Let’s talk about U=U: seizing a valuable opportunity to better support adolescents living with HIV
Sarah Bernays
A B * , Joni Lariat A , Wole Ameyan C and Nicola Willis D
+ Author Affiliations
- Author Affiliations
A School of Public Health, Edward Ford Building, Fisher Road, University of Sydney, Camperdown, NSW 2006, Australia.
B Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 15–17 Tavistock Place, London WC1H9H, UK.
C Global HIV, Hepatitis and Sexually Transmitted Infections Programmes, World Health Organization, 20 Avenue Appia, Geneva 1211, Switzerland.
D Zvandiri, Zvandiri House Headquarters, 11–12 Stoneridge Way North, Avondale, Harare, Zimbabwe.
Sexual Health - https://doi.org/10.1071/SH23049
Submitted: 8 March 2023 Accepted: 2 June 2023 Published online: 29 June 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-NoDerivatives 4.0 International License (CC BY-NC-ND)
Abstract
The clinical knowledge that people living with HIV who maintain an undetectable viral load and therefore cannot transmit HIV sexually, known as Undetectable equals Untransmittable (U=U), has reached a critical mass of adults, but it is relatively silenced within adolescent HIV care and support. We argue that understanding the full range of opportunities enabled by viral suppression, including the elimination of transmission risk, could transform adolescents’ understanding of living with HIV, incentivise optimal treatment engagement and support and sustain their positive mental health. However, the reluctance to discuss U=U with adolescents means that we are not providing them with adequate access to the information and tools that would help them to succeed. We need to recognise, value, and invest in the mediating role of building viral load literacy, illustrated by conveying U=U in ways that are meaningful for adolescents, to accelerate viral suppression. Rather than protect, rationing access to information on U=U only increases their vulnerability and risk to poor HIV and mental health outcomes.
Keywords: Africa, community interventions, HIV/AIDS, HIV literacy, living with HIV, mental health, wellbeing, youth.
References
[1] World Health Organzation. Viral suppression for HIV treatment success and prevention of sexual transmission of HIV. Geneva: World Health Organzation; 2018.[2] UNAIDS. Undetectable = untransmittable: public health and HIV viral load suppression. Geneva: Joint United Nations Programme on HIV/AIDS (UNAIDS); 2018.
[3] Bernays S, Bourne A, Kippax S, Aggleton P, Parker R. Remaking HIV prevention: the promise of TasP, U=U and PrEP. In: Bernays S, Bourne A, Kippax S, Aggleton P, Parker R, editors. Remaking HIV prevention in the 21st century: the promise of TasP, U=U and PrEP. Social aspects of HIV. Cham: Springer Nature Switzerland; 2021. pp. 1–18.
[4] Cohen MS. Successful treatment of HIV eliminates sexual transmission. Lancet 2019; 393 2366–7.
| Successful treatment of HIV eliminates sexual transmission.Crossref | GoogleScholarGoogle Scholar |
[5] Prevention Access Campaign. Risk of sexual transmission of HIV from a person living with HIV who has an undetectable viral load: messaging primer and consensus statement. Prevention Access Campaign; 2016.
[6] World Health Organization. Consolidated guidelines on HIV prevention, testing, treatment, service delivery and monitoring: recommendations for a public health approach. Geneva: World Health Organization; 2021.
[7] Remien RH, Stirratt MJ, Nguyen N, Robbins RN, Pala AN, Mellins CA. Mental health and HIV/AIDS: the need for an integrated response. AIDS 2019; 33 1411–20.
| Mental health and HIV/AIDS: the need for an integrated response.Crossref | GoogleScholarGoogle Scholar |
[8] UNAIDS. Integration of mental health and HIV interventions: key considerations. Geneva: Joint United Nations Programme on HIV/AIDS and the World Health Organization; 2022.
[9] Vreeman RC, McCoy BM, Lee S. Mental health challenges among adolescents living with HIV. J Int AIDS Soc 2017; 20 21497
| Mental health challenges among adolescents living with HIV.Crossref | GoogleScholarGoogle Scholar |
[10] 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; 34 444–51.
| Treatment is more than prevention: perceived personal and social benefits of undetectable = untransmittable messaging among sexual minority men living with HIV.Crossref | GoogleScholarGoogle Scholar |
[11] Smith P, Buttenheim A, Schmucker L, Bekker L-G, Thirumurthy H, Davey DLJ. Undetectable = untransmittable (U = U) messaging increases uptake of HIV testing among men: results from a pilot cluster randomized trial. AIDS Behav 2021; 25 3128–36.
| Undetectable = untransmittable (U = U) messaging increases uptake of HIV testing among men: results from a pilot cluster randomized trial.Crossref | GoogleScholarGoogle Scholar |
[12] Smith PJ, Joseph Davey DL, Schmucker L, Bruns C, Bekker L-G, Medina-Marino A, et al. Participatory prototyping of a tailored undetectable equals untransmittable message to increase HIV testing among men in Western Cape, South Africa. AIDS Patient Care STDS 2021; 35 428–34.
| Participatory prototyping of a tailored undetectable equals untransmittable message to increase HIV testing among men in Western Cape, South Africa.Crossref | GoogleScholarGoogle Scholar |
[13] Calabrese SK, Mayer KH, Marcus JL. Prioritising pleasure and correcting misinformation in the era of U=U. Lancet HIV 2021; 8 e175–e80.
