Untransmittable but unequal? Sexual wellbeing disparities in the context of PrEP and U=U.

Abstract

Background: Biomedical prevention technologies, such as pre-exposure prophylaxis, treatment as prevention and the principle of Undetectable = Untransmittable, have transformed HIV care and opened new possibilities for enhancing the sexual wellbeing of people living with HIV. Yet, the psychosocial and relational benefits of these tools, particularly their impact on sexual wellbeing, remain underexplored, especially across diverse subpopulations.

Methods: Using data from 669 people living with HIV participating in a large-scale survey of people living with HIV in Australia, this study developed the Sexual Wellbeing through Biomedical Prevention scale, a five-item measure assessing sexual wellbeing (e.g. confidence, enjoyment) in the context of biomedical HIV prevention (score range 0-20; higher scores = greater wellbeing). ANOVA tests examined differences in Sexual Wellbeing through Biomedical Prevention scores across demographic, relational, psychosocial and health-related variables.

Results: Exploratory factor analysis supported a single-factor structure. The mean Sexual Wellbeing through Biomedical Prevention score was moderate overall (M = 13.0), but varied significantly by gender, sexuality, relationship status, partner pre-exposure prophylaxis use, stigma and quality of life. Gay/queer men reported markedly higher scores than women and heterosexual participants. Higher scores were associated with partner pre-exposure prophylaxis use, reduced fear of transmission, and better self-reported health and quality of life. Participants who reported 'always' experiencing HIV-related stigma had significantly lower mean scores.

Discussion: Biomedical advances have improved virological outcomes, but their sexual wellbeing benefits appear unevenly distributed. Targeted interventions that address stigma, strengthen HIV literacy and support sexual confidence, particularly among women and heterosexual people living with HIV, are essential to realising the full potential of biomedical prevention and advancing equity in wellbeing.