Gay, bisexual, and queer men’s confidence in the Undetectable equals Untransmittable HIV prevention message: longitudinal qualitative analysis of the sexual decision-making of pre-exposure prophylaxis users over time

Abstract

Background Our objective was to understand what gay, bisexual, and queer men (GBQM) who had experience using pre-exposure prophylaxis (PrEP) thought about the ‘Undetectable equals Untransmittable’ (U=U) message and how it informed their sexual decision-making over time. Methods We conducted annual longitudinal qualitative interviews (2020–22) with 17 current or former PrEP users as part of a mixed-methods implementation science study examining barriers and facilitators to PrEP awareness, access, and adherence. Over 3 years, 47 interviews were conducted with GBQM in Ontario, Canada. Interviews were transcribed verbatim and coded in NVivo following reflexive thematic analysis. Results Participants’ sexual health decision-making was informed by their confidence in biomedical HIV prevention and the person taking medication (i.e. themselves using PrEP versus a real/imagined person living with HIV (PLHIV)). Longitudinal narratives of U=U clustered around four overarching themes: (1) U=U confidence (i.e. increasing trust in U=U irrespective of their PrEP use); (2) PrEP confidence (i.e. accounts of self-reliance and PrEP as sufficient HIV protection); (3) combination confidence (i.e. trusting U=U and PrEP as a package); and (4) partner confidence (i.e. potential ‘distrust’ of U=U due to uncertainties about partners’ medication adherence). Overall, men described increased sex with PLHIV over time, including some participants who, during earlier interviews, said they would ‘never be comfortable’ with serodifferent sexual partners. Conclusions GBQM’s use of PrEP shaped how they thought about U=U and sex with PLHIV. Although many GBQM embraced treatment as prevention/U=U as significant to their sexual lives, longitudinal analysis revealed its varied and uneven adoption across participants and time.

Global evidence, impact and implementation of U=U

“…In a longitudinal qualitative analysis conducted by Grace et al, the researchers examined the confidence levels of GBM who had experienced using pre-exposure prophylaxis in Canada regarding the U=U message. 6 The study found that participants' confidence in U=U increased over time, leading them to feel comfortable engaging in sexual activities with partners who had undetectable viral loads. However, it is important to note that some participants still harboured reservations and did not fully trust U=U.…”

2023 Undetectable = Untransmittable global policy roundtable report: a multistakeholder perspective on Undetectable = Untransmittable research and policy priorities

“…There was widespread consensus that although awareness of U=U is increasing, knowledge and trust in U=U is uneven, and predominantly concentrated among people living with HIV who are connected to gay, bisexual and queer communities. 6,[12][13][14][15][16][17][18][19] Among other populations at heightened vulnerability to HIV acquisition, awareness and trust of U=U is more limited. [20][21][22] Participants identified a need for members of all priority populations, including women, Indigenous and First Nations peoples, racially minoritised groups, migrants, people who use drugs, and sex workers to be explicitly included in policies that utilise and promote U=U.…”