U=U, PrEP and the unrealised promise of ending HIV-related stigma

There is now widespread consensus that by reducing HIV viral load to undetectable levels, HIV treatment also eliminates the risk of HIV sexual transmission.^1,2 This consensus underpins the global ‘Undetectable equals Untransmissible’ (U=U) campaign which promotes undetectable viral load as an effective HIV prevention strategy. Advocates behind this campaign have been optimistic that increasing awareness of U=U will be accompanied by a decrease in HIV-related stigma, including self-stigma.³

Alongside U=U, HIV pre-exposure prophylaxis (PrEP) has emerged as a highly effective HIV prevention strategy. Similar to U=U, PrEP relies on the use of antiretroviral therapies by those who are HIV-negative. Both PrEP and U=U have ushered in a new era of HIV in which HIV treatment is central to the Australian and global responses to HIV.^4,5

Given this new era of HIV prevention, it could be expected that those not living with HIV, and particularly those using PrEP, might be less anxious about HIV transmission. At the 2022 Australasian HIV&AIDS conference, however, it was reported that people living with HIV continue to experience sexual rejection from their HIV-negative peers, including those using PrEP.⁶ Moreover, a recent Australian survey of people living with HIV found that HIV continues to be a highly stigmatised condition.⁷ In other words, people living with HIV continue to experience stigma in the form of sexual rejection, even in the face of zero HIV transmission risk.

In Australia, the vast majority of people living with HIV are aware of their status, on treatment, and have sustained undetectable viral load.⁸ Given the high numbers of people living with HIV who have a sustained, undetectable viral load, there is more risk of HIV transmission occurring from sex with someone who incorrectly believes themselves to be HIV-negative. Which begs the question: why do some individuals who are not living with HIV trust those who claim to be HIV-negative, an HIV status that is only as true as their previous HIV test? And for those using PrEP, why trust the effectiveness of medications used as PrEP, but not those same medications when used by people living with HIV?

Nearly all of us have experienced sexual rejection before and no individual is obligated to engage in sexual relationships with another. However, when that rejection is based on a perceived, non-existent risk, that rejection is simply discrimination. That is not to say unpacking our anxieties about HIV is easy. For many Australians, HIV continues to conjure up images of the 1987 Grim Reaper awareness campaign and an understanding of HIV as a miserable, fatal condition. While fears of HIV transmission remain grounded in the Grim Reaper years, the science behind HIV treatment and prevention has significantly moved on.

For years, the burden of challenging HIV-related stigma and promoting U=U has fallen on people living with HIV. It is time for those of us who are not living with HIV, especially those using PrEP, to step up and help eliminate HIV stigma. After all, it was people living with HIV who put their bodies on the line, often with debilitating side-effects, that led to the development of the drugs we use as PrEP today. Everyone, regardless of HIV status, deserves a full and healthy sex like, and one key to such empowerment is knowledge. It is high time to leave the Grim Reaper in the past and work together to realise the full potential of U=U.

Data availability

Data sharing is not applicable as no new data were generated or analysed during this study.

Conflicts of interest

The author declare no conflicts of interest.

Declaration of funding

This research did not receive any specific funding.