Undisclosed HIV Status to Sex Partners and Its Unintended Consequences in the Era of Undetectable = Untransmittable : JAIDS Journal of Acquired Immune Deficiency Syndromes

Secondary Logo

Journal Logo

Prevention Research

Undisclosed HIV Status to Sex Partners and Its Unintended Consequences in the Era of Undetectable = Untransmittable

Kalichman, Seth C. PhD; Kalichman, Moira O. MSW; Eaton, Lisa A. PhD

Author Information
JAIDS Journal of Acquired Immune Deficiency Syndromes: October 1, 2021 - Volume 88 - Issue 2 - p 149-156
doi: 10.1097/QAI.0000000000002762
  • Free


Ending HIV epidemics hinges on antiretroviral therapies (ARTs) for both pre-exposure prophylaxis and treatment of HIV infection. In the treatment context, public health policies have shifted to encompass HIV treatment as prevention (TasP),1 with broad implications including reducing stigma and enhancing relationship satisfaction.2 The evidence that sustained HIV suppression eliminates the risk of sexual transmission of HIV is definitive3 and has brought about international campaigns and public health messages that an undetectable viral load renders HIV untransmittable, commonly known as undetectable equals untransmittable (U=U4–6). Adopting U=U as a prevention strategy can be transformative, improving self-image, and buffering societal HIV stigma.7

The impact of TasP is dependent on the durability of viral suppression, with viral rebound and gaps in viral load testing undermining the ability of ARTs to prevent HIV transmission.8,9 In addition, not all people living with HIV are aware of, or are accurately informed about, the relationship between HIV suppression and HIV transmissibility.10–12 In a study that included 16,392 men living with HIV, 51% believed the premise of U=U is completely accurate and an additional 32% believed it was somewhat accurate.13 Studies show that a sizable number of men state that they do not know their HIV viral load,14 and as many as one in 4 men living with HIV who self-report having an undetectable HIV viral load are incorrect about their actual viral load.14–16 Accurate knowledge of one's viral load is essential to achieving the goals of U=U. In addition, the risks for HIV transmission among men living with HIV who are not viral suppressed are further amplified by untreated genital tract inflammation.17 Because men who adopt U=U as a personal prevention strategy will believe they are unable to transmit HIV when they have an undetectable viral load, they may be more likely to engage in condomless intercourse11 and placing themselves at higher risk for sexually transmitted infections and subclinical genital tract inflammation.18,19

Condomless sexual intercourse remains commonplace in serodifferent sexual relationships, with more than half of serodifferent couples who have HIV-positive partners not on ART engaging in condomless sex.20 A benefit of the U=U prevention strategy for people living with HIV is to have sexual relationships with partners of unknown or HIV-negative statuses without concern for transmitting HIV,11,20 including without disclosing their HIV status.21 Among sexual minority men, Rendina et al7 found that two-thirds had talked with a health care provider about viral load and HIV transmission. In a study of people living with HIV in 25 countries, Okoli et al22 also found that two-thirds on ART had discussed U=U with their health care providers and that those persons who had discussed U=U with providers self-reported better ART adherence and greater HIV viral suppression compared with individuals who were unaware of U=U. Furthermore, among individuals who were aware of U=U, 62% had not disclosed their HIV status to sex partners. This important finding indicates that U=U awareness and beliefs may reduce the stress of disclosing HIV status to sex partners.23 Disclosure barriers posed by stigma therefore extend to sex partners and may be removed by U=U messaging.24,25

The current study examined the behaviors of younger men living with HIV who report engaging in condomless anal and/or vaginal (anal/vaginal) intercourse with partners to whom they have not disclosed their HIV status. We examined factors that may contribute to sexual behaviors and decisions including HIV status disclosure, such as substance use,26,27 HIV stigma experiences,28 ART adherence, and HIV viral load.


Participants and Setting

Cisgender men living with HIV (N = 430) were recruited throughout the state of Georgia, USA, between September 2017 and December 2019. Eligible participants were between ages 18 and 36 years, and all participants showed documentation of age and HIV-positive status (eg, antiretroviral medication prescription, HIV test result, viral load laboratory result, and HIV clinic card). The enrollment interview determined that 85 participants (19%) were not currently taking ART and were not included in the current study. This study therefore includes 345 young men who were currently taking ART.


Participants were recruited to take part in a 1-month run-in study to determine eligibility for a treatment engagement and ART adherence trial targeting men aged 18 through 36 years. Men living with HIV were recruited through flyers distributed to local community services, infectious disease clinics, social media websites (eg, Grindr, Jack'd, and Facebook), targeted online advertisements, and a participant-driven adaptation of snowball sampling using respondent-driven sampling techniques, where participants were encouraged to refer their HIV-positive friends to the study and were offered a modest incentive for their efforts. Interested persons were directed to a telephone screener who assessed their eligibility criteria.

