Undetectable=Untransmittable=Universal Access (U=U=U): transforming a foundational, community-led HIV/AIDS health informational advocacy campaign into a global HIV/AIDS health equity strategy and policy priority
Christian Hui
A *
+ Author Affiliations
- Author Affiliations
A School of Public Policy and Democratic Innovation, Faculty of Arts, Toronto Metropolitan University, Toronto, ON M5B 2K3, Canada.
Sexual Health - https://doi.org/10.1071/SH23068
Submitted: 4 April 2023 Accepted: 14 June 2023 Published online: 11 July 2023
© 2023 The Author(s) (or their employer(s)). Published by CSIRO Publishing. This is an open access article distributed under the Creative Commons Attribution-NonCommercial 4.0 International License (CC BY-NC)
Abstract
Background: Undetectable=Untransmittable (U=U) first emerged in 2016 as a health information campaign to promote rigorous scientific evidence that people living with HIV (PLHIV) on effective treatment who have reached an undetectable or suppressed viral load cannot pass on the virus sexually. Within 7 years, U=U underwent transformation from a global community-led, grassroots movement into a global HIV/AIDS health equity strategy and policy priority.
Methods: For this narrative review, a targeted literature search on ‘history’ + ‘Undetectable=Untransmittable’ and/or ‘U=U’ on Google and Google Scholar, in addition to a search of online documents on the Prevention Access Campaign (PAC) website, was conducted. The article utilises an interdisciplinary policy studies approach that recognises the roles of multi-stakeholder, especially that of the community and civil society, to effect policy change.
Results: The narrative review first provides a synopsis of the scientific origination of U=U. The second section highlights the progress and leadership on U=U led by the PAC and civil society partners and efforts of the PLHIV and ally communities in advocating for the broad recognition and dissemination of the evidence, which has proven to be a game-changer within the HIV/AIDS response. The third section spotlights the recent developments of U=U within the local, national, and multilateral spheres.
Conclusion: The article ends with recommendations for community and HIV/AIDS multi-stakeholders on how they can further integrate, implement, and strategically utilise U=U as an essential and complementary HIV/AIDS pillar to the current Global AIDS Strategy 2021–2026 to end inequalities to end AIDS by 2030.
Keywords: civil society, health equity, health promotion, HIV/AIDS, human rights, living with HIV, policy, undetectable, viral suppression.
References
[1] O’Connor J, Smith C, Lampe FC, Johnson MA, Chadwick DR, et al. Durability of viral suppression with first-line antiretroviral therapy in patients with HIV in the UK: an observational cohort study. Lancet HIV 2017; 4 e295–e302.| Durability of viral suppression with first-line antiretroviral therapy in patients with HIV in the UK: an observational cohort study.Crossref | GoogleScholarGoogle Scholar |
[2] Eisinger RW, Dieffenbach CW, Fauci AS. HIV viral load and transmissibility of HIV infection: undetectable equals untransmittable. JAMA 2019; 321 451–452.
| HIV viral load and transmissibility of HIV infection: undetectable equals untransmittable.Crossref | GoogleScholarGoogle Scholar |
[3] Prevention Access Campaign. The U=U global community. 2023. Available at https://preventionaccess.org/community/
[4] Tran BX, Wong FY, Huy-Pham KT, Latkin CA, Hai-Ha G, et al. Evolution of interdisciplinary landscapes of HIV/AIDS studies from 1983 to 2017: results from the Global Analysis for Policy in Research (GAPRESEARCH). AIDS Rev 2019; 21 184–194.
| Evolution of interdisciplinary landscapes of HIV/AIDS studies from 1983 to 2017: results from the Global Analysis for Policy in Research (GAPRESEARCH).Crossref | GoogleScholarGoogle Scholar |
[5] Montaner JSG, Hogg R, Wood E, Kerr T, Tyndall M, Levy AR, et al. The case for expanding access to highly active antiretroviral therapy to curb the growth of the HIV epidemic. Lancet 2006; 368 531–536.
