• U = U enables HIV prevention by proxy through sustained viral suppression. • Unequal ART access limits who can rely on U = U for HIV prevention. • Prevention by proxy raises sexual justice and autonomy concerns. • Harm reduction must address relational and structural inequities. Ethical debates on HIV harm reduction have traditionally focused on prevention strategies used directly by individuals at risk of acquiring HIV, such as condoms and pre-exposure prophylaxis. The scientific evidence underpinning “Undetectable = Untransmittable” (U = U) introduces a distinct ethical configuration by establishing viral suppression among people living with HIV as a means of HIV prevention, allowing HIV-negative individuals to rely on partners’ undetectable status for protection. To examine how global inequities in antiretroviral therapy (ART) access prevents HIV-negative individuals to practice HIV prevention by proxy through U = U, drawing on harm reduction ethics and sexual justice. U = U constitutes a novel harm reduction strategy in which prevention is contingent on others’ access to treatment and sustained viral suppression, allowing individuals to reduce sexual risk without relying on self-directed biomedical interventions. Because access to continuous ART and viral load suppression remains highly unequal within and across countries, prevention by proxy is unevenly available. These structural disparities restrict HIV-negative individuals’ ability to choose U = U as a legitimate prevention strategy, thereby constraining their sexual autonomy. From a sexual justice perspective, such inequities constitute a form of public health injustice that extends beyond the health rights of people living with HIV. Equitable access to ART is ethically necessary not only to protect the rights of people living with HIV, but also to enable HIV-negative individuals to exercise prevention autonomy through HIV prevention by proxy. Framing ART access as a condition of sexual justice foregrounds the relational ethics of contemporary HIV harm reduction.
Brisson et al. (Thu,) studied this question.