U=U is short for “Undetectable = Untransmittable”, meaning that when people living with HIV have an undetectable viral load, they do not transmit HIV to their sexual partners. On the basis of the cumulative evidence to date, community members and leading researchers have endorsed U=U messaging. An individual is deemed “undetectable” when their viral load cannot be identified by a viral load test because the amount of HIV in their blood is below a certain threshold. In Ontario, if someone sustains a suppressed viral load for at least six months (of 200 copies or less of the virus), their HIV is considered to be untransmittable.

People living with HIV can achieve and sustain an undetectable viral load over time by adhering to treatment. However, this does not mean that someone is cured of HIV. If anti-retroviral drugs are not taken consistently, the virus will begin replicating again and the viral load will become detectable.¹ U=U: A guide for service providers [Internet]. [cited 2019 November 16]. Available from: https://www.catie.ca/en/uu-guide-service-providersThe U=U campaign builds on the concept of Treatment as Prevention (TasP). TasP emphasizes the importance of HIV treatment in reducing the onwards transmission of the virus, in addition to improving the health of people living with HIV.

There are significant concerns that the promise of U=U is not fully reaching ACB communities. Knowledge of U=U is not uniformly distributed, especially among people living with HIV and the health and service providers with whom they interact. Though U=U may be a tool to strengthen patients’ motivation to initiate and adhere to treatment, this relies on the existence of an enabling environment that facilitates treatment initiation and adherence in the first place. Important barriers like stigma, discrimination and anti-Black racism influence health seeking behaviour and can impact health outcomes. Data shows that ACB populations have lower Care Cascade outcomes in Ontario: viral suppression among clients on ART is 92.7% for ACB people compared to 95.5% for non-ACB people. Other related barriers include: challenges related to immigration/migration; criminalization of HIV non-disclosure; lack of universal coverage for prescription drugs; treatment initiation delays; food insecurity; living in a service desert; low levels of formal education and/or English language skills; treatment failure; over-policing, incarceration and lack of post-incarceration support; lack of affordable housing; and mental health and addiction issues.

While the U=U message means that people living with HIV who have attained an undetectable viral load can have condomless sex without fear of transmission, it is important to remind individuals that they could still be the subject of criminal prosecution despite what the science says. Remember that ACB people living with HIV are disproportionately affected by the criminalization of HIV non-disclosure.² Mykhalovskiy E, Hastings C, Sanders DC, Hayman M, Bisaillon L. “Callous, Cold and Deliberately Duplicitous”: Racialization, Immigration and the Representation of HIV Criminalization in Canadian Mainstream Newspapers [Internet]. Rochester, NY: Social Science Research Network; 2016 Nov [cited 2017 May 14]. Report No.: ID 2874409. Available from: https://papers.ssrn.com/abstract=2874409

There is a need to develop ACB-specific messaging and materials that speak to the realities of ACB people, and for health providers and service organizations to share this information with their clients. These materials should address misconceptions (i.e. undetectable viral load means one is cured) and the concern of some community members that U=U contradicts decades of public health messaging around safer sex practices.

It is critical that we improve models of care to eliminate gaps in the HIV prevention, engagement, treatment and care cascade in Ontario. Using a holistic and client-centred approach means that we look at a client through the lens of their mind, body and spirit, and not merely as a set of symptoms to be addressed. Respecting clients’ dignity and autonomy is another essential piece of this work. Peer engagement with other ACB people living with HIV, psychosocial support and regular viral load testing have also been identified as important enablers for getting people to “undetectable”.

Click here to see more information about U=U 

Pre-exposure prophylaxis (PrEP) is a highly effective HIV prevention strategy. It involves someone who is HIV-negative taking daily HIV treatment to prevent HIV. PrEP is part of a combination prevention package that includes regular medical check-ups, HIV and STI testing, and adherence and risk reduction counselling.

There are several tools to help providers build their capacity to prescribe PrEP and support individuals who are taking it. These include national clinical guidelines for PrEP³ Tan DHS, Hull MW, Yoong D, Tremblay C, O’Byrne P, Thomas R, et al. Canadian guideline on HIV pre-exposure prophylaxis and nonoccupational postexposure prophylaxis. Can Med Assoc J. 2017 Nov 27;189(47):E1448–58.and a comprehensive Ontario website dedicated to PrEP and PrEP access: ontarioprep.ca.

