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Richterman A, Klaiman T, Palma D, Ryu E, Schmucker L, Villarin K, Grosso G, Brady KA, Thirumurthy H, Buttenheim A. B-OK: A Visual and Tactile Tool for HIV Treatment Adherence Support in a United States Urban Center. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.02.28.24303498. [PMID: 38463947 PMCID: PMC10925346 DOI: 10.1101/2024.02.28.24303498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
Lack of adherence to antiretroviral therapy (ART) and poor retention in care are significant barriers to ending HIV epidemics. Treatment adherence support (TAS) effectiveness may be constrained by limited awareness and understanding of the benefits of ART, particularly the concepts of treatment as prevention and Undetectable=Untransmittable (U=U), for which substantial knowledge gaps persist. We used mixed methods to evaluate a straightforward visual and tactile tool, the B-OK Bottles ("B-OK"), that incorporates human-centered design and behavioral economics principles and is designed to change and strengthen mental models about HIV disease progression and transmission. We enrolled 118 consenting adults living with HIV who were clients of medical case managers at one of four case management agencies in Philadelphia. All participants completed a pre-intervention survey, a B-OK intervention, and a post-intervention survey. A subset (N=52) also completed qualitative interviews before (N=20) or after (N=32) B-OK. Participants had a median age of 55 years (IQR 47-60), about two-thirds were male sex (N=77, 65%), nearly three-quarters identified as non-Hispanic Black (N=85, 72%), and almost all reported receiving ART (N=116, 98%). Exposure to B-OK was associated with improved awareness and understanding of HIV terminology, changes in attitudes about HIV treatment, and increased intention to rely on HIV treatment for transmission prevention. Insights from qualitative interviews aligned with the quantitative findings as respondents expressed a better understanding of U=U and felt that B-OK clearly explained concepts of HIV treatment and prevention. These findings provide a strong rationale to further evaluate the potential for B-OK to improve TAS for PLWH.
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Onoya D, Sineke T, King R, Mokhele I, Sharma S, Dukashe M, Cele R, Bokaba D, Inglis R, Sigasa S, Bor J. Designing effective U = U communication strategies considering the needs of PLHIV, their partners, and healthcare worker constraints in South African clinics. PLoS One 2023; 18:e0295920. [PMID: 38117817 PMCID: PMC10732369 DOI: 10.1371/journal.pone.0295920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 12/04/2023] [Indexed: 12/22/2023] Open
Abstract
INTRODUCTION We sought to understand the Undetectable = Untransmittable (U = U) communication needs of persons living with HIV (PLHIV) and barriers to U = U communication among healthcare providers (HCPs) in South Africa. METHODS We conducted five focus group discussions (FGDs) with HCPs (N = 42) including nurses and counsellors from primary healthcare clinics (PHCs) in the Gauteng and Free State Provinces of South Africa, three FGDs (N = 27) with PLHIV recruited by snowball sampling from civil society organizations, and 27 in-depth interviews (IDIs) with recently diagnosed PLHIV in Johannesburg. IDIs and FGDs were audio recorded, transcribed, translated to English, and analysed thematically. RESULTS PLHIV were largely unaware and sceptical of U = U as the message appeared to contradict the mainstream HIV prevention clinical guidance. The low viral load (VL) knowledge further reduced confidence in U = U. PLHIV need support and guidance on the best approaches for sharing U = U information and disclosing their VL status to their partners, highlighting the central role of community understanding of U = U and VL to mediate the desired stigma reduction, social acceptance and emotional benefits of U = U for PLHIV. HCPs were uneasy about sharing U = U due to concerns about risk compensation and ART non-adherence and worried about enabling any ensuing HIV transmission. HCPs also need a simple, unambiguous, and consistent narrative for U = U, integrated with other HIV prevention messages. PLHIV and HCPs alike recommended a patient-centred approach to communicating U = U, focusing primarily on attaining viral suppression and emphasizing that condomless sex is only safe during periods of ART adherence. CONCLUSIONS These data highlight the need for simple U = U communication support targeting both HCP and PLHIV. Culturally appropriate communication materials, with training and ongoing mentorship of the clinic staff, are essential to improve patient-centred U = U communication in clinics.
