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REPORT BY THE NGO
REPRESENTATIVE
Undetectable = Untransmittable =
Universal Access (U=U=U):
A foundational, community-led global
HIV health equity strategy
Agenda item 1.4
13–16 December 2022 | Chiang-Mai, Thailand
UNAIDS Programme Coordinating Board
Issue date: 14 November 2022
UNAIDS/PCB (51)/22.29
Additional documents for this item: None
Action required at this meeting––the Programme Coordinating Board is invited to:
92. take note of the Report by the NGO Representative;
93. call upon Member States, UNAIDS and Cosponsors to:
o embed Undetectable = Untransmittable (U=U) in global, regional, national and subnational
health and/or HIV strategic plans;
o promote anti-stigma interventions, through updated comprehensive sexuality education
curricula and across the HIV combination prevention, testing, treatment and care cascade,
where community-led U=U initiatives and U=U research are well resourced; and
o ensure that U=U is leveraged to support expanded health equity efforts to improve the
health and well-being of people living with and affected by HIV, especially members of key
populations and other vulnerable groups, such as women and girls, adolescents and
young people, Indigenous Peoples, and migrants;
o accelerate progress to get the global HIV response back on-track to meet the SDGs by
fast-tracking equitable access to HIV combination prevention, testing, treatment, care and
support through the planning, costing, implementation, scaling up, and the monitoring and
evaluation of rights- and evidence-based community-led U=U programming, service
delivery and monitoring, including the accelerated expansion of viral load diagnostics and
viral load testing strategies without sacrificing other planned prevention and treatment
initiatives;
94. call upon UNAIDS to:
o utilize the growing body of evidence on the multimodal use of U=U, ensuring that U=U is
incorporated as a key health equity strategy and policy instrument to complement and
enhance the attainment of 2021–2026 Global AIDS Strategy targets (95–95–95, 10–10–
10, 30–80–60), including by:
▪ meeting HIV prevention and treatment targets;
▪ promoting initiatives to support health and allied professionals, law enforcement,
decision-makers, and members of key populations and other vulnerable groups;
▪ leveraging U=U for greater access to effective treatment, diagnostics and testing;
▪ promoting enabling and supportive environments at global, regional, national and
subnational levels; and
▪ supporting improved health outcomes, well-being and quality of life for people living
with HIV;
o convene a multi-stakeholder U=U working group co-led by WHO to support the
development of harmonized definition(s) of U=U as a health-equity strategy that is
designed to accelerate equitable, barrier-free access to affordable HIV treatments, health
commodities and health technology innovations within the HIV response. The multi-
stakeholder working group should advise on the following parameters:
▪ common policy definition(s) accompanied by evaluation metrics to support and
encourage consistency across policy, programming and technical guidance;
▪ common clinical standard(s) on viral load suppression, including the updating of such
definition(s) when new evidence becomes available;
▪ recommendations on appropriate multimodal strategies to be incorporated into
technical support to Member States and Co-sponsors on the integration and
implementation of U=U; and
▪ appropriate U=U targets and metrics to be included into routine Global AIDS
Monitoring and UBRAF reporting.
Cost implications for the implementation of the decisions: none
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Table of contents
Acronyms and abbreviations ................................................................................................. 4
Executive summary: .............................................................................................................. 5
Introduction ........................................................................................................................... 7
Methodology ......................................................................................................................... 8
Defining our terminology ....................................................................................................... 9
The landscape today ........................................................................................................... 11
Investing for impact: U=U = U, a foundational health equity strategy ................................... 15
Conclusion .......................................................................................................................... 23
Proposed decision points .................................................................................................... 24
Annexes .............................................................................................................................. 26
Case study 1: The Undetectable Viral Load Suppression Program (UND) for highly
vulnerable people living with HIV; Housing Works, USA........................................... 26
Case study 2: ICW Argentina ................................................................................... 27
Case Study 3: Building common understanding and tailoring key messaging on
Undetectable = Untransmittable in Asia-Pacific ........................................................ 28
Case study 4: ICASO global community survey 2022: what drives U=U? ................. 30
Case study 5: United States Centers for Disease Control and Prevention, on behalf
of the Vietnam Authority for AIDS Control and the Vietnam Network of People Living
with HIV and other community partners .................................................................... 31
Case study 6: Centre for Youth of Hope ................................................................... 32
Case study 7: A U=U public education and communication campaign ..................... 33
Case study 8: Public Health Center of the Ministry of Health of Ukraine ................... 35
Case study 9: Elizabeth Glaser Pediatric AIDS Foundation ...................................... 36
Case study 10: Blue Diamond Society ..................................................................... 37
Case study 11: Two Canadian studies working with community partners doing
community-based research related to U=U and HIV undetectability. ........................ 38
Case study 12: Media guidelines for reporting on U=U: working with journalists to
reduce stigma .......................................................................................................... 39
Case study 13: #DoubleKnowledge ......................................................................... 40
Case study 14: The use of U=U to promote equal access to viral load testing:
experience of community workers with MSM in Yaoundé, Cameroon ...................... 42
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Acronyms and abbreviations
AIDS
ARV
ART
CDC
CSE
Global Fund
HIV
NGO
PEPFAR
SDG
SRH
STI
U=U
UHC
WHO
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Executive summary
1. The latest UNAIDS data show that the pace of progress in preventing new HIV
infections continues to slow. Alarming numbers of new infections still occur each year
and far too many people living with or at risk of HIV remain without access to life-saving
treatment and prevention services.
1
2. Despite the many evidence-based strategies that chart paths to “a world free from
poverty, hunger, disease and want, and where all life can thrive”,
2
too many global
reports continue to show that we are not moving fast enough to end the social and
structural drivers of current pandemics. In some cases, entrenched inequities are
reversing hard-won gains.
3
4
5
Widening inequalities within and between countries are a
primary driver of HIV and other pandemics, including but not limited to tuberculosis,
malaria, cholera, Ebola, Monkeypox and COVID-19.
6
3. Undetectable = Untransmittable (U=U) is a concept that has been endorsed by
governments and diverse communities around the world. It has transformed the lives of
millions of people living with and affected by HIV, and HIV prevention, testing,
treatment, care and support generally. Robust evidence shows that U=U is a highly
effective approach for eliminating HIV stigma and discrimination through access to
information, knowledge (education) and advocacy that is tailored to local contexts and
communities. U=U has been described as "one of the most effective and historic
counter-narratives to HIV stigma".
7
4. This annual report by the NGO Delegation to the UNAIDS's Programme Coordinating
Board focuses on the untapped potential of U=U as a vital community-led, global HIV
health equity strategy. It describes how U=U can improve the health and quality of life of
people living with HIV, key populations and other vulnerable groups,
i
and it underscores
the fundamental role U=U can play in achieving the 95–95–95 treatment targets and in
ending AIDS by 2030.
5. In preparing this report, it was clear that U=U means many things to many people. For
the purpose of this report, U=U refers to a multimodal concept that is:
• based on biomedical evidence that a person with a suppressed viral load cannot
sexually transmit HIV;
• centred on the experiences and treatment needs of people living with HIV, while
supporting evidence-based combination prevention efforts for seronegative people
and those who still need to learn about their status;
• an advocacy campaign that arose from the collaborative efforts of people living with
HIV and leading scientists to ensure that people living with HIV have access to the
latest scientific evidence that can have a direct impact on their health, well-being
and quality of life;
• an expansion beyond the normative description of U=U as a biomedical and anti-
stigma intervention to a global movement led by people living with HIV to help
support people in attaining and maintaining optimal health, while also improving
outcomes in HIV prevention, diagnosis, care and treatment; and
• to be recognized as a new community-led health equity policy instrument following
the inclusion of U=U in the 2021 High-Level Political Declaration on HIV and AIDS.
6. Ending AIDS by 2030 requires ending inequality and inequity. It requires strengthening
the health and community systems that can better prepare the world to prevent, identify
i
Key populations and other vulnerable groups such as, women and girls, adolescents and young people, and
migrants who are disproportionately affected by HIV.
https://www.unaids.org/sites/default/files/media_asset/PCB49_Decisions_EN_.pdf
UNAIDS/PCB (51)/22.29
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and respond to future pandemics and health challenges.
8
9
Achieving the UNAIDS
global treatment targets means making good on commitments to global solidarity and
ensuring universal access to quality HIV combination prevention, testing, treatment,
care and support for all.
7. The report has six sections:
• an introduction to the topic of U=U, along with key terminology and a review of the
methodology used in developing the report;
• a review of the landscape to provide context for discussion of U=U as a global,
community-led HIV health equity strategy that harmonizes with the UNAIDS global
treatment targets of 95–95–95 and the Global AIDS Strategy (2021–2026);
• a discussion of critical issues related to U=U and specific areas of alignment with the
Global AIDS Strategy;
• a summary of key challenges and facilitators for U=U, including stigma and
discrimination; ensuring enabling environments to support marginalized communities
that are not yet engaged in U=U and the HIV treatment cascade; investments in
community systems, leadership and responses, including within global pandemic
prevention, preparedness and responses; and access to technology and innovation;
• proposed decision points for consideration by members of the PCB; and
• 14 illustrative case studies from government and nongovernmental partners
implementing U=U in regions across the world.
Key points
8. Limited and inequitable access to HIV combination prevention and testing services
means that not enough people know their HIV status and receiving life-saving HIV
treatment. This threatens their health and well-being and contributes to the ongoing
cycle of HIV transmission.
10
9. U=U represents a grassroots, rights-based, community-led public health paradigm shift
that repositions the understanding of what it means to be living full and healthy lives
with HIV without stigma, shame or the fear of transmitting HIV on to others.
10. The scientific evidence shows that effective antireretroviral therapy reduces viral loads
to such low levels that a person cannot transmit HIV to others. Yet, limited research has
been conducted on the applicability of U=U for all key populations and vulnerable
groups. This gap in research undermines the pursuit of health inequity and the
potentially powerful role of universal access to ART, diagnostics and sustained (health)
care in reducing new HIV infections.
11. The transformative and untapped potential of U=U is optimized when services are
designed and delivered in strategic and supportive partnership with facility-based and
community-led health providers, communities living with and affected by HIV, and
government programmes.
11
They:
• improve the well-being of people living with HIV by incorporating U=U in
comprehensive sexuality education, transforming the social, sexual, and
reproductive lives and legal rights of people living with HIV by freeing them from the
shame and fear of sexual transmission to their partners;
• challenge and dismantle deep-seated HIV-related stigma and discrimination and
public perception about HIV transmissibility;
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• support HIV combination prevention and treatment goals by reducing the structural
barriers and anxiety connected with testing and treatment; and
• advance an evidence-based public health and health equity argument for universal
access to HIV testing, diagnostics, treatment, and care that will support improved
health outcomes, save lives and prevent new HIV infections.
12
Introduction
12. The NGO Delegation to the UNAIDS Programme Coordinating Board (PCB) produces
an annual NGO report that is presented during one of the biannual PCB meetings. The
Delegation selects the topic of the report. The highest priority is given to a topic that is
timely, critically important to communities and civil society, and seen to require urgent
action at global and national levels in order to end AIDS by 2030.
13. This year’s NGO report focuses on the untapped potential of U=U as a vital community-
led, global HIV health equity strategy to improve the health and quality of life of people
living with HIV and contribute to the global treatment targets of 95–95–95 by advancing
universal access to antiretroviral therapy (ART), diagnostics and sustained care, while
reducing HIV transmission.
14. The NGO Delegation acknowledges the 2021 United Nations High-Level Political
Declaration on HIV and AIDS: Ending inequalities and getting on-track to end AIDS by
2030, the Global AIDS Strategy 2021–2026, and the WHO Global Health Sector
Strategies on, respectively, HIV, viral hepatitis and sexually transmitted infections (STIs)
and the recognition of Undetectable = Untransmittable (U=U) as a highly effective tool
for eliminating HIV-related stigma and discrimination, and its significant HIV prevention
benefits.
13
15. The report recalls UNAIDS’s support for the U=U concept in the 2018 UNAIDS
document Undetectable = Untransmittable: Public health and HIV viral load suppression
and the renewed call to action in the Global AIDS Strategy (2021–2026) to end
inequities. The Global AIDS Strategy 2021–2026 states the ambition to “fulfill the
potential of treatment as prevention” and to prioritize the “urgent implementation and
scale-up of evidence-based tools, strategies and approaches that will turn incremental
gains into transformative results … while importantly avoiding the artificial dichotomies
between treatment and prevention, focusing instead on fully leveraging the synergies
between combination prevention and treatment”.