| The case for expanding access to highly active antiretroviral therapy to curb the growth of the HIV epidemic.Crossref | GoogleScholarGoogle Scholar |
[6] Lima VD, Johnston K, Hogg RS, Levy AR, Harrigan PR, et al. Expanded access to highly active antiretroviral therapy: a potentially powerful strategy to curb the growth of the HIV epidemic. J Infect Dis 2008; 198 59–67.
| Expanded access to highly active antiretroviral therapy: a potentially powerful strategy to curb the growth of the HIV epidemic.Crossref | GoogleScholarGoogle Scholar |
[7] Eaton LA, Kalichman SC. Risk compensation in HIV prevention: implications for vaccines, microbicides, and other biomedical HIV prevention technologies. Curr HIV/AIDS Rep 2007; 4 165–172.
[8] Granich RM, Gilks CF, Dye C, De Cock KM, Williams BG. Universal voluntary HIV testing with immediate antiretroviral therapy as a strategy for elimination of HIV transmission: a mathematical model. Lancet 2009; 373 48–57.
| Universal voluntary HIV testing with immediate antiretroviral therapy as a strategy for elimination of HIV transmission: a mathematical model.Crossref | GoogleScholarGoogle Scholar |
[9] WHO and UNAIDS. The treatment 2.0 framework for action: catalysing the next phase of treatment, care and support. 2012. Available at http://www.who.int/hiv/arv/treatment
[10] Vernazza P, Hirschel B, Bernasconi E, Flepp M. HIV-positive individuals not suffering from any other STD and adhering to an effective antiretroviral treatment do not transmit HIV sexually. Bull Swiss Doctors 2008; 89 165–167.
[11] Kalichman SC, Cherry C, Kalichman MO, Washington C, Grebler T, et al. Sexual behaviors and transmission risks among people living with HIV: beliefs, perceptions, and challenges to using treatments as prevention. Arch Sex Behav 2016; 45 1421–1430.
| Sexual behaviors and transmission risks among people living with HIV: beliefs, perceptions, and challenges to using treatments as prevention.Crossref | GoogleScholarGoogle Scholar |
[12] Vernazza P, Bernard EJ. HIV is not transmitted under fully suppressive therapy: the Swiss statement – eight years later. Swiss Med Wkly 2016; w14246 1–6.
| HIV is not transmitted under fully suppressive therapy: the Swiss statement – eight years later.Crossref | GoogleScholarGoogle Scholar |
[13] Cohen MS, Chen YQ, McCauley M, Gamble T, Hosseinipour MC, Kumarasamy N, et al. Antiretroviral therapy for the prevention of HIV-1 transmission. N Engl J Med 2016; 375 830–839.
| Antiretroviral therapy for the prevention of HIV-1 transmission.Crossref | GoogleScholarGoogle Scholar |
[14] Rodger AJ, Cambiano V, Bruun T, Vernazza P, Collins S, et al. Sexual activity without condoms and risk of HIV transmission in Serodifferent couples when the HIV-positive partner is using suppressive antiretroviral therapy. J Am Med Assoc 2016; 316 171–181.
| Sexual activity without condoms and risk of HIV transmission in Serodifferent couples when the HIV-positive partner is using suppressive antiretroviral therapy.Crossref | GoogleScholarGoogle Scholar |
[15] European AIDS Treatment Group. Position on HIV prevention. 2015. Brussels: European AIDS Treatment Group.
[16] Prevention Access Campaign. Consensus statement. Prevention Access Campaign; 2017. Available at https://www.preventionaccess.org/consensus
[17] Bereczky T. U=U is a blessing: but only for patients with access to HIV treatment: an essay by Tamás Bereczky. BMJ 2019; 366 l5554
| U=U is a blessing: but only for patients with access to HIV treatment: an essay by Tamás Bereczky.Crossref | GoogleScholarGoogle Scholar |
[18] Carter M. Less frequent CD4 and viral load monitoring safe for people doing well on art. HIV Australia 2016; 14 54–55.
