U = U: A Catalyst for Ending AIDS as a Public Health Threat

The announcement of U = U University at the AIDS 2024 conference in Munich, Germany, marked an important milestone for the global HIV community. This new initiative, developed through the leadership of the Prevention Access Campaign, seeks to scale up the implementation of the Undetectable equals Untransmittable (U = U) message, which was community-inspired in 2016 as a user-friendly translation of HIV treatment as prevention (TasP) whose real-world effectiveness evidence dates back to 2010. ¹

Despite the abundant scientific evidence behind the U = U message, its adoption by health systems and the health workforce has been unacceptably slow. Since the burden of scaling up implementation of the U = U message should not rest solely on the shoulders of the HIV community, health systems and the health workforce must play a critical role, not only in embracing U = U but in ensuring the message and culturally responsive methods to communicate it to people living with HIV (PLHIV) are reflected in clinical guidelines, algorithms, and practice.

The U = U movement emerged as a powerful response to decades of stigma and misinformation surrounding HIV. The message is rooted in the simple yet indisputable scientific fact that PLHIV who achieve and maintain an undetectable viral load through effective antiretroviral therapy (ART) cannot sexually transmit the virus.^2,3,4 This evidence-based assertion, supported by the World Health Organization (WHO) and numerous other health authorities, should have transformed the landscape of HIV prevention and treatment. Yet, the full potential of U = U remains unrealized, particularly within the context of health systems. U = U University was conceived to address this gap by providing a structured, accessible platform for education, advocacy, and empowerment. U = U University is envisioned as a place where PLHIV, health care providers, and advocates can come together to learn about the science behind U = U, share experiences, and collaborate on strategies to integrate U = U into every aspect of HIV care.

The slow pace of U = U adoption by the health workforce is not only frustrating but inexcusable. The WHO's assertion of zero risk of sexual transmission of the virus by PLHIV with an undetectable viral load, ⁵ should have catalyzed widespread integration of this message into clinical practice. However, many health systems and providers have been hesitant to embrace U = U, often citing outdated concerns about the potential for HIV transmission, a lack of confidence in the effectiveness of modern ART, and a lack of trust in PLHIV to make U = U-informed decisions about their HIV care, notably maintaining optimal ART adherence. This hesitation is not just a scientific or clinical issue; it is a moral one. Every day that health care providers fail to communicate the U = U message to their patients, they perpetuate stigma. The barrier to positive health outcomes that stigma represents not only undermines the mental health and well-being of PLHIV but also contributes to fueling new avertable HIV infections by discouraging individuals from seeking testing and treatment.

The challenge of slow U = U uptake is not confined to any single region; it is a global issue, including in countries with robust healthcare systems like the United States. Results from the U.S. THRIVE study presented at the AIDS 2024 conference showed that among 781 PLHIV with a lack of understanding of U = U, 45% had never heard about U = U from a health care provider, among whom 59% had suboptimal ART adherence. ⁶ Moreover, about 69% of PLHIV in the study with detectable viral loads or who were unaware of their viral load levels lacked an understanding of U = U. ⁶ Another U.S. study of 925 HIV-treating clinicians found a wide range of U = U communication taking place, with nurse practitioners (74%), specialist physicians (71%), and general practitioners (58%) saying they communicated the message to PLHIV in their care. ⁷ With few exceptions, (eg, Kenya, South Africa, Vietnam), in many low- and middle-income countries, where HIV prevalence is highest, U = U is far from being a universally understood or applied message. This lack of awareness and implementation underscores the urgent need for targeted education and advocacy efforts to ensure that the life-saving benefits of U = U reach everyone, everywhere.

