Awareness of U=U among sexual and gender minorities in Brazil, Mexico and Peru: differences according to self-reported HIV status

BACKGROUND: The slogan 'Undetectable=Untransmittable' (U=U) was created to translate the message that people living with HIV (PLHIV) using antiretroviral treatment (ART) with undetectable viral load will not transmit HIV to sex partners. We describe U=U awareness among sexual and gender minorities (SGM) in Latin America and investigate differences by self-reported HIV status.
METHODS: We conducted an online survey among SGM ('¥18 years) living in Brazil, Mexico, and Peru during 2021. We used Poisson regression to calculate prevalence ratios of factors associated with awareness of U=U stratified by self-reported HIV status (PWH, negative and unknown). First, we estimated initial models (Model A), including socio-demographic factors (country, gender, age, race, education, and income) and then subsequent models (Model B), including risk behavior, ever taking PrEP, and HIV risk perception for HIV-negative/unknowns or taking ART for PLHIV.
RESULTS: A total of 21,374 respondents were included (Brazil: 61%, Mexico: 30%, Peru: 8%); median age was 32(IQR:26-39), 96% cisgender man, 57% Black/Mixed-race; 3% <secondary education and 23% <minimum wage. Among HIV-negative (16338/21374; 76%) and unknown status (2169/21374; 10%) SGM, 9% reported high self-perceived HIV risk, 58% were classified as high-risk for HIV, and 13% ever used PrEP. Among HIV-positive SGM (2867/21374; 10%), 93% were using ART. Awareness of U=U was 89% in both Brazil and Mexico, higher than Peru 65%. Awareness of U=U was higher among HIV-positive (96%) than negative (88%) and unknown (69%) SGM. In multivariate models, U=U awareness was lower among lower-income and Black/Mixed-race SGM. Among HIV-negative SGM, trans/non-binary had lower awareness of U=U compared to cisgender men, while those reporting high HIV-risk and ever using PrEP had higher awareness.

Characteristics	PLHIV Model A	PLHIV Model B	HIV Negative Model A	HIV Negative Model B	Unknown HIV Status Model A	Unknown HIV Status Model B
Country (ref. Brazil) Mexico Peru	1.04 [1.03-1.06] 0.93 [0.88-0.98]	1.04 [1.02-1.05] 0.92 [0.87-0.97]	1.02 [1.01-1.04] 0.78 [0.75-0.82]	1.01 [0.99-1.02] 0.79 [0.76-0.83]	1.01 [0.95-1.08] 0.59 [0.51-0.68]	0.95 [0.89-1.00] 0.60 [0.51-0.71]
Trans/non-binary (ref. Cisgender men)	0.96 [0.91-1.01]	0.97 [0.92-1.02]	0.91 [0.88-0.95]	0.95 [0.92-0.99]	0.89 [0.77-1.04]	0.90 [0.77-1.06]
Age 25+ (ref. Age 18-24)	1.00 [0.96-1.03]	0.98 [0.95-1.02]	1.00 [0.98-1.02]	1.01 [0.99-1.03]	0.97 [0.90-1.03]	0.96 [0.90-1.02]
Black/Mixed-race (ref. White)	0.98 [0.96-1.00]	0.99 [0.97-1.00]	0.98 [0.97-1.00]	0.98 [0.98-1.00]	0.95 [0.90-1.01]	0.95 [0.89-1.01]
<Secondary education (ref. >0=secondary)	0.97 [0.91-1.03]	0.96 [0.90-1.02]	0.86 [0.81-0.90]	0.91 [0.86-0.96]	0.79 [0.66-0.95]	0.86 [0.71-1.04]
<Minimum wage (ref. >=Minimum wage)	0.97 [0.94-0.99]	0.98 [0.96-1.00]	0.94 [0.92-0.95]	0.95 [0.93-0.96]	0.93 [0.87-1.00]	0.95 [0.88-1.01]
ART use / PrEP use	-	1.18 [1.09-1.26]	-	1.07 [1.06-1.08]	-	0.98 [0.75-1.29]
High HIV risk perception	-	-	-	0.99 [0.97-1.01]	-	1.02 [0.91-1.14]
>=10 (ref. <10, MSM risk index)	-	-	-	1.01 [1.01-1.03]	-	1.01 [0.95-1.07]

CONCLUSIONS: Awareness of U=U varied according to HIV status, sociodemographic characteristics, and HIV risk behavior. Broad educational strategies, including teaching U=U , focusing on SGM vulnerable to HIV infection are urgent to decrease stigma against PLHIV.

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