A conversation between Dr. Theresa Tam and Jade Elektra
Undetectable = Untransmittable (U=U) refers to the scientific consensus that HIV cannot be sexually transmitted when a person living with HIV consistently takes antiretroviral therapy (ART) and the amount of HIV in their blood remains very low—so low that it cannot be detected by many standard HIV tests.
While the U=U message empowers people living with HIV and reduces stigma associated with the virus, it is only effective if individuals living with HIV are able to continuously take their medication. Some people in Canada, such as African, Caribbean and Black communities, Indigenous people, gay, bisexual, and other men who have sex with men, people who use drugs and incarcerated people, face social and structural barriers that can impact access to HIV care and make it difficult to maintain consistent access to treatment. In order for U=U to have the greatest impact, people living with HIV must be supported by promoting U=U, advocating for those who face barriers in medication adherence and facilitating access to care. All public health and health professionals can help normalize and share the U=U message.
Dr. Theresa Tam, Canada’s chief public health officer, had a discussion with Jade Elektra, HIV activist, drag performer, recording artist and community builder about the social and structural nuances of U=U.
Dr. Theresa Tam: Jade, it’s a pleasure speaking with you about U=U. You’ve done so much to create safe spaces and address HIV-related stigma. The magazine you’ve founded by and for people living with HIV is just one example. I’m looking forward to delving into this topic with you.
Jade Elektra: Thank you, Dr. Tam. I’m always happy to talk about U=U—it’s a topic close to my heart and one that needs more attention.
U=U can have a tremendous impact on a person living with HIV, especially if they are sexually active, and can be empowering for young people and recently diagnosed folks living with HIV. However, I’d be interested in hearing your perspective as a public health leader on why U=U is so important.
Dr. Theresa Tam: Looking back, it’s amazing to see how far treatment and care for HIV has come in the past 45 years. Thanks to scientific advances, HIV has become a treatable chronic condition. Don’t get me wrong, we still have a ways to go, but now people with HIV are living longer and healthier lives than before. People living with HIV who are aware of U=U are more likely to report better mental, physical and sexual health. This science has transformed what it means to live and love with HIV on a global scale.
However, we also need to address the stigma and discrimination experienced by people living with HIV, both socially and within healthcare settings. It can really affect people’s well-being, including their willingness to seek out testing and treatment.
Jade Elektra: Yes, there are many barriers that could contribute to not achieving an undetectable status.
Dr. Theresa Tam: In 2020, close to 17,000 people in Canada did not achieve viral suppression. Because they lacked access to effective HIV treatment options or didn’t take any treatments, they were still at risk of transmitting HIV. The U=U message is important because it reduces HIV-associated stigma and encourages people to access testing and treatment needed to reach an undetectable status. As much as there is still work to be done, Canada has made great strides and has already reached one of the UNAIDS interim HIV treatment targets for the year 2025 of ensuring 95% of people with HIV who are on treatment have a suppressed viral load.
We know that there are barriers to becoming undetectable. Jade, could you share your views on what might prevent someone from achieving “undetectable” status?
Jade Elektra: Yes, there are many possible contributing barriers such as lack of education, racism and limited access to healthcare facilities. African, Caribbean and Black communities in particular experience higher rates of HIV, but these communities may also face more systemic and structural barriers preventing access to medication. Some people may have to choose between buying food, paying rent or getting their medication. Other folks may experience intermittent access to treatment, multiple health problems at once or precarious housing without a set routine. Any of these situations affects their ability to stick to a treatment plan. What’s more, people may be reluctant to continue seeking care if they experience racism in healthcare settings or cannot access culturally appropriate care. But I believe the stigma of being HIV-positive, or even being perceived as being HIV-positive, is the biggest hurdle.
Dr. Theresa Tam: Clearly there are complex and compounding systemic factors that may impact someone’s ability to consistently take medication or access testing and care to begin with.
