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Bergam S, Harrison AD, Benghu N, Khumalo S, Tesfay N, Exner T, Miller L, Dolezal C, Hanass-Hancock J, Hoffman S. Women's Perceptions of HIV- and Sexuality-Related Stigma in Relation to PrEP: Qualitative Findings from the Masibambane Study, Durban, South Africa. AIDS Behav 2022; 26:2881-2890. [PMID: 35218452 PMCID: PMC9378426 DOI: 10.1007/s10461-022-03632-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2022] [Indexed: 11/01/2022]
Abstract
Daily oral pre-exposure prophylaxis (PrEP) offers effective HIV prevention. In South Africa, PrEP is publicly available, but use among young women remains low. We explored young women's perceptions of PrEP to inform a gender-focused intervention to promote PrEP uptake. Six focus group discussions and eight in-depth interviews exploring perceptions of PrEP were conducted with forty-six women not using PrEP, ages 18-25, from central Durban. Data were thematically analyzed using a team-based consensus approach. The study was conducted among likely PrEP users: women were highly-educated, with 84.8% enrolled in post-secondary education. Qualitative data revealed intersecting social stigmas related to HIV and women's sexuality. Women feared that daily PrEP pills would be confused with anti-retroviral treatment, creating vulnerability to misplaced HIV stigma. Women also anticipated that taking PrEP could expose them to assumptions of promiscuity from the community. To address these anticipated community-level reactions, women suggested community-facing interventions to reduce the burden on young women considering PrEP. Concerns around PrEP use in this group of urban, educated women reflects layered stigmas that may inhibit future PrEP use. Stigma-reducing strategies, such as media campaigns and educational interventions directed at communities who could benefit from PrEP, should re-frame PrEP as an empowering and responsible choice for young women.
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Affiliation(s)
- S Bergam
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI, USA.
- Department of Paediatric Infectious Disease, Nelson Mandela School of Medicine, University of KwaZulu Natal, Umbilo, Durban, Kwa-Zulu Natal, South Africa.
| | - A D Harrison
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI, USA
| | - N Benghu
- Gender and Health Research Unit, South African Medical Research Council, Durban, Kwa-Zulu Natal, South Africa
| | - S Khumalo
- Gender and Health Research Unit, South African Medical Research Council, Durban, Kwa-Zulu Natal, South Africa
| | - N Tesfay
- Gender and Health Research Unit, South African Medical Research Council, Durban, Kwa-Zulu Natal, South Africa
| | - T Exner
- Department of Psychiatry, Columbia University, New York, NY, USA
- HIV Center for Clinical and Behavioral Studies, NYS Psychiatric Institute, Columbia University, New York, NY, USA
| | - L Miller
- ICAP, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - C Dolezal
- Department of Psychiatry, Columbia University, New York, NY, USA
- HIV Center for Clinical and Behavioral Studies, NYS Psychiatric Institute, Columbia University, New York, NY, USA
| | - J Hanass-Hancock
- Gender and Health Research Unit, South African Medical Research Council, Durban, Kwa-Zulu Natal, South Africa
| | - S Hoffman
- Department of Psychiatry, Columbia University, New York, NY, USA
- HIV Center for Clinical and Behavioral Studies, NYS Psychiatric Institute, Columbia University, New York, NY, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
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Does the Ring Work? Perceptions and Understanding of the Efficacy of a Dapivirine Vaginal Ring for HIV Prevention Amongst Women in a Placebo-Controlled Trial. AIDS Behav 2022; 26:1597-1606. [PMID: 34727272 DOI: 10.1007/s10461-021-03512-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2021] [Indexed: 10/19/2022]
Abstract
As demonstrated by the Phase III clinical trial, MTN-020/ASPIRE, the monthly dapivirine vaginal ring is well tolerated and reduces the risk of HIV-1 as a woman-initiated prevention option. This analysis uses data from the follow-on MTN-032/Assessment of ASPIRE and HOPE Adherence (AHA) qualitative study to understand how perceptions (or misperceptions) of ring efficacy may have influenced behavior during ASPIRE, and affected intention to use the ring in future ring projects, specifically HOPE, the planned open-label extension study. Single in-depth interviews (n = 98) and 12 focus group discussions (n = 89) were conducted with women at seven sites in Malawi, South Africa, Uganda and Zimbabwe. Eligibility included participation in the ASPIRE active arm, and ring use for ≥ 3 months or at least 1 month if seroconversion occurred. Interviews were audio-recorded, transcribed into English, coded in Dedoose and thematically analyzed. Demographic and behavioral questionnaire data were summarized in Stata. Most AHA participants perceived the ring to be effective, and described simply trusting it or having confidence in it because they, or other participants in risky situations, remained HIV-uninfected. Participants described ring efficacy after receiving ASPIRE results as a binary assessment: the ring worked or not. Many did not remember exact efficacy percentages because of lack of comprehension or memory but recalled key details about age differences. The majority expressed interest in future ring use. There is a need to investigate improved ways of explaining placebo-controlled trials and efficacy to women in Sub-Saharan Africa. Now that ring efficacy, is known, these benefits must be well communicated, and understood by end-users and key stakeholders. Engagement with end-users to construct effective messages and to develop tools to measure understanding of partial efficacy will be essential.
