Updated Australian guidance for health care providers about “undetectable = untransmittable” for HIV

Whether the U = U message is received with scepticism or not, it is clear it is radically challenging the stigma associated with HIV

“Undetectable = untransmittable” (U = U) is a public health campaign that summarises the scientific advances confirming that an undetectable human immunodeficiency virus (HIV) viral load means there is no risk of the sexual transmission of HIV. U = U was launched in 2016, with an international consensus statement from researchers, people with HIV and community partners, to summarise the science around HIV treatment to prevent transmission and improve the lives of people with HIV.1

More than a decade after the controversial Swiss statement2,3 — where the Swiss Federal Commission for AIDS‐related Issues) suggested that individuals with HIV who maintain an undetectable viral load for over 6 months can have unprotected sex without risk of transmission — the science is now clear.

Scientific evidence for U = U

Based on four key studies — HIV Prevention Trials Network (HPTN) 052,4 Opposites Attract5 and the PARTNER 1 and 2 studies6,7 — which looked at how antiretroviral therapy (ART) prevents the sexual transmission of HIV, there was irrefutable evidence that for people who take treatment daily as prescribed and achieve and maintain a durable undetectable viral load (HIV viral load < 200 copies per mL in blood), there is no risk of sexually transmitting the virus to an HIV‐negative partner. The HPTN 052 trial randomly assigned people with HIV who were part of serodiscordant couples to ART at enrolment or to delayed ART when their CD4⁺ T cell count declined below 250 cells/mm³.4 HPTN 052 was conducted in heterosexual couples, but further data were needed in men who have sex with men, for whom the risk of HIV transmission is higher, leading to the observational studies Opposites Attract and PARTNER, which heavily recruited serodiscordant couples of men who have sex with men.5,6,7

Across these studies, 3000 serodiscordant couples were included where the HIV‐positive partner had a viral load below 200 copies per mL5,6,7 or 400 copies per mL4 in blood. With over 6000 couple‐years of follow‐up, there was not a single linked HIV transmission in these couples. Importantly, data from high risk groups included over 90 000 condomless sex acts in men who have sex with men.

Importance of U = U for health care providers

These findings and the term “U = U” are important for health care providers to understand in order to combat HIV stigma and improve the quality of life for people with HIV. U = U is being used by communities around the world to confirm that individuals living with HIV who maintain a durable and undetectable viral load have effectively zero chance of transmitting the virus through sex. But it is not just the message that is important for people living with HIV and their loved ones; there is new evidence that the discussions a health care provider has with their patient regarding U = U can have a profoundly positive impact on a variety of their health outcomes, including sexual, mental and overall physical health.8 Also, while it is gaining traction around the world, it is concerning that a recent study of people with HIV in 25 countries found that upwards of 30% of health care providers have not informed their patients of the message.8

Health care providers are likely the first professionals a newly diagnosed person with HIV will turn to for advice about their new health circumstance. Therefore, it is essential that health care providers are aware of the impact that such a simple message will have on the patients’ health outcomes. Given the understandable fear, concern and anxiety an individual may be experiencing at their point of diagnosis, the message of U = U is crucial for the person’s sense of wellbeing and future expectations, and medical providers must be prepared to integrate this language and knowledge of U = U into their practice.

Updated Australian guidance on U = U

The Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM) has updated their guidance on U = U for health care workers.9 This guidance discusses the implications and real‐world ramifications of U = U and how to approach the discussion with patients in their care. They reinforce that a person with HIV must maintain adherence to treatment with an undetectable viral load to not sexually transmit HIV and also to explore any potential barriers to adherence that would increase the risk of virological failure when receiving ART.

The guidance has five recommendations, which are tailored to the Australian context and include advice to be shared with all patients regarding their sexual health and testing for sexually transmissible infections:

• inform all patients that people who keep their HIV viral load at an undetectable level by consistently taking HIV medications will not pass HIV to others through sex;
• encourage patients newly diagnosed with HIV and those previously diagnosed but not taking ART to immediately start (or restart) treatment;
• provide consistent and clear information about U = U to patients as relevant and appropriate;
• counsel patients to share information about the research on U = U with their sexual partners; and
• health care providers should encourage all sexually active patients and their partners, particularly those who do not use condoms consistently, to get tested regularly for bacterial sexually transmissible infections.

In order to aid the health care practitioner and provide a visual cue to patient and practitioner alike, the guidance includes an easy to read infographic for the health care practitioner to make available for patients and also display in their practice setting. Such resources provide an implicit message that the U = U campaign is supported, which can further stimulate and reinforce patient–provider conversations about this topic.10

Importance of U = U for people living with HIV

The implications of U = U are significant. For decades, living with HIV meant negotiating complex social, legal and health care stigmas, stemming largely from the perception that people with HIV pose a risk to others. This characterisation has persisted since the beginning of the epidemic and has been internalised by some people living with HIV. These stigmas can lead to an increase in depression and mental illness, with Australian data reporting that Australian people living with HIV were over 20% more likely to have reported a mental health condition in their lifetime compared with the general population, which was also highly correlated with poorer quality of life.11

In previous Australian guidance, the message behind U = U was proving difficult for some people to absorb, as it runs contrary to the widely held view that people with HIV are infectious, which propels the stigma associated with HIV.12 However, it is also important to acknowledge that conscious (explicit) and unconscious (implicit) health care provider stigma — that is, social devaluation based on one or more distinguishing characteristics — could be a key reason underlying the lack of consistent U = U patient education.10

In a recent global study surveying people living with HIV across 25 countries about their awareness of U = U, Australia ranked third highest of 25 countries surveyed, with 80% of people with HIV in Australia indicating that they had been told about U = U from their health care provider.8 While this is encouraging, it leads to the question of whether the remaining 20% of providers in Australia have discussed U = U with their patients. While some respondents may have already been aware of U = U and thus not discussed it with their providers, and others may not have recalled this conversation, some providers may face challenges talking about this with their patients. Reasons for this could be a lack of knowledge about U = U, unrecognised stigma on behalf of the health care provider, or doubt about the evidence despite widespread endorsement of U = U by government bodies and HIV management guideline panels.

Whether the U = U message is received with scepticism or not,13 it is clear it is radically challenging the stigma associated with HIV. This will result in a lasting improvement on mental health for people living with HIV who carry the burden or fear that they might infect another person.

Alleviation of HIV transmission‐related anxiety can empower people with HIV to have a greater confidence in their sexual lives, encourage those living with HIV to disclose their status confidently, and serve as an additional incentive to consider starting ART. It also has community‐wide impacts, as it shifts the trepidation of HIV testing to a less fearful position.

Call to action

This updated guidance emphasises that the message behind U = U is positive. This is not about discouraging condom use or responsible sexual behaviour; it is about providing assurance to patients about their sometimes unexpressed fear of infecting others — a key cause of stigma, shame and poor psychological wellbeing.

The science is clear: the meaning of the message behind U = U is that maintaining an undetectable viral load means there is no risk of sexual transmission of HIV to their partners.

There are now zero reasons not to share this life‐altering information with people living with HIV and those at risk of HIV infection.