“I just believe there is a risk” understanding of undetectable equals untransmissible (U = U) among health providers and HIV‐negative partners in serodiscordant relationships in Kenya

Abstract

Introduction Sustained HIV viral suppression resulting from antiretroviral therapy (ART) eliminates the risk of HIV transmission, a concept popularly framed as Undetectable = Untransmittable (U = U). We explored knowledge and acceptance of information around the elimination of HIV transmission risk with ART (U = U) in Kenya. Methods Our qualitative study was conducted within a project evaluating the use of pre‐exposure prophylaxis (PrEP) integrated into ART care for HIV serodiscordant couples in public clinics in Kenya (the Partners Scale Up Project). From February 2017 to April 2019, we conducted semi‐structured key informant interviews with 83 health providers and in‐depth interviews with 61 HIV‐negative people in serodiscordant relationships receiving PrEP services. Transcripts were coded using thematic analysis. Results Health providers reported being aware of reduced risk of HIV transmission as a result of consistent ART use and used words such as “very low,” “minimal” and “like zero” to describe HIV transmission risk after viral suppression. Providers reported finding viral load results helpful when counselling clients about the risk of HIV transmission. Many lacked confidence in U = U and counselled on consistent condom use even after viral suppression while some expressed concerns that communicating this message to people living with HIV (PLHIV) would lead them to engage in multiple sexual relationships. Other providers reported that they did not counsel about the reduced risk of HIV transmission after viral suppression for fear of being blamed if HIV transmission occurred. HIV‐negative partners reported being informed about U = U by providers but they did not believe nor trust the message. Even after their partners achieved viral suppression, some HIV‐negative partners were unwilling to stop PrEP, while others indicated that they would use condoms if they stopped PrEP to be sure that they were protected from HIV. Conclusions Despite awareness that effective ART use eliminates HIV transmission risk, there is both a lack of in‐depth knowledge and conviction about the strategy among health providers and HIV‐negative partners in serodiscordant relationships. New strategies that go beyond communicating the science of U = U to consider the local social and clinical environments could maximize the effectiveness of U = U.

A call to improve understanding of Undetectable equals Untransmittable (U = U) in Brazil: a web‐based survey

“…Though most of the prevention benefits from U = U will be realized from an accurate understanding of U = U among PLHIV and those most vulnerable to HIV, we echo the need for a broader understanding as suggested by others [13]. Indeed, recent findings highlight how implicit and explicit stigma of healthcare professionals towards PLHIV may be a key driver of the lack of U = U communication [8,9]. HIV-related stigma negatively impacts HIV prevention and treatment [8,17], and, more generally, stigma has been proposed as fundamental cause of health inequality [20].…”

“…In the interim, studies have shown that the slogan U = U, has not been clearly communicated by health providers in clinical care [8]. A qualitative study conducted in Kenya of HIV serodiscordant couples attending public clinics, showed how healthcare providers lacked "in-depth knowledge and conviction" on U = U [9]. Similarly, studies conducted in high-income settings (Canada [10,11], Italy [12], Australia [13] and the United States [14][15][16]), mostly on gay, bisexual and other men who have sex with men, have reported low awareness, understanding, belief or perceived accuracy of TasP or U = U, depending on the study.…”

Promoting Undetectable Equals Untransmittable in Sub-Saharan Africa: Implication for Clinical Practice and ART Adherence

“…In SSA countries, the U = U campaign/slogan is gradually being integrated into HIV prevention promotion, although a more vigorous campaign strategy is needed. For PLWHIV, sustained viral suppression with a VL of <200 copies/mL, plus adherence to ART can lead to the maintenance of VLs and zero transmission [ 80 ]. Promoting strategies for U = U in SSA countries needs better communication and behavioral commitments [ 81 ] ( Box 2 ).…”

Adherence to recommendations for ART and targeted PrEP use among HIV serodiscordant couples in East Africa: the “PrEP as a bridge to ART” strategy

“…Future studies should assess this strategy in routine clinical settings with clear messaging about prevention-effective adherence and U=U, particularly among young PrEP users. The influence of more readily available viral load testing (e.g., with point-of-care technology [ 38 ] will also be important to explore. Counseling about this strategy should consider the factors that were associated with more or less PrEP use than expected.…”