[19] Edmiston L. Undetectable=Untransmittable – CATIE signs on. 2017. Available at https://blog.catie.ca/2017/01/13/undetectableuntransmittable-catie-signs-on/
[20] ICASO. Undetectable = Untransmittable, a community brief. 2017. Available at https://icaso.org/undetectable-untransmittable-community-brief/
[21] Hui C, Dhakal M, Shaikh S, Usman M, Penner M, Richman B. Celebrating Successes while Continuing Our Fight for Rights: U=U Campaign and more. 2019; 5 110–15.
[22] Rodger AJ, Cambiano V, Bruun T, Vernazza P, Collins S, et al. Risk of HIV transmission through condomless sex in serodifferent gay couples with the HIV-positive partner taking suppressive antiretroviral therapy (PARTNER): final results of a multicentre, prospective, observational study. Lancet 2019; 393 2428–2438.
| Risk of HIV transmission through condomless sex in serodifferent gay couples with the HIV-positive partner taking suppressive antiretroviral therapy (PARTNER): final results of a multicentre, prospective, observational study.Crossref | GoogleScholarGoogle Scholar |
[23] Bavinton BR, Pinto AN, Phanuphak N, Grinsztejn B, Prestage GP, et al. Viral suppression and HIV transmission in serodiscordant male couples: an international, prospective, observational, cohort study. Lancet HIV 2018; 5 e438–e447.
| Viral suppression and HIV transmission in serodiscordant male couples: an international, prospective, observational, cohort study.Crossref | GoogleScholarGoogle Scholar |
[24] The Hon Jill Hennessy MP. Eliminating stigma in HIV treatment. 2017. Available at https://58b1608b-fe15-46bb-818a-cd15168c0910.filesusr.com/ugd/de0404_931a4c322f8a4a709a581c5851a71c57.pdf
[25] Victoria State Government. HIV and AIDS. 2021. Available at https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/hiv-and-aids/
[26] VIC Health. Victorian HIV Plan 2022-30. 2023. Available at https://www.health.vic.gov.au/publications/victorian-hiv-plan-2022-30
[27] ASHM. U=U guidance for health professionals. 2020. Available at https://ashm.org.au/wp-content/uploads/2022/04/Resource_ASHMuuguidancehandbookFAweb.pdf
[28] NYC Health. The New York City HIV status neutral prevention and treatment cycle. 2016. Available at http://www1.nyc.gov/site/doh/health/health-topics/hiv-status-neutral-prevention-and-treatment-cycle.page
[29] Government of the District of Columbia Muriel Bowser, Mayor. Mayor Bowser highlights administration efforts to prevent new cases of HIV. 2017. Available at https://mayor.dc.gov/release/mayor-bowser-highlights-administration-efforts-prevent-new-cases-hiv
[30] Josh R. #UequalsU Hits Washington D.C. @DCtakesonHIV. 2020. Available at https://imstilljosh.com/uequalsu-dctakesonhiv/
[31] Centers for Disease Control and Prevention. The journey to undetectable. 2023. Available at https://www.cdc.gov/hiv/pdf/risk/art/The-Journey-to-Undetectable-Brochure.pdf
[32] Centers for Disease Control and Prevention. HIV treatment works. 2020. Available at https://www.cdc.gov/stophivtogether/partnerships/toolkit/fall-2022-toolkit.html
[33] National Institutes of Health. HIV Undetectable=Untransmittable (U=U), or treatment as prevention. 2019. Available at https://www.niaid.nih.gov/diseases-conditions/treatment-prevention
[34] National Institutes of Health. For HIV, treatment is prevention. 2019. Available at https://directorsblog.nih.gov/2019/01/22/for-hiv-treatment-is-prevention/
[35] National Institutes of Health. 10 things to know about HIV suppression. 2020. Available at https://www.niaid.nih.gov/diseases-conditions/10-things-know-about-hiv-suppression
[36] Indian Health Services. Treatment as Prevention Undetectable=Untransmittable (U=U). Available at https://www.ihs.gov/hivaids/clinicalinfo/treatment/
[37] Rodgers K. NASTAD creates Undetectable = Untransmittable health department engagement map. 2019. Available at https://www.naccho.org/blog/articles/nastad-creates-undetectable-untransmittable-health-department-engagement-map