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Wilkinson A, Slack C, Thabethe S, Salzwedel J. " It's Almost as if Stakeholder Engagement is the Annoying 'Have-to-do'…": Can Ethics Review Help Address the "3 Ts" of Tokenism, Toxicity, and Tailoring in Stakeholder Engagement? J Empir Res Hum Res Ethics 2022; 17:292-303. [PMID: 35164594 PMCID: PMC9136363 DOI: 10.1177/15562646221078415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Ethics guidance recommends that researchers engage stakeholders and that RECs review research for such engagement. The ethics review process may present a unique opportunity to support stakeholder engagement practices for HIV prevention studies. We conducted 28 interviews with experts from 12 countries to explore this issue, and analyzed the data using Thematic Analysis. We found that the value of engagement and review processes was strongly endorsed. However, we identified 3 major thematic complexities, namely: "Tokenism" where processes risk being "tick-box"; "Toxicity", where practices may inadvertently have negative consequences; and "Tailoring", where processes need careful variation in intensity. We make recommendations for how these "Ts" can be addressed during the review process to help contribute to thoughtful review of meaningful stakeholder engagement in research.
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Affiliation(s)
- Abigail Wilkinson
- HIV AIDS Vaccines Ethics Group (HAVEG), School of Applied Human Sciences, College of Humanities, 71874University of KwaZulu-Natal, Pietermaritzburg, KwaZulu-Natal, South Africa
| | - Catherine Slack
- HIV AIDS Vaccines Ethics Group (HAVEG), School of Applied Human Sciences, College of Humanities, 71874University of KwaZulu-Natal, Pietermaritzburg, KwaZulu-Natal, South Africa
| | - Siyabonga Thabethe
- HIV AIDS Vaccines Ethics Group (HAVEG), School of Applied Human Sciences, College of Humanities, 71874University of KwaZulu-Natal, Pietermaritzburg, KwaZulu-Natal, South Africa
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Calabrese SK, Mayer KH, Marcus JL. Prioritising pleasure and correcting misinformation in the era of U=U. Lancet HIV 2021; 8:e175-e180. [PMID: 33662266 DOI: 10.1016/s2352-3018(20)30341-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 12/05/2020] [Accepted: 12/10/2020] [Indexed: 10/22/2022]
Abstract
There is widespread unawareness and disbelief regarding the evidence-based conclusion that people who have a sustained undetectable HIV viral load cannot sexually transmit HIV-ie, undetectable=untransmittable (U=U). Long-standing, misguided fear about HIV transmission persists; consequently, so does the policing of sexual expression and the penalisation of pleasure faced by people with HIV. Many people with HIV with an undetectable viral load have unnecessarily abstained from condomless sex, avoided serodifferent partnering, and had anxiety about onward sexual transmission due to perceived HIV risk that is now known to be non-existent. Some health professionals have refrained from correcting this misinformation because of concerns that people with HIV will engage in more condomless sex or have more sexual partners upon learning of U=U. Withholding information about U=U is thus rooted in behavioural assumptions and is scientifically unfounded. Moreover, withholding such information violates medical ethics, perpetuates health inequities, and infringes on the sexual health and human rights of people with HIV. Health professionals and the broader public health community have an ethical responsibility to actively address misinformation about HIV transmission and disseminate the U=U message to all people.