14
“I as person living with HIV, who personally benefits from U=U because U=U is
about making sure I have access to optimal diagnostics, optimal treatment
regimens, affordable medicines, must adhere to my meds and be virally
suppressed in order to maximize benefits. However, there is also the collective
responsibility to create enabling ecosystems where being HIV+ or loving who we
want to love is not a criminalized offence. U=U will not be achieved where health
services are not available, viral loud not accessible, medicines not affordable. Then
the failure to achieve U=U is a government failure not mine.”
– Dr. Vuyiseka Dubula-Majola, Centre for Civil Society, University of KwaZulu-
Natal, South Africa
“We can win the fight to end pandemics, but only if we are bold enough to end the
inequalities which drive them.”
– Helen Clark, Co-chair of the Independent Panel for Pandemic Preparedness and
Response
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16. The NGO Delegation recognizes the transformative potential of U=U as an evidence
and rights-based global response that is driven by communities living with and affected
by HIV and their allies, as an embodiment of the principles the Greater Involvement of
People Living with HIV (the GIPA Principles) and the meaningful engagement of all
communities who are vulnerable to HIV.
17. This NGO report builds on a series of previous reports from the Delegation to the
UNAIDS Programme Coordinating Board, including but not limited to:
• Left out: the HIV community and societal enablers in the HIV response
(UNAIDS/PCB (49/21.24.rev1);
• If it is to be truly universal: Why universal health coverage will not succeed without
people living with HIV and other key populations, women and young people
(UNAIDS/PCB (45)/19.23);
• People on the move––key to ending AIDS (UNAIDS/PCB (43)/18.20);
• An unlikely ending: ending AIDS by 2030 without sustainable funding for the
community-led response (UNAIDS/PCB (39)/16.23);
• Sexual and reproductive health and rights of people most affected by HIV: the right
to development (UNAIDS/PCB (38)/16.4);
• When rights cause wrongs: addressing intellectual property barriers to ensure
access to treatment for all people living with HIV (UNAIDS/PCB (35)/14.19); and
• The equity deficit: unequal and unfair access to HIV treatment, care and support for
key and affected communities (UNAIDS/PCB (33)/13.16).
18. In developing this report, the Delegation collected community experiences and
reflections on key considerations about U=U, its current and potential benefits, and
important lessons learned from the COVID-19 pandemic. Key messages and
recommendations were developed in consultation with community and civil society
experts. They are presented here with a set of illustrative case studies of community
leadership and good practice research, policy and practice from around the world.
19. The NGO Delegation urges Member States and UNAIDS to take immediate and
accelerated action to tackle the challenges that continue to slow progress towards the
UNAIDS global targets and to act on the “untapped potential”
15
of U=U by taking to
scale this foundational, community-led, global HIV health equity strategy.
Methodology
20. Between July-September 2022, a mixed methods approach was used in preparing this
report, including:
• a literature review of more than 90 articles and publications, including UNAIDS
and other UN publications, peer-reviewed journal articles, reports, policy briefs, and
resources prepared by community-led groups and civil society partners.
• key informant interviews with 18 individuals, using a semi-structured question set.
Interviews done via zoom sought the perspectives, reflections and
recommendations of community and civil society activists, community-led service
providers, and representatives from governments and leading multilateral
organizations and UN partner agencies. Interviews were conducted across all
regions represented on the Delegation: Africa, Asia-Pacific, Europe, Latin America
and the Caribbean, and North America.
• case studies that were collected via an open call for submissions. Twenty case
studies were submitted by government and nongovernmental partners. They
feature examples of good practices and community recommendations at country,
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regional and global levels. They show how
community-led U=U has contributed to
increased and more equitable access and
improved uptake of testing, treatment and
care services across diverse communities
in low-, middle-, and high-income settings.
• a peer review process that entailed draft
iterations of the report being reviewed by
serving members of the NGO Delegation,
13 community and civil society experts,
representatives of key population across all
regions, and members of the UNAIDS
Secretariat.
21. The methods used were not intended to
provide quantitative data or to produce
measurements, numerical data or statistical
analysis. The report therefore does not provide
a quantification of knowledge, attitudes,
behaviours or practices in relation to U=U. The
intention is to provide a literature review and
qualitative data, including community and
expert opinions, by using a range of methods.
Defining the terminology
22. Undetectable = Untransmittable (U=U) refers to the scientifically proven fact that a
person living with HIV who is on effective ART that lowers the amount of virus in their
body to undetectable levels cannot sexually transmit HIV to another person. The low
level of virus in the blood is referred to as an undetectable viral load. This means that
the viral level is too low to be detected by viral load test or they are below an agreed
threshold (such as 50 copies/ml
16
or 200 copies/ml for undetectable viral load).
17
ii
23. An undetectable viral load is the first goal of ART.
18
When people living with HIV are on
treatment and have undetectable viral loads, they protect their own health and cannot
transmit HIV to their sexual partners.
19
U=U is achieved by knowing one’s status and by
having equitable access to effective HIV diagnostics, testing, treatment, care and
support to maintain viral suppression.
24. U=U is a crucial biomedical tool in a comprehensive HIV prevention toolkit, but it is also
much more than an instrument for successfully reaching the global 95–95–95 treatment
targets. It represents a rights-based, community-led public health paradigm shift that
reshapes understandings of what it can mean to live full and healthy lives with HIV
without stigma, shame or the fear of transmitting HIV to others.
ii
The UNAIDS Indicator Registry describes viral suppression as: “Individual-level viral load is the recommended
measure of antiretroviral therapy efficacy and indicates treatment adherence and the risk of transmitting HIV. A
viral load threshold of <1000 copies/mL defines treatment success according to the 2016 World Health
Organization's Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection.
People with viral load test result below the threshold should be considered as having suppressed viral loads …
Viral suppression among people living with HIV provides a benchmark for monitoring global targets over time and
a standardized indicator of HIV treatment and prevention success, critical to ending the AIDS epidemic. When
considered as a proportion of the number of people on treatment (the numerator of Indicator 2.2), this indicator
monitors the third 95 of the UNAIDS 95–95–95 targets: that 95% of the people receiving antiretroviral therapy will
have suppressed viral loads by 2025” (https://indicatorregistry.unaids.org/indicator/people-living-hiv-who-have-
suppressed-viral-loads#:~:text=Viral%20suppression%20is%20defined%20as,95%2D95%2D95%20target).
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25. The term U=U was pioneered by the Prevention Access Campaign (PAC) in 2016 as
part of an anti-stigma communication campaign that evolved into a global, community-
led movement of people living with HIV, HIV advocates, activists, researchers,
governments and other community and private sector partners who are committed to
end the AIDS epidemic. U=U has been integrated into local contexts and communities
in over 105 countries. For instance, communities in Viet Nam refer to U=U as K=K. In
Russian, it is referred to as N=N, in French and Spanish it is known as I=I, and in
Chinese, it is known as 測不到=不傳染.
26. Treatment as prevention is a biomedical HIV prevention approach that refers to any
HIV prevention method that uses ART to decrease the risk of HIV transmission through
sexual, blood-borne or through vertical transmission (pregnancy, childbirth and
breast/chest-feeding). The preventive effect stems from lowered community viral load
as a result of ART within a population. ART reduces the HIV viral load in blood, semen,
vaginal fluid, breastmilk and rectal fluid to very low levels, and as a result reduces HIV
transmission. Historically, many people living with HIV had concerns with the term
"treatment as prevention" because of its singular focus on prevention. U=U is centered
on both combination prevention and treatment.
iii
By combining the tools of U=U, pre-
exposure (PrEP) and post-exposure prophylaxis (PEP) supports a “status neutral
approach”, which supports people to reach and maintain their optimal health, while also
improving outcomes in HIV prevention, diagnosis, care and treatment.
20
27. PrEP is defined in the WHO 2021 Consolidated HIV guidelines as the use of
antiretroviral (ARV) drugs by HIV-negative people to reduce the risk of acquiring HIV
infection. Based on evidence from randomized trials, open-label extension studies and
demonstration projects, WHO recommended daily oral PrEP containing tenofovir in
2015 as an additional prevention choice for people at substantial risk of HIV infection.
28. The updated Consolidated guidelines on HIV, viral hepatitis and STI prevention,
diagnosis, treatment and care for key populations (July 2022) present important new
recommendations and guidance. This includes the use of long-acting, injectable
cabotegravir as an additional HIV prevention choice in combination prevention
approaches for people at substantial risk of HIV infection, including sex workers, gay
men and other men who have sex with men, people who inject drugs,
iv
people in
prisons and other closed settings, and transgender and gender-diverse people.
21
U=U,
PrEP and PEP, and other prevention technologies such as "post-exposure prophylaxis-
in-pocket",
v
the Dapivirine vaginal ring and long-acting injectable ARVs are crucial tools
for effective combination HIV prevention and treatment strategies. In 2021, WHO
released a conditional recommendation for the Dapivirine ring as an additional
prevention choice for women who are at substantial risk of HIV infection, as part of
combination prevention approaches.
22
iii
For a history of the evolution of U=U, please see: U=U taking off in 2017. Lancet HIV. 2017;4(1):e475
(www.thelancet.com/journals/lanhiv/article/PIIS2352-3018(17)30183-2/fulltext).
iv
“PrEP services for people who inject drugs and their sexual partners can provide benefits both in the prevention
of sexual transmission, and likely in the prevention of HIV, acquired through unsafe injection practices. PrEP
services should not replace needle and syringe exchange programs (NSPs). NSPs have the greatest impact in
preventing the transmission of HIV and other bloodborne infections, including hepatitis C (HCV) associated with
injecting drug use.” WHO Consolidated Guidelines, p. 50.
v
PIP refers to "post-exposure prophylaxis-in-pocket" and is used by individuals with low-frequency, high-risk, HIV
exposures. The approach involves providing selected patients with a 28-day prescription for PEP before
exposure occurs. See: https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(19)30152-5/fulltext.
UNAIDS/PCB (51)/22.29
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29. Post-exposure prophylaxis is the use of ARVs in emergency situations by people who
possibly have been exposed to HIV. PEP must be taken within 72 hours of exposure if it
is to be effective.
23
30. Community-led responses
vi
are actions and strategies that seek to improve the health
and human rights of their constituencies, and that are specifically informed and
implemented by and for communities.
24
U=U is a prime example of an effective
community-led response that has evolved into a grassroots-led global movement to
improve the health, well-being and quality of life of people living with HIV, while
contributing to HIV prevention efforts when people know their HIV status, are on
effective HIV treatment and are supported in maintaining an undetectable viral load.
31. Community-led organizations
vii
are groups and networks in which the majority of
leadership, staff, spokespeople, membership and volunteers represent the experiences,
perspectives and voices of their constituencies and which have transparent
mechanisms of accountability. Community-led organizations, groups and networks are
self-determining and autonomous, and are not influenced by government, commercial
or donor agendas. Not all community-based organizations are community-led.
25
32. Community-based responses are delivered in settings or locations outside formal
health facilities and are run by civil society organizations.
26
33. Community systems strengthening refers to the development and fortification of
informed, capable and coordinated communities that work to achieve improved health
through their involvement in the design, delivery, monitoring and evaluation of health-
care services and programmes, including for HIV, COVID-19 and other ongoing
pandemics. Resilient health and community systems are the essential building blocks
for progressing towards universal health coverage (UHC), and all the Sustainable
Development Goals (SDGs). They are foundational for effective, efficient and
sustainable responses to HIV and other health-related threats.
27
28
The current landscape
34. In 2021, the world marked 40 years since the first cases of AIDS were reported. In
settings where investments have matched ambitions, we have had four decades of
progress in tackling one of the deadliest and most complex pandemics of modern
vi
Discussions about the definitions of community-led organizations and community-led responses are ongoing in
the context of the work of a MultiStakeholder Task Team on Community-Led AIDS Responses, at the request of
the UNAIDS Programme Coordinating Board. The definitions were conceived as umbrella terms, inclusive of the
leadership of people living with HIV, key populations, women and youth in all their diversity. The definitions under
discussion can be accessed here.
vii
Ibid
“End AIDS by ending inequalities, and because inequalities affect access to testing,
diagnostics, treatment and care, it also affects U=U”.
– Community member, Latin America and Caribbean region
Never before has it been more clear that increasing access to treatment, including
addressing ARV stock-outs, ending criminalization and removing barriers to U=U
not only saves the lives of people living with HIV, but also prevents new
transmissions, reduces health-care costs and burden, contributes to economic
growth, and accelerates progress toward ending the epidemic.
– The Win-Win agenda, Prevention Access Campaign, 2022
UNAIDS/PCB (51)/22.29
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times.
