Agreement of and discussion with clients about Undetectable equals Untransmissible among general practitioners in Australia: a cross-sectional survey

Introduction

The concept that an undetectable viral load equals untransmissible HIV infection (U=U) is supported by robust evidence from several large studies. The PARTNER1 study¹ involved 548 men who have sex with men (MSM) and heterosexual HIV serodiscordant couples who reported 58 000 condomless sexual acts with no phylogenetically linked transmission of HIV. This was followed up by the PARTNER2 study,² which had a sample of 782 MSM serodiscordant couples who reported 76 088 condomless sexual acts with no phylogenetically linked transmission. The OPPOSITES attract study³ provided further evidence, with 343 MSM couples who reported 16 800 condomless sexual acts with no linked HIV transmission. This is clear evidence that U=U, and this messaging of 100% efficacy should not be replaced with doubt-provoking comments such as ‘next to zero’ or ‘extremely low’ risk.⁴ These studies were completed in 2016 and 2018; however, there has still been no documented case of phylogenetically linked transmission of a person with undetectable viral load to a HIV-negative partner.

U=U has the potential to improve several health outcomes for clients living with HIV. A study from 25 countries⁵ showed that 718 people living with HIV who had discussed U=U with their healthcare provider were less likely to have suboptimal adherence to medications (adjusted odds ratios (AOR) = 0.59, 95% CI: 0.44–0.78), have self-reported optimal sexual health (AOR = 1.48, 95% CI: 1.14–1.92), and more likely to disclose their HIV status with other people in their life (AOR = 2.06, CI 1.50–2.84). This was compared to clients living with HIV who were completely unaware of U=U. There was a greater chance of suboptimal medication adherence when clients obtained U=U information from sources other than a healthcare provider compared to receiving information from a healthcare provider (AOR = 0.94, CI: 0.68–1.30, compared to 0.59).

Qualitative and quantitative studies have assessed healthcare providers giving information about U=U. Healthcare providers are in a prime position to inform clients about U=U and to provide reassurance of its validity. Okoli et al.⁵ found that approximately 34% of people living with HIV (PLHIV) have never had a U=U discussion with their healthcare providers. This study involved 25 countries (N = 2389), with 120 (5%) respondents from Australia. A study from Brazil identified that 74% of healthcare providers agreed with U=U; however, only 66% strongly agreed or agreed that PLHIV should be informed about U=U.⁶ Studies have reported barriers to communicating U=U from the healthcare providers’ perspective. A UK study⁷ identified the following barriers: hesitation with communicating zero transmission risk of HIV; and perceptions that clients may not want to hear this message. A study from Kenya⁸ also reported some healthcare providers were fearful that clients would blame them if HIV transmission were to occur. A Korean study⁹ described health providers taking a paternalistic approach and withholding U=U discussions through fear of clients taking legal action against them for transmission of HIV to others, which is unethical as it goes against the four key principles of medical ethics: respect for client’s autonomy, non-maleficence, beneficence, and justice. There are no Australian studies examining health professionals’ agreement with and discussion of U=U.

In Australia, general practitioners (GPs) can prescribe PrEP, but cannot prescribe HIV medications unless they undergo additional training to obtain accreditation as an S100 prescriber. GPs would be the most ideally placed to provide the U=U message to the key populations (clients living with HIV and partners of people with HIV), as most Australians visit a GP (84%) compared to all other medical specialities (39%).¹⁰ We conducted this study to understand what proportion of GPs in Australia was aware of and agreed with U=U and how many were discussing this with their clients. We also aimed to identify the barriers to discussing U=U to inform continuing medical education training curricula to address these barriers.

Methods

Results

We received 703 survey responses, but 296 were excluded if they only had a few questions answered, were non-sensical, and/or were completed in countries outside of Australia. In 2021–2022, there were 39 259 GPs working in Australia.¹¹

We summarised the sociodemographic characteristics of the 407 study participants included in the analysis (Table 1). The median age of the participants was 38 years, with an interquartile range (IQR) of 33–44. The median number of years of practising as a GP was six, with an IQR of 4–12.

The majority (74%, 302/407) of GPs strongly agreed or agreed with U=U (33.7% strongly agreed, 40.5% agreed); however, only 33.9% (138/407) had ever discussed U=U with their clients. Fig. 1 demonstrates that the majority (70.8%, 97/137) of those who strongly agreed with U=U had ever discussed U=U with their clients; however, only a minority (17.6%, 29/165) of those who agreed with U=U had ever discussed U=U with their clients.

Fig. 1. 

Number and proportion of Australian GPs who agreed with U=U and whether they had ever discussed U=U with their clients.

Discussion

This online survey among 407 Australian GPs demonstrated that although a majority agreed with U=U, only a minority had discussed U=U with clients. We add to the growing literature on promoting U=U, specifically among healthcare providers. Our study highlights the current gaps in Australian GPs’ attitudes and practice regarding U=U, providing helpful data to inform further education to improve the dissemination of the U=U message.

