Research has shown that people living with HIV who are on antiretroviral treatment and whose viral load is consistently undetectable cannot transmit the virus to their sexual partners. However, that information has not been made widely available to people living with HIV, panelists at a recent webinar sponsored by Positive Women’s Network – USA (PWN-USA) pointed out. To combat this lack of knowledge, PWN-USA produced a video entitled “U=U,” the shorthand for “undetectable = untransmittable.”

In the video, four women living with HIV recount their experiences when they first learned that they had seroconverted and when they discovered that they could not transmit the virus because their viral load is undetectable. The video also provides brief explanations of terms, such as “viral load” or “CD4 count,” and explains the difference between “viral suppression” and “an undetectable viral load.” It was presented publicly for the first time during this webinar.

The panelists were all four video participants, representatives of organizations working to spread this information, and Ben Young, M.D., Ph.D., senior vice president of the International Association of Physicians in AIDS Care (IAPAC) and a practicing HIV physician. Young noted that while research has focused on people living with HIV who are on antiretroviral treatment, the principle of U=U also applies to long-term nonprogressors or elite controllers, two groups of people whose bodies are able to keep HIV in check without medication.

Insufficient research exists on how an undetectable viral load affects breastfeeding by HIV-positive women, Shannon Weber of HIVE noted. She pointed out that there are already two sets of guidelines recommending exclusive formula feeding in the U.S. and six months of exclusive breast-feeding in countries where clean water is not easily available. Her organization’s website includes information to help women decide whether to breastfeed. Women living with HIV who are concerned that deciding to breastfeed in the U.S. could subject them to charges of child neglect should seek help from a trusted provider in their area to determine local regulations and practices, she recommended.

Another legal issue potentially impacted by U=U is the criminalization of HIV itself. Many U.S. states currently have laws on the books that require people living with HIV to disclose their status before having sex. In some cases, even disclosure is not enough and the act of having condomless sex while living with HIV is by itself grounds for prosecution. U=U has been used as a defense in some of these cases, Bruce Richman of Prevention Access Campaign noted. He warned, however, that changing these laws to include undetectable viral load as an exception could lead to labeling people with detectable viral loads, who are often already marginalized, as “the dangerous ones,” further marginalizing them. Instead, HIV criminalization laws must be rewritten from the ground up, Weber demanded. IAPAC plans to issue an international statement on law and HIV early next year, Young said.

There is a “third U” to the U=U campaign, Richman explained: unequal access. Undetectable viral loads can only be achieved if people living with HIV can obtain appropriate care and the necessary medications. Thus, U=U can be used as another argument for treatment access, he said: Providing HIV-positive people with HIV care and drugs to enable them to achieve an undetectable viral load protects people not living with the virus from seroconverting. However, simply making HIV care available may not be enough, said Tiommi Luckett, one of the women in the video. The provider’s environment must also be perceived as welcoming to LGBTQ folks who may not return to a medical office where they feel stigmatized, she added.

In serodiscordant relationships, pre-exposure prophylaxis (PrEP) is no longer strictly necessary if the partner living with HIV has a sustained undetectable viral load, Richman explained. However, PrEP may still be helpful in some situations. In the end, individuals and couples need to have as much information as possible to allow them to decide what is best for them, said Shyronn Jones, another video participant. This includes information on PrEP, U=U, treatment as prevention (TasP), and post-exposure prophylaxis (PEP), she added. It is up to the couple to decide whether to use condoms when the partner living with HIV has an undetectable viral load. The women in the video recounted different experiences with that issue, but as Jones put it, “U=U has greatly reduced my stress” about transmitting the virus.

Prevention Access Campaign has also produced a video about U=U. Its website also features resources for sharing information about this issue.