29
Yet, despite the sophisticated knowledge about HIV and an extensive evidence
base of effective approaches to prevention, treatment, care and support, the world is not
on-track to meet the global commitment to end AIDS as a global public health threat by
2030.
30
HIV remains an urgent global health crisis.
31
35. The COVID-19 pandemic continues to wreak havoc on health and social systems,
plunging the economies of households, communities and entire nations into crisis.
COVID-19 continues to lay bare the underinvestment in public health systems and
social protection,
32
ongoing inequalities, glaring fissures in the social fabric, and the
impact of social and structural barriers on efforts to achieve the 2030 Agenda for
Sustainable Development.
33
36. Status reports by UNAIDS and other global entities continue to show that HIV infections
and AIDS-related deaths are not decreasing quickly enough to reach the 2030 targets.
34
Globally, more than 13 000 deaths a week are attributed to HIV
35
and an estimated 7.7
million AIDS-related deaths will occur in the current decade if the international
community fails to build on the gains and meet the commitments made in the 2021
Political Declaration on HIV and AIDS.
36
37. The global scale-up of and access to life-saving ART is widely recognized as one of the
greatest achievements of the global HIV response to date.
37
However, while some
countries have succeeded in drastically reducing HIV morbidity and mortality, progress
has been uneven within and between countries.
38
HIV continues to affect millions of
people and communities around the world.
39
38. The UNAIDS Global AIDS Strategy targets for 2030 require that countries provide
effective HIV combination prevention options to at least 95% of all people at risk of HIV;
ensure that at least 95% of people living with HIV are aware of their HIV status; ensure
that at least 95% of people who know their status are on effective HIV treatments; and,
that at least 95% of all people on HIV treatment achieve viral suppression.
40
39. In 2021, approximately 85% of all people living with HIV knew their HIV status. That
meant that about 6 million people did not know they were living with HIV.
41
Approximately 88% of people who knew their HIV status were accessing treatment and
92% of those on treatment were virally suppressed.
42
40. Of the estimated 38.4 million people living with HIV, approximately 10 million are not
receiving the quality information, testing, treatment, and care that is necessary to reach
U=U and protect their health, while being relieved from stigma and anxiety around
onward transmission.
43
For many people living with HIV who have access to quality
treatment and services, the virus is a manageable, lifelong condition. With appropriate
support, people can manage their health in ways that fit their daily lives and can be
empowered to achieve undetectable viral load levels.
44
41. U=U harmonizes well with the UNAIDS global treatment targets because it envisions a
world where, in the absence of an HIV vaccine, or cure, people living with HIV can
improve the quality of their lives and halt the sexual transmission of HIV. This can be
“In this time of COVID-19, there is a significant risk that political attention to and
financing for HIV will drift. If we do not take the steps needed to tackle the inequalities
driving HIV today, not only will we fail to end the AIDS pandemic, we also will leave our
world dangerously unprepared for future pandemics”.
– Helen Clark, Co-chair of the Independent Panel for Pandemic Preparedness and
Response
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achieved by knowing one’s HIV status and having equitable access to effective
treatment, testing and the supports necessary to achieve and maintain viral
suppression.
42. Common clinical standard(s) on viral load suppression and policy definition(s) of U=U
are crucial to leverage U=U as a policy tool to advance health equity, with appropriate
monitoring and evaluation metrics. Making U=U a reality for all people living with HIV
improves individual and population health, transforms the lives of people living with HIV,
and is essential for accelerating progress towards ending the pandemic.
45
43. HIV is both a cause and a consequence of poverty and inequity.
46
47
In all HIV settings,
barriers to combination prevention, treatment, care and support occur at the individual,
interpersonal, community and societal level.
48
Stigma, discrimination, criminalization,
gender-based violence, poverty and a range of social, racial, age and gender
inequalities and social and structural determinants of health continue to fuel HIV
epidemics. They often exact the heaviest toll on populations that experience higher
disease mortality and morbidity and that have lower access to life-saving prevention,
treatment, care and support programmes and services.
49
44. Key and vulnerable populations
viii
face multiple and intersecting inequities that expose
them to higher risks of HIV and other life-threatening infections and that subject them to
social exclusion and marginalization in society (Figure 1).
50
51
52
Key and vulnerable
populations include sex workers, people who inject drugs, people in closed settings
such as prisoners, transgender people, gay and bisexual men and other men who have
sex with men, adolescent girls and women, Indigenous peoples and mobile populations.
45. Gender inequality and gender-based violence continue to drive the heightened risk of
HIV infection experienced by women and adolescent girls. Approximately 5,000 young
women worldwide aged 15–24 years become infected with HIV weekly. In sub-Saharan
Africa, women and girls accounted for 63% of all new HIV infections in 2021.
53
Combination prevention approaches that include U=U, PrEP, PEP, and the Dapivirine
vaginal ring must be integrated into comprehensive sexuality education (CSE) for
improved sexual and reproductive health (SRH) and rights of women and girls, boys
and men, trans and gender diverse people. If the underlying inequities are addressed,
prevention and treatment outcomes will improve (Figure 1).
46. The NGO Delegation sees health inequity as a normative concept that describes
systematic differences in health between population sub-groups that are unjust, unfair,
and avoidable or remediable.
54
47. An equity-oriented approach recognizes that systemic and structural inequality, rather
than solely individual behaviours and practices, are the root causes of health disparities
that drive the disproportionate impact of HIV on key and vulnerable populations. An
equity-oriented approach entails targeting population groups that have greater exposure
and vulnerability to risk of infection and lesser access to a continuum of quality, right-
based services that promote better health, well-being and quality of life.
55
This approach
embodies the SDG principle of leaving no one behind, and it applies to the vision of
viii
“Key populations or key populations at higher risk, are groups of people who are more likely to be exposed to
HIV or to transmit it and whose engagement is critical to a successful HIV response. In all countries, key
populations include people living with HIV, in most settings, gay men and other men who have sex with men,
transgender people, people who inject drugs and sex workers and their clients are at higher risk of exposure to
HIV than other groups. However, each country should define the specific populations that are key to their
epidemic and response based on the epidemiological and social context.” Global AIDS Strategy, footnote 9, p8.
UNAIDS/PCB (51)/22.29
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ending HIV as much as it does to pandemic prevention, preparedness and response,
and other global goals such as UHC and the SDGs more broadly.
In the case of HIV, tackling the inequities that create the fault lines in the HIV care
continuum is needed to ensure that everyone with HIV knows their status and receives
the quality treatment, support and care they need to achieve viral suppression.
Outcomes of U=U will improve the health and well-being of all people living with HIV,
improve their quality of life, drive down rates of new HIV infections, reduce health-care
costs, and lead to a healthier society, which will contribute to economic growth.
Figure 1: Factors contributing to HIV, STIs and viral hepatitis in key populations
Source: WHO, 2022
56
48. The Global AIDS Strategy (2021–2026) uses an equity-oriented approach that
prioritizes actions to first reach key and underserved populations and to close the gaps
in access to prevention, treatment and care that undermine the benefits of ART. The
Strategy calls for “substantially greater prioritization of tailored, combination HIV
prevention packages, including scaling up underutilized prevention approaches and
community-led responses, such as comprehensive sexuality education, harm reduction
services, PrEP and U=U.”
57
49. A U.S.-based study conducted by Quan and others (2021) provides a strong cost-
effectiveness argument for equity-oriented HIV combination implementation strategies
in reducing long-term health care costs, as well as reductions to incidence-related
disparities and health inequity measures in racialized communities.
58
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50. Case study 1 (United States) provides a best practice example of how equity-focused
HIV combination prevention intervention strategies
59
within community-based care
settings can use U=U to address persistent disparities in viral load suppression and
barriers to care for highly vulnerable populations living with HIV. This work has led to
institutional policy changes and the use of the U=U health equity intervention by seven
additional service providers in 20 locations in the New York City region.
60
Investing for impact: U=U=U, a foundational health equity strategy
51. Despite the proven benefits of U=U, its application to other modes of transmission,
including breast- or chest-feeding and blood-borne transmission, is under-researched
and requires more attention, investment and policy/clinical guidance.
61
The need for
further research to address the current gaps in the U=U evidence base was noted in the
2021 Political Declaration on HIV and AIDS.
62
52. Clinical recommendations and guidelines on HIV and infant feeding are not
unequivocal. In resource-constrained parts of the world, the standard of care calls for
parents living with HIV to breast-feed their infants while on ART, but in high-income
countries public health guidelines call for replacement feeding.
63
Noted by public health
experts, civil society and community members, the complexity and confusion around
feeding guidelines in the era of U=U is challenging, particularly in contexts where HIV is
criminalized.
64
Existing studies demonstrate an extremely low to zero risk of HIV
transmission when the breast-feeding parent has sustained viral suppression.
65
66
67
68
53. Viral load tests are a key marker of treatment success. However, only 38% of people
living with HIV who receive ART currently have access to viral load tests. Access is
even more limited in some parts of the world, especially in countries with low HIV
prevalence and weak health systems. There is a need to invest in viral load technology
for U=U in low- and middle-income countries.
69
54. Pregnant people and parents living with HIV must have easy access to the information,
resources and structures to support their autonomy and informed decision-making when
considering their infant feeding options. Case study 2 (Argentina) presents research
findings from community-led research on the experiences and perspectives of cisgender
women living with HIV in Argentina, as well as recommendations for research, policy
and practice.
55. Similarly, there remains a dearth of research on the applicability of U=U for people who
use drugs. Evidence shows that people who inject drugs will not transmit HIV through
sexual activity if they have a suppressed viral load. Although earlier research (2013)
suggested that an undetectable viral load may also reduce the risk of HIV transmission
through needle-sharing, research findings remain inconclusive on this matter.
70
56. Also needed is research into the applicability of U=U for younger populations,
71
as well
as on how U=U could affect policy and clinical guidance for blood donations.
57. Given the scientifically proven benefits of effective ART that reduce viral loads to
undetectable levels in the blood, the limited research on the applicability of U=U for all
key populations and other vulnerable groups compounds health inequities and
undermines HIV prevention efforts.
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58. In 2019, Dr. Anthony Fauci, Director of the National Institute of Allergy and Infectious
Diseases in the United States, called the U=U campaign “the foundation of being able to
end the epidemic”, along with the use of PrEP for HIV prevention.
72
A wealth of
research has arrived at similar conclusions, underscoring the enormous opportunity for
clear, positive and evidence-based communication about the value of U=U for ending
HIV-related discrimination, advancing health equity for people living with HIV, and
ending AIDS.
73
To harness this opportunity, all HIV partners must ensure U=U is
consistently integrated and implemented.
59. U=U threads across the three interlinked strategic priorities of the Global AIDS Strategy
and potentially contributes to each of its 10 result areas. This transformative but
untapped potential of U=U can be realized if services are designed and delivered in
strategic and supportive partnerships with facility-based and community-led health
providers, communities living with and affected by HIV, and government programmes.
74
The services would:
• improve the well-being of people living with HIV by incorporating U=U in CSE,
transforming the social, sexual and reproductive lives and legal rights of people
living with HIV by freeing them from the shame and fear of sexual transmission to
their partners;
• challenge and dismantle deep-seated HIV-related stigma and discrimination and
public perception about HIV transmissibility;
• support HIV combination prevention and treatment goals by reducing the structural
barriers and anxiety connected with testing and treatment; and
• advance an evidence-based public health and health equity argument for universal
access to HIV testing, diagnostics, treatment and care that can support improved
health outcomes, save lives and prevent new HIV infections.
75
60. The transformative impact of U=U can be unleashed if Member States and UN
Cosponsors integrate U=U into national HIV and health strategies and guidelines. Case
study 3 offers examples from the Asia-Pacific region of the importance of early
government endorsement of U=U. The experience shows that when used strategically,
U=U will dismantle stigma and discrimination, increase demand for ART, address
“U=U, it's not about looking at you as a vector of disease, but taking that burden away,
placing that burden completely outside of the individual and giving you back your
dignity and empowerment to know that I have the option. It's in my hands, I can design
this, but also the peace of mind in knowing that we are part of a solution to ending
AIDS.”
– Community representative, Europe
“[U=U] really highlights the structural issues, but it also gives us hope. U=U is a tool of
hope: that we can end the AIDS pandemic and new HIV infections and destroy
internalized stigma.”
– Community representative, Asia-Pacific
“First of all, there's a lot of misconception. But secondly, it's not a thing about
privilege––it's about right, it's about access, it's about having quality health care and a
quality of life that is attainable by anyone. It doesn't matter where you are. It doesn't
necessarily mean you need to have 40 options of treatment. A country can have six
options and still ensure that the [viral loads of the] population can be undetectable. It's
just how those options are managed.”