| Prioritising pleasure and correcting misinformation in the era of U=U.Crossref | GoogleScholarGoogle Scholar |
[14] Agaku I, Nkosi L, Gwar JN, Tsafa T. A cross-sectional analysis of U=U as a potential educative Intervention to mitigate HIV stigma among youth living with HIV in South Africa. Pan Afr Med J 2022; 41 248
| A cross-sectional analysis of U=U as a potential educative Intervention to mitigate HIV stigma among youth living with HIV in South Africa.Crossref | GoogleScholarGoogle Scholar |
[15] Bor J, Fischer C, Modi M, Richman B, Kinker C, King R, et al. Changing knowledge and attitudes towards HIV treatment-as-prevention and “undetectable = untransmittable”: a systematic review. AIDS Behav 2021; 25 4209–4224.
| Changing knowledge and attitudes towards HIV treatment-as-prevention and “undetectable = untransmittable”: a systematic review.Crossref | GoogleScholarGoogle Scholar |
[16] Coyne R, Noone C. Investigating the effect of undetectable = untransmittable message frames on HIV stigma: an online experiment. AIDS Care 2022; 34 55–59.
| Investigating the effect of undetectable = untransmittable message frames on HIV stigma: an online experiment.Crossref | GoogleScholarGoogle Scholar |
[17] Ford OG, Rufurwadzo TG, Richman B, Green I, Alesi J. Adopting U = U to end stigma and discrimination. J Int AIDS Soc 2022; 25 e25891
| Adopting U = U to end stigma and discrimination.Crossref | GoogleScholarGoogle Scholar |
[18] 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 |
[19] Calabrese SK, Mayer KH. Stigma impedes HIV prevention by stifling patient-provider communication about U = U. J Int AIDS Soc 2020; 23 e25559
| Stigma impedes HIV prevention by stifling patient-provider communication about U = U.Crossref | GoogleScholarGoogle Scholar |
[20] Calabrese SK, Mayer KH. Providers should discuss U=U with all patients living with HIV. Lancet HIV 2019; 6 e211–e3.
| Providers should discuss U=U with all patients living with HIV.Crossref | GoogleScholarGoogle Scholar |
[21] Grace D, Stewart M, Blaque E, Ryu H, Anand P, Gaspar M, et al. Challenges to communicating the undetectable equals untransmittable (U=U) HIV prevention message: healthcare provider perspectives. PLoS ONE 2022; 17 e0271607
| Challenges to communicating the undetectable equals untransmittable (U=U) HIV prevention message: healthcare provider perspectives.Crossref | GoogleScholarGoogle Scholar |
[22] Ammon N, Mason S, Corkery JM. Factors impacting antiretroviral therapy adherence among human immunodeficiency virus–positive adolescents in Sub-Saharan Africa: a systematic review. Public Health 2018; 157 20–31.
| Factors impacting antiretroviral therapy adherence among human immunodeficiency virus–positive adolescents in Sub-Saharan Africa: a systematic review.Crossref | GoogleScholarGoogle Scholar |
[23] Bernays S, Paparini S, Seeley J, Rhodes T. “Not taking it will just be like a sin”: young people living with HIV and the stigmatization of less-than-perfect adherence to antiretroviral therapy. Med Anthropol 2017; 36 485–499.
| “Not taking it will just be like a sin”: young people living with HIV and the stigmatization of less-than-perfect adherence to antiretroviral therapy.Crossref | GoogleScholarGoogle Scholar |
[24] Bernays S, Seeley J, Rhodes T, Mupambireyi Z. What am I ‘living’ with? Growing up with HIV in Uganda and Zimbabwe. Socil Health Illn 2015; 37 270–283.
| What am I ‘living’ with? Growing up with HIV in Uganda and Zimbabwe.Crossref | GoogleScholarGoogle Scholar |
[25] MacCarthy S, Saya U, Samba C, Birungi J, Okoboi S, Linnemayr S. “How am I going to live?”: exploring barriers to ART adherence among adolescents and young adults living with HIV in Uganda. BMC Public Health 2018; 18 1158
| “How am I going to live?”: exploring barriers to ART adherence among adolescents and young adults living with HIV in Uganda.Crossref | GoogleScholarGoogle Scholar |
[26] World Health Organization. WHO guidelines 2021: the importance of psychosocial support in HIV treatment and care for adolescents. 4:47 edn. World Health Organization; 2021.
[27] Zvandiri Africaid. Adolescent voices on the role of psychosocial support in HIV care. 2:38 edn. Zvandiri Africaid; 2020.
[28] Bernays S, Willis N, Batchelor A. A consultation to explore the values and preferences of adolescents and young people living with HIV (10-24 years) on the impact of psychosocial interventions in improving HIV outcomes as well as other service delivery questions to support the WHO consolidated guidelines process: study report. Zvandiri Africaid The University of Sydney; 2020.
[29] Macleod CI. ‘Adolescent’ sexual and reproductive health: controversies, rights, and justice. In: Cherry AL, Baltag V, Dillon ME, editors. International handbook on adolescent health and development. Cham: Springer Link; 2017. pp. 169–81.
[30] Ross DA, Hinton R, Melles-Brewer M, Engel D, Zeck W, Fagan L, et al. Adolescent well-being: a definition and conceptual framework. J Adolesc Health 2020; 67 472–6.
[31] Zvandiri. Not just a number: understanding your viral load. 3:38 edn. Harare: Zvandiri Africaid; 2021. Available at https://www.youtube.com/watch?v=AG9gs2GFmkw&ab_channel=Zvandiri
[32] Zvandiri. Taking charge of HIV: the journey to undetectable. 4:02 edn. Harare: Zvandiri Africaid; 2021. Available at https://www.youtube.com/watch?v=jJty0y8S0Xg&ab_channel=Zvandiri
