The global perspective

By the end of this section you'll be able to:

• Know why U=U is a game changer in the fight against HIV around the world.
• Understand the impact of not telling patients that people living with HIV who have an undetectable viral load can’t pass it on.
• Know what language to use and not to use when explaining U=U to your patients.
• See what role you can play in the global movement.

• Why U=U is a game changer.

• Why there is a U=U campaign.

• The effects of not telling people about U=U.

• Why a global message is important to help end the epidemic.

• The importance of the third ‘U’ – ‘universal access’ – disparities in countries where testing and access to drugs are not universally available, and how U=U helps strengthens calls for universal access.

• Recognising that it’s not possible for everyone to achieve a undetectable viral load.

• Why U=U is the foundation of being able to end the HIV epidemic.

• How far we have come in changing the dialogue.

• How to be clear about language, including what to say and not to say.

• The importance of clearly communicating U=U and educating staff.

• The role of healthcare professionals in the worldwide movement.

• U=U as a global campaign.

• Medical coverage.

Bruce Richman is Founding Executive Director of the Prevention Access Campaign which launched the U=U movement.

In this video, he talks about the history of the U=U message, and why and how the campaign came about. He explains why it’s vitally important to share the message of U=U and how you can do this.

U=U stands for Undetectable = Untransmittable. This means that a person living with HIV who is on treatment and has an undetectable viral load cannot transmit HIV sexually.

This does not apply to breastfeeding or injecting drug use.

U=U applies regardless of :

• If there is HIV RNA or DNA in the semen.
• The presence of other sexually transmitted infections (STIs).

Why is U=U a game changer?

• It transforms social, sexual and reproductive lives.
• It dismantles HIV stigma.
• It reduces anxiety associated with HIV testing and adds an incentive to start and stay on treatment and in care.
• It provides a strong public health argument to increase access and eliminate barriers to treatment and care (the third U = Universal).
• It empowers people with HIV to love and live without fear.
• It saves lives and prevents new transmissions.
• It provides the foundation for ending the epidemic.

U=U is based on a groundswell of evidence built over 20 years that included observations that people who had an undetectable viral load were not passing on HIV to their sexual partners.

• Many studies were produced but didn’t get exposure internationally.
• U=U wasn’t widely known or publicly endorsed by medical bodies and people who were marginalised by the system were not learning about it.
• All people living with HIV have a right to accurate information about their social, sexual and reproductive health.
• Before the campaign started, Bruce Richman saw leaders talk about how HIV stigma is the greatest challenge to ending the epidemic, but they were also exaggerating the risk from people living with HIV and perpetuating stigma. U=U is an effective and immediate response to HIV stigma.
• The Prevention Access Campaign was started to educate and inform people about U=U around the world. They worked with the different people who had conducted the research available at the time to clear up mixed messages and confirm U=U was true.
• They issued a consensus statement in July 2016, and created an advocacy video of people living with HIV from every key population demanding that this truth be shared with everyone living with HIV.
• New York City health department signed on to the consensus statement and confirmed it was true. At the same time Terrence Higgins Trust issued the first statement from a non-profit organisation confirming that when you are on effective treatment you cannot pass it on sexually.
• More organisations and federal health departments in the USA came on board.
• The campaign started to go viral internationally. Because of the unique collaborations (or partnerships) between activists, public health officials and researchers, the campaign grew.
• As of November 2021 there were 1,050 partner organisations from 104 countries signed on to the campaign to get this message out and commit to sharing this with people with HIV, healthcare providers, policymakers and the public.
• It is now referenced in the leading medical journals of the world including The Lancet.
• The World Health Organisation agrees with U=U and National Guidelines have been updated to include U=U in many countries around the world.
• U=U is now seen in popular culture, with Welsh rugby player Gareth Thomas sharing his story in the UK and reality show star Jonathan Van Ness talking about U=U, which educates the public and policy makers.

All of us have a responsibility and an opportunity to share the U=U message. Not just sexual health educators or HIV clinicians, but everyone.

When you share the message of U=U, be definitive with your language and state that a person living with HIV who is on treatment and has an undetectable viral load cannot transmit HIV sexually.

When talking about U=U, be clear about risk.

Don't use terms like:

• negligible
• greatly reduces
• extremely unlikely
• virtually impossible
• close to zero
• helps prevent
• makes it hard to transmit.

Do use phrases like:

• can’t pass it on
• can’t transmit
• no risk
• zero risk
• prevents HIV
• eliminates onward transmission.
• impossible.

When you exaggerate the risk for people living with HIV, you put the lives of people living with HIV at risk. Even conveying there is a little window of risk can be tremendously damaging.

Globally, people living with HIV are suffering from social rejection, isolation, depression, suicide, intimate partner violence, prosecution and murder because they and others think they are infectious when they are not. So the language that we use really matters.

• Educate all staff in U=U basic science and communications, including people at your front desk (and everyone you know).
• Communicate clearly, confidently and consistently as people may need to hear it in different ways in order to accept it. We also need to be conscious in the way we communicate, so as not to shame anyone who doesn’t have an undetectable viral load. 
• Connect to the Prevention Access Campaign: join as a community partner and take part in social media using the hashtag #UequalsU

• The Prevention Access campaign
• World Health Organisation guidelines
• Gareth Thomas in conversation with Professor Chloe Orkin.
• Myths around HIV transmission
• The evidence supporting U=U
• Talking to patients about U=U

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