After informed consent, participants completed an enrollment interview that included a computer-assisted self-interview (CASI), collection of blood samples for HIV viral load testing, and urine samples for substance use testing and urogenital health markers. After the initial assessment, participants completed 28 daily brief phone text message sexual behavior assessments. In addition, participants completed 2 phone-based unannounced pill counts over the 1-month period to assess ART adherence. Participants were reimbursed $193 for completing all measures over the course of the month and for providing blood and urine samples. Participant privacy was protected through a federal certificate of confidentiality. The university institutional review board approved all study procedures.


Demographic Characteristics

The CASI asked participants their self-identified race, age, and income. Participants also reported whether they knew the results of their most recent HIV viral load test, and if so, whether it was undetectable or detectable. We included the Center for Epidemiological Studies Depression scale to assess emotional distress,29 Cronbach α = 0.91.

Substance Use

To screen for drug use, we conducted a multipanel urine dip test to detect common illicit drugs. The test strip uses a lateral flow chromatographic immunoassay for qualitative detection of 12 drugs/metabolites, including tetrahydrocannabinol (THC), cocaine, and methamphetamine (Redwood Toxicology Laboratory, Santa Rosa, CA—Reditest-12). These tests are Food and Drug Administration -approved and are reliable and valid for detecting recent (72–96 hours) substance use. For data analytic purposes, cannabis use indicated by the presence of THC was examined separate from the other 11 drugs. Participants also completed the Alcohol Use Disorders Identification Test30,31 in the CASI as a comprehensive assessment of alcohol use.

Health Indicators

To determine HIV RNA concentrations (viral load), participants provided 80 µL of finger-stick blood for dried blood spots collected in HemaSpot-HF devices that were frozen before laboratory delivery. HIV-1 viral load testing was conducted using the Abbott RealTime HIV-1 assay, a reverse transcription polymerase chain reaction assay performed on the automated Abbott m2000 platform (Abbott Molecular Inc., Des Plaines, IL).32 The limit of detection for the assay is 2.92 log copies/mL, and it can quantify up to 7.0 log copies/mL.33 We also used the urine specimens collected onsite for drug testing described above to test for 3 markers of urogenital health: leukocytes (an inflammation marker34,35), nitrites, and blood (indicators of renal and urinary disease processes36).

HIV Stigma and HIV Status Disclosure

Enacted and Internalized HIV Stigma

Included in the CASI were measures of enacted and internalized HIV stigma. The enacted stigma scale was adapted from the HIV Stigma Mechanisms Scale.37,38 We used 24 items to assess participant experiences of discrimination, stereotyping, and prejudice placed on a 4-point scale, 0 = never and 3 = often, Cronbach α = 0.94. For internalized stigma, we used 6 items adapted from the Internalized AIDS-Related Stigma Scale placed on a 6-point scale, 1 = strongly disagree and 6 = strongly agree,39 Cronbach α = 0.91.

HIV Status Disclosure

To assess participant disclosure of their HIV status to persons other than sex partners, we asked in the CASI whether individuals had disclosed their HIV status to family (parents, siblings, children, or other family members), friends, and employers. Responses were on a 3-point scale, 0 = none, 1 = some, and 2 = all. Scores were also summed across relationships.

ART Adherence

Participants completed 2 unannounced phone-based pill counts over 30 days. Unannounced pill counts are reliable and valid in assessing medication adherence when conducted in the home40 and on the phone.41,42 After an office-based training session, participants were called at 2 unscheduled times over 30 days. The first pill count was used to establish the initial number of pills in possession with the subsequent pill count used for calculating adherence, defined as the ratio of pills counted relative to pills prescribed, taking into account the number of pills previously counted and the number of pills dispensed.

Undetectable = Untransmittable as a Personal Strategy

Participants completed a single item included in the CASI to assess adoption of the premise that an undetectable viral load means they cannot transmit HIV to sex partners. The item specifically read “If my viral load is undetectable, I do not worry about passing HIV to a sex partner.” This item was adapted from previous research43,44 and was selected because of its face validity.22 Affirmative responses represented the endorsement of the U=U message as applied to one's own behavior. Responses were on a 6-point scale, 1 = strongly disagree and 6 = strongly agree.