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Affiliation(s)
- Sarah K Calabrese
- Department of Psychological and Brain Sciences, and Department of Prevention and Community Health, George Washington University, Washington, DC, USA.
| | - Kenneth H Mayer
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; The Fenway Institute, Fenway Health, Boston, MA, USA
| | - Julia L Marcus
- Department of Population Medicine, Harvard Medical School, Boston, MA, USA; The Fenway Institute, Fenway Health, Boston, MA, USA
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Skovdal M. Facilitating engagement with PrEP and other HIV prevention technologies through practice-based combination prevention. J Int AIDS Soc 2019; 22 Suppl 4:e25294. [PMID: 31328412 PMCID: PMC6643071 DOI: 10.1002/jia2.25294] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 05/08/2019] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Recent years have witnessed a rapid expansion of efficacious biomedical HIV prevention technologies. Promising as they may be, they are largely delivered through standard, clinic-based models, often in isolation from structural and behavioural interventions. This contributes to varied, and often poor, uptake and adherence. There is a critical need to develop analytical tools that can advance our understandings and responses to the combination of interventions that affect engagement with HIV prevention technologies. This commentary makes a call for practice-based combination HIV prevention analysis and action, and presents a tool to facilitate this challenging but crucial endeavour. DISCUSSION Models and frameworks for combination HIV prevention already exist, but the process of identifying precisely what multi-level factors that need to be considered as part of a combination of HIV interventions for particular populations and settings is unclear. Drawing on contemporary social practice theory, this paper develops a "table of questioning" to help interrogate the chain and combination of multi-level factors that shape engagement with HIV prevention technologies. The tool also supports an examination of other shared social practices, which at different levels, and in different ways, affect engagement with HIV prevention technologies. It facilitates an analysis of the range of factors and social practices that need to be synchronized in order to establish engagement with HIV prevention technologies as a possible and desirable thing to do. Such analysis can help uncover local hitherto un-identified issues and provide a platform for novel synergistic approaches for action that are not otherwise obvious. The tool is discussed in relation to PrEP among adolescent girls and young women in sub-Saharan Africa. CONCLUSIONS By treating engagement with HIV prevention technologies as a social practice and site of analysis and public health action, HIV prevention service planners and evaluators can identify and respond to the combination of factors and social practices that interact to form the context that supports or prohibits engagement with HIV prevention technologies for particular populations.
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Affiliation(s)
- Morten Skovdal
- Department of Public HealthUniversity of CopenhagenCopenhagenDenmark
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Selinger C, Dimitrov DT, Welkhoff PA, Bershteyn A. The future of a partially effective HIV vaccine: assessing limitations at the population level. Int J Public Health 2019; 64:957-964. [PMID: 30982082 PMCID: PMC6614161 DOI: 10.1007/s00038-019-01234-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 03/02/2019] [Accepted: 03/12/2019] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES Mathematical models have unanimously predicted that a first-generation HIV vaccine would be useful and cost-effective to roll out, but that its overall impact would be insufficient to reverse the epidemic. Here, we explore what factors contribute most to limiting the impact of such a vaccine. METHODS Ranging from a theoretical ideal to a more realistic regimen, mirroring the one used in the currently ongoing trial in South Africa (HVTN 702), we model a nested hierarchy of vaccine attributes such as speed of scale-up, efficacy, durability, and return rates for booster doses. RESULTS The predominant reasons leading to a substantial loss of vaccine impact on the HIV epidemic are the time required to scale up mass vaccination, limited durability, and waning of efficacy. CONCLUSIONS A first-generation partially effective vaccine would primarily serve as an intermediate milestone, furnishing correlates of immunity and platforms that could serve to accelerate future development of a highly effective, durable, and scalable next-generation vaccine capable of reversing the HIV epidemic.
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Affiliation(s)
- Christian Selinger
- Institute for Disease Modeling, 3150 139th Ave SE, Bellevue, WA 98005 USA
| | - Dobromir T. Dimitrov
- Fred Hutchinson Cancer Research Center, 1100 Fairview Ave N, Seattle, WA 98109 USA
| | - Philip A. Welkhoff
- Institute for Disease Modeling, 3150 139th Ave SE, Bellevue, WA 98005 USA
| | - Anna Bershteyn
- Institute for Disease Modeling, 3150 139th Ave SE, Bellevue, WA 98005 USA
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