Awareness and use of Undetectable=Untransmittable (U=U) among gay, bisexual, and other men who have sex with men in five Asian countries: results of the Asia Pacific MSM internet survey


BACKGROUND: The global Undetectable=Untransmittable (U=U) campaign informs people that a person living with HIV who is on antiretroviral therapy (ART) with undetectable viral load (UVL) cannot sexually transmit HIV. However, the extent of U=U awareness among gay, bisexual, and other men who have sex with men (GBM) in many Asian countries is unclear.
METHODS: An online cross-sectional survey targeting GBM in Indonesia, Japan, Malaysia, Thailand, and Vietnam was conducted from May 2020'January 2021. Factors independently associated with U=U awareness were determined by multivariable logistic regression, stratified by HIV status.
RESULTS: We recruited 15,872 participants (Indonesia=1,342; Japan=7,452; Malaysia=849; Thailand=1,566; Vietnam=4,663). Overall, 6.8% were HIV-positive, 46.2% HIV-negative, and 47.0% of unknown-status. Overall, 35.9% were aware of U=U, 44.8% had never heard of it prior to the survey, and 19.3% were not sure. U=U awareness varied by country (Indonesia=27.6%; Japan=41.1%; Malaysia=39.3%; Thailand=33.4%; Vietnam=30.2%; p<0.001) and by HIV status (HIV-positive=75.5%; HIV-negative=43.8%; unknown-status=22.4%; p<0.001). Among HIV-positive men, factors independently associated with U=U awareness included: university education (p=0.014); reporting any condomless anal intercourse (CLAI; p=0.004); currently being on ART (p<0.001); having UVL at last test (p<0.001); and having fewer experiences of sexuality-related stigma (p=0.002). Among non-HIV-positive men, U=U awareness was associated with: being older (p=0.002); being 'out' to more people (p<0.001); university education (p=0.003); identifying as gay (p=0.009); reporting sex with >10 male partners in the previous year (p=0.001); having an HIV test in the previous year (p<0.001); and currently taking PrEP (p<0.001). Of 4,707 men reporting CLAI with a regular partner in the previous 12 months, 30.4% had used UVL to prevent HIV transmission (HIV-positive men=75.2%; non-HIV-positive men=25.1%; p<0.001). Among 1,797 men reporting CLAI with casual partners, 22.8% reported using UVL to prevent transmission (HIV-positive men=70.2%; HIV-negative men=17.2%; p<0.001).
CONCLUSIONS: Two-thirds of GBM were not aware that U=U and one-quarter of HIV-positive men lacked this awareness. While a large proportion of HIV-positive men used UVL to prevent transmission when having CLAI, this was uncommon among non-HIV-positive men. Such a situation significantly challenges the ability of GBM to utilise proven safer-sex options and diminishes opportunities to disrupt pervasive stigma experienced by people living with HIV.

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