The U=U Message Isn't Spreading Fast Enough

Researchers are demanding that health care providers do more to promote the undetectable equals untransmittable consensus by informing those living with HIV that they cannot transmit the virus to a sexual partner when their viral load is suppressed to undetectable levels.

“Providers caring for patients with HIV should universally inform their patients about U=U as part of their routine care,” Dr. Sarah Calabrese of George Washington University and Kenneth Mayer of the Harvard Medical School and Fenway Institute write in The Lancet HIV. “Conveying benefits and risks surrounding any treatment is fundamental to patients’ decision-making, and this HIV treatment benefit should be no exception.”

Calabrese and Mayer’s testimony points to four studies involving serodiscordant couples (in which one is poz and the other isn’t), all of which have failed to find a single confirmed case of sexual transmission when the HIV-positive partner is on antiretroviral therapy and has a stable undetectable viral load.

Knowing that they cannot transmit HIV while undetectable can be life-changing for many people living with the virus, and publicizing the information about U=U can combat HIV stigma.

“With evidence supporting undetectable equals untransmittable now overwhelming, providers should be routinely communicating the message to all of their patients living with HIV,” Calabrese and Mayer argue.

The U=U consensus has been supported by numerous government agencies and HIV organizations, including the Centers for Disease Control and Prevention, the World Health Organization, and over 750 organizations worldwide. Yet many doctors fail to share the significant findings with patients who are living with HIV.

As reported by NAM’s AIDSMap, an international survey involving more than 1,000 providers found that only 77 percent of infectious disease specialists and 42 percent of primary care physicians pass along the U=U message when telling folks that their viral load is undetectable.

The reasons doctors fail to disclose the information include disbelief in the U=U findings, the perception that promoting the undetectable equals untransmittable message could undermine personal responsibility, and concerns about patients not correctly understanding the findings and therefore engaging in risky behavior while assuming they cannot transmit the virus.

As the authors note, sharing the U=U message has numerous benefits, including encouragement for people to start and adhere to antiretroviral therapy in order to reach and maintain an undetectable viral load; psychosocial advantages such as enabling those living with HIV to have sexual relationships without fear, reducing internalized stigma, and alleviating anxiety about the possibility of transmission; helping to reduce HIV transmission by giving people more reasons to learn their status and start HIV treatment; and accelerating reforms in government policy and the law, especially concerning the criminalization of HIV exposure and nondisclosure (earlier this year, for example, Sanjay Johnson, who had been accused of exposing a sexual partner to HIV, was able to use his undetectable viral load to defend himself in court).

Communities most affected by HIV are often misinformed about the undetectable equals untransmittable consensus. And the authors worry, “Whether consciously or not, providers’ biases about the type of patient whose personal responsibility, behavior, and capacity for understanding is in question might manifest in their decisions about whom to educate about U=U. This presents the opportunity for clinical practices to exacerbate existing HIV disparities.”

Increasing knowledge and understanding of U=U could reduce HIV-related stigma in the broader world, encourage testing and treatment, and lessen anxiety about acquiring HIV. As the authors conclude, “For the U=U message to be withheld from any person living with HIV is inexcusable, particularly in settings where treatment is accessible.”