MHM Magazine

The message of U=U (Undetectable = Untransmittable) has become one of the most powerful developments in HIV treatment and advocacy. It signifies that individuals on consistent antiretroviral therapy (ART) who maintain an undetectable viral load cannot sexually transmit HIV. Yet, U=U represents far more than a scientific truth; it is a message of healing, dignity, and hope. It challenges long- standing stigma and restores a sense of worth among people living with HIV. Having lived openly with HIV for more than two decades, I’ve seen how information can transform despair into empowerment. Through my work as co-founder of the U=U Africa Forum, a member of the U=U Global Advisory Board, and in my role at the South African National AIDS Council (SANAC), I have witnessed the ways in which U=U can change both personal narratives and public perceptions. The Foundation for Professional Development (FPD) recently hosted a webinar on improving mental health and HIV/TB service integration, where I had the opportunity to speak about this critical connection. For U=U to be more than a slogan, we must recognise that mental health plays a vital role in how people living with HIV receive, internalise, and live out this message. Scientific progress alone is not enough; emotional and psychological well-being are central to treatment success. Mental health conditions such as depression, anxiety, trauma, and internalised stigma remain significantly higher among people living with HIV than among the general population. Research shows that: • A recent meta-analysis found pooled prevalences among people living with HIV (PLHIV) of depression at 31%, anxiety at 29%, psychological distress at 44%, and stigma at 47%. • In Africa, the prevalence of depressive symptoms among PLHIV ranges between 20–40%, with a pooled estimate of approximately 33%. These figures highlight an urgent need to integrate mental health into HIV care. Psychological distress can affect adherence to ART, reduce motivation to test or stay in care, and increase the risk of viral rebound. Both UNAIDS and WHO stress that mental health integration is essential for improving outcomes and ensuring overall well-being. As I often say, “This is how intersectionality works: mental health affects HIV, and HIV affects mental health.” Stigma is often internalised, leading people to believe they are unworthy of love or that they pose a danger to others. Even when presented with the U=U message, some find it difficult to believe they cannot transmit HIV, even with an undetectable viral load. Silence, misinformation, and fear have long damaged self-perception and limited people’s ability to live freely. At SANAC, we strive to make the U=U message visible through national campaigns that humanise the experience of living with HIV. Billboards showing couples living openly with HIV, and youth-led initiatives that promote resilience, bring a sense of normality and visibility to the community. I often recall stories that show the power of U=U in changing lives. One man, a 45-year-old bodybuilder, fell into depression and alcohol misuse after his diagnosis. Learning about U=U became a turning point; he rebuilt his confidence and returned to the gym. A married woman, rejected by her husband who saw HIV as a death sentence, found renewed strength through U=U, determined to live fully and love openly. Another person, once suicidal, discovered peace after understanding the truth behind U=U. These stories remind us that U=U must be paired with psychological support to realise its full potential. It’s important to note that U=U complements, rather than replaces, traditional prevention methods such as condom use, which remain essential for broader sexual health. My own journey began in 2002, during my nursing training, when I was diagnosed with HIV. I experienced fear, shame, and depression, retreating into isolation. Over time, disclosure and self-acceptance allowed me to reclaimmy life. Sharing my status with my husband was an act of honesty and protection for my family. It also reminded me that when individuals are mentally well, they create healthier families and stronger communities. The reach of U=U extends beyond individual transformation. A study conducted in Cape Town found that men who received U=U information were more likely to seek HIV testing compared to those who received standard messages. By reducing fear and replacing it with understanding, U=U helps promote testing, engagement, and long-term retention in care - all key factors in controlling the epidemic. However, implementation remains uneven across the country. While several provinces - including the Eastern Cape, Western Cape, Limpopo, and North-West - have launched U=U campaigns, followed by a national rollout in 2024, challenges nevertheless persist in ensuring that these policies are effectively translated into practice. As I often caution, “We’re good at developing policies, but the issue is translating them into practice. Tomorrow is too late.” To meet national treatment targets, including enrolling 1.1 million individuals on treatment by December 2025, mental health must be embedded within HIV services. This can be achieved through: 1. Early mental health screening at testing sites to address RESTORING HOPE, DIGNITY, AND SUSTAINING LIFE AMONG PEOPLE LIVING WITH HIV EDITORIAL Mandisa Dukashe HIV activist and public health professional mandisa@sanac.org.za Issue 5 | 2025 | MENTAL HEALTH MATTERS | 1 MHM