Sexual Behavior Daily Electronic Diaries

We used an interactive text-diary assessment to collect daily sexual behavior data over 28 days. Brief (10 items) daily assessments were administered using interactive short message system response. Electronic diaries provide reliable data collection of socially sensitive behaviors.45,46 Participants received a text prompt to initiate and answer questions about their sexual activity during the previous day. The questions specifically asked about whether participants had sex yesterday, and if so, whether they engaged in anal intercourse with or without condoms, vaginal intercourse with or without condoms; whether they had disclosed their HIV status to their partner, their knowledge of their partner's HIV status; and whether they used alcohol or other drugs in the context of sex. Each behavior was dichotomous, indicating that it had occurred (coded 1) or not occurred (coded 0) the previous day. Sexual behaviors were aggregated across days to form reliable composites.46,47

Data Analyses

We conducted descriptive analyses for participants who did not (n = 228) and who did (n =117) engage in condomless anal/vaginal sex with a partner to whom they had not disclosed their HIV status over the 28-day assessment period. Groups were compared using contingency table χ2 tests for categorical variables and independent t tests for noncount continuous variables. We also used a contingency table χ2 test for the association between self-reported and biologically confirmed viral load. For variables that represent counts (HIV RNA copies, enacted stigma events, and sexual behaviors), we used Poisson regression, reporting the regression weights and standard errors. For these models, the group not engaging in undisclosed condomless sex was entered as the reference.

To test the main study hypothesis that endorsing U=U as a personal prevention strategy would be associated with undisclosed condomless anal/vaginal sex, we performed a series of a priori hierarchically ordered logistic regression models with the outcome variable defined as not reporting (coded 0) vs. reporting (coded 1) condomless anal/vaginal sex with an undisclosed HIV status to partner over the 28 days. The models were hierarchically ordered from distal factors (ie, years since testing HIV-positive) to proximal (ART adherence, log-transformed viral load, and endorsing a U=U prevention strategy). The models controlled for potential confounds and explanatory factors. The results report the odds ratios, χ2 tests, and Cox–Snell R2 for each model. All statistical tests defined significance as P < 0.05.


Among the 345 participants, 34% (n = 117) engaged in condomless anal/vaginal intercourse with a partner to whom they had not disclosed their HIV status over the 28-day observation period (undisclosed condomless sex). All the undisclosed condomless sexual events occurred with a partner of HIV-negative/unknown HIV status. Table 1 presents the demographic and health characteristics of men who had not (n = 228, 66%) and men who had (n = 117, 34%) engaged in undisclosed condomless sex. The overall proportion of men with undetectable HIV RNA did not differ between groups. However, men who had undisclosed condomless sex did have significantly greater HIV viremia.

TABLE 1. - Demographic and Health Characteristics of Men Living With HIV Reporting and Not Reporting Condomless Anal/Vaginal Sex With Undisclosed HIV Status to Sex Partners
Characteristic No Undisclosed Condomless Sex (n = 228) Undisclosed Condomless Sex (N = 117) χ2
N % N %
 Black/African American 202 89 104 89 4.25
 White 19 8 9 7
 Others 7 3 5 4
Annual income under $20,000 136 60 63 53 2.13
History of substance use treatment 36 16 19 16 0.01
Urinary tract health markers
 Leukocytes 52 23 23 20 0.45
 Nitrites 18 8 11 10 0.23
 Blood 24 11 22 19 4.66*
Drug use
 Cannabis (THC) 144 63 65 56 1.87
 1 other drug 33 15 19 16
 2 other drugs 10 4 7 6
 3+ other drugs 5 2 10 9
 No other drugs 180 79 81 69 8.70*
Self-reported HIV viral load
 Do not know 121 53 59 50 0.22
 Undetectable 88 39 48 41
 Detectable 19 8 10 9
Biologically confirmed HIV viral load
 Undetectable 176 79 85 75 0.82
 Detectable 47 21 29 25
Not having fully disclosed HIV status to others
 Parents 56 25 36 31 6.65*
 Siblings (n = 331) 66 30 48 42 5.04
 Children (n = 62) 18 52 20 71 2.54
 Other family members 91 42 60 56 6.31*
 Friends 17 8 21 19 10.21**
 Employers (n = 315) 14 70 84 76 1.88
Characteristic No Undisclosed Condomless Sex (n = 228) Undisclosed Condomless Sex (N = 117) t
Age 28.8 3.8 29.3 3.4 1.03
Years testing HIV-positive 5.9 4.8 6.1 4.0 0.37
CES-Depression 19.0 12.4 18.6 11.5 0.27
AUDIT alcohol use 4.48 4.51 5.9 6.3 2.42*
Enacted stigma events 10.7 12.4 9.3 12.8 0.13,**
Internalized stigma 2.6 1.5 2.6 1.6 0.36
Disclosure to others score 7.34 3.38 6.23 3.07 2.98**
ART adherence 70.4 25.0 76.7 21.7 2.30*
HIV viral load RNA copies 9625 51,106 16,461 75,703 0.44,**
U=U as a personal strategy§ 3.5 2.0 4.0 2.1 2.14*
*P < 0.05, **P < 0.01.
Tested using the Poisson regression, value is for B = 0.13 (se = 0.0364), reference = no undisclosed condomless sex.
Tested using the Poisson regression, value is for B = 0.44 (se = 0.0017), reference = no undisclosed condomless sex.
§Responses, 1 = strongly disagree and 6 = strongly agree.
AUDIT, Alcohol Use Disorders Identification Test; CES, Center for Epidemiological Studies; se, standard error.