Jade Elektra: Definitely. I went many years without any medical treatment and was extremely ashamed and felt afraid to let anyone know that I was HIV-positive. I believe that shame and fear actually made my health worse. But once I started antiretroviral meds and started watching my numbers [my CD4 count] get better I took pride in taking care of myself.
That said, not everyone who is living with HIV has access to medical treatment or an adherence routine due to the factors we’ve been talking about. The shame and fear these individuals may feel might be reinforced by general HIV-related stigma, not being able to reach viral suppression, or even specific healthcare-related stigma. They may face discrimination and judgment by health professionals for not adhering to treatment or not getting support in leading full social and sexual lives. They may even be labelled as “non-compliant” in adhering to medication, which adds to the stigma, when in fact the barriers these individuals face are systemic and not a reflection of a personal failing.
Dr. Theresa Tam: For patients who face barriers to U=U, it is important for us, as health professionals, to recognize our own personal biases and avoid stigmatizing patients that aren’t adhering to medication. As health professionals, it is important we take a person-centered approach and provide support that meets patients’ needs.
Jade Elektra: I feel strongly that health professionals need to support patients living with HIV, especially those who face barriers to U=U. U=U should be a practiced, normalized conversation with patients and clients, and awareness of barriers should be well known. I have experienced healthcare settings where the provider is not promoting U=U or doesn’t know about it. What would you recommend health professionals do to support patients with HIV who face barriers to U=U?
Dr. Theresa Tam: Not just as health professionals, we need to normalize sexual health and sexual health conversations, including talking about sexually transmitted and blood-borne infections, to reduce stigma associated with HIV testing and treatment.
We can continue to support patients who face barriers to U=U by promoting the full range of effective, evidence-based prevention options for HIV and other sexually transmitted and blood-borne infections, like condoms, pre-exposure prophylaxis (PrEP), post-exposure prophylaxis (PEP) and harm reduction. We can connect patients with other health or social services, which may then help address the barriers our patients face to reaching undetectable. How do we encourage health professionals to champion U=U while also meeting patients where they are at?
Jade Elektra: I believe a bigger push to educate all health professionals, people living with HIV and the general public at large about U=U could help close the gap. Pamphlets in waiting rooms and clinics and displaying posters in public areas is a great way to start the conversation. Now we can add the Public Health Agency of Canada’s recent public awareness campaign on U=U and its helpful resources such as the Communication Tips for Health Professionals factsheet. Another good source of information is CATIE, a community-based organization promoting good practices for prevention and treatment that also has great HIV and U=U related materials available, free of charge. We need the information widely available in the public sphere.
Encouraging patients to ask questions is another great way to start the conversation and meet people where they are at. Health professionals can ask patients about their situation and the barriers they may face to learn how to best support their health needs. Always remember that each person has their own circumstances of why they can or cannot achieve an undetectable status. It’s helpful to focus on what can be done to support patients within their unique circumstances.
Dr. Theresa Tam: Thank you, Jade, for taking the time to speak about U=U and openly sharing your thoughts and experiences. Our conversation today emphasizes that all health professionals, whether or not they work in sexual health or HIV-specific fields, have the power to create positive change through initiating and promoting conversations about HIV, U=U and safer sex.
To learn more about U=U and to access resources for health professionals, please visit Canada.ca/HIV.
Dr. Theresa Tam was named Canada’s chief public health officer in June 2017. As the federal government’s lead public health professional, she provides guidance to help protect the people of Canada against health threats, advance health equity and promote healthier communities, using the best available data and evidence. For her full bio, click here.
Jade Elektra (born Alphonso King Jr.) is a Black queer HIV activist, drag queen, singer, recording artist (DJ Relentless) and stage performer from Tampa, Florida, now based in Toronto, Ontario. Jade is openly living with HIV and through activism and outreach, has strived to make a positive impact for HIV-positive and queer people of colour, as well as LGBTQ communities in Toronto and around the world. Jade is a founder of POZPLANET and POZ-TO, which fight HIV/AIDS stigma by hosting social events, as well as partnering with and fundraising for community-based HIV/AIDS organizations.