– Community Representative, Global Key Population Network
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barriers to accessing life-saving ART and decrease loss to follow-up by promoting
adherence.
61. Case study 4 provides insight from a 2022 global survey conducted among civil society
and community partners to better understand the critical components of being able
achieve and sustain an undetectable HIV viral load and to better understand the
experiences of people living with HIV when U=U is promoted.
62. Key informant interviewees highlighted some of the positive lessons learned from the
COVID-19 experience that should be maintained beyond the COVID-19 era to propel
forward the U=U movement and the HIV response more broadly. These include:
• the power of digital technologies to mobilize communities and to design and deliver
complex programmes, services and advocacy efforts by using virtual platforms,
including ensuring equitable internet access for remote or key and vulnerable
populations;
• the power of digital online platforms as a dissemination channel for teaching,
providing training and accessing wider audiences through the internet;
• the role of heightened public awareness of health, treatment and vaccine equity to
elevate debates and public pressure around the barriers which intellectual property
rights pose to effective public health emergency responses;
• increased awareness about the importance of treatment literacy in the general
public, and literacy about pandemics more generally, including awareness about
how pandemics evolve and cross geographic borders;
• heightened public awareness about the need for strong public health systems to
manage and overcome the COVID-19 pandemic, which offers a chance to renew
attention on the HIV pandemic. The COVID-19 experience has reinforced the
understanding that, in order to overcome pandemics, people must have equal
access to testing, treatment and care;
• evidence that multi-month dispensing of ART and point-of-care viral load testing
helped reduce the impact of service disruptions on treatment access and
adherence;
76
and
• evidence that swift, systemic change is possible when there is political will,
investment, public pressure and motivation to act appropriately.
63. Moving forward, it is important that these and other lessons and innovations drawn from
the COVID-19 experience are integrated into the scale-up of U=U across all settings,
particularly in resource-constrained and conflict areas, to mitigate HIV service
disruptions and treatment access.
64. Since the emergence of U=U in 2016, significant momentum has been achieved to
institutionalize the campaign. Public and actionable endorsements have been made by
HIV researchers and activists, community and civil society organizations, bilateral and
multilateral partners (e.g. PEPFAR, UNAIDS, US CDC and WHO) and national
governments (e.g. Canada, Thailand, the USA,
ix
Viet Nam and many others), as well as
eminent academic journals such as Lancet, the Journal of the International AIDS
Society and the Journal of the American Medical Association.
77
65. In Viet Nam, for instance, U=U is at the heart of the country’s response to their HIV
epidemic. The country was the first PEPFAR country to achieve viral suppression in
ix
U=U is endorsed and has been made actionable in policy and programming as outlined in the US National
HIV/AIDS Strategy (2022–2025). https://www.whitehouse.gov/wp-content/uploads/2021/11/National-HIV-AIDS-
Strategy.pdf
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over 95% of people on ART (Case study 5).
78
PEPFAR's updated (2022) country
guidance emphasizes the need to integrate U=U along the HIV care continuum.
66. U=U has become widely known in the global HIV sector as a powerful, scientifically
proven communication tool that brings together biomedical progress with contemporary
knowledge in behavioural and social science.
79
Yet, myths and misinformation about
U=U and HIV transmission abound. Case study 6 (Botswana) offers a good practice
example of the crucial roles of community-led, peer-based U=U communication and
treatment literacy strategies to improve the quality of life and treatment outcomes of
people living with HIV, while addressing internalized stigma and popular misconceptions
about HIV testing and treatment.
67. Case study 7 (Canada) showcases an online public education and communication
campaign led by the Canadian government in partnership with community partners. It
was aimed at dispelling incorrect HIV-related information in the general population,
while reducing the social stigma and discrimination associated with an HIV diagnosis.
Another Canadian online educational video titled "Strong medicine", has been
developed in partnership with Communities, Alliances & Networks (formerly the
Canadian Aboriginal AIDS Network) and CATIE, with and for Indigenous people living
with HIV. The video shares accurate information about HIV testing and treatment by
weaving Indigenous knowledge of culture and wellness with western knowledge of HIV
testing and treatment. It encourages people to get tested and to start, resume or stay on
HIV treatment for their own health and wellness.
80
68. Case study 8 (Ukraine) presents the experiences of a Government-funded national
care and support programme aimed at supporting viral suppression among people living
with HIV. Activities include support for treatment adherence and access to viral load
testing to help people achieve and maintain viral suppression.
69. Case study 9 presents a multicountry, youth-led intervention involving young people
between 15–29 years in 11 sub-Saharan African countries. The initiative was developed
in response to an identified gap in the provision of practical and tailored materials to
facilitate productive U=U dialogues with adolescents and youth living with HIV. The
case study provides further evidence for integrating U=U and other combination
prevention tools into CSE.
70. Respondents' reflections on the most critical issues and considerations around U=U
included:
• emphasizing and advancing U=U as an advocacy tool and health equity policy
instrument to improve equitable access to testing, diagnosis, quality treatment and
care, including equitable access to medical advancements such as long-acting
injectables;
• unlocking data generated by U=U to change harmful laws and policies that
criminalize people living with and at risk of HIV; and
• dispelling common concerns that U=U will result in surging rates of STIs if it
encourages people to have more condomless sex. Some studies have shown
people living with HIV, with regular access to healthcare, tend to have better overall
health than the general population. From a biomedical standpoint, U=U encourages
regular/more frequent health visits, as well as viral load and STI testing for the
individual.
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U=U: facilitators and challenges
71. Structural and systemic inequities continue to affect the ability of key populations and
other vulnerable groups to experience the benefits of effective HIV treatment. They
include poverty, inequitable access to treatment and viral load testing, stigma and HIV
criminalization. This section summarizes key barriers to achieving the goal of ending
AIDS by 2030. They include stigma and discrimination; a lack of enabling environments
to support marginalized communities who are not yet engaged in U=U and the HIV
treatment cascade; insufficient investments in community systems, leadership and
responses; and a lack of access to technologies and innovations.
Stigma and discrimination
72. Numerous studies have identified the quintessential role of health-care providers in
raising awareness and improving knowledge about U=U, in addition to their role in
achieving positive health outcomes. Despite progress in the past six years by the U=U
campaign, research has shown that limited awareness about U=U among people living
with and at risk of HIV remains a significant barrier across population groups and
country income status. A robust body of research shows that, while learning about U=U
from non-health-care providers is beneficial, patient discussions with health-care
workers:
• is associated with favourable mental, sexual and general health outcomes,
medication adherence and rates of viral suppression;
• can constitute an effective primary prevention tool; and
• is in line with health workers' ethical obligation to do no harm, provide optimal care
and support patients in accessing accurate information and health education.
81
As such, U=U must be considered a standard of care in medical education and clinical
guidelines.
82
83
84
73. This body of evidence points to the value of training health-care providers and allied
professionals on U=U and sexual health assessments. Furthermore, U=U should
become a mandatory component of the standard of care for primary health care and
HIV specialty care visits.
"I think it would be great to like to have something like universal, let's say a guideline,
or let's say, some kind of instruction for health-care providers [on] how to discuss
U=U with patients or with other people. Because it's still, like, questionable concepts
for many of them."
– Medical professional, Eastern Europe
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Figure 2. Percentage of people living with HIV who experienced stigma and
discrimination in health-care and community settings, countries with available
data, 2018–2021
Source: Global AIDS update 2022. Geneva: UNAIDS; 2022
74. Stigma and discrimination remain among the major barriers blocking key and vulnerable
populations from accessing quality and timely health care, including HIV combination
prevention, testing, treatment, care and support services. The 2021 Political Declaration
on HIV and AIDS commits countries to ensure that less than 10% of people living with
and at-risk of HIV experience stigma and discrimination by 2025. The current Global
AIDS Strategy has added a sub-target to track experienced stigma and discrimination
within formal health care settings. The 2022 Global AIDS update confirms the continued
pervasiveness of this barrier to care despite decades of education and advocacy. Figure
2 shows that countries are off-track in meeting the target of ensuring less that 10% of
people living with HIV report experiencing stigma and discrimination in health and
community settings by 2025.
85
75. Case study 11 (Canada) presents results from two Canadian studies. The first focuses
on barriers in the uptake of U=U among sexual minority men, while the second offers
insights on communicating U=U messaging in everyday practice. Case study 12
(Australia) presents good practice media guidelines on HIV and U=U to improve the
quality of HIV information reported by journalists. Case study 13 (Germany) offers a
snapshot of the #DoubleKnowledge (#wissenverdoppeln) anti-stigma media campaign.
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It was aimed at improving the low levels of public awareness and knowledge about U=U
by using multiple media platforms to publicize accurate information about effective,
rights-based HIV prevention and treatment.
Enabling environments: reaching the 5–5–5
76. The "5–5–5" concept refers to those population groups who are not being reached by
efforts to achieve the UNAIDS global 95–95–95 treatment targets. Population groups
within the 5–5–5 are often the most marginalized and hardest to reach with facility-
based HIV programmes and services.
77. "Reaching the last mile first means that health-care models that work for the minority
will also work for the majority"––this was a critical contribution made by the Global
Network of People Living with HIV (GNP+) to the High-Level Meeting on UHC. Placing
the needs of the poorest and most marginalized members of society at the centre of
programmes and services is crucial for the HIV response. Within the context of the 95–
95–95 targets, reaching the last mile first means first reaching those communities that
fall within the 5–5–5 in ways that support their ability to enjoy the health and quality of
life benefits of U=U, while also accelerating progress towards ending AIDS.
78. Enabling environments are key for reaching and engaging the poorest and most
marginalized communities in the 5–5–5. Those environments protect people's rights,
facilitate the elimination of stigma and discrimination, and remove or reduce obstacles
such as criminalization and punitive legal frameworks, gender and racial discrimination,
gender-based violence, unemployment and poverty, poor access to education and
social protection. Partners and advocates of U=U emphasize its positive implications in
legal environments that criminalize people living with HIV and members of key and
vulnerable populations.
86
79. As noted by Stefan Baral and others, HIV treatment implementation strategies that are
directed at the most marginalized communities will have important differences
compared with programs focused only on treatment numbers.
87
In this new era of U=U,
crucial considerations include ensuring that shifts in legal environments do not further
victimize or threaten individuals who are not virally suppressed, reinforce disparities, or
stoke HIV-related stigma and discrimination.
88
"There's, I think, a false dichotomy in treatment and prevention as opposing forces
when actually they're the yin and yang. Because if you see people that are not
getting proper treatment and care, yeah, then why disclose, why if they're being
discriminated against, it puts people underground, or people are being criminalized,
and it makes people not want to go out, and they don't even want to mention HIV is
the bad thing in the closet. And when you get people living with HIV standing up and
saying, I got tested, I got treatment, I'm gonna live forever, I can't pass on HIV…
well, those are extremely strong messages, to know that, that we have tools, it's a
way to open up a conversation and show them all new tools, we have. It’s a huge
thing."
– Community representative, North America
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Investing in community systems, leadership and responses
80. Community-led responses provide vital lifelines to communities who are cut off from
formal health and social services. Irrespective of the public health challenge,
community-led responses help ensure that no one is left behind. Lessons learned from
the ongoing COVID-19 pandemic show that resilient community-led responses play
central roles in keeping people healthy and protecting vulnerable communities.
89
90
91
81. Organizations and services that are led and delivered by communities living with and
affected by HIV play a particularly crucial role in national HIV responses and boost the
effectiveness of prevention, treatment, care and support programmes.
92
93
As a
grassroots community-led global movement with close to 1,100 community partners, on
every continent and across 105 countries, U=U is a shining example of the
transformative power of community leadership in the HIV and global health landscape
improving the health and quality of life for people living with HIV, eliminating stigma and
accelerating progress to end the HIV epidemic.
82. Community-led systems and responses have measurable impact, the potential to reach
people at scale, and serve populations who are not accessing formal health services.
94
95
Yet, the essential role of community systems and responses, including community-
led monitoring remains severely underfunded and under-acknowledged. They generally
are not prioritized and/or integrated into national plans or domestic health budgets.
96
Without adequate resources, civic space and autonomy, the potential of community
systems and responses to make a lasting impact in addressing the health disparities
affecting the poorest and most marginalized members of society, will continue to be an
"untapped potential" of the global HIV response.
Access to technology and innovation
83. Barrier-free access to quality, rights-based combination prevention, testing, treatment,
care and support services includes equitable access to technology and innovation.
