U=U: A guide for service providers


A very important message

U=U is shorthand for Undetectable equals Untransmittable. This is a simple but very important message, based on a solid foundation of scientific evidence, that someone with HIV who is taking antiretroviral treatment (ART) and who has maintained for at least six months an undetectable1 level of the virus in their blood cannot transmit it to someone else sexually, with or without the use of a condom.

The U=U message was pioneered by a global community of people living with HIV, researchers, clinicians and community-based organizations under the auspices of the Prevention Access Campaign as a health equity initiative to end the dual epidemics of HIV and HIV-related stigma. It has been a game changer in the way organizations and people with HIV talk and think about viral undetectability and infectiousness, and it has changed what it means to live with HIV.

The U=U message has been successful in influencing public opinion: more people with HIV, along with their friends, families, and coworkers, now understand that people living with HIV can live long, healthy lives, can have HIV-negative children, and do not need to worry about passing on HIV to people they have sex with.

The clarity of this message makes it easier for service providers to promote the undeniable benefits of treatment. In turn, this will encourage more and more people with HIV to seek treatment, bringing the HIV community, across Canada and globally, one step closer to achieving the UNAIDS 90-90-90 targets2 and to reducing the entirely unfair and outdated stigma still faced by many people living with HIV today.3

Although the health benefits of treatment will always be the primary purpose of antiretroviral therapy (ART), this  guide provides the boards, executive directors, management, and frontline service providers of organizations across Canada with a summary and analysis of the secondary benefits of ART in terms  of preventing HIV transmission to the sexual partners of people living with HIV and transforming what it means to live with HIV.

It is vital that these secondary benefits for people living with HIV and their sexual partners be fully understood and communicated to influence practice, to encourage health-seeking behaviours, and to challenge stigma.

The abundance of scientific evidence behind the message of U=U provides an opportunity for us all, whether or not we have HIV, to reflect on, celebrate, and embrace a new era in the HIV epidemic the likes of which we have not experienced since combination ART4 was introduced in 1996. Over time, combination ART changed HIV from an almost certain death sentence into a chronic but manageable lifelong condition, and it allowed healthy HIV-negative babies to be born to people living with HIV. U=U provides us with one of the best opportunities we have to end the epidemic of new infections, to optimize the lives of people living with HIV, and to diminish HIV-related stigma and discrimination.

U=U builds on treatment as prevention.5 U=U changes what it means to live with HIV. It opens up social, sexual, and reproductive choices that people with HIV, their sexual partners, and in some cases entire communities, never thought would be possible. It encourages people with HIV to start and stay on treatment to keep both themselves and their sexual partners healthy. It is an opportunity to transform how people living with HIV see themselves and how they are perceived by their families, by their friends, by their current and potential sexual partners, and by people in general.

While the U=U message is primarily focused on the individual, it provides those of us who work in the community with a new tool for advocacy. Much of the messaging from public health authorities, the media, and the HIV sector for the past 35 years contributed to an image of people with HIV as vectors of disease from whom the public had to be protected. Whether this effect was intentional or not, the messaging has had a detrimental impact on people living with HIV that has to change.

U=U can raise broader public awareness of the reality of HIV today, help reduce stigma toward people living with HIV, transform self-stigma, increase testing rates, motivate people to initiate treatment early, and improve treatment adherence. And it offers a strong public health argument for equitable provision of, and access to, testing, care, and treatment, leading to viral suppression. It also provides us with an opportunity to imagine the existence of a community where the principles of access and equity apply to everyone, whatever their HIV status, a community where the lives of all are equally valued.

  1. Less than 200 copies per mililitre of blood. For the purposes of the U=U message, the term “undetectable” is used synonymously with “virally suppressed.”
  2. UNAIDS. 90-90-90: An ambitious treatment target to help end the AIDS epidemic. Geneva: Joint United Nations Programme on HIV/AIDS; 2014. Available from: https://www.unaids.org/en/resources/documents/2017/90-90-90 [accessed June 20, 2019].
  3. U=U taking off in 2017 [editorial]. Lancet HIV 2017;4(11):PE475. Available from: https://www.thelancet.com/journals/lanhiv/article/PIIS2352-3018(17)30183-2/fulltext?elsca1=etoc [accessed June 20, 2019].
  4. Combination ART refers to the combinations of two or more classes of HIV drugs used to keep HIV infections under control. It is sometimes abbreviated as cART, or more commonly as ART, which is the abbreviation used in this guide.
  5. The concept of using ART to prevent the transmission of HIV.