Endorsing U=U as a Personal Prevention Strategy

Participants who had undisclosed condomless sex indicated greater endorsement of U=U as a prevention strategy, specifically that if their HIV viral load is undetectable, they do not worry about passing HIV to sex partners (Table 1). There were no differences between groups in the number of men who believed their viral load was undetectable as assessed by self-report. The association between self-reported viral load and biologically confirmed viral load was significant (Table 2). More than half of the participants indicated that they did not know their most recent viral load. Among those who stated they did know their viral load, half (15/31, 48%) who had biologically confirmed detectable viral load falsely believed that their viral load was undetectable.

TABLE 2. - Self-Reported and Biologically Confirmed HIV Viral Load Among Men Living With HIV Reporting and Not Reporting Condomless Sex With Undisclosed HIV Status to Sex Partners
Self-Reported Biologically Confirmed Undetectable (N = 269) Biologically Confirmed Detectable (N = 76) χ2
N % N %
Do not know 132 49 45 59 28.65*
Undetectable 123 46 15 20
Detectable 14 5 16 21
*P < 0.01.

HIV Status Disclosure and Stigma Experiences

Comparisons of sexual behavior groups showed that men who had undisclosed condomless sex were significantly less likely to have disclosed their HIV status to others, including parents, other family members, and friends (Table 1). Participants who had undisclosed condomless sex had also experienced fewer acts of HIV stigma. The groups did not differ regarding internalized stigma.

Sexual Behaviors

All participants responded to at least 1 day of text assessments, with 85% of participants responding to 22 or more days and 59% of participants responding to all 28 days. Table 3 presents the sexual behaviors reported over the 28-day period for men who did not and men who did engage in undisclosed condomless sex. Poisson models indicated that men who had undisclosed condomless sex reported greater condomless anal sex, total anal/vaginal condomless sex, greater condom-protected sex with undisclosed HIV status to partners, greater condomless sex with HIV-negative/unknown status partners, and greater condomless and condom-protected sex while using substances. By contrast, men who did not have undisclosed condomless sex had more condomless and condom-protected sex with HIV-positive partners and more condomless and condom-protected sex with partners to whom they had disclosed their HIV status.

TABLE 3. - Sexual Behaviors Reported Over 28 Days Among Men Living With HIV Reporting or Not Reporting Condomless Sex With Undisclosed HIV Status to Sex Partners
No Undisclosed Condomless Sex (n = 228) Undisclosed Condomless Sex (N = 117) B (se)
Sexual behaviors
 Anal condomless sex 2.7 4.0 4.2 4.6 0.45* (0.066)
 Anal condom-protected sex 1.3 2.6 1.5 1.9 0.09 (0.093)
 Vaginal condomless sex 0.8 2.3 0.9 1.3 0.18 (0.118)
 Vaginal condom-protected sex 0.9 1.3 0.4 2.3 −0.21 (0.177)
 Total condomless sex 3.1 3.9 4.9 4.5 0.45* (0.055)
 Total condom-protected sex 1.5 2.7 1.7 2.1 0.09 (0.087)
HIV-positive partners
 Condomless anal/vaginal 2.4 4.0 1.6 2.8 −0.43* (0.084)
 Condom protected anal/vaginal 0.8 2.4 0.4 0.8 −0.07* (0.156)
HIV-negative/unknown status partners
 Condomless anal/vaginal 0.6 1.3 3.2 3.3 1.59* (0.096)
 Condom protected anal/vaginal 0.5 1.1 1.1 1.7 0.66* (0.122)
Partners not disclosed HIV status to
 Condomless anal/vaginal 2.8 2.9 n/a
 Condom protected anal/vaginal 0.1 0.3 1.1 1.9 2.30* (0.218)
Partners disclosed HIV status to
 Condomless anal/vaginal 3.5 5.4 2.3 3.4 −0.41* (0.070)
 Condom protected anal/vaginal 1.7 4.6 0.7 1.2 −0.82* (0.117)
Substance use in sexual context
 Condomless anal/vaginal 1.2 2.4 2.5 3.2 0.68* (0.082)
 Condom protected anal/vaginal 0.5 1.4 0.8 1.3 0.41* (0.135)
*P < 0.01.
Reference = no undisclosed anal/vaginal condomless sex.
se, standard error; n/a, not applicable.