Scaling up access to treatment and affordable medicines requires that countries are
empowered to make full use of flexibilities regarding intellectual property rights in
current international trade agreements (including but not limited to compulsory
licensing). It also requires pursuing alternative initiatives to stimulate both the
development of, and equitable access to, affordable medicines and other innovative
health technologies in response to public health needs.
84. Access to routine viral load testing and ARV stock-outs resulting from disruptions in
procurement and supply chain systems are significant health systems barriers.
97
A
wealth of research indicates that achievement of the global 95–95–95 targets,
particularly the final "95", is at risk in many low- and middle-income countries due to
gaps in viral load coverage, poor follow-up on viral load results , weak supply chains
(e.g. cold chains, especially in remote areas) and treatment stock-outs.
98
99
85. An extensive systematic review published in June 2022 by Pham et al. identified several
critical gaps. They included insufficient access to viral load testing; a lack of appropriate
"The reality is that from theory and evidence to practice in many cases there is a
wide gap. The shortages of ARVs in middle- and low-income countries were
significant during COVID-19 and showed us that PrEP and other approaches that
science has given us, can be lost or heavily affected in a pandemic."
– Community representative, Latin America and the Caribbean
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follow-up on viral load results (patient management); and a lack of access to second-
and third-line ARV regimens.
100
That review raises vital questions on how to best
provide viral load services in weak health system settings. Its findings suggest that
community-based models of care, implemented with local health authorities, can deliver
high viral load coverage. However, common clinical standards and policy guidance are
needed. Case study 10 (Nepal) speaks to the need for common clinical standards that
can support consistency in U=U messaging and in national policy documents.
86. Decentralized models of HIV treatment and care such as “hub-and-spoke” approaches,
differentiated care, adherence clubs”, new point-of-care viral load technologies, and
research clinics with free HIV services (including free viral load testing) support better
health, improved quality of care, reduced treatment failure and the scale-up of effective
treatment in low- and middle-income settings.
101
Importantly, while resource constraints
may be slowing the expansion of viral load testing, they should not impede the
integration of U=U as a health equity policy instrument while global health bodies,
decision-makers and civil society address the ongoing inequity of global resources.
Resource limitations have real-life implications for people living with HIV, especially
on issues of criminalization, which remain a key barrier to reaching the 10–10–10
targets of the UNAIDS Global AIDS Strategy.
87. Case study 14 (Cameroon) presents the experience of a U.S.-funded community-
based project led by Humanity First Cameroon Plus that focused on strengthening the
capacities of community health workers to collect blood samples and deliver them to
laboratories as a way to increase access to HIV viral load testing.
Conclusion
88. Global health institutions recognize that overcoming the widening inequities that
constitute key social determinants of health is the top priority for reaching our global
2030 SDG goals and targets, including ending AIDS as a public health threat,
accelerating the pace of UHC and of pandemic prevention, preparedness and
response.
89. U=U as a health equity strategy is a critical facilitator to meet the global commitments
which Member States endorsed at the 2021 High-Level Meeting on HIV (and in the
2021 Political Declaration on HIV and AIDS). However, formidable challenges stand in
the way of realizing the full potential of U=U. They call for:
• reducing stigma and discrimination (individual, systemic and structural
discrimination, such as systemic racism and punitive legal frameworks that
criminalize key and vulnerable populations);
• ensuring enabling environments to support key and vulnerable populations that are
not yet engaged in U=U and the HIV treatment cascade;
• investing in community systems, leadership and responses;
• increasing access to medicines, health technologies and innovations; and
• relieving the fiscal constraints and economic realities that hinder programmes and
services in many of the countries hardest hit by HIV.
90. The UNAIDS PCB is uniquely placed to drive action at the global and national levels
and to accelerate the roll-out and uptake of U=U as a means to everyone enjoying
individual and public health, personal well-being and improved quality of life.
91. With this report and the recommendations presented, the NGO Delegation urges
Member States to take immediate and accelerated action to tackle the challenges that
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are slowing progress towards the global targets and to act on the “untapped potential”
102
by taking to scale U=U as a foundational, community-led, global HIV health equity
strategy to get us back on-track to end AIDS by 2030.
Proposed decision points
The Programme Coordinating Board is invited to:
92. take note of the Report by the NGO Representative;
93. call upon Member States, UNAIDS and Cosponsors to:
o embed Undetectable = Untransmittable (U=U) in global, regional, national and
subnational health and/or HIV strategic plans;
o promote anti-stigma interventions, through updated comprehensive sexuality
education curricula and across the HIV combination prevention, testing, treatment
and care cascade, where community-led U=U initiatives and U=U research are well
resourced; and
o ensure that U=U is leveraged to support expanded health equity efforts to improve
the health and well-being of people living with and affected by HIV, especially
members of key populations and other vulnerable groups, such as women and girls,
adolescents and young people, Indigenous Peoples, and migrants;
o accelerate progress to get the global HIV response back on-track to meet the SDGs
by fast-tracking equitable access to HIV combination prevention, testing, treatment,
care and support through the planning, costing, implementation, scaling up, and the
monitoring and evaluation of rights- and evidence-based community-led U=U
programming, service delivery and monitoring, including the accelerated expansion
of viral load diagnostics and viral load testing strategies without sacrificing other
planned prevention and treatment initiatives;
94. call upon UNAIDS to:
o utilize the growing body of evidence on the multimodal use of U=U, ensuring that
U=U is incorporated as a key health equity strategy and policy instrument to
complement and enhance the attainment of 2021–2026 Global AIDS Strategy targets
(95–95–95, 10–10–10, 30–80–60), including by:
▪ meeting HIV prevention and treatment targets;
▪ promoting initiatives to support health and allied professionals, law enforcement,
decision-makers, and members of key populations and other vulnerable groups;
▪ leveraging U=U for greater access to effective treatment, diagnostics and testing;
▪ promoting enabling and supportive environments at global, regional, national and
subnational levels; and
▪ supporting improved health outcomes, well-being and quality of life for people
living with HIV;
o convene a multistakeholder U=U working group co-led by WHO to support the
development of harmonized definition(s) of U=U as a health-equity strategy that is
designed to accelerate equitable, barrier-free access to affordable HIV treatments,
health commodities and health technology innovations within the HIV response. The
multistakeholder working group should advise on the following parameters:
▪ common policy definition(s) accompanied by evaluation metrics to support and
encourage consistency across policy, programming and technical guidance;
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▪ common clinical standard(s) on viral load suppression, including the updating of
such definition(s) when new evidence becomes available;
▪ recommendations on appropriate multimodal strategies to be incorporated into
technical support to Member States and Co-sponsors on the integration and
implementation of U=U; and
▪ appropriate U=U targets and metrics to be included into routine Global AIDS
Monitoring and UBRAF reporting.
[Annexes follow]
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Annexes
Case study 1
The undetectable viral load suppression programme(UND) for highly vulnerable
people living with HIV; Housing Works, USA
United States of America
Objectives
To advance the transformative fact that Undetectable = Untransmittable (U=U), via: (1)
organizational change to elevate viral load suppression as a key goal across our multiservice
community-based organization that is critical to our commitment to ending the epidemic; (2)
a broad superhero themed anti-stigma social marketing campaign that acknowledges viral
load suppression as a heroic act that protects individual and community health to end the
epidemic; and (3) a tool kit of evidence-based adherence strategies, including financial
incentives, designed to advance HIV health equity by supporting people living with HIV to
overcome social and structural barriers to achieving and sustaining viral load suppression.
Outcomes
Sustained viral load suppression among people living with HIV who face barriers to care;
reduction of inequities in rates of viral load suppression; an organizational culture free of fear
and stigma that is centered on ending the AIDS epidemic; celebrating people living with HIV
as heroes for keeping themselves and their communities healthy.
Populations
People with HIV who face demonstrated social and structural barriers to treatment
adherence and sustained viral suppression; among demonstration project participants (n-
502), 50% had a mental health diagnosis, 63% used unregulated drugs and 60%
experienced homelessness during the 24-month study period; 71% identified as Black, 20%
Hispanic/Latino, 27% female and 2% transgender.
Stakeholders
Communities living with HIV; health professionals; civil society organizations; government
officials (local, national, global); HIV case coordinators/case managers.
Abstract
To share the ground-breaking U=U message, address persistent viral load suppression
disparities, and advance ending the epidemic, in 2014, New York City service provider
Housing Works collaborated with the University of Pennsylvania to develop, implement and
evaluate The Undetectables Viral Load Suppression Program (UND) (liveundetectable.org).
This client-centered model employs innovative superhero-themed, antistigma social
marketing, agency cultural change and a tool kit of evidence-based ART adherence
strategies (including quarterly US$ 100 financial incentives) to support people living with HIV
to achieve and sustain viral load suppression (<200 copies/ml).
Many people living with HIV face social, structural and behavioural health barriers to viral
load suppression, including poverty, homelessness, mental health issues, racism and/or
marginalization due to substance use, gender identity, sex work or other factors. The UND
programme adds individualized ART adherence planning to integrated medical, behavioural,
and care management services, via case conferences for people living with HIV and care
team members to consider barriers and the toolkit of adherence supports. A broad social
marketing campaign features superheroes known as "The Undetectables". They combat
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stigma and apathy, and emphasize elements of the U=U message to demonstrate how
being undetectable improves individual and community health, making the individual a hero
in combating the HIV epidemic. Published evaluation results of a 24-month demonstration
(n=502) showed significant positive impacts, with a 15% increase in the mean proportion of
suppressed time-points for each participant (from 67% to 82% in the 24 months pre- to post-
enrollment, p < 0.0001) and a 23% increase in the proportion of participants virally
suppressed at all time-points (from 39% to 62% pre- to post-enrollment, p <0.0001).
Significant social/racial disparities in viral suppression found at baseline disappeared post-
enrollment.
Beginning in 2016, the New York City Department of Health and Mental Hygiene scaled the
intervention to seven additional providers offering the UND programme in 20 locations, and
the intervention is now included in in IAPAC's Best Practices Repository.
Further reading: https://liveundetectable.org/assets/images/Ghose-et-al-2019-
Undetectables-evaluation.pdf
Case study 2
ICW Argentina
Argentina
Objectives
Breast-feeding for people with lactating capacities is a topic that is often relegated in the
context of U=U. In low- and middle-income countries with high infant mortality rates, breast-
feeding can be heavily promoted as a harm reduction practice. In other parts of the world, it
is prohibited, while some regions are already applying the first recommendations on
breastfeeding with undetectable viral load being allowed for “at least 12 months and up to 24
months or longer, similar to the general population”. However, there is no clear consensus
on the topic.
This study sought to investigate perceptions of this situation, with the understanding that
reproductive rights are human rights. Women of reproductive age who are living with HIV
and are members of ICW Argentina were asked about the options that are presented in the
case of the impossibility of breast-feeding, how they experience this, and possible relevant
intervention in order to address the problem.
Outcomes
The interviews highlighted that providing updated information on breast-feeding to women
living with HIV requires taking into account the social, economic, and geographical
conditions that mark their lives and affording them access to information that is essential for
their lives and the lives of their babies.
Women with HIV of reproductive age in Argentina are discouraged from breast-feeding, but
do not have access to updated information regarding to the choices and possibilities they
have, as well as the reasoning behind all them. They tend to seek the information from
health authorities, but often find that the authorities do not offer the information or manage
the enquiries in a satisfactory manner. This constitutes a violation of their right to
information, to health, to breast-feed, and to make decisions about their bodies.
Stigmatization weighs on the women: that of the "bad" mother, mainly associated with not
breast-feeding. "If you don't breast-feed, you're a bad mother", according to one of the
interviewees.
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Populations served
Women with HIV of reproductive age from Argentina.
Stakeholders engaged
Communities living with HIV; health professionals; civil society organizations; government
officials (local, national, global)
Abstract
I=I (Spanish for U=U) is a transformative movement for people living with HIV. Several
studies document how women in all of their diversity are more exposed to expressions of
violence and discrimination. Breast-feeding is not an exception to this, with research not
having deepened significantly on the impact of viral load suppression on transmission via
lactation since the adoption of U=U. This has generated a lack of consensus regarding if and
how people with gestational capacity can breast-feed their babies should they have an
undetectable viral load. Different countries have different, even contradictory guidelines.
Description
27 cisgender women living with HIV from different provinces of Argentina were interviewed.
They were asked about their experiences of lactation, the importance of this practice in their
lives, and knowledge management of current public policies regarding breast-feeding in
people with HIV.
Lessons learned
The interviews showcased the harm caused by not having access to up-to-date information,
which has repercussions in the intimate-political space, the affective field, the physical
health, the exercise of the sovereignty of bodies and the political-collective space. Access to
knowledge should not be a privilege for a few people and information should not be filtered
by prejudice or opinion nor should it be provided in a biased manner. Above all, it should not
be offered without empathy or be at the service of biocontrol.