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Affiliation(s)
- Dorina Onoya
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Tembeka Sineke
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, The Netherlands
| | - Rachel King
- Institute for Global Health Sciences, University of California, San Francisco, San Francisco, CA, United States of America
| | - Idah Mokhele
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Shubhi Sharma
- Department of Global Health, Boston University School of Public Health, Boston, MA, United States of America
| | - Mandisa Dukashe
- South African National AIDS Council (SANAC), Pretoria, South Africa
| | - Refiloe Cele
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Dorah Bokaba
- Tshwane Department of Health, Tshwane, South Africa
| | | | - Simangele Sigasa
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Jacob Bor
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University School of Public Health, Boston, MA, United States of America
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Sineke T, Onoya D, Mokhele I, Cele R, Sharma S, Sigasa P, Dukashe M, Hansrod L, Inglis R, King R, Bor J. "I was scared dating… who would take me with my status?"-Living with HIV in the era of UTT and U = U: A qualitative study in Johannesburg, South Africa. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0000829. [PMID: 37831644 PMCID: PMC10575521 DOI: 10.1371/journal.pgph.0000829] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 08/16/2023] [Indexed: 10/15/2023]
Abstract
South Africa rolled out Universal Test-and-Treat (UTT) in 2016, extending treatment eligibility to all persons living with HIV (PLHIV). We sought to understand how PLHIV in Johannesburg, South Africa, interpret and experience their HIV status, five years into the UTT era. In May 2021, we conducted in-depth interviews (IDI) (N = 27) with adult (≥18 years) PLHIV referred by HIV counsellors at three peri-urban primary healthcare clinics. We also conducted three focus group discussions (FGDs) (N = 27) with adult PLHIV recruited from clinics or from civil society organisations through snowball sampling. Follow-up interviews were conducted with 29 IDI and FGD participants. Participants were asked to reflect on their HIV diagnosis, what their HIV status meant to them and how, if at all, being HIV-positive affected their lives. Interviews and focus group discussions were audio-recorded, transcribed, translated to English, and analysed using a grounded theory approach. Participants perceived that HIV was common, that PLHIV could live a normal life with antiretroviral therapy (ART), and that ART was widely accessible. However, HIV elicited feelings of guilt and shame as a sexually transmitted disease. Participants used the language of "blame" in discussing HIV transmission, citing their own reckless behaviour or blaming their partner for infecting them. Participants feared transmitting HIV to others and felt responsible for avoiding transmission. To manage transmission anxiety, participants avoided sexual relationships, chose HIV-positive partners, and/or insisted on using condoms. Many participants feared-or had previously experienced-rejection by partners due to their HIV status and reported hiding their medication, avoiding disclosure, or avoiding relationships altogether. Most participants were not aware that undetectable HIV is untransmittable (U = U). Participants who were aware of U = U expressed less anxiety about transmitting HIV to others and greater confidence in having relationships. Despite perceiving HIV as a manageable chronic condition, PLHIV still faced transmission anxiety and fears of rejection by their partners. Disseminating information on U = U could reduce the psychosocial burdens of living with HIV, encourage open communication with partners, and remove barriers to HIV testing and treatment adherence.