Hierarchical Logistic Regression Models

Table 4 presents the results of the 5 a priori ordered hierarchical logistic regression models predicting having had undisclosed condomless sex. Model 1 entered the number of years since testing HIV-positive and was not significant, χ2 = 0.02, P = 0.86, R2 = 0.001. Model 2 added substance use to the equation, and the resulting model was significant, χ2 = 16.93, P = 0.002, R2 = 0.051, alcohol use and total number of other drugs detected in urine were significantly related to undisclosed condomless sex. In model 3, HIV status disclosure to others and stigma were added to the model, χ2 = 23.68, P = 0.001, R2 = 0.070, with HIV status disclosure to others significantly related to undisclosed condomless sex. In model 4, ART adherence and HIV viral load were added, and the model remained significant, χ2 = 31.73, P = 0.001, R2 = 0.093, with ART adherence significantly related to undisclosed condomless sex. Finally, model 5 added endorsement of U=U as a personal prevention strategy, and the result was significant, χ2 = 36.60, P = 0.001, R2 = 0.110, with HIV viral load becoming significant in this model along with alcohol and drug use, disclosure to others, ART adherence, and endorsing U=U as a prevention strategy.

TABLE 4. - Odds Ratios (95% CI) Resulting From Hierarchical Logistic Regression Models Predicting Having Reported Condomless Anal/Vaginal Sex With an Undisclosed HIV Status to Partner Over a Prospective 28-Day Period
Predictors Model 1 Model 2 Model 3 Model 4 Model 5
Years HIV-positive 0.99 (0.94 to 1.04) 0.98 (0.93 to 1.03) 1.00 (0.94 to 1.05) 1.00 (0.94 to 1.06) 1.00 (0.95 to 1.06)
Substance use
 AUDIT alcohol score 1.05** (1.01 to 1.09) 1.05** (1.01 to 1.10) 1.05** (1.00 to 1.09) 1.05** (1.00 to 1.10)
 THC-positive screen 0.65 (0.40 to 1.06) 0.64 (0.39 to 1.05) 0.69 (0.41 to 1.13) 0.69 (0.41 to 1.14)
 Number of other drugs 1.64*** (1.20 to 2.23) 1.64*** (1.20 to 2.25) 1.68*** (1.22 to 2.33) 1.67*** (1.21 to 2.31)
HIV stigma and disclosure
 Enacted stigma 0.79 (0.45 to 1.38) 0.84 (0.47 to 1.51) 0.78 (0.43 to 1.44)
 Internalized stigma 1.00 (0.83 to 1.21) 0.98 (0.81 to 1.19) 1.00 (0.82 to 1.21)
 HIV Status disclosure to others 0.54** (0.31 to 0.93) 0.52** (0.30 to 0.92) 0.49*** (0.27 to 0.86)
HIV treatment
 ART adherence 3.78** (1.22 to 11.63) 3.41** (1.10 to 10.56)
 HIV (log) viral load 1.15* (1.00 to 1.34) 1.16** (1.00 to 1.35)
 U=U as a personal strategy 1.14** (1.01 to 1.28)
Model χ2 0.02 16.93*** 23.68*** 31.73*** 36.60***
R2 0.00 0.05 0.07 0.09 0.11
*P = 0.058; **P < 0.05, P < 0.01***.
AUDIT, Alcohol Use Disorders Identification Test; CI, confidence interval.


We found that over a 28-day prospective period, one in 3 men living with HIV engaged in condomless anal/vaginal sex with a non–HIV-positive partner to whom they had not disclosed their HIV status. Nondisclosure of HIV status is itself socially stigmatized,48 frequently condemned,49 and illegal in the state where we conducted this study [Ga. Code Ann. § 16-5-60(c)]. Thus, men who acknowledged engaging in undisclosed condomless sex engaged in the behavior under extreme stigmatization. Men who engaged in undisclosed condomless sex often did so under the belief that they were not placing their partners at risk for HIV given their endorsement of U=U and their overly optimist estimation of their HIV viral load.50,51

Unfortunately, objective reality was not always aligned with the premise of U=U. Sexual behaviors and health indicators suggest that men who engaged in undisclosed condomless sex may have placed partners at greater risk for HIV than they believed they were based on their U=U beliefs and self-reported viral load. As a group, men who had undisclosed condomless sex engaged in more overall condomless sex, more sex with HIV-negative/unknown status partners, and more sex when using substances. Undisclosed condomless sex was also associated with the greater use of alcohol and other drugs. We found that men who engaged in undisclosed condomless sex had greater HIV viremia. Furthermore, higher viremia occurred in the context of unawareness and incorrect knowledge of their viral load, a pattern reported in other studies.14,15 Our results found that 60% of participants did not know or were misinformed about their viral load. In addition, one in 5 participants had elevated leukocyte activity detected in urine, an indicator of genital tract inflammation, and 19% had blood detected in their urine, another indicator of urogenital disease. The combination of genital inflammation and higher HIV viremia significantly increases the risk for HIV transmission.52

Findings from the current study add to the growing body of research on HIV disclosure to sex partners in the era of U=U. Similar to past research, we found that disclosing one's HIV status clustered with disclosure across multiple relationships.22 Men who had not disclosed their HIV status to partners with whom they engaged in condomless anal/vaginal sex reported having not fully disclosed their HIV status to their parents, other family members, and friends. Men who engaged in undisclosed condomless sex also reported fewer enacted stigma experiences, which may reflect the self-protective functions of nondisclosure.53 Thus, although U=U may account for some HIV disclosure decision-making to sex partners, the overall results indicate a broader pattern of consistency in HIV status disclosure across relationships with stigma avoidance as a potential motivator. In addition, a pattern of HIV status disclosure across relationships may reflect improved self-image and reduced stigma brought by U=U messaging.7

