10 Years of the U=U campaign: Where it’s succeeded—and fallen short

It was 10 years ago last winter in Boston, at the Conference on Retroviruses and Opportunistic Infections (CROI), that Bruce Richman, a New York City-based philanthropic adviser with a Harvard law degree, and Gus Cairns, a longtime HIV advocate and journalist from the U.K., had a heart-to-heart. Both living with HIV, they lamented that it wasn’t commonly known worldwide that people with HIV who take antiretroviral medication and maintain an undetectable viral load cannot transmit the virus sexually. That fact had been definitively proven by a series of large studies published throughout the 2010s. But too few people—among them people living with HIV, their care providers, advocates and the general public—had any idea.

So a few months later, Richman launched the Prevention Access Campaign (PAC) to spread the word, abbreviating the slogan “Undetectable = Untransmittable” to the simple, catchy “U=U.” By the end of 2016, with even more data to back up the science, New York City’s health department became the first in the world to officially endorse and promote U=U (with an outdoor dance party the following spring, no less). Federal health agencies started making videos to promote U=U. In the ensuing years, U=U would be publicly embraced by dozens of governments and health agencies worldwide, with the U.S. Centers for Disease Control (CDC)—at the time, the world’s most respected public health agency—announcing that people with HIV with suppressed virus on meds posed “effectively no risk” of passing the virus to their sex partners. (For U=U purposes, suppressed—or undetectable—viral load means less than 200 copies/mL.)

It was a huge sea change, dramatically reducing the stigmatizing idea of people living with HIV as a vector of disease. Dissemination of the U=U message changed HIV treatment guidelines and helped repeal or soften longstanding laws in about half of U.S. states that criminalized people with HIV for not disclosing their HIV status to partners. It was also a huge self-esteem lift for people living with the virus worldwide. 

“It was very empowering,” says Todd Fuqua, an Indiana activist living with HIV. “It removed a layer where [people with HIV would think of themselves] ‘I’m broken, I’m a threat, I’m dangerous, I’m sick.’ It really helped our outlook on life and relationships.”

A decade in, though, the U=U campaign has not accomplished all it intended to. Studies show that many people—living with HIV or not—haven’t heard of the idea behind U=U or they don’t believe or trust it, even in the face of ample data. In scientific communities, and in U.S. HIV care guidelines, it’s known as Treatment as Prevention (TasP). Only five states have fully repealed their HIV criminalization laws, with 32 states still criminalizing people with HIV—28 states still have harsh enhanced penalties for people with HIV. And though individuals, groups and governments in countries worldwide continue to robustly promote U=U, here in the U.S., the momentum behind U=U, which was aided by both the Trump 1.0 and Biden administrations, has slowed amid the Trump 2.0 administration’s widespread rejection of longstanding global research and public-health best practices.

Where has U=U succeeded and where has it failed in the past decade? And what comes next? Let’s take a look.

On one hand, an astounding success 

It’s hard to underestimate the reach of a campaign that was started by two individuals without initial support from major agencies or institutions. According to PAC, since its launch in 2016, the U=U message has been officially adopted by more than 1,100 organizations or agencies in 108 countries. It has shot across social media worldwide, often appearing before the eyes of people who are outside of the global HIV activist community, who had no idea that people living with HIV on meds were unable to transmit the virus sexually. And as Fuqua noted, it has empowered people with HIV across the world to be more open and unashamed about their status.

“Over the past decade, the U=U movement has had profound global impact by revolutionizing what it means to live and love with HIV and accelerating progress toward ending the epidemic,” Richman, who recently left the organization he founded to pursue other projects, wrote in an email. “It has transformed public understanding and personal lives by reducing fear, stigma and misinformation, reshaping clinical practice, reforming discriminatory laws and policies and offering millions of people living with HIV a new sense of freedom from the fear of transmission.”

He was echoed by PAC interim executive director Monique Carry, PhD, who wrote in an email: “Over the past decade, U=U has fundamentally changed how we understand HIV, not just scientifically, but socially. It has reshaped clinical guidance, influenced policy and advocacy and transformed provider–patient conversations in many settings. In health systems that have embraced U=U, we’ve seen more affirming counseling, better engagement in care and a shift away from fear-based messaging. For many people living with HIV, U=U has restored a sense of agency, opened the door to relationships and family planning and reduced internalized stigma in ways no other public health message has done.”

She continued: “U=U has also helped move conversations about HIV criminalization, disclosure and rights toward evidence rather than moral judgment. Perhaps most importantly, it has demonstrated the power of a movement led by people living with HIV who insisted that the science be communicated honestly and without fear.”