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Affiliation(s)
- Tembeka Sineke
- Faculty of Health Sciences, Department of Internal Medicine, Health Economics and Epidemiology Research Office, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Dorina Onoya
- Faculty of Health Sciences, Department of Internal Medicine, Health Economics and Epidemiology Research Office, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Idah Mokhele
- Faculty of Health Sciences, Department of Internal Medicine, Health Economics and Epidemiology Research Office, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Refiloe Cele
- Faculty of Health Sciences, Department of Internal Medicine, Health Economics and Epidemiology Research Office, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Shubhi Sharma
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Patience Sigasa
- Faculty of Health Sciences, Department of Internal Medicine, Health Economics and Epidemiology Research Office, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | | | | | | | - Rachel King
- Institute for Global Health Sciences, University of California, San Francisco, California, United States of America
| | - Jacob Bor
- Faculty of Health Sciences, Department of Internal Medicine, Health Economics and Epidemiology Research Office, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, United States of America
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Borsa A, Siegel K. Barriers to Treatment as Prevention Adoption Among Sexual and Gender Minority Individuals Who Have Sex with Men in the United States. AIDS Patient Care STDS 2023; 37:268-277. [PMID: 37155966 PMCID: PMC10171941 DOI: 10.1089/apc.2023.0001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023] Open
Abstract
The discovery that people with an undetectable HIV viral load are unable to transmit the virus to sex partners (U = U) has ushered in a new era in HIV care. As a result of this discovery, treatment as prevention (TasP) has become a powerful tool toward ending the epidemic. However, despite its sound scientific basis, many communities affected by HIV face barriers toward adopting TasP as a complete HIV prevention strategy. In addition, most research to date has only focused on TasP in the context of committed monogamous partnerships. To identify barriers to TasP adoption among some of those most affected by HIV, we conducted in-depth qualitative interviews with 62 sexual and gender minority individuals of varying serostatuses. Participants were identified from the results of an online survey, where those who indicated at least some awareness of TasP were invited to partake in a follow-up interview. Interviews were thematically coded to identify emergent themes relating to TasP adoption. Seven primary barriers emerged from data analysis pertaining to TasP science, internalized beliefs about HIV safety, and interactional dynamics between partners: (1) unfamiliarity with TasP science, (2) perceived limitations of TasP science, (3) difficulty changing understanding of "safe sex," (4) unwillingness to rely on partners' reports of being undetectable, (5) persistent HIV stigma, (6) less difficulty finding serosimilar partners, and (7) difficulty incorporating TasP into casual encounters. Together, these barriers confirm the existing findings about TasP adoption, and extend the literature by identifying barriers beyond a lack of education and outside of monogamous contexts.
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Affiliation(s)
- Alexander Borsa
- Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University Irving Medical Center, New York, New York, USA
| | - Karolynn Siegel
- Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University Irving Medical Center, New York, New York, USA
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Sokhela S, Lalla-Edward S, Siedner MJ, Majam M, Venter WDF. Roadmap for Achieving Universal Antiretroviral Treatment. Annu Rev Pharmacol Toxicol 2023; 63:99-117. [PMID: 36662580 PMCID: PMC10807407 DOI: 10.1146/annurev-pharmtox-052020-094321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Modern antiretroviral therapy safely, potently, and durably suppresses human immunodeficiency virus (HIV) that, if left untreated, predictably causes acquired immunodeficiency syndrome (AIDS), which has been responsible for tens of millions of deaths globally since it was described in 1981. In one of the most extraordinary medical success stories in modern times, a combination of pioneering basic science, innovative drug development, and ambitious public health programming resulted in access to lifesaving, safe drugs, taken as an oral tablet daily, for most of the world. However, substantial challenges remain in the fields of prevention, timely access to diagnosis, and treatment, especially in pediatric and adolescent patients. As HIV-positive adults age, treating their comorbidities will require understanding the course of different chronic diseases complicated by HIV-related and antiretroviral toxicities and finding potential treatments. Finally, new long-acting antiretrovirals on the horizon promise exciting new options in both the prevention and treatment fields.
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Affiliation(s)
- Simiso Sokhela
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa;
| | - Samanta Lalla-Edward
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa;
| | - Mark J Siedner
- Harvard Medical School and Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Mohammed Majam
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa;
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How much could long-acting PrEP cost in South Africa? THE LANCET HIV 2022; 9:e814-e815. [DOI: 10.1016/s2352-3018(22)00293-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 09/23/2022] [Indexed: 11/09/2022]
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