Our study found that only 34% of Australian GPs had ever discussed U=U with their clients. We could not identify any other study examining the proportion of doctors who discussed U=U with their clients. There was a UK study⁵ that reported 34% of clients living with HIV had discussed U=U with their healthcare provider, although this is not directly comparable as it involved the client perspective rather than the healthcare provider perspective. The main barriers to having the U=U conversation in our study related to the perceived lack of exposure to clients living with HIV and a lack of understanding of U=U. It is possible that GPs have a narrow view of which client groups would be suitable for a U=U conversation. For the U=U message to be the most effective, it should be shared with all clients; however, this may not be practical in a busy GP setting. So, at the minimum, it should be shared with all clients living with HIV and clients with a partner living with HIV. A public health campaign reducing stigma would be helpful to encourage more clients to disclose their HIV status with a GP. Clinics could place posters with inclusive language and positive messages regarding HIV to help encourage clients to initiate these discussions.

The other significant health communication barrier was a lack of understanding of U=U. Our study identified 26% of GPs were neutral towards or disagreed with U=U. Nunes et al.⁶ reported a similar result of 26% of health professionals in Brazil being neutral or disagreeing with U=U. The messages from doctors regarding HIV have been about using condoms since the 1980s, and this is entrenched, so it is difficult for GPs, especially with no training on the most updated science of HIV transmission, to believe in the accuracy of U=U. We found that agreement with U=U resulted in a doctor being 5.3-fold more likely to discuss U=U, so there is a need for better education and promotion of the U=U message to doctors for more GPs to discuss U=U with their clients. Our study also reported that two-thirds of respondents could not identify resources to learn about U=U. Together, this evidence suggests an urgent need for further training on U=U for all Australian GPs.

Interestingly, some GPs who disagreed with U=U still discussed this HIV prevention message. A possible reason might be due to them having some belief in U=U, but not 100% belief, as it is difficult in medicine to advise a client there is a ‘100% guarantee’ that something will happen. This was described by Grace et al.⁷: health providers describing U=U as ‘99% effective’ rather than 100%, and by Ngure et al.⁸ where providers used terms such as a ‘very low’ and ‘minimal’ chance of transmitting HIV. This indicates the need for training about U=U to involve presenting the data and evidence on U=U; for example, 76 088 sexual acts, with zero of these resulting in HIV transmission.² As described by a practitioner in the study by Grace et al.,⁷ ‘we never talk about anything as ‘zero risk’ (in medicine)’,there needs to be an emphasis in training about how to be confident in advising that undetectable equals zero risk of transmission. As mentioned in the ASHM U=U guidance, there are risks with using terms such as ‘extremely low’ and ‘negligible’.¹²

For GPs who discussed U=U, the main reason they brought up the topic was that the GP was already talking about sexual health at the time (26%). It is useful for GPs to initiate discussions about sexual health with clients so it can permit the clients to bring it up. Historically, GPs have found it challenging to start conversations about sexual health with clients and/or take a sexual history: one study¹³ found 39% of GPs thought their clients would be very embarrassed if they were to take a sexual history. Further training should be provided on how to bring up and continue a sexual health history within a GP consult. One of the most effective ways to increase the uptake of an intervention in a GP practice is to provide a medicare item number.¹⁴ There should be a specific Medicare item for U=U discussions or more detailed sexual health discussions in general.

The strength of this study was it involved GPs working in a range of settings (metropolitan, regional and rural) and from different states and territories within Australia. Our study should be read in light of some limitations. First, we only included GPs, but there could be a benefit in future studies to include other medical specialties. Second, there could be a potential for recall or social desirability bias, although we mitigated this by the survey being anonymous. Third, this was a cross-sectional study, so we cannot infer causality. Fourth, the sample may not be representative of all GPs in Australia as it is likely that participants who had some interest in the topic of sexual health were more likely to participate and, therefore, more likely to be aware of U=U. The results may be biased by a female predominance as 70.5% of the participants were female, whereas for 2021–2022, there were 20 168 male GPs and 19 083 female GPs. This makes for a ratio of about 1.06–1.¹¹ Future studies planned include a qualitative study to understand better how and why GPs communicate about U=U in a methodology similar to that presented by Grace et al.⁷ Our study identified that GPs with extra HIV training, S100 prescribers, were more likely to discuss U=U (AOR 4.35, 95%CI: 2.24–8.44); however, applying this same survey to more HIV medicine experts in Australia would be useful as a comparison. There is also a need for a study to look at what messages clients are actually receiving from services, and their understanding and use of these messages. This will help provide a better picture of U=U communication in Australia.

Conclusion

Most GPs agreed with U=U (74%), but had not discussed U=U with their clients. Concerningly, one in four GPs were neutral or disagreed with U=U, suggesting that further qualitative research to understand this finding and implementation research to promote U=U among Australian GPs is urgently needed. Detailed training on U=U is crucial to address the barriers identified by GPs: lack of ability to identify relevant client groups and lack of understanding of U=U. The most effective way to increase the proportion of GPs discussing U=U might be to increase their confidence in the evidence of U=U.

Supplementary material

Supplementary material is available online.

Data availability

The data that support this study are available in the article and accompanying online supplementary material.

Conflicts of interest

Jason Ong is the Editor-In-Chief and Eric Chow is a Joint Editor of Sexual Health. They were both blinded from the peer review process for this paper. There are no other competing interests.

Declaration of funding

DG is supported by a Canada Research Chair in Sexual and Gender Minority Health. EPFC and JJO are each supported by an NHMRC Emerging Leadership Investigator Grant (GNT1172873 and GNT1193955, respectively). CKF is supported by an Australian NHMRC Leadership Investigator Grant (GNT1172900).