The current study findings should be interpreted in light of their methodological limitations. The sample for this study was one of convenience and cannot be considered representative of people living with HIV and receiving ARTs. Although we used a face valid item to assess personally adopting U=U as a prevention strategy, the messaging around HIV TasP can be more complex and messages can be more nuanced. In addition, our biomarkers for genital inflammation indicated the potential for disease processes that we could not confirm. We also did not assess sexual orientation and other sources of nondisclosure, such as biphobia among bisexual men. Finally, our measures of sexual behavior are limited by self-report. We used a daily assessment strategy that likely represents more accurate responding compared with retrospective recall,46 but the social biases of self-report remain. Thus, rates of social behaviors such as nondisclosure of HIV status to sex partners are likely underestimated. Furthermore, our text message assessments were constrained to a limited number of questions and did not include important behaviors such as sexual positioning. With these limitations in mind, our findings have implications for U=U as a policy position and public health intervention.

When the tenets of U=U are achieved, specifically sustained HIV suppression through optimal ART adherence, HIV is rendered untransmittable. Unfortunately, when ART adherence is suboptimal and HIV is not fully suppressed, U=U does not resolve issues of condom use and HIV disclosure to sex partners. Our findings, along with other studies,13 suggest that men's beliefs about their own viral load and their interpretation of U=U as a concept are not always aligned with the realities of HIV transmission. U=U promotion campaigns have likely been effective in that a majority of men endorse the premise behind U=U, and it seems that the U=U message may influence behavior. However, there is the risk that U=U messaging can become little more than a slogan with its meaning not necessarily fully understood and potentially lost.54 Although U=U messaging can motivate treatment behaviors, persistent adherence to ART that is necessary for durable HIV suppression was not realized for one in 5 of our participants, with adherence levels indicating considerable risk for viral breakthrough.51 In addition, half of the participants did not know their viral load and another 17% of those who stated they did know their viral load did not match their biologically confirmed viral load. The current findings therefore demonstrate a need for interventions that extend beyond a U=U message to achieve its objectives, such as interventions that provide accurate information about the meaning of viral load and support ART adherence, manage HIV disclosure, and maintain sexual health.43,55


