{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T01:22:30Z","timestamp":1760059350790,"version":"build-2065373602"},"reference-count":63,"publisher":"Public Library of Science (PLoS)","issue":"10","license":[{"start":{"date-parts":[[2025,10,9]],"date-time":"2025-10-09T00:00:00Z","timestamp":1759968000000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100000024","name":"Canadian Institutes of Health Research","doi-asserted-by":"publisher","award":["MOP-137009"],"award-info":[{"award-number":["MOP-137009"]}],"id":[{"id":"10.13039\/501100000024","id-type":"DOI","asserted-by":"publisher"}]},{"name":"Canadian Institutes of Health Research Tier 2 Canada Research Chair in HIV Prevention and STI Research"},{"name":"Canadian Institutes of Health Research Tier 2 Canada Research Chair in Sexually Transmitted Infection Prevention"},{"DOI":"10.13039\/501100000156","name":"Fonds de Recherche du Qu\u00c3\u00a9bec - Sant\u00c3\u00a9","doi-asserted-by":"publisher","award":["311200"],"award-info":[{"award-number":["311200"]}],"id":[{"id":"10.13039\/501100000156","id-type":"DOI","asserted-by":"publisher"}]},{"name":"Qu\u00c3\u00a9bec Ministry of Health for researchers in Family Medicine","award":["LE 250"],"award-info":[{"award-number":["LE 250"]}]},{"name":"Canadian Institutes of Health Research Strategy for Patient-Oriented Research Mentorship Chair in Innovative Clinical Trials for HIV Care"},{"DOI":"10.13039\/100004330","name":"GlaxoSmithKline","doi-asserted-by":"publisher","id":[{"id":"10.13039\/100004330","id-type":"DOI","asserted-by":"publisher"}]},{"name":"Gilead"},{"DOI":"10.13039\/100006483","name":"AbbVie","doi-asserted-by":"publisher","id":[{"id":"10.13039\/100006483","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100004330","name":"GlaxoSmithKline","doi-asserted-by":"publisher","id":[{"id":"10.13039\/100004330","id-type":"DOI","asserted-by":"publisher"}]},{"name":"ViiV"},{"DOI":"10.13039\/100019533","name":"Moderna","doi-asserted-by":"publisher","id":[{"id":"10.13039\/100019533","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100004334","name":"Merck","doi-asserted-by":"publisher","id":[{"id":"10.13039\/100004334","id-type":"DOI","asserted-by":"publisher"}]},{"name":"Gilead"},{"DOI":"10.13039\/100010877","name":"ViiV Healthcare","doi-asserted-by":"crossref","id":[{"id":"10.13039\/100010877","id-type":"DOI","asserted-by":"crossref"}]},{"DOI":"10.13039\/100004334","name":"Merck","doi-asserted-by":"publisher","id":[{"id":"10.13039\/100004334","id-type":"DOI","asserted-by":"publisher"}]},{"name":"Gilead"}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS One"],"abstract":"<jats:sec id=\"sec001\">\n<jats:title>Introduction\/Objectives<\/jats:title>\n<jats:p>Undetectable\u2009=\u2009Untransmittable (U\u2009=\u2009U) means that virally suppressed HIV-positive partners cannot transmit HIV. With advancements in HIV care and the increasing number of mixed HIV-status relationships, we quantified U\u2009=\u2009U agreement (agreeing\/disagreeing that U\u2009=\u2009U is true) among people in mixed HIV-status relationships, assessed response concordance between partners, quantified the association between dyad-level U\u2009=\u2009U agreement and condomless sex, and estimated interaction effects of viral suppression.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec002\">\n<jats:title>Methods<\/jats:title>\n<jats:p>A cross-sectional opportunistic and snowball sampled survey explored condom use, U\u2009=\u2009U agreement, viral suppression, sociodemographic\/relationship characteristics, and sexual behavior among 306 participants (153 matched dyads) in mixed HIV-status relationships (2016\u20132018). Bivariate analyses identified sociodemographic\/relationship characteristics associated with U\u2009=\u2009U agreement. Cohen\u2019s Kappa assessed response concordance between partners. Firth logistic regression estimated associations between dyad-level U\u2009=\u2009U agreement and condomless sex with effect modification by viral suppression.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec003\">\n<jats:title>Results<\/jats:title>\n<jats:p>Of 293 responses to the U\u2009=\u2009U question, 53.2% agreed with U\u2009=\u2009U. Agreement was associated with younger age (p\u2009=\u20090.006) and shorter duration of HIV in relationships (p\u2009=\u20090.034).