Last September, on National Gay Men's HIV/AIDS Awareness Day, the Center for Disease Control (CDC) declared that men with HIV who have an undetectable viral load—levels of HIV in the blood that are below the threshold of detection—are unable to transmit HIV to their partners. This is often summarized with the phrase Undetectable = Untransmittable or U = U.
The CDC came to this conclusion after evaluating three studies that included thousands of couples engaging in unprotected sexual acts in which one partner was HIV-positive with an undetectable viral load, and the other was HIV-negative and not on pre-exposure prophylaxis (PrEP).
“No HIV transmissions to an HIV-negative partner were observed when the HIV-positive person was virally suppressed,” the CDC reported.
When levels are this low, the virus is so suppressed that it’s impossible to pass on the virus to a partner sexually. Consequently, HIV treatment is now being used as a form of prevention, commonly referred to a TasP (Treatment as Prevention).
It’s been over 30 years since the inception of the virus, and still, there is so much shaming and stigma surrounding people living with HIV. This in large part due to misinformation and fear of contracting the virus. That’s what led Drs. Jonathon Rendina and Jeffrey Parsons of Hunter College to explore whether gay, bisexual, and other men who have sex with men actually believe that undetectable = untransmittable.
After the AIDS epidemic there was “a sense that nobody could be trusted that had negative effects on guys with and without HIV,” Dr. Rendina tells Newnownext.
“TasP, along with other forms of biomedical prevention,” Rendina continues, “has the power to help to eliminate HIV stigma, enhance the freedom of sexual expression, and start to undo the damage caused by having to treat every sexual or romantic partner as a potential threat.”
As Dr. Rendina implies, HIV stigma in the gay community doesn’t only affect the quality of life for men living with the virus, it also affects the larger gay community. It behooves everyone in the gay community regardless of status to believe that undetectable = untransmittable.
Dr. Rendina’s study, titled “Factors associated with perceived accuracy of the Undetectable = Untransmittable slogan among men who have sex with men: Implications for messaging scale-up and implementation,” was published in the Journal of The International AIDS Society.
The study recruited men who have sex with men (MSM) through a sexual networking app geared to gay/bisexual men. Participants needed to be of 18 years of age, live in the United States, had sex with at least one man in the past year and identify as male (either cisgender or transgender). After excluding those who didn’t meet the requirements, a total of 12,222 participants’ answers were analyzed.
Participants were asked to provide various sociodemographic characteristics including age, education, race, sexual orientation, and level out “outness.” They were also asked about drug use, the frequency with which they have condomless anal sex (CAS) with multiple partners, and how concerned they were about acquiring an STI other than HIV.
Lastly, they were asked to report their HIV status. If positive, men were asked about their viral load levels; if negative, men were asked if on PrEP. Then they answered the question, “With regard to HIV-positive individuals transmitting HIV through sexual contact, how accurate do you believe the slogan Undetectable = Untransmittable is?”
There were four possible answers: completely accurate, somewhat accurate, somewhat inaccurate, and completely inaccurate.
Only one third of men who were negative (or unaware of their status) believed that the statement is somewhat or completely accurate compared to 70% of HIV-positive men.
HIV-negative men were more likely to believe the statement as accurate if they were on PrEP, got tested for HIV at least every 6 months, and if they reported more CAS with HIV-positive men. Interestingly, men who identified as “gay” or “queer” were more likely to believe the statement as accurate than men who identified as “bisexual” or “straight.”
Regardless of status, those who reported higher concerns for contracting STIs other than HIV were more likely to believe the statement as inaccurate.
It’s of particular note than nearly a third of men who were HIV-positive didn’t believe that U = U. The positive men who did not believe the statement was accurate were less likely to have an undetectable viral load.
Rendina notes that it will be challenging work to convince MSM that U = U, largely because HIV activists and scientists spent decades hammering home the necessity of wearing a condom in order to prevent HIV transmission.
“We pushed that message hard,” he says, “And people were regularly told that even if someone was undetectable in their blood, they may still have detectable levels of virus in their semen—not surprisingly, people picked up this message and are now a bit skeptical that we are telling them this isn’t true anymore.”
Nevertheless, it’s the nature of science to develop over time, “But I think we need to do a better job communicating to people why our HIV prevention messages focused only on condoms for a long time, how our knowledge about undetectable viral load and transmission risk has changed, and what this means for their own sex lives.”
The good news is that researchers are already seeing more MSM believe in the accuracy of U = U. Rendina collected the presented data during a four-week period between May and June of 2017, a few months before the CDC’s public endorsement of U = U.
When I asked him if there was any more recent data collected following the CDC statement, he told me, “We have new data to suggest a greater percent of HIV-negative guys believe the statement is accurate – about half as compared to one-third.”
He continued, ‘I also know that agencies like CDC are actively testing out the best way to message TasP to the public, so we will likely see even more shifts in the future.”