[38] National Coalition of STDs Directors. Supporting U=U & sexual health. 2019. Available at https://www.ncsddc.org/supporting-uu-sexual-health/
[39] Public Health Agency of Canada. Remarks for Ginette Petitpas Taylor, Minister of Health – AIDS 2018 Conference Symposia “Anti-fragile: Strengthening the HIV Response through Addressing Stigma, Prejudice and Discrimination”. Public Health Agency of Canada; 2018. Available at https://www.canada.ca/en/public-health/news/2018/07/remarks-for-ginette-petitpas-taylor-minister-of-health---aids-2018-conference-symposiaanti-fragile-strengthening-the-hiv-response-through-addressin.html
[40] Prevention Access Campaign. UequalsU. Canadian Government Health Officials Re-Affirm Commitment to U=U (2022). 2022. Available at https://www.youtube.com/watch?v=TmZxOzbDqRE
[41] Prevention Access Campaign. Multinational Undetectable = Untransmittable (U=U) call-to-action. 2022. Available at https://preventionaccess.org/c2a/
[42] US Embassy and Consulate in Vietnam. United States and Vietnam Launch National Undetectable equals Untransmittable (U=U) or Không phát hiện bằng Không lây truyền (K=K) Campaign. 2019. Available at https://vn.usembassy.gov/pr10222019-us-and-vietnam-launch-national-undetectable-equals-untransmittable-uu-or-khong-phat-hien-bang-khong-lay-truyen-kk-campaign/
[43] Viet Nam News. Toolkit released to combat HIV-related stigma and discrimination. 2018. Available at https://vietnamnews.vn/society/481025/toolkit-released-to-combat-hiv-related-stigma-and-discrimination.html#wKyFdB4OuxLjlVWv.97
[44] Prevention Access Campaign. UequalsU. LIVE LOVE K=K IN VIETNAM – Model National U=U Program. 2022. Available at https://www.youtube.com/watch?v=1DN0HPF16xs
[45] Public Health England. Towards elimination of HIV transmission, AIDS and HIV related deaths in the UK. 2017. Available at https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/675809/Towards_elimination_of_HIV_transmission_AIDS_and_HIV_related_deaths_in_the_UK.pdf
[46] Government of Nepal. National consolidated guidelines on strategic information of HIV response in Nepal 2022-2026. 2022. Available at http://www.ncasc.gov.np/uploaded/publication/NHSP-2021-2026/NHSP-2021-2026-English.pdf
[47] Hall O. The PM gets serious. 2018. Available at https://gayexpress.co.nz/2018/04/pm-gets-serious/
[48] Prevention Access Campaign. U=U campaign launched in Zambia’s Western Province, an Initiative towards elimination of HIV transmission. 2019. Available at https://preventionaccess.org/uu-campaign-launched-in-zambias-western-province-an-initiative-towards-elimination-of-hiv-transmission
[49] Bonsu PA. HIV/AIDS prevention; PEPAR takes U=U and anti-stigmatization campaign to senior high schools in Kumasi. 2022. Available at https://www.myjoyonline.com/hiv-aids-prevention-pepfar-takes-uu-and-anti-stigmatization-campaign-to-senior-high-schools-in-kumasi/
[50] UNAIDS. Feature story: Eastern Cape becomes the first South Africa province to campaign on U = U. 2022. Available at https://www.unaids.org/en/resources/presscentre/featurestories/2022/march/20220321_eastern-cape-u-u
[51] HIV.gov. What is PEPFAR?. 2023. Available at https://www.hiv.gov/federal-response/pepfar-global-aids/pepfar#:~:text=What%20is%20PEPFAR%3F,through%20the%20American%20people’s%20generosity
[52] State Department Washington, D.C., U.S.A. PEPAR 2019 country operational guidance for all PEPFAR countries. 2019. Available at https://www.state.gov/wp-content/uploads/2019/08/PEPFAR-Fiscal-Year-2019-Country-Operational-Plan-Guidance.pdf
[53] State Department Washington, D.C., U.S.A. PEPAR 2020 country operational guidance for all PEPFAR countries. 2020. Available at https://www.state.gov/wp-content/uploads/2020/01/COP20-Guidance_Final-1-15-2020.pdf
