Associations between exposure to the U=U message and perceived HIV stigma among both the HIV and non-HIV adult populations in South Africa

Abstract

INTRODUCTION HIV stigma is a major barrier to care in South Africa, the country with the world’s largest HIV epidemic. The educational message ‘Undetectable Equals Untransmittable’ (U=U) may mitigate stigma. We examined the percentage of South African adults believing the U=U message and the associations with perceived stigma. METHODS We analyzed data of South Africans aged ≥18 years from two sources: 1) The 2017–2018 South African National HIV Prevalence, Incidence, Behavior and Communication Survey (n=26875). HIV status was ascertained using both laboratory confirmation and self-reports. U=U belief was an affirmative response to the statement ‘the risk of HIV transmission through sex can be reduced by an HIV-positive partner consistently taking drugs that treat HIV’; and 2) The 2019 Positive Perspectives Study of people living with HIV (PLHIV) on treatment (n=179) was analyzed to describe provider-administered U=U counseling. Data were analyzed using descriptive and multivariable approaches (p<0.05). RESULTS Overall, 20.0% of South African adults aged ≥18 years were HIV seropositive. Only 55.6% of those reporting they were living with HIV believed that the risk of HIV transmission through sex can be reduced by an HIV-positive partner consistently taking drugs that treat HIV (52.9% among non-HIV individuals, p=0.1915). U=U belief among PLHIV was associated with less likelihood of internalizing stigma. For example, the likelihood of refusing to care for a family member with AIDS was significantly lower among PLHIV with vs without belief in U=U (adjusted prevalence ratio, APR=0.38; 95% CI: 0.16–0.92). Among the non-HIV population, U=U belief was also inversely associated with stigma sentiments directed at PLHIV. Among PLHIV on treatment surveyed in the Positive Perspectives study, close to 1 in 3 (30.2%) indicated their healthcare provider had not discussed U=U with them. CONCLUSIONS The U=U message may help reduce perceived stigma. Incorporating it into HIV policies, guidelines, and service delivery in South Africa may benefit public health.