Next steps
This study aims to enrich the conversation regarding a wider framework of choice for women
and all people with lactating capacities and to provide recommendations to those who hold
institutional authority in the field of health, who perform research on the subject or who in the
field of symbolic production and activism.
Case study 3
Building common understanding and tailoring key messaging on Undetectable =
Untransmittable in Asia-Pacific
Asia-Pacific
Implementer
APCOM, Asia-Pacific region (Indonesia, Japan, Malaysia, Nepal, the Philippines, South
Korea, Taiwan, Thailand and Viet Nam).
Background
PARTNERS2’s finding that "undetectable equals untransmittable (U=U)"––i.e. that people
living with HIV who are virally suppressed cannot pass on the virus through sexual
transmission––was a landmark scientific finding. However, awareness about U=U among
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people living with HIV in the Asia-Pacific region remains low. Their access to routine viral
load testing is limited and viral load tests are often not available in HIV clinics.
Misinformation about U=U also persists among health-care providers in the region. This is
one of the reasons why HIV-related stigma and discrimination against key populations
persist in health-care settings.
Objectives
Translate the scientific findings of PARTNERS2 into sets of understandable messages that
are tailored around the HIV contexts of countries in the region, and share strategies and key
messages for those that have rolled out U=U campaigns.
Specifically, this initiative:
• establishes a common understanding about U=U among community-based organizations
and key populations at regional and country level;
• serves as technical assistance to partner community-based organizations at the country
level in developing messages around U=U in their respective contexts. These are
relevant to access to ART and viral load testing for people living with HIV, stigma and
discrimination, and mental health;
• strengthens the communication strategies of partner community-based organizations to
tailor and adapt the stages and key messages to guide active engagements with
communities, health providers and national HIV programmes; and
• serves as a knowledge-sharing platform for community-based organizations around U=U.
Approach
APCOM facilitated a regional consultation on U=U to map out existing initiatives about U=U
at the country level. Several sessions were also organized to determine the applicability in
Asia of examples of good practices from other countries. The consultations allowed
communities to share their perspectives about integrating U=U in national HIV programmes,
especially in relation to challenges in integrating U=U in national guidelines and identifying
the role(s) of PEPFAR or the Global Fund in integrating U=U in national policies.
APCOM provided support in developing U=U fact sheets that were tailored to HIV
stakeholders. Fact sheets increased the awareness of U=U among people living with HIV.
Fact sheets for health-care providers addressed stigma and discrimination in health-care
settings and helped reduced discontinuation of ART.
Lessons learned
Examples of good practices around U=U demonstrated that early government endorsement
are key for successfully integrating U=U in HIV responses. However, in some countries in
Asia, high levels of stigma and discrimination blocks the integration of U=U and undermines
access to ART. Hence, it is vital to bring the science of U=U to both health practitioners and
people living with HIV.
U=U often does not appear in national HIV guidelines. When used strategically, U=U can
reduce stigma and discrimination, increase demand for ART, address barriers to access to
life-saving ART, and decrease loss-to-follow-up by promoting adherence.
More information
https://www.apcom.org/wp-content/uploads/2021/12/Factsheets-APCOM_UNAIDS-HIV-
treatment_v3.pdf
https://www.apcom.org/contextualizing-uu-at-countries-in-asia/
https://www.apcom.org/experiences-of-uu-campaign-in-tokyo/
https://www.apcom.org/uu-in-taiwan-no-track/
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https://www.apcom.org/uu-in-korea-the-repeal-article-19-movement-and-beyond/
https://www.apcom.org/getting-to-zero-leveraging-uu-for-community-empowerment-eliminating-
stigma/
https://www.apcom.org/no-time-for-excuses-uu-in-asia-pacific-at-rrrap-con-2020/
Case study 4
ICASO Global Community Survey 2022: what drives U=U?
Global
Aims
To improve understandings of the critical factors for achieving and sustaining an
undetectable HIV viral load and of the experiences of people living with HIV as a result of the
promotion of U=U.
Methods
During two weeks in April 2022, ICASO sought feedback through an online survey from over
50 community leaders in 16 countries with regard to the research questions (aims) of the
project. The responses offered a range of perspectives, opinions and insights which the
researchers distilled into 10 categories based on each of the two research questions. A
global survey targeting people living with HIV was translated and provided in three
languages (English, French and Spanish). The survey was promoted via social media and
emails. It made use of three unique QR codes for each of the different languages. Over the
period of five weeks (mid-April to mid-May 2022), 549 people living with HIV from 56
countries responded to the survey (n=295 Spanish language survey; n=229 English
language survey; n=19 French language survey). Respondents were aged between 19 and
80 years, with a median age of 41 years. Men comprised 60%, women 35%, and trans- and
gender-non-conforming people 5% of the sample.
Results
The tables below show the rankings and scores in relation to the two research questions.
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Conclusions
Consistent access and adherence to affordable HIV treatment, diagnostics and health-care
services are seen and both critical and vital to being able to achieve and sustain an
undetectable viral load. The U=U message can be seen to have significant effects on the
empowerment of people living with HIV, improved sexual health, improved adherence and
as having a significant impact on HIV stigma and fear of onward transmission of HIV to
sexual partners.
Case study 5
United States Centers for Disease Control and Prevention, on behalf of the Viet Nam
Authority for AIDS Control and the Viet Nam Network of People Living with HIV, and
other community partners
Viet Nam
Objectives
To foster an all-of-programme commitment within policy, collaboration, coordination across
government and community to make U=U foundational to the HIV response in Vietnam.
Outcomes
1. Political commitment and policy is critical for centering U=U in HIV programmes and
responses.
2. Impactful public messaging on U=U can change stigmatizing perceptions of HIV and
empower HIV-affected communities.
3. To deliver comprehensive U=U messaging in health settings, health providers must be
equipped, confident and empowered by U=U science.
4. Community advocacy, demand and dissemination created a positive environment to tailor
U=U messaging to key populations.
Populations
Government officials; community leaders, organizations and members; health providers;
influencers and thought leaders; and the general public.
Stakeholders
Communities living with HIV; health professionals; civil society organizations; government
officials (local, national and global); international agencies and donors (including PEPFAR);
an LGBTQ-led media firms.
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Abstract
In Viet Nam, the Ministry of Health, National Network of People Living with HIV, and
community leaders rapidly and comprehensively leveraged U=U (K=K in Vietnamese) as a
programme catalyst and driver for eliminating HIV stigma and meeting epidemic control
goals. K=K is a versatile concept beyond reducing stigma that drives Viet Nam's programme
priorities for case finding and ART initiation, especially among gay men and other men who
have sex with men.
Since its 2017 inception, the K=K movement ushered policies to document viral load
suppression <200 ml/copies as treatment success and mandated integration of K=K
messaging into health practice. Three successful public campaigns (first in Hanoi and Ho
Chi Minh City, and then nationally) confronted public perceptions around HIV. Grants to
community-based organizations ensured widespread dissemination of K=K to key population
and people living with HIV networks, especially young urban gay men and other men who
have sex with men.
Lessons
Coordinated Ministry of Health and community commitment is critical to place K=K at the
centre of HIV programme strategy. Despite global endorsements, health-care providers were
initially reluctant to inform patients of the benefits of K=K. Simple, visually powerful materials
clarified K=K messaging and addressed concerns around the prevention of mother-to-child
transmission, blood transfusion transmission, and the prevention of other sexually
transmitted infections. Initial campaigns were conducted in cities where success could
influence broader commitment and leverage Viet Nam’s impressive viral suppression rates.
In response, the Ministry of Health officially endorsed K=K and issued national
implementation guidelines. Community forums confirmed regionally nuanced messaging and
preferred platforms for effective dissemination, as well as the design of a national campaign.
K=K revolutionized the national HIV response. In September 2019, Viet Nam became the
first PEPFAR country to disseminate official U=U/K=K guidance and document 95% viral
load suppression <200 copies/ml among ART patients. In 2021, it reached 97% <50
copies/ml. In 2021, Viet Nam combined messaging around effective ART for people living
with HIV and PrEP for people at substantial risk of HIV so that the preventive use of ARVs
offers a clear path to HIV epidemic control.
Case study 6
Centre for youth of hope
Botswana
What were the objectives of your work described in your case study?
To train 15 peer educators living with HIV in basic HIV treatment literacy. Training focused
mainly on the HIV viral cycle and actions of different classes of ARVs in the viral cycle. This
training provided our peer educators with basic understanding of viral suppression in the
context of U=U. Basic research literacy sessions formed part of this training. Studies
confirming that U=U were used for the training. HPTN052, the Opposite Attract study, and
the PARTNER 1/2 studies were included in the training curriculum.
To train 15 peer educators living with HIV in basic U=U patient communication strategy.
Educators were trained in health messaging and communication focusing on, audience
analysis, setting goals/objectives and crafting tailored U=U messages. HIV basic treatment
literacy helped the educators to build confidence and capacities to accurately communicate
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the U=U message to 2,000 clients living with HIV in Gaborone in 12 months (April 2021 –
March 2022). Global U=U consensus and U=U statements from the US Centers for Disease
Control and PEPFAR were used.
What key outcomes does your case study address?
Value of people living with HIV on the ground who have been contributing their community's
members.
What population groups were engaged in your case study?
People living with HIV.
What stakeholders were engaged in the work described by your case study?
Communities living with HIV; health professionals; civil society organizations.
Abstract
We used a qualitative evaluation approach to evaluate outcomes of U=U messaging to
clients living with HIV in Gaborone health catchment ARV clinics. We compared baseline
data and current 12 months’ data. The following were the level results:
• quality of life for people living with HIV (social, sexual and reproductive lives): 89% of the
2,000 clients reported a reduction in HIV anxiety associated with HIV and their sexual and
reproductive life;
• HIV stigma: Internalized stigma fell by 89% among participants; and
• treatment goals (U=U added an incentive to remain on treatment and in care). There was
99% retention (n= 2000) in care during the 12-month study.
Conclusion
U=U messaging can be used as an incentive to fast-track the achievements of 95–95–95
global targets, which Botswana has achieved. Messages can be integrated into existing
testing and care programmes.
Case study 7
A U=U public education and communication campaign
Canada, Public Health Agency of Canada
Objectives
Undetectable = Untransmittable (U=U) video testimonials were used to share the
perspectives of people living with HIV in a positive, uplifting, compassionate and meaningful
manner, with a focus on reducing HIV stigma and raising awareness of the impact of U=U.
The videos explore how HIV stigma has affected people, and how their lives have been and
can be transformed, including their relationships, romances and partner-seeking. They seek
to represent diverse perspectives, including those of members of key populations and across
age groups, in a non-stereotypical manner. The videos provide a case study of a U=U
education and communication campaign aimed at reducing the stigma and discrimination
that is often associated with an HIV diagnosis.
Outcomes
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The primary outcomes of the video testimonials were increased awareness of the U= U
concept and reduced HIV stigma.
The videos served to increase public understanding of the following key messages:
• by sticking with their treatment plans, people living with HIV have taken control of their
health. U=U means life can be lived to the fullest;
• U=U challenges the stigma that people living with HIV are less sexual or are dangerous,
to be avoided and stigmatized;
• prevention tools such as PrEP and PEP help prevent HIV from being passed on to a
sexual partner;
• U=U means that treatment can serve as prevention;
• with treatment, HIV becomes an invisible manageable condition––it is invisible yet real
with episodic physical, psychological, social and spiritual manifestations (good and bad);
• dating with HIV, finding partners and romance with HIV is possible. U=U means sexual
relationships are possible without the risk of passing on HIV; and
• What U=U means to long term survivors.
The goal of the video testimonials was to have representation from all of the key populations
most affected by HIV, as well as others participants. Including a broad cross-section of
participants helped avoid stigmatization, reinforced the fact that anyone can get HIV, and
provided more opportunities for viewers to find a perspective they could identify with. The
U=U video testimonials had in 43 684 YouTube views (English and French versions).
Population groups
• People born with HIV (youth),
• Indigenous peoples,
• older persons and long-term survivors,
• LGBTQ2S+ community members,
• people who uses or used drugs,
• heterosexual females, and
• Black Canadians.
Stakeholders
Communities living with HIV; civil society organizations; government officials (local, national,
global).
Abstract
In 2019, the Public Health Agency of Canada produced a series of testimonial videos
highlighting the impact that U=U had on the lives of people living with HIV. The project was
aimed at reducing HIV stigma by demystifying and addressing misconceptions. The inspiring
stories raised awareness about the potential of U=U and supported the changing of societal
attitudes.