<\/jats:p>\n<jats:p>Concordance between partners was higher for factual questions (kappa&gt;0.50) and lower for belief\/decision-making questions (kappa&lt;0.40). The predicted probability of always having condomless sex was 0.60 (95% CI:0.57,0.64) when dyads agreed with U\u2009=\u2009U and the HIV-positive partner was virally suppressed. The likelihood of always having condomless sex was low when the HIV-positive partner was not virally suppressed, whether or not dyads agreed with U\u2009=\u2009U (predicted probability range: 0.08;95% CI:0.06,0.11 to 0.25;95% CI:0.17,0.33), or when only one partner agreed with U\u2009=\u2009U (predicted probability range:0.02;95% CI:0.01,0.02 to 0.11;95% CI:0.07,0.15).<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec004\">\n<jats:title>Conclusions<\/jats:title>\n<jats:p>Dyad-level U\u2009=\u2009U agreement, viral suppression, and views of both partners were key factors in mixed HIV-status couples\u2019 decisions to have condomless sex. Future representative studies among sexual identity and racialized minority sub-populations are needed to better understand how mixed HIV-status relationships receive and apply U\u2009=\u2009U messaging, with a focus on partner age and the duration of HIV within relationships.<\/jats:p>\n<\/jats:sec>","DOI":"10.1371\/journal.pone.0332926","type":"journal-article","created":{"date-parts":[[2025,10,9]],"date-time":"2025-10-09T17:48:02Z","timestamp":1760032082000},"page":"e0332926","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":0,"title":["The impact of Undetectable=Untransmittable and viral suppression on condomless sex among mixed HIV-status couples in Canada"],"prefix":"10.1371","volume":"20","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-8398-7239","authenticated-orcid":true,"given":"Min","family":"Xi","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Sandra","family":"Bullock","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8500-1683","authenticated-orcid":true,"given":"Joshua B.","family":"Mendelsohn","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Veronika","family":"Moravan","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ann N.","family":"Burchell","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Darrell H. S.","family":"Tan","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Bertrand","family":"Lebouch\u00e9","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jean-Pierre","family":"Routy","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2275-3540","authenticated-orcid":true,"given":"Amrita","family":"Daftary","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Tamara","family":"Thompson","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Liviana","family":"Calzavara","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"340","published-online":{"date-parts":[[2025,10,9]]},"reference":[{"issue":"9635","key":"pone.0332926.ref001","doi-asserted-by":"crossref","first-page":"293","DOI":"10.1016\/S0140-6736(08)61113-7","article-title":"Life expectancy of individuals on combination antiretroviral therapy in high-income countries: a collaborative analysis of 14 cohort studies","volume":"372","author":"Antiretroviral Therapy Cohort Collaboration","year":"2008","journal-title":"Lancet"},{"key":"pone.0332926.ref002","first-page":"117","article-title":"Quality of life of people living with HIV and AIDS and antiretroviral therapy","volume":"4","author":"OO Oguntibeju","year":"2012","journal-title":"HIV AIDS (Auckl)"},{"issue":"4","key":"pone.0332926.ref003","doi-asserted-by":"crossref","first-page":"256","DOI":"10.1111\/hiv.12421","article-title":"Life expectancy of HIV-positive people after starting combination antiretroviral therapy: a meta-analysis","volume":"18","author":"S Teeraananchai","year":"2017","journal-title":"HIV Med"},{"issue":"1","key":"pone.0332926.ref004","doi-asserted-by":"crossref","first-page":"92","DOI":"10.1007\/s10461-009-9548-8","article-title":"Is sexual serosorting occurring among HIV-positive injection drug users? 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