There is still room for improvement among men who have sex with men (MSM) with regard to educating them that HIV treatment is an effective way to prevent transmission of the virus. In a recent large survey of this population, more than half of the HIV-negative men and one third of the HIV-positive respondents perceived the “Undetectable = Untransmittable” slogan as inaccurate.

Multiple large studies in which mixed-HIV-status couples were followed for extended periods have seen no transmissions of the virus when the HIV-positive partner was on antiretrovirals (ARVs) and had an undetectable viral load. The cumulative findings of these studies have led to an increasing scientific consensus that, as the Centers for Disease Control and Prevention (CDC) characterizes the matter, having a sustained undetectable viral load is associated with effectively no risk of transmitting HIV to others through sex, even without the use of a condom.

The HIV-awareness group the Prevention Access Campaign, responding to this research, has taken on the phrase “Undetectable = Untransmittable,” known by the shorthand “U=U,” as its mantra in a grand-scale effort to educate the world about the efficacy of HIV treatment as prevention (TasP).

Publishing their findings in JIAS, the Journal of the International AIDS Society, researchers recruited 12,222 MSM through an online social networking site and a mobile sexual networking app. The men completed a survey that addressed various sociodemographic and behavioral factors as well as their perception, on a four-point scale, of the accuracy of the U=U statement.

The survey included 10,140 men who reported they were HIV negative or did not know their status and 2,082 HIV-positive men. Of the entire sample of 12,222 men, 11.2 percent were HIV-negative and on Truvada (tenofovir disoproxil fumarate/emtricitabine) as pre-exposure prophylaxis (PrEP), 63.5 percent were HIV-negative and not on PrEP, 8.3 percent did not know their HIV status, 14.6 percent were HIV-positive with an undetectable viral load and 2.4 percent were HIV-positive with a detectable viral load.

A total of 10.4 percent of the respondents were Black, 22.4 percent were Latino, 53.1 percent were white and 14.2 percent were multiracial or “other.” A total of 1.4 percent of the respondents were transgender men. A total of 81.9 percent identified as gay or queer, 16.4 percent as bisexual and 1.7 percent as straight or “other.” A total of 15.2 percent said they identified as a “top” (the insertive partner in anal sex), 67.9 percent as “versatile” (practicing both the insertive and receptive positions in anal sex) and 16.8 percent as a “bottom” (the receptive partner).

Among the two main groups of participants, the negative or unknown-HIV-status men on the one hand and the HIV-positive men on the other, a respective 9 percent and 32 percent perceived the U=U slogan as completely accurate, 27 percent and 38 percent said it was somewhat inaccurate, 26 percent and 16 percent said it was somewhat accurate, and 38 percent and 14 percent said it was completely accurate. The researchers collapsed these four points to two—perceiving U=U as either accurate or inaccurate (ignoring the “somewhat” or “completely” qualifiers)—to find that 36 percent of the HIV-negative men and 70 percent of the HIV-positive men perceived U=U as an accurate slogan, while a respective 64 percent and 30 percent believe it is inaccurate.

These figures about the perceived accuracy of U=U excluded the 6.7 percent (686) of the HIV-negative men and the 0.8 percent (17) of the HIV-positive men who said they did not know what undetectable means.

Looking at the HIV-negative men, the researchers conducted an analysis to identify factors associated with being unsure what undetectable means. The following factors were associated with the accompanying degrees of likelihood of being unsure of the definition of undetectable: being on PrEP, a 40 percent reduced likelihood (meaning they were more likely to be sure of the definition of undetectable); having an unknown HIV status, a 1.59-fold greater likelihood (less likely to be sure of the definition); being Latino compared with being white, a 1.33-fold greater likelihood; identifying as gay or queer compared with identifying as straight or bisexual, a 19 percent reduced likelihood; compared with having a high school diploma or less education, an 18 percent reduced likelihood for those with some college education, a 46 percent reduced likelihood for those with a college degree, and a 44 reduced likelihood for those with a graduate degree; compared with being versatile, being a bottom, a 1.23-fold increased likelihood; and compared with testing for HIV less frequently than every six months, testing every six months or more often, 31 percent reduced likelihood.

Among the HIV-negative and unknown-HIV-status men who knew what undetectable means, factors associated with a greater likelihood of perceiving U=U as accurate included being on PrEP, identifying as gay or queer rather than bisexual or straight, recently having condomless sex with an HIV-positive man, testing every six months or more frequently, having less concern about sexually transmitted infections (STIs) and having a lower perceived risk of contracting HIV.

As for the HIV-positive men who knew what undetectable means, factors associated with perceiving U=U as accurate included reporting an undetectable viral load, having received an AIDS diagnosis and having a lower concern about contracting STIs.

“What we may be seeing is that some guys who aren’t able to maintain a sustained undetectable viral load either have lower levels of knowledge potentially due to being less well-retained in care or that they may feel left out of the [U=U] message and concerned it will lead to additional stigma placed on them,” Jonathon Rendina, PhD, MPH, an assistant professor at Hunter College and the paper’s lead author, said in a press release. “There is great promise for the [U=U] message to reduce HIV stigma, but at the same time, we need to make sure we don’t end up marginalizing or stigmatizing those who struggle with keeping their viral loads undetectable.”

The researchers concluded that their findings “highlight variability in the perceived accuracy of the Undetectable = Untransmittable message, suggesting potential subgroups who might benefit from targeted educational campaigns, perhaps broadcast utilizing sexual network apps.”

The study authors also concluded, based on the findings that PrEP and testing for HIV regularly were both strongly associated with a higher likelihood of perceiving U=U as accurate, that “HIV prevention services [may be] potential points of intervention for increasing HIV knowledge and decreasing HIV stigma.”

The study was conducted by Jonathon Rendina, PhD, MPH, an assistant professor at Hunter College and director of quantitative methods at Hunter’s Center for HIV Educational Studies & Training (CHEST), and Jeffrey Parsons, PhD, distinguished professor at Hunter College and director of CHEST.

To read a press release about the study, click here.

To read the study, click here.