Clinicians agree, too, that U=U has had an impact. “The biggest thing it’s done is to further drive us, as a field, to emphasize how critical it is to get fully suppressed,” says Jeanne Marazzo, MD, MPH, FACP, FIDSA, the CEO of the Infectious

Disease Society of America (IDSA), which contains the HIV Medicine Association (HIVMA). “You can tell people now that if they fully adhere to their meds, they can be non-infectious to their partners. That’s such a powerful message that changes the game of motivating people [to take] antiretrovirals. HIV was once a death sentence, but now you can live a full life, whether it’s wanting to have a healthy sex life or a child.”

Her words are backed up by data. A 2020 study of thousands of people with HIV in several countries found that those who have discussed U=U with their health provider—which is often when they are most likely to absorb and believe new health information—had better outcomes in terms of adherence to their meds, getting to undetectable and disclosing their status to sexual partners.

And at least one study has also shown that knowledge of U=U makes people with unknown HIV status more likely to get tested. Fuqua says he learned this fact through PAC’s “U=U University” initiative, which educates providers and advocates and prepares them to pass on the message. 

“That was an a-ha moment for me,” says Fuqua, noting that the study suggested that people were more likely to get tested because, after learning about U=U, the idea of HIV as a fairly easily managed virus that can be rendered untransmittable “doesn’t seem so scary.”

According to Bruce J. Packett II, executive director of the American Academy of HIV Medicine (AAHIVM), U=U has “served as a foundational element for status-neutral care.” By that he means care that informs people living with HIV about the benefits of being adherent to meds and maintaining an undetectable load, while informing people who do not have HIV, but who have the potential for acquisition, of available prevention options such as condoms and preexposure prophylaxis (known as PrEP). But perhaps where U=U has done the most good in reducing harm to people living with HIV is the key role it has played in efforts to repeal—or at least modernize—HIV criminalization laws so that they reflect current science. Often written in the 1980s and ’90s at the peak of the epidemic, HIV criminalization laws penalize people with HIV who don’t disclose sexually even if no HIV was transmitted—or impose an additional harsher sentence in some cases if the person charged has HIV. Many of these state laws have remained on the books even after highly effective antiretroviral treatment has become the norm since the late 1990s. 

Since the 2016 rollout of U=U, at least 13 states have either repealed or softened their HIV criminalization laws. “I’d say that in every one of those changes, U=U played a significant role,” says Kamaria Laffrey, co-executive director of The Sero Project, which advocates for such changes in HIV laws. “Without the science and the campaign behind U=U, we can’t express [a core reason why these laws should be changed] in a clear way.”

But Laffrey says that she, like many advocates against HIV criminalization, has been careful not to make U=U the linchpin for law change because some people with HIV are either unable or unwilling to get and stay undetectable—for complicated reasons that can include mental illness, substance use, unstable or nonexistent housing or healthcare or a combination of these. That’s why advocates have pushed for law changes to be based not only on undetectability but, for example, on shifting the burden of proof of intent to transmit HIV to the accuser.

“That’s why I don’t lead with U=U” in her law-change advocacy, says Laffrey. “I don’t want to create legislation that would hinge [being protected from charges] on being undetectable.”

But on the flip side...

The simple fact remains that, as much as the U=U campaign has gotten its message out globally over the past decade, vast swaths of people in healthcare, the legal system and the general public—including people living with HIV—haven’t heard of the concept (if they even know what undetectable HIV means) or, if they have, don't believe it or entirely trust it.

This is borne out by research. One 2024 survey found that among about 106 mostly gay white men living with HIV and another 351 living without HIV or of unknown status, about 95% of all participants were aware of U=U, but only 41% believed it. Among men living with HIV, two-thirds (66%) accepted U=U, compared with about one-third (33.6%) of those who were HIV-negative or of unknown status. (The study concluded that society could benefit by broader and deeper promotion of the U=U message.) 

A 2022 survey found that, of more than 700 people living with HIV—most of them cisgender men under age 50 with some college education—more than half didn’t know the meaning of U=U. But for those who did, more than half learned it from their health provider, not from informational campaigns, which points to the importance of provider education on U=U so they can pass the knowledge on to patients. 

And a 2024 study of mostly older Black low-income heterosexual people in South Carolina found that most of them didn’t believe or trust the U=U message (particularly if they hadn’t heard of U=U previously). Wrote the study authors: “These findings are of grave importance to the fight against the HIV epidemic in the U.S., since belief or confidence in U=U could help reduce sexual HIV transmission, reduce HIV-related stigma, promote adherence to ART and improve the general well-being of [people with HIV].”

