Sustained viral suppression resulting from antiretroviral therapy (ART) eliminates the risk of HIV transmission. Scientific and popular messaging has framed this elimination of risk in concepts such as treatment as prevention (TasP) and Undetectable = Untransmittable (U=U). We explored knowledge and acceptance of information around the elimination of HIV transmission risk with ART among health providers and HIV serodiscordant couples in Kenya.
The Partners Scale-up Project is evaluating PrEP delivery to HIV uninfected individuals in serodiscordant relationships in 24 public HIV clinics in Central and Western Kenya. We conducted semi-structured in-depth interviews with 69 health providers and 35 HIV uninfected people in serodiscordant relationships receiving PrEP services. Transcripts were coded using framework analysis.
Health providers reported being aware of reduced risk of HIV transmission as a result of consistent ART use and used words such as ‘very low’, ‘minimal’, ‘like zero’ to describe HIV transmission risk after viral suppression: but did not use the words ‘no risk.’ Additionally, providers reportedly found viral load results helpful when counseling clients on the ‘very low risk’ of HIV transmission after viral suppression. Others believed that U=U works, but only in the context of consistent condom use but concerns were expressed that communicating this message to HIV infected persons would lead them to engaging in multiple sexual relationships. Other providers reported avoiding counseling on risk of HIV transmission even after viral suppression for fear in case a seroconversion occurred they would be blamed. Similarly, members of HIV serodiscordant couples reported being informed about U=U by the providers but they did not believe/trust the message. Even after the HIV infected partners reached viral suppression, most HIV uninfected members of couples reported unwillingness to stop PrEP while others reported that they would use condoms if they stopped PrEP.
Despite high awareness that ART eliminates HIV transmission risk, there is both a lack of in depth knowledge and conviction among health providers and PrEP users. New strategies to communicate U=U in a reliable and believable way are urgently needed.