The direction of these videos, from conceptualization to implementation, was led by a
steering committee composed of people living with HIV and community-based stakeholders.
They identified priority themes/stories to be profiled, identified individuals to be interviewed,
and developed interview questions. The committee also provided feedback on the format
and approach of each video. They suggested that the focus should be on the impact of
social determinants, as well as why certain populations are disproportionately affected by
HIV, in order to avoid stigmatization. The collaboration allowed for a tailored dissemination
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strategy to reach people who were not already engaged. Their guidance and insight ensured
that the videos resonated with audiences and demonstrated sensitivity and compassion for
people living with HIV.
An introductory compilation video presented a wide variety of people living with HIV and
introduced key facts about the HIV epidemic in Canada. The testimonial videos explored five
people’s experiences of living with HIV.
The videos were posted on the Government of Canada website and YouTube, and video
snippets were produced to promote the series via the Government of Canada’s various
social media accounts. The videos were also promoted through community partners,
including Canada’s knowledge broker for HIV/STBBI information, CATIE, and other HIV
community-based organizations and provincial/territorial partners. The videos have been
showcased at conferences and on social media on an ongoing basis.
Case study 8
Public Health Center of the Ministry of Health of Ukraine
Ukraine
What were the objectives of the work described in your case study?
Care and support services for people living with HIV funded by state budget.
What key outcomes does your case study address?
The number of people living with HIV who received care and support services in 2021 at the
expense of the state budget through NGOs.
What population groups were engaged in your case study?
People living with HIV.
What stakeholders were engaged in the work described by your case study?
Civil society organizations; government Officials (local, national, global).
Abstract
According to the national assessment of the HIV/AIDS situation in Ukraine in 2021, there
about 174 000 people living with HIV in government-controlled areas
(https://npsi.phc.org.ua/Wiki/717). Since 2019, the Public Health Center has been
implementing a state programme for the care and support of people living with HIV. Activities
are implemented through NGOs with experience in working with people living with HIV. The
cost of providing these services is covered by the state budget. Public Health Center
monitors the indicators of the work performed by NGOs, provides recommendations to
improve the quality of services and programme effectiveness. Thus, during 2021, 32 720
people were covered by care and support services, 98% of whom regularly visited a doctor
and received ART without interruption.
The state programme of care and support has two directions of work: "formation of
adherence to HIV treatment and maintenance under medical supervision" and "involvement
of people who inject drugs in the provision of medical care in connection with HIV and
formation of adherence to ART". Clients are included in the programme for six months. The
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basis of the programme is consultations that are aimed at motivating clients to start HIV
treatment and acquire the skills to regular take the medicines. Service providers refer clients
to medical facilities and develop their skills to take care of their own health. The results of
medical examinations, in particular viral load testing, are recorded in clients' laboratory card.
One of the consultation sessions of the programme is devoted to the topic of reproductive
health. Service providers also work with clients on safe behaviour skills, discuss readiness to
disclose HIV status to relatives, and inform them about reducing the risk of partner infection.
Those activities are aimed at increasing adherence to treatment and reducing viral loads to
undetectable levels.
Case study 9
Elizabeth Glaser Pediatric AIDS Foundation
Multicountry, sub-Saharan Africa
What were the objectives of the work described in your case study?
The overall aim is the development of a practical tool that provides direction in initiating
discussions around U=U with adolescents and youth navigating different scenarios for use
by health-care workers and young peers in various psychosocial support settings. It was
important that this tool’s development be youth-led to ensure that the stories were authentic
and represented youths’ lives and experiences realistically. It also needed to be responsive
to the gaps in messaging and present solutions to the difficulties faced by youth.
What key outcomes does your case study address?
Increased comprehension and understanding of the concept of U=U, as well as relating it to
people's lives, including:
• deeper insight into effective means for messaging U=U for adolescent and young people
living with HIV, key populations, and adolescents and youth generally, as well as the
means to increase the capacity and awareness of U=U among providers and adolescent
and youth facilitators working with all adolescents and youth living with HIV; and
• adding to the evidence on meaningful adolescent and youth engagement and leadership
in the development of relevant and practical tools for the adolescent and youth
population.
Initial reactions from young people while gathering additional inputs:
“The tool explains very well about U=U and adolescent appealing to young people”;
“The tool is good and awesome and directly responded to most of young people’s needs”.
What population groups were engaged in your case study?
Young people between 15–29 years in the Elizabeth Glaser Pediatric AIDS Foundation’s
Committee of African Youth Advisors were engaged as partners in the development of the
tool. The Committee sought additional insights from adolescents and youth aged 15–24
years.
Stakeholders
Communities living with HIV, adolescents and youth.
Abstract
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In response to a recognized gap in the provision of practical and tailored materials to
facilitate productive U=U dialogues with adolescents and youth living with HIV, the Elizabeth
Glaser Pediatric AIDS Foundation’s Committee of African Youth Advisors (CAYA), with
support from the University of Cape Town, proceeded with a youth-designed tool. CAYA
members are young leaders aged 15–29 years from 11 sub-Saharan African countries. A
gap analysis was conducted to avoid redundancy among existing U=U tools focused on
adolescent and youth living with HIV.
Virtual discussions with CAYA members identified areas of focus and determined the
particular form the delivery of the messaging should take. Through an iterative process, a
short graphic-based story collection was drafted. CAYA members developed character
profiles, story lines and dialogues. With support from the Urithi design team based in
Uganda, CAYA members then led initial validation discussions with adolescents and youth in
their networks (including in psychosocial support groups and networks of young people living
with HIV) using a standardized questionnaire to gather additional insights. Almost 190
adolescents and youth living with HIV in Kenya, Malawi and Uganda shared insights.
Highlighted was the need for simpler, everyday language, designing characters with more
youthful looks and ensuring conversations take place in confidential settings in the stories.
The final stories are in development.
Case study 10
Blue Diamond Society
Nepal
Objectives
To communicate proper messaging of U=U; initiate comprehensive intervention for viral load
suppression; and incorporate and proper implementation of U=U in a policy document.
Outcomes
Proper messaging and implementation of U=U in policy document.
Populations
All key populations.
Stakeholders
Communities living with HIV; health professionals; civil society organizations; government
officials (local, national, global).
Abstract
During consultations to develop the national guidelines on HIV testing and treatment (2021–
2026), many local NGOs (including Blue Diamond Society, Nepal’s leading LGBTIQ+
organization) advocated strongly for the inclusion of U=U and an emphasis on its
implementation in local HIV/AIDS programming. This led to inclusion of U=U in the national
guidelines (http://www.ncasc.gov.np/uploaded/publication/NHSP-2021-2026/NHSP-2021-
2026-English.pdf), which notes the need to “increase the focus on effective HIV awareness
messaging for all key populations such as treatment leads to better health outcomes
including survival, U=U, etc.”.
UNAIDS/PCB (51)/22.29
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While the Government of Nepal swiftly integrated U=U in its policy document, the wording is
brief and is based on the clinical definitions (e.g. in the guidelines, an undetectable viral load
is set at less than 200 copies/mL, whereas viral suppression is set at less 1000 copies/mL).
Nepal is following the WHO 2016 Consolidated guidelines on the use of ARV drugs for
treating and preventing HIV infection. Community members appreciate the inclusion of U=U
in the policy document. However, they are confused by the fact that viral suppression is
defined as having less than 200 copies/mL of HIV as per the US CDC.
Proper implementation of U=U as a national guidelines strategic action is needed.
Successful, holistic integration of U=U (e.g. accurate messaging and quality services, and
promotion of U=U for treatment adherence and as part of comprehensive prevention
interventions along with PrEP) require community-led monitoring. At a systems level, U=U
should be leveraged as evidence-informed rationale for uninterrupted dispensing of ART as
well as for expanded and more equitable access to well-maintained viral load testing
technology, diagnostic tools, regular viral load testing.
Case study 11
Two Canadian studies working with community partners doing community-based
research related to U=U and HIV undetectability.
Canada
What were the objectives of the work described in your case study?
British Columbia: The objective was to inductively learn from diverse sexual minority men
with different HIV serostatuses to understand what HIV undetectability means to them,
including its sexual significance and contested interpretations amid an evolving and uneven
landscape of biomedical HIV prevention strategies
(https://www.tandfonline.com/doi/full/10.1080/13691058.2020.1776397#:~:text=We%20desc
ribe%20this%20as%20a,who%20have%20sex%20with%20men).
Ontario: The objective was to better understand how various HIV/STI service providers (e.g.
nurses, public health workers, physicians, frontline providers, and sexual health educators)
communicate the U=U message to sexual health service users in Ontario, Canada. We were
specifically interested in understanding the communication of the U=U message in everyday
practice, including barriers experienced by service providers to consistently convey this HIV
prevention message
(https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0271607).
What key outcomes does your case study address?
Barriers to health communication for service users and health-care providers.
What population groups were engaged in your case study?
Gay, bisexual, and other men who have sex with men; HIV/STI service providers (e.g.
nurses, public health workers, physicians, frontline providers, and sexual health educators).
What stakeholders were engaged in the work described by your case study?
Communities living with HIV; health professionals; civil society organizations.
Abstract
UNAIDS/PCB (51)/22.29
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U=U is a public health message that is designed to reduce HIV stigma and help
communicate the scientific consensus that HIV cannot be sexually transmitted when a
person living with HIV has an undetectable viral load. Between October 2020 and February
2021, we conducted 11 in-depth interviews and 3 focus groups with diverse HIV/STI service
providers (nurses, public health workers, physicians, frontline providers, and sexual health
educators) in Ontario, Canada (n=18). The objective was to understand how U=U was
communicated to sexual health service users in health-care interactions. Interview questions
were embedded in a larger study focused on improving access to HIV/STI testing.
Most providers emphasized the significance of U=U as a biomedical advance in HIV
prevention, but experienced some challenges communicating U=U in everyday practice. We
discovered 4 interrelated barriers when communicating the U=U message: (1) provider-
perceived challenges with “zero risk” messaging (e.g. wanting to “leave a margin” of HIV
risk); (2) service users not interested in receiving sexual health information (e.g. in order to
provide “client-centered care” some providers do not share U=U messages if service users
are only interested in HIV/STI testing or if other discussions must be prioritized); (3)
skepticism and HIV stigma from service users (e.g. providers explained how the hesitancy of
some service users to accept the U=U message was shaped by a legacy of HIV prevention
messages and persistent HIV stigma); and (4) need for more culturally appropriate
resources (e.g. communities other than sexual and gender minority men, non-English
speaking service users). We discuss ways to overcome barriers to communicating the U=U
message, as well as limitations and potential unintended consequences of U=U framings in
the context of unequal access to HIV prevention and treatment.
Case study 12
Media guidelines for reporting on U=U: working with journalists to reduce stigma
Australia
Objectives
To develop a set of media guidelines to assist journalists reporting on HIV to encourage the
inclusion of factual and appropriate information about U=U in order to:
• reduce the HIV-related stigma that continues to be present within Australian news
reporting on HIV, particularly in relation to exaggerated reporting of HIV transmission risk;
and
• reduce HIV-related stigma associated with sensationalized and negative news reporting
on HIV, and people living with HIV.
Outcomes
The media guidelines were developed and published in consultation with people living with
HIV, and journalists working in Australian news media. They were distributed among
networks of Australian journalists and have been cited in Australian news reporting on HIV.
Groups involved
People living with HIV.
Stakeholders
Communities living with HIV; representatives from a wide range of Australian community
organizations representing people living with HIV; journalists in the Australian news media
UNAIDS/PCB (51)/22.29
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reporting on HIV; broader networks of Australian news journalists; journalists attending 2022
International AIDS Conference in Montreal.
Background/purpose
Research has shown a link between low HIV knowledge and stigmatizing attitudes.
Journalists who are unfamiliar with the evidence behind U=U may be skeptical about the
principle and minimize its validity, contributing to stigmatizing depictions of HIV in their
reporting.
Media guidelines are information packs for journalists to guide reporting on specialist
subjects and have been used to inform reporting on topics such as suicide. The
development of U=U media guidelines aims to support more factual reporting on HIV
transmission and to reduce stigmatizing depictions of people living with HIV.
Approach
A thorough review of existing media guidelines and their use in Australian media identified
best practice for development and implementation. Interviews were conducted with
journalists to determine their knowledge of HIV and U=U. Journalists were asked what
barriers might prevent them from using available media guidelines. In interviews, people
living with HIV shared their views about the depictions of HIV in news media they found
stigmatizing, and how this might be addressed. Based on this research, a set of media
guidelines was developed to improve journalists’ understanding of HIV transmission risk in
relation to U=U. The guidelines were promoted to media contacts.
