Changing Knowledge and Attitudes Towards HIV Treatment-as-Prevention and “Undetectable = Untransmittable”: A Systematic Review

People on HIV treatment with undetectable virus cannot transmit HIV sexually (Undetectable = Untransmittable, U = U). However, the science of treatment-as-prevention (TasP) may not be widely understood by people with and without HIV who could benefit from this information. We systematically reviewed the global literature on knowledge and attitudes related to TasP and interventions providing TasP or U = U information. We included studies of providers, patients, and communities from all regions of the world, published 2008–2020. We screened 885 papers and abstracts and identified 72 for inclusion. Studies in high-income settings reported high awareness of TasP but gaps in knowledge about the likelihood of transmission with undetectable HIV. Greater knowledge was associated with more positive attitudes towards TasP. Extant literature shows low awareness of TasP in Africa where 2 in 3 people with HIV live. The emerging evidence on interventions delivering information on TasP suggests beneficial impacts on knowledge, stigma, HIV testing, and viral suppression.Review was pre-registered at PROSPERO: CRD42020153725

How the Science of HIV Treatment-as-Prevention Restructured PEPFAR’s Strategy: The Case for Scaling up ART in ‘Epidemic Control’ Countries

The clinical logics of TasP shaped PEPFAR’s latest strategic initiative to achieve ‘epidemic control’ including the organisation’s use of metrics for evaluating performance, and decisions for allocating funds to specific programs and countries. TasP was conceptualised as an ‘evidence-based’ solution for effectively treating and preventing HIV, which could be consistently measured and reported on, however its ability to produce the right kinds of evidence remained abstract and hypothetical. The effects of TasP have also been evident in the budget since PEPFAR launched the strategy to achieve ‘epidemic control’. Whereas under previous initiatives to ‘lead to the global response’ to the epidemic, PEPFAR supported a wider variety of program areas, including by strengthening health systems, under the strategy of epidemic control PEPFAR has prioritised treatment programs over and above all others. TasP also justified disproportionate spending on a subset of countries. By adopting the clinical logics of TasP, PEPFAR justified spending on a limited number of programmes in a small set of countries that could produce what it defined as the right kinds of outcomes, and laid the groundwork for the retreat of US foreign aid.