Leaders in U=U messaging echo this. 

“U=U’s impact has been uneven,” Richman wrote in his email. “It has not fully reached communities where there is a lack of bold leadership and a persistent devaluing of the lives of people living with HIV, especially those already marginalized by health systems. This gap exists because stigma, inequity and chronic underinvestment in public health continue to shape who benefits most from scientific progress. There is also still limited understanding of U=U’s value beyond individual health, including its broader social, economic, public health and prevention importance. And this is true on every continent. Until both the personal and public health power of U=U are fully understood and embraced, its promise will remain only partially fulfilled.”

Wrote Carry in her email: “U =U has not reached everyone equally. Awareness remains uneven across regions, communities and healthcare settings. Provider resistance is still a real barrier. Outdated beliefs, fear of liability or discomfort with sexuality prevent providers from fully embracing or communicating U=U, despite the science being clear. In other settings, health systems have been slow to integrate U=U into training, counseling and public-facing materials, leaving clients to learn about U=U elsewhere or not at all.”

She added: “Making U=U a reality for everyone also falls short where access to treatment is fragile or inconsistent. Structural barriers like racism, criminalization, poverty, gender inequities and political hostility toward public health continue to shape who can benefit from U=U in practice.”

In Indiana, says Fuqua, even the best presentation of U=U has not been enough to get the state’s HIV criminalization laws reformed. “We see many cases where people plea-bargain and are charged even though they’re undetectable,” he says. “We haven’t done our job in [sufficiently] educating the public defenders, prosecutors and judges” about U=U. 

And Indiana is just one of many states where the U=U message hasn’t been enough to reform such laws. 

But Fuqua notes that U=U’s insufficient reach isn’t just in the legal space. 

“I think it’s been adopted in [HIV] clinics faster than it’s been absorbed by general culture. Beliefs spread more slowly than evidence, so it’s hard to change people’s minds. And I think there are still providers out there who hedge a little or stay silent on U=U” with their patients, he says, perhaps because of some gut mistrust or because they still don’t want their undetectable patients having sex without a condom. 

What happens now?

Experts agree that, with the Trump 2.0 administration abruptly abandoning standard, evidence-based public health measures both at home and abroad, now is probably not the best time to expect the federal government to carry the torch for U=U as it did under Trump 1.0 and Biden. And they worry that the full potential of U=U—getting more than 90% of Americans with HIV to undetectable as a means of effectively ending the HIV epidemic in the U.S.—is truly threatened now that both huge impending cuts to Medicaid and the end of subsidies for Obamacare plans threaten to throw countless Americans, some living with HIV, off health coverage entirely. (Deep-red Florida, with a large HIV population, has even gone so far as to drastically scale back income eligibility for its AIDS Drug Assistance Program (ADAP), each state’s payer of last resort for HIV meds and care.) 

Laffrey says she worries that deep cuts to HIV prevention funding the past year will lead to more HIV cases—and more people living with HIV who are unaware of U=U. “I think the science is going to take a hit and we’ll have to start all over again. We have no federal partners right now, so I think our advocacy will become more localized around making sure that people stay in care.”

But even though the current climate may not be optimal for continuing to get the U=U word out, Carry says that PAC will be, well, carrying on—including soon launching a “10 Years of U=U” campaign across its social media channels. There, she wrote, “we’ll be sharing stories, partner highlights, events and milestones,” building to a crescendo for a strong U=U presence at the AIDS 2026 International AIDS Conference in Rio de Janeiro in late July. 

“For example,” she wrote, “last month in partnership with The Global Network of People Living with HIV (GNP+), “we hosted two global webinars”—one for leaders across the Americas and West Africa and another for Europe, Asia and East Africa.

Other components of the campaign, she wrote, will include a digital storytelling series highlighting U=U’s impact over the past decade, U=U University and capacity-building activities, a 10 Years of U=U Awards Celebration Dinner, the unveiling of the U=U Youth Manifesto developed with Y+ Global at AIDS 2026 and ongoing digital and social engagement spotlighting regional and partner-led efforts.

“Looking beyond 2026,” she wrote, “our focus is on durability: embedding U=U in education, practice and leadership so that it can withstand political cycles and continue advancing access and truth.”

“They’ve been doing a good job of it already for the past 10 years,” he says. They’re the heroes in this story.”