[54] State Department Washington, D.C., U.S.A. PEPAR 2021 Country and Regional Operational (COP/ROP) Guidance for all PEPFAR Countries. 2021. Available at https://www.state.gov/wp-content/uploads/2020/12/PEPFAR-COP21-Guidance-Final.pdf
[55] UNAIDS. UNAIDS Explainer. Undetectable=Untransmittable – public health and HIV viral load suppression. 2018. Available at https://www.unaids.org/sites/default/files/media_asset/undetectable-untransmittable_en.pdf
[56] United Nations General Assembly. Political declaration on HIV and AIDS: ending inequalities and getting back on track to end AIDS by 2030. 2021. Available at https://www.unaids.org/sites/default/files/media_asset/2021_political-declaration-on-hiv-and-aids_en.pdf
[57] UNAIDS. Agenda item 1.4: report by the NGO representative: Undetectable=Untransmittable=Universal Access (U=U=U): a foundational, community-led global HIV/AIDS health equity strategy. 2022. Available at https://www.unaids.org/en/resources/documents/2022/PCB51_Report_NGO_Representative
[58] UNAIDS. Decisions – 51st meeting of the hybrid UNAIDS Programme Coordinating Board. 2022. Available at https://www.unaids.org/en/resources/documents/2022/PCB51_Decisions
[59] Rendina HJ, Talan AJ, Cienfuegos-Szalay J, Carter JA, Shalhav O. Treatment is more than prevention: perceived personal and social benefits of Undetectable = Untransmittable messaging among sexual minority men living with HIV. AIDS Patient Care STDS 2020; 34 444–451.
| Treatment is more than prevention: perceived personal and social benefits of Undetectable = Untransmittable messaging among sexual minority men living with HIV.Crossref | GoogleScholarGoogle Scholar |
[60] Rivera AV, Carrillo SA, Braunstein SL. Prevalence of U = U awareness and its association with anticipated HIV stigma among low-income heterosexually active Black and Latino adults in New York City, 2019. AIDS Patient Care STDS 2021; 35 370–376.
| Prevalence of U = U awareness and its association with anticipated HIV stigma among low-income heterosexually active Black and Latino adults in New York City, 2019.Crossref | GoogleScholarGoogle Scholar |
[61] Okoli C, Van de Velde N, Richman B, Allan B, Castellanos E, Young B, Brough G, Eremin A, Corbelli GM, Mc Britton M, Hardy WD, de los Rios P. Undetectable equals untransmittable (U = U): awareness and associations with health outcomes among people living with HIV in 25 countries. Sex Transm Infect 2021; 97 18–26.
| Undetectable equals untransmittable (U = U): awareness and associations with health outcomes among people living with HIV in 25 countries.Crossref | GoogleScholarGoogle Scholar |
[62] Huebenthal J. Un/detectability in times of “equality”: HIV, queer health, and homonormativity. Eur J Am Stud 2017; 11 1–23.
| Un/detectability in times of “equality”: HIV, queer health, and homonormativity.Crossref | GoogleScholarGoogle Scholar |
[63] Ackerly B. Human rights enjoyment in theory and activism. Hum Rights Rev 2011; 12 221–239.
| Human rights enjoyment in theory and activism.Crossref | GoogleScholarGoogle Scholar |
[64] UNAIDS. Global AIDS strategy 2021-2026 end inequalities, end AIDS. 2021. Available at https://www.unaids.org/en/Global-AIDS-Strategy-2021-2026
[65] Predmore Z, Doby B, Bozzi DG, Durand C, Segev D, Sugarman J, Tobian AAR, Wu AW. Barriers experienced by organ procurement organizations in implementing the HOPE act and HIV-positive organ donation. AIDS Care 2022; 34 1144–1150.
| Barriers experienced by organ procurement organizations in implementing the HOPE act and HIV-positive organ donation.Crossref | GoogleScholarGoogle Scholar |
[66] Robins S. From “rights” to “ritual”: AIDS activism in South Africa. Am Anthropol 2006; 108 312–323.
| From “rights” to “ritual”: AIDS activism in South Africa.Crossref | GoogleScholarGoogle Scholar |
