Background: Several studies have demonstrated no linked HIV transmissions in serodifferent sexual encounters where the partner with HIV has an undetectable viral load. As a result, awareness and dissemination of treatment as prevention, and movements such as “Undetectable = Untransmittable” (U = U), has grown. Setting: We conducted an online cross-sectional survey from November 2017 through September 2018 to gather data from a total of 111,747 sexual minority men (SMM) in the United States. Methods: Participants provided sociodemographic data and answered questions regarding biomedical status, HIV and STI prevention behaviors, drug use, condomless anal sex, and perceived accuracy of the U = U message. We conducted analyses to understand factors associated with perceived accuracy of U = U stratified by HIV status. Results: Overall, 53.2% of the sample perceived U = U as accurate, with the highest rates among HIV-positive SMM (83.9%), followed by HIV-negative (53.8%) and status-unknown (39.0%) SMM. Multivariable models showed accuracy beliefs were, on average, 1–2% higher for each consecutive month of recruitment. Consistent with previous work, there was greater heterogeneity among HIV-negative and unknown men, with several factors differentiating perceived accuracy, compared with SMM with HIV. Perceived transmission risk levels with undetectable partners were skewed well above accurate levels, and greater perceived transmission risk was associated with lower perceived accuracy of U = U. Conclusions: Public confidence in treatment as prevention and U = U is growing, but clear, unequivocal messaging about the effectiveness of U = U is critical. Owing to misunderstandings of risk, language that focuses on protective benefits rather than transmission risks may reach more people and allow for better comparisons with PrEP and condoms.

Stigma against sexual and gender minorities is a major driver of health disparities. Psychological and behavioral interventions that do not address the stigma experienced by sexual and gender minorities may be less efficacious. We conducted a systematic review of existing psychological and behavioral health interventions for sexual and gender minorities to investigate how interventions target sexual and gender minority stigma and consider how stigma could affect intervention efficacy. Preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines were followed. Eligible studies were peer reviewed and published in English between January 2003 and July 2019 and reported empirical results of behavioral or psychological interventions implemented among sexual and gender minorities. All interventions addressed stigma. We identified 37 eligible interventions. Most interventions targeted sexual minority men. Interventions were frequently developed or adapted for implementation among sexual and gender minorities and addressed multiple levels and types of stigma. Interventions most frequently targeted proximal stressors, including internalized and anticipated stigma. HIV and mental health were the most commonly targeted health outcomes. A limited number of studies investigated the moderating or mediating effects of stigma on intervention efficacy. The application of an intersectional framework was frequently absent and rarely amounted to addressing sources of stigma beyond sexual and gender minority identities. A growing number of interventions address sexual and gender minority stigma in an effort to prevent deleterious health effects. Future research is needed to assess whether stigma modifies the effectiveness of existing psychological and behavioral interventions among sexual and gender minorities. Further, the application of intersectional frameworks is needed to more comprehensively intervene on multiple, intersecting sources of stigma faced by the diverse sexual and gender minority community.