1. CDC. Letter to Health Departments and CBO Grantees: CDC. 2019. Available at: https://58b1608b-fe15-46bb-818a-cd15168c0910.filesusr.com/ugd/de0404_966c29f826d4481abf8bba0690bdd439.pdf. Accessed February 20, 2021.
2. UNAIDS. Undetectable = Untransmittable: UNAIDS. 2018. Available at: https://www.unaids.org/en/resources/presscentre/featurestories/2018/july/undetectable-untransmittable. Accessed February 20, 2021.
3. Eisinger RW, Dieffenbach CW, Fauci AS. HIV viral load and transmissibility of HIV infection: undetectable equals untransmittable. JAMA. 2019;321:451–452.
4. The Lancet H. U=U taking off in 2017. Lancet HIV. 2017;4:e475.
5. Tobin SC. U=U gains strength with release of PARTNER2 data. AIDS. 2019;33:N1.
6. Patel RR, Curoe KA, Chan PA. Undetectable equals untransmittable: a game changer for HIV prevention. Clin Chem. 2020;66:406–407.
7. Rendina HJ, Talan AJ, Cienfuegos-Szalay J, et al. Treatment is more than prevention: perceived personal and social benefits of undetectable = untransmittable messaging among sexual minority men living with HIV. AIDS Patient Care STDS. 2020;34:444–451.
8. Madeddu G, De Vito A, Cozzi-Lepri A, et al. Time spent with viral load ≤200 copies/mL in a cohort of people with HIV seen for care in Italy during the U=U prevention campaign era. AIDS. 2021;35:1103–1112.
9. Min S, Gillani FS, Aung S, et al. Evaluating HIV viral rebound among persons on suppressive antiretroviral treatment in the era of “undetectable equals untransmittable (U=U)”. Open Forum Infect Dis. 2020;7:ofaa529.
10. Card KG, St Denis F, Higgins R, et al. Who knows about U=U? Social positionality and knowledge about the (un)transmissibility of HIV from people with undetectable viral loads. AIDS Care. 2021:1–9. doi: 10.1080/09540121.2021.1902928 [epub ahead of print].
11. Calabrese SK, Mayer KH, Marcus JL. Prioritising pleasure and correcting misinformation in the era of U=U. Lancet HIV. 2021;8:e175–e180.
12. Torres TS, Cox J, Marins LM, et al. A call to improve understanding of undetectable equals untransmittable (U=U) in Brazil: a web-based survey. J Int AIDS Soc. 2020;23:e25630.
13. Rendina HJ, Cienfuegos-Szalay J, Talan A, et al. Growing acceptability of undetectable = untransmittable but widespread misunderstanding of transmission risk: findings from a very large sample of sexual minority men in the United States. J Acquir Immune Defic Syndr. 2020;83:215–222.
14. Sewell J, Daskalopoulou M, Nakagawa F, et al. Accuracy of self-report of HIV viral load among people with HIV on antiretroviral treatment. HIV Med. 2017;18:463–473.
15. Stephenson R, Bratcher A, Mimiaga MJ, et al. Brief report: accuracy in self-report of viral suppression among HIV-positive men with HIV-negative male partners. J Acquir Immune Defic Syndr. 2020;83:210–214.
16. Mustanski B, Ryan DT, Remble TA, et al. Discordance of self-report and laboratory measures of HIV viral load among young men who have sex with men and transgender women in Chicago: implications for epidemiology, care, and prevention. AIDS Behav. 2018;22:2360–2367.
17. Chitneni P, Matthews LT. The other U=U. Untested and untreated genital tract inflammation in people living with and exposed to HIV. J Infect Dis. 2021;224:1–4.
18. Kalichman SC, Grebler T, Amaral CM, et al. Assumed infectiousness, treatment adherence and sexual behaviours: applying the Swiss statement on infectiousness to HIV-positive alcohol drinkers. HIV Med. 2013;14:263–272.
19. Kalichman SC, Eaton L, Cherry C. Sexually transmitted infections and infectiousness beliefs among people living with HIV/AIDS: implications for HIV treatment as prevention. HIV Med. 2010;11:502–509.
20. Goodreau SM, Maloney KM, Sanchez TH, et al. A behavioral cascade of HIV seroadaptation among US men who have sex with men in the era of PrEP and U=U. AIDS Behav. 2021. doi: 10.1007/s10461-021-03266-0 [epub ahead of print].
21. Sang JM, Wang L, Moore DM, et al. Undetectable or unknown? A longitudinal event-level analysis of disclosure of HIV serostatus and undetectability among gay, bisexual, and other men who have sex with men (gbMSM) in Metro Vancouver. AIDS Behav. 2021;25:2630–2643.
22. Okoli C, Van de Velde N, Richman B, et al. Undetectable equals untransmittable (U=U): awareness and associations with health outcomes among people living with HIV in 25 countries. Sex Transm Infect. 2021;97:18–26.
23. Calabrese SK, Mayer KH. Stigma impedes HIV prevention by stifling patient-provider communication about U=U. J Int AIDS Soc. 2020;23:e25559.
24. Spangler SA, Abuogi LL, Akama E, et al. From “half-dead” to being “free”: resistance to HIV stigma, self-disclosure and support for PMTCT/HIV care among couples living with HIV in Kenya. Cult Health Sex. 2018;20:489–503.
25. Kalichman S, Mathews C, Banas E, et al. HIV status disclosure and sexual transmission risks among people who are living with HIV and receiving treatment for non-HIV sexually transmitted infections, Cape Town, South Africa. J Acquir Immune Defic Syndr. 2020;83:223–229.
26. Scott-Sheldon LAJ, Carey KB, Johnson BT, et al. Behavioral interventions targeting alcohol use among people living with HIV/AIDS: a systematic review and meta-analysis. AIDS Behav. 2017;21(suppl 2):126–143.
27. Sullivan MC, Cruess DG, Huedo-Medina TB, et al. Substance use, HIV serostatus disclosure, and sexual risk behavior in people living with HIV: an event-level analysis. Arch Sex Behav. 2020;49:2005–2018.