Knowledge and uptake of PrEP in ACB communities is relatively low. Focus groups conducted with ACB individuals in Ontario revealed common misperceptions regarding the difference between PrEP and post-exposure prophylaxis (PEP), whether it is covered by various insurance plans and how to access it.⁴ Zhabokritsky A, Nelson LE, Tharao W, Husbands W, Sa T, Zhang N, et al. Barriers to HIV pre-exposure prophylaxis among African, Caribbean and Black men in Toronto, Canada. PLoS ONE. 2019 Mar 29;14(3):e0213740. doi: 10.1371/journal.pone.0213740.Another prevailing belief was that PrEP was only for gay men and not for women or heterosexual men. When accurate information was provided to focus group participants, the majority approved of PrEP as an HIV prevention option.

The willingness to take PrEP likely varies across different segments of the community. For example, one study on PrEP uptake amongst ACB men in Toronto found that ACB GBMSM were more likely to accept PrEP than ACB men who reported only having sex with women. Young ACB men and those born in Canada exhibited the lowest uptake. Low self-perceived risk and concerns regarding side-effects were the main reasons cited by participants who chose not to take PrEP.⁵ Zhabokritsky A, Nelson LE, Tharao W, Husbands W, Sa T, Zhang N, et al. Barriers to HIV pre-exposure prophylaxis among African, Caribbean and Black men in Toronto, Canada. PLoS ONE. 2019 Mar 29;14(3):e0213740. doi: 10.1371/journal.pone.0213740.

According to the focus group research cited earlier, the level and quality of care and sexual health information available from an individual’s primary care doctor or specialist clinic had a great deal of influence on their decision to start taking PrEP. The majority of participants, who had not taken PrEP, stated that their preferred mode of access would be from an AIDS service organization. The main barriers identified in this study were HIV-related stigma and mistrust of non-HIV specialist health providers. When asked how stigma prevented them from accessing PrEP, participants described fears of receiving an HIV-positive diagnosis in the process of trying to start PrEP, as well as the challenges associated with explaining this tool to sexual partners who might assume that the individual is living with HIV.

There is a need for integrated, community-based approaches to HIV prevention in ACB communities, and PrEP education and services are no exception. Many community members would trust the recommendation to begin taking PrEP if it came from a service provider with an understanding of ACB experiences.

Check out this site for more information on PrEP in Ontario: ontarioprep.ca 

GROUP SKILLS BUILDING
A fundamental goal of HIV prevention is to change the behaviours that put individuals at risk of infection. These individual-level behavioural interventions seek to influence knowledge, attitudes, and behaviours, such as promotion of sexual-health education and personal empowerment for people at risk of or living with HIV.

Programs that deliver education and skills-building experiences to small groups have been successful in reducing behavioural risks in ACB communities. These interventions are often targeted to specific populations, such as youth, GBMSM, women or people living with HIV.

FAITH-BASED INTERVENTIONS 
According to the literature, faith-based interventions are a culturally relevant and effective method to deliver HIV prevention and education within ACB communities. Faith-based organizations have considerable power in influencing behaviour. Through their broad presence in ACB communities, faith-based organizations have access to a wide audience and can be used to disseminate key prevention messages.

These programs show that public health, community-based services and faith-based communities can partner and develop successful collaborations. Limitations to working with faith-based organizations can include the unwillingness of faith leaders to discuss sensitive topics and an emphasis on abstinence versus comprehensive sex education or risk-reduction strategies. Strengths include their captive audience of youth, parents and potential volunteers; their community credibility; and their potential to reach youth and adults outside of their communities in Canada.⁶ OHTN. Effective HIV prevention, education and outreach activities in African, Caribbean and Black communities. 2014.

PEER-LED INTERVENTIONS 
Community-based organizations have implemented peer-led HIV prevention interventions that engage community members in informal, non-intrusive settings. Such programs in Ontario have been largely successful at involving the broader community in preventing HIV, building rapport and developing culturally and linguistically appropriate tools.⁷ OHTN. Effective HIV prevention, education and outreach activities in African, Caribbean and Black communities. 2014.

Below you will find a link to HIV/AIDS service providers in Ontario. You can contact these organizations to find out more about their current programming and referral/partnership opportunities.