Outcomes/impact
Interviewees said omissions of information about U=U in news media contributed to false
and stigmatizing views that presented a risk to them and others. Journalists said that a lack
of easy access to clear, authoritative information and time pressures were barriers to
increasing their understanding of U=U.
The guidelines developed accounted for pressured work environments of Australian
journalists and provided clear, concise information. Examples of stigmatizing HIV reporting
were used to show how the inclusion of U=U messages could reduce stigmatizing depictions
of people living with HIV .
The guidelines were adapted for an international audience and provided to journalists at
AIDS 2022 and have been shared with multiple news media organizations in Australia,
including the Science Journalists Association of Australia. The guidelines are being used by
journalists reporting on HIV in Australia.
Innovation and significance
These are the first such guidelines to be produced globally. They provide an innovative
example of a stigma-reducing activity that connects media practice to clinical and community
experience and expertise.
Case study 13
#DoubleKnowledge
Deutsche Aidshilfe, Germany
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What population groups were engaged in your case study?
People living with HIV, key audiences of Deutsche Aidshilfe, the general public.
What stakeholders were engaged in the work described by your case study?
Communities living with HIV; health professionals; civil society organizations;
parliamentarians.
What were the objectives of the work described in your case study?
Generating outreach, spreading knowledge of U=U.
What key outcomes does your case study address?
Raised awareness for the U=U fact among general public and key audiences.
Abstract
#wissenverdoppeln (which translates as #DoubleKnowledge) is a cross-media campaign
which Deutsche Aidshilfe conducted in 2018–2020. The overall objective was to publicize
the U=U message in the wider public and to reduce HIV-related stigma and discrimination. a
request to spread the knowledge (by sharing it on social media or telling friends and
colleagues) was the campaign's central "call to action". The campaign generated strong
outreach and press coverage.
Background
The objective of doubling the knowledge of U=U until everyone knows relates to a survey in
2017, which showed that only 10% of the general public in Germany knew that HIV cannot
be transmitted sexually by a person who is virally suppressed. The campaign was financed
by Bundeszentrale für gesundheitliche Aufklärung/Federal Centre for Health Education
(BZgA) in the context of the annual campaigns around World-Aids-Day on December 1.
Campaign elements
The campaign featured a campaign website (www.wissen-verdoppeln.hiv, in German),
videos with role models, digital and print advertisements and giveaways.
The campaign was also supported by many local member organizations of Deutsche
Aidshilfe and self-organized communities of people living with HIV, who both were provided
with information material and assistance in publicizing the message.
Outcomes
The campaign generated very high outreach. Many prominent people shared the information
in social media profiles (e.g. artists and politicians) and there was broad media coverage
(including on the public broadcaster). The campaign videos had more than 1 million views on
social media. A follow-up survey in 2020 showed that knowledge of U=U had increased
significantly in the general public (up by 18%) and some discriminatory beliefs regarding
people living with HIV had been reduced.
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Case study 14
The use of U=U to promote equal access to viral load testing: experience of
community workers with gay men and other men who have sex with men in Yaoundé,
Cameroon
Humanity First Cameroon Plus, Cameroon
What were the objectives of the work described in your case study?
Use the U=U approach to enhance access to viral load testing for key populations, and train
community workers to perform blood sample collection and safe transportation to
laboratories for testing.
What key outcomes does your case study address?
Key populations know their viral load testing and can live without fear of transmitting HIV to
others. Understanding that U=U is a reality, not just a slogan.
What population groups were engaged in your case study?
Gay men and other men who have sex with men.
Stakeholders
Communities living with HIV; health professionals; civil society organizations.
Background
Achieving an undetectable viral load for successful HIV treatment is often fraught with
challenges. In low- and middle-income countries, although many efforts are being made to
test and link to treatment people living with HIV, access to viral load testing remains difficult,
with very few laboratories performing these tests. Furthermore, discrimination encountered
in health facilities prevents key populations at high risk of HIV from accessing the services.
Humanity First Cameroon Plus (HFC+), through implementation of the CHAMP project
(continuum of prevention, care and treatment with most at-risk populations in Cameroon),
put in place a programme to strengthen the capacity of community workers to collect blood
samples and transport them to laboratories. The CHAMP project aims to limit the incidence
of HIV by starting key populations living with HIV on treatment so they can achieve and
maintain an undetectable viral load.
Description
The CHAMP programme has been implemented in Cameroon since 2014 and is supported
by the US Government. HFC+ is a community-based organization which benefits from that
programme and works with gay men and other men who have sex with men in Yaoundé. To
facilitate access to viral load testing, 15 men were trained to collect and transport blood
samples for testing in laboratories.
Lesson learned
In fiscal year 2021, during the COVID-19 crisis, we collected 960 blood samples and
transported them to laboratories, 912 of which had an undetectable viral load, (95%).
Through this work, we have understood that it is important to include most affected
communities if we are to make U=U a reality.
Next steps
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We will advocate to perform viral load testing directly at the community level by using less
sophisticated equipment.
UNAIDS/PCB (51)/22.29
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Acknowledgements
We extend our heartfelt appreciation for the time, thoughtful reflections, invaluable
contributions and country case studies shared by our key informant interview participants
and civil society experts and reviewers. Due to confidentiality, participants in key informant
interviews are not named here.
Regions represented in key informant interviews
Region
Number of interviews
Africa
4
Asia-Pacific and Middle East and North Africa
3
Eastern Europe and central Asia
2
Europe
3
Latin America and the Caribbean
2
North America
4
Total
18
Civil society experts for peer review of the NGO report
Name
Organization
Country and region
Brent Allan
ICASO
Global
Solange Baptiste Simon
International Treatment Preparedness
Coalition
South Africa (Africa)
Javier Hourcade-Bellocq
Plataforma VIH 2025
Argentina (Latin American
and the Caribbean)
Laurie Edmiston
CATIE
Canada (North America)
Sandra Ka Hon Chu
HIV Legal Network
Canada (North America)
Erika Castellanos
GATE
Netherlands (Europe)
Lucy Wanjiku Njenga
Positive Young Women Voices
Kenya (Africa)
Mat Southwell
International Drug Policy Consortium
United Kingdom (Europe)
Kaythi Wynn
Asia Pacific Network of Sex Workers
Thailand (Asia-Pacific)
[End of document]
UNAIDS/PCB (51)/22.29
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Endnotes
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5
State of inequality: HIV, tuberculosis and malaria. Geneva: WHO: 2021
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World AIDS Day report 2021: Unequal, unprepared, under threat. why bold action against inequalities is needed
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8
In danger: UNAIDS Global AIDS Update 2022. Geneva: UNAIDS; 2022
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9
Ibid
10
Global Fund results report (https://www.theglobalfund.org/en/results/).
11
Ayala G, Sprague L, van der Merwe L et al. Peer-and community-led responses to HIV: A scoping review.
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Prevention Access Campaign. Why is U=U important? Accessed at: https://preventionaccess.org/about-
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13
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14
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In danger: UNAIDS Global AIDS Update 2022. Geneva: UNAIDS; 2022
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Updated recommendations on HIV prevention, infant diagnosis, antiretroviral initiation and monitoring. Geneva:
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Viral suppression. Fact sheet. Atlanta: U.S. CDC; 2022 (https://www.cdc.gov/hiv/statistics/overview/in-us/viral-
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18
https://www.aidsmap.com/about-hiv/glossary?term=#alpha-U
19
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Status neutral HIV care and service delivery eliminating stigma and reducing health disparities. Atlanta: U.S.
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21
Consolidated guidelines on HIV, viral hepatitis and STI prevention, diagnosis, treatment and care for key
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22
Ibid
23
National HIV/AIDS Strategy for the United States, 2022–2025. (https://www.whitehouse.gov/wp-
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24
Progress report of the Multistakeholder Task Team on Community-Led AIDS Responses. Geneva: UNAIDS
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25
Ibid
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https://www.theglobalfund.org/media/4790/core_communitysystems_technicalbrief_en.pdf
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29
End inequalities. end AIDS. Global AIDS Strategy 2021–2026. Geneva: UNAIDS; 2021, p. 6
(https://www.unaids.org/en/Global-AIDS-Strategy-2021-2026).
30
Ibid
31
Ibid
32
World AIDS Day report 2021: Unequal, unprepared, under threat. why bold action against inequalities is
needed to end AIDS, stop Covid-19 and prepare for future pandemics. Geneva: UNAIDS; 2021
(https://www.unaids.org/en/2021-world-aids-day).
UNAIDS/PCB (51)/22.29
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33
High-level Committee on Programmes Inequalities Task Team. Covid-19, inequalities and building back better:
policy brief by the HLCP inequalities task team. New York: UN; 2020
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34
Report of the Secretary-General: Tackling inequalities to end the AIDS pandemic. Seventy-sixth session:
Implementation of the Declaration of Commitment on HIV/AIDS and the Political Declaration on HIV/AIDS. New
York: UN General Assembly; 12 May 2022
(https://www.unaids.org/sites/default/files/media_asset/A_76_783_en.pdf).
35
Ibid
36
Ibid
37
Bekker L-G, Alleyne G, Baral S et al. Advancing global health and strengthening the HIV response in the era of
the Sustainable Development Goals: International AIDS Society – Lancet Commission. Lancet; 2018;392:312–
358.
38
In danger: Global AIDS update 2022. Geneva: UNAIDS; 2022
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39
State of inequality: HIV, tuberculosis and malaria. Geneva: WHO; 2021
(https://www.who.int/publications/i/item/9789240039445).
40
Understanding Fast-Track: Accelerating action to end the AIDS epidemic by 2030. Geneva: UNAIDS; 2021
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Global HIV statistics. Geneva: UNAIDS; 2021
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42
Ibid
43
Prevention Access Campaign. The WIN-WIN agenda, 2022 (https://preventionaccess.org/about-introduction/).
44
Consolidated guidelines on HIV prevention, testing, treatment, service delivery and monitoring:
recommendations for a public health approach. Geneva: WHO; 2021
(https://www.who.int/publications/i/item/9789240031593).
45
Acclaimed global activist to lead U =U innovations in advocacy for health equity. POZ Magazine; 2022
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46
https://www.ilo.org/wcmsp5/groups/public/---ed_protect/---protrav/---
ilo_aids/documents/publication/wcms_120468.pdf
47
https://journals.lww.com/aidsonline/Fulltext/2007/11007/Is_poverty_or_wealth_driving_HIV_transmission_.2.as
px
48
State of inequality: HIV, tuberculosis and malaria. Geneva: WHO: 2021
(https://www.who.int/publications/i/item/9789240039445).
49
Report of the Secretary-General: Tackling inequalities to end the AIDS pandemic. Seventy-sixth session:
Implementation of the Declaration of Commitment on HIV/AIDS and the Political Declaration on HIV/AIDS. New
York: UN General Assembly; 12 May 2022
(https://www.unaids.org/sites/default/files/media_asset/A_76_783_en.pdf).
50
Ibid
51
State of inequality: HIV, tuberculosis and malaria. Geneva: WHO: 2021
(https://www.who.int/publications/i/item/9789240039445).
52
World AIDS Day report 2021: Unequal, Unprepared, under threat. why bold action against inequalities is
needed to end AIDS, stop COVID-19 and prepare for future pandemics. Geneva: UNAIDS; 2021
(https://www.unaids.org/en/2021-world-aids-day).
53
Ibid
54
State of inequality: HIV, tuberculosis and malaria. Geneva: World Health Organization: 2021. Licence: CC BY-
NC-SA 3.0 IGO, p.3. Accessed at: https://www.who.int/publications/i/item/9789240039445
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Ibid, p. 3
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Global AIDS Strategy (2021–2026). Geneva: UNAIDS; 2021
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ibid.
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64
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Communities, Alliances & Networks (CAAN) and CATIE. Strong Medicine.
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84
Ford O, Rufurwadzo T, Richman B et al. Adopting U=U to end stigma and discrimination. J Internat AIDS Soc.
2022;25:25891.
85
In danger: UNAIDS Global AIDS update 2022. Geneva: UNAIDS; 2022
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86
Eisinger R, Dieffenbach, C, Fauci, A. HIV viral load and transmissibility of HIV infection: Undetectable equals
untransmittable. J Americ Med Ass, 2019;321(5).
87
Baral S, Rao A, Sullivan P et al. The disconnect between individual-level and population-level HIV prevention
benefits of antiretroviral treatment. The Lancet. 2019:6 (e632-638).
88
Ibid
89
Confronting inequalities: Lessons for pandemic responses from 40 years of AIDS. Global AIDS update 2021.
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