28. Mugo C, Seeh D, Guthrie B, et al. Association of experienced and internalized stigma with self-disclosure of HIV status by youth living with HIV. AIDS Behav. 2021;25:2084–2093.
29. Radloff LS. The CES-D scale: a self-report depression scale for research in the general population. Appl Psychol Meas. 1977;1:385–401.
30. Saunders JB, Aasland OG, Babor TF, et al. Development of the alcohol use disorders identification test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption—II. Addiction. 1993;88:791–804.
31. Maisto SA, Conigliaro J, McNeil M, et al. An empirical investigation of the factor structure of the AUDIT. Psychol Assess. 2000;12:346–353.
32. Molecular A. RealTime HIV-1 Assay. Abbott Park, IL: Abbott Laboratories; 2020. Available at: https://www.molecular.abbott/us/en/products/infectious-disease/realtime-hiv-1-viral-load. Accessed February 20, 2021.
33. Tang N, Pahalawatta V, Frank A, et al. HIV-1 viral load measurement in venous blood and fingerprick blood using Abbott RealTime HIV-1 DBS assay. J Clin Virol. 2017;92:56–61.
34. Anderson BL, Wang CC, Delong AK, et al. Genital tract leukocytes and shedding of genital HIV type 1 RNA. Clin Infect Dis. 2008;47:1216–1221.
35. Laisaar KT, Uusküla A, Sharma A, et al. Developing an adherence support intervention for patients on antiretroviral therapy in the context of the recent IDU-driven HIV/AIDS epidemic in Estonia. AIDS Care. 2013;25:863–873.
36. Kutter D, van Oudheusden AP, Hilvers AG, et al. A new test-strip for demonstrating erythrocytes and haemoglobin in urine [in German]. Dtsch Med Wochenschr. 1974;99:2332–2335.
37. Earnshaw VA, Chaudoir SR. From conceptualizing to measuring HIV stigma: a review of HIV stigma mechanism measures. AIDS Behav. 2009;13:1160–1177.
38. Earnshaw VA, Smith LR, Chaudoir SR, et al. HIV stigma mechanisms and well-being among PLWH: a test of the HIV stigma framework. AIDS Behav. 2013;17:1785–1795.
39. Kalichman SC, Simbayi LC, Cloete A, et al. Measuring AIDS stigmas in people living with HIV/AIDS: the internalized AIDS-related stigma scale. AIDS Care. 2009;21:87–93.
40. Bangsberg DR, Hecht FM, Charlebois ED, et al. Comparing objective measures of adherence to HIV antiretroviral therapy: electronic medication monitors and unannounced pill counts. AIDS Behav. 2001;5:275–281.
41. Kalichman SC, Amaral CM, Cherry C, et al. Monitoring Antiretroviral adherence by unannounced pill counts conducted by telephone: reliability and criterion-related validity. HIV Clin Trials. 2008;9:298–308.
42. Kalichman SC, Amaral CM, Stearns H, et al. Adherence to antiretroviral therapy assessed by unannounced pill counts conducted by telephone. J Gen Intern Med. 2007;22:1003–1006.
43. Kalichman SC, Cherry C, Kalichman MO, et al. Mobile health intervention to reduce HIV transmission: a randomized trial of behaviorally enhanced HIV treatment as prevention (B-TasP). J Acquir Immune Defic Syndr. 2018;78:34–42.
44. Kalichman SC, Cherry C, Kalichman MO, et al. Sexual behaviors and transmission risks among people living with HIV: beliefs, perceptions, and challenges to using treatments as prevention. Arch Sex Behav. 2016;45:1421–1430.
45. Bernhardt JM, Usdan S, Mays D, et al. Alcohol assessment among college students using wireless mobile technology. J Stud Alcohol Drugs. 2009;70:771–775.
46. McAuliffe TL, DiFranceisco W, Reed BR. Low numeracy predicts reduced accuracy of retrospective reports of frequency of sexual behavior. AIDS Behav. 2010;14:1320–1329.
47. Conner TS, Barrett LF. Trends in ambulatory self-report: the role of momentary experience in psychosomatic medicine. Psychosom Med. 2012;74:327–337.
48. Perlson J, Scholl J, Mayer KH, et al. To disclose, not disclose, or conceal: a qualitative study of HIV-positive men with multiple concealable stigmatized identities. AIDS Patient Care STDS. 2021;35:47–55.
49. Roth J, Sanders C. “Incorrigible slag,” the case of Jennifer Murphy's HIV non-disclosure: gender norm policing and the production of gender-class-race categories in Canadian news coverage. Women's Stud Int Forum. 2018;68:113–120.
50. Bangsberg DR, Deeks SG. Is average adherence to HIV antiretroviral therapy enough? J Gen Intern Med. 2002;17:812–813.
51. Byrd KK, Hou JG, Hazen R, et al. Antiretroviral adherence level necessary for HIV viral suppression using real-world data. J Acquir Immune Defic Syndr. 2019;82:245–251.
52. Wall KM, Nyombayire J, Parker R, et al. Etiologies of genital inflammation and ulceration in symptomatic Rwandan men and women responding to radio promotions of free screening and treatment services. PLoS One. 2021;16:e0250044.
53. Velloza J, Khoza N, Scorgie F, et al. The influence of HIV-related stigma on PrEP disclosure and adherence among adolescent girls and young women in HPTN 082: a qualitative study. J Int AIDS Soc. 2020;23:e25463.
54. Grace D, Nath R, Parry R, et al. “… if U equals U what does the second U mean?”: sexual minority men's accounts of HIV undetectability and untransmittable scepticism. Cult Health Sex. 2020:1–17. doi: 10.1080/13691058.2020.1776397.
55. Kalichman SC, Cherry C, Kalichman MO, et al. Integrated behavioral intervention to improve HIV/AIDS treatment adherence and reduce HIV transmission. Am J Public Health. 2011;101:531–538.

undetectable equals untransmittable; HIV prevention; HIV treatment; HIV treatment as prevention

Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.