The responsibility for scaling up and implementing the U = U message cannot and should not rest solely with the HIV community. Health systems and the health workforce have a duty to integrate U = U into their practices, from clinical guidelines to patient education and public health campaigns. This integration is essential if we are to achieve the ambitious targets set by the Joint United Nations Programme on HIV/AIDS (UNAIDS) for 2025, including the goal of 95% of all PLHIV knowing their status, 95% of those diagnosed receiving sustained ART, and 95% of those on ART achieving viral suppression. ⁸ U = U is not just a message; it is a key to unlocking these targets and ultimately ending AIDS as a public health threat by 2030, in line with Sustainable Development Goal (SDG) 3.3.

While the role of HIV specialists is crucial, it is not sufficient to rely on them alone to promote and implement the U = U message. People living with HIV interact with a wide range of health care professionals beyond HIV specialists, including primary care physicians, specialists in other fields, and paraprofessional cadres such as community health workers. These health care providers are often the first point of contact for many PLHIV and play a pivotal role in ongoing care. For U = U to be fully integrated into day-to-day healthcare delivery, it must be embraced by every sector of the health workforce. Primary care providers, in particular, must be educated and empowered to discuss U = U with PLHIV. Likewise, specialists in fields such as obstetrics and gynecology, mental health, and other infectious diseases must also be engaged, given the intersections of HIV with other health conditions. Community health workers, who often serve as a bridge between health care systems and marginalized communities, are essential partners in spreading the U = U message, particularly in settings where stigma remains a persistent challenge.

One of the most effective ways to ensure the widespread adoption of U = U is to embed the message within clinical guidelines and algorithms. Beyond simply endorsing the U = U message, health authorities must mount a concerted effort to educate and train the health workforce on its implications for person-centered care. Health care providers must be equipped with the knowledge and tools to communicate the U = U message to their patients clearly and confidently. This capacity-building should also address any misconceptions about the effectiveness of ART, the importance of optimal ART adherence, and the role of viral load monitoring in achieving and maintaining an undetectable viral load.

Moreover, health systems must prioritize the integration of U = U into wide-ranging public health campaigns and educational materials. U = U should be a central component of every conversation about HIV prevention and care, from the moment a person is diagnosed with HIV to their ongoing management and support. Moreover, it is not just PLHIV who need awareness about and an understanding about U = U, but also HIV-negative individuals to further assist with de-stigmatizing PLHIV. A study of 309 HIV-negative individuals in the United States found that 29% did not have confidence in or were unsure about U = U, notably the assertion of zero risk of sexual transmission of HIV by PLHIV who achieve an undetectable viral load. ⁹

The success of U = U University and the broader U = U movement depends on a collaborative effort between the HIV community, health systems, and the health workforce. While the HIV community has led the way in advocating for U = U, it is now time for health systems and providers to take up the mantle and ensure that U = U is fully integrated into the fabric of HIV care. That is why the International Association of Providers of AIDS Care (IAPAC) has signed on as a founding partner of U = U University, offering our technical expertise, but also our advocacy capabilities within and among the health professions. Our aim is to build capacity for U = U implementation across the health workforce, as well as influence change in clinical guidelines, policies, and programs to create an enabling environment for U = U. As important, the U = U University collaboration must also extend to policymakers and other stakeholders who have the power to influence the direction of HIV programs and services. U = U should be recognized as a cornerstone of HIV prevention and treatment strategies, and adequate resources must be allocated to support its implementation.

U = U, in combination with ART and preexposure prophylaxis (PrEP), is a powerful tool we can and must leverage. But for its potential to be fully realized, the health workforce and health systems must step up and take responsibility for implementing U = U. By doing so, they will not only help to achieve the UNAIDS 2025 targets and SDG 3.3 but also affirm the dignity, equality, and rights of all PLHIV. The time for hesitation is over. The science is clear, the message is powerful, and the stakes are too high to allow inertia or fear to stand in the way. U = U is more than a slogan; it is a promise of a future where AIDS is no longer a public health threat, and where all people, regardless of their HIV status, can live free from stigma.

Dr José M. Zuniga is President/CEO of the International Association of Providers of AIDS Care (IAPAC) and its affiliated Fast-Track Cities Institute.