Prevalence was lowest among heterosexual men (57.6%) and PLHIV in Asia (51.3%). Compared with those unaware of U=U, those reporting U=U discussions with their HCP had lower odds of suboptimal adherence (AOR=0.59, 95% CI 0.44 to 0.78) and higher odds of self-reported viral suppression (AOR=2.34, 95% CI 1.72 to 3.20), optimal sexual health (AOR=1.48, 95% CI 1.14 to 1.92) and reporting they 'always shared' their HIV status (AOR=2.99, 95% CI 1.42 to 6.28). While exposure to U=U information from non-HCP sources was beneficial too, the observed associations were attenuated relative to those seen with reported discussions with HCPs.

Conclusion: HCP discussion of U=U with PLHIV was associated with favourable health outcomes. However, missed opportunities exist since a third of PLHIV reported not having any U=U discussion with their HCP. U=U discussions with PLHIV should be considered as a standard of care in clinical guidelines.

Keywords: HIV clinical care; attitudes; behavioural interventions; communication skills; education.

Figure 1

Percentage of people living with HIV who reported being told by their healthcare provider of ‘Undetectable=Untransmittable’, by selected characteristics, Positive Perspectives Study, 2019 (n=2389). Note: relationship status was assessed indirectly using a series of survey questions that asked participants with whom they had shared their HIV status. Those not in the relationship of interest selected ‘not applicable’. Separate assessments were done for partner/spouse/significant other (indicated here as ‘serious relationship’) versus other sexual partners (indicated here as ‘casual sex partners’). Those identifying they were in both relationships were classified as having multiple partners whereas those selecting ‘not applicable’ to both were classified as not being in any relationship. Because of skip patterns in the survey, data on relationship status could not be assessed for 302 individuals. The sum of men who have sex with men and men who have sex with women does not equal the total number of men because of individuals with missing/indeterminate information for sexual orientation; the same applies for women.