A scoping study to identify opportunities to advance the ethical implementation and scale-up of HIV treatment as prevention: priorities for empirical research

Ethics and the treatment as prevention strategy among transgender women living with HIV in Argentina

While numerous ethical concerns have been voiced regarding HIV service scale-up strategies targeting key populations, few studies have examined these from the perspective of affected groups. This study therefore sought to understand transgender women's experiences and perspectives of targeted HIV services scale-up in the context of Argentina's Treatment as Prevention strategy. In 2016, 25 purposively selected transgender women living with HIV were interviewed by a peer research associate. Interviews were audio recorded, transcribed verbatim and analysed using participatory coding techniques. Findings suggest that procedures around informed consent, including the provision of full information in lay language and voluntariness, were lacking both pre- and post-HIV test. Further, many transgender women felt disrespected and disregarded by healthcare workers. While the majority of participants were unaware of Treatment as Prevention, once explained, most felt the approach was ethical overall, and helped improve equity in HIV service access. Study findings offer several community-driven suggestions to support patient rights and the ethical scale-up of HIV services for transgender women in Buenos Aires, including the need for training in and the provision of non-judgemental, gender-affirmative care and the inclusion of peer-navigators.

A 'scoping review' of qualitative literature about engagement with HIV care in Indonesia

Background The Indonesian response to HIV has been informed largely by quantitative evidence. This review examines what is known about the Indonesian HIV care cascade from published qualitative research.

METHODS

A 'scoping review' method was used to synthesise and interpret the findings of 17 eligible peer-reviewed publications.

RESULTS

Qualitative findings are reported in relation to two themes. Factors influencing successful engagement include a lack of HIV-related knowledge among clients, fear of stigma or lack of privacy/confidentiality at services, limited accessibility and affordability, and poor linkages between services. Factors affecting the broader response include a failure to adapt programs to specific socio-cultural settings, political issues in the distribution of donor funding, distrust and poor communication between service users and providers, the need for cultural privacy in particular community settings, and systemic experiences of gendered stigmatisation.

CONCLUSIONS

Enhancing understanding of the Indonesian context would benefit from future qualitative research on HIV care in urban settings, describing the experiences of the most at-risk populations, and examining the role of clinics and providers in delivering HIV care in an increasingly decentralised health system.

A scoping review describes methods used to identify, prioritize and display gaps in health research

BACKGROUND AND OBJECTIVES

Different methods to examine research gaps have been described, but there are still no standard methods for identifying, prioritizing, or reporting research gaps. This study aimed to describe the methods used to identify, prioritize, and display gaps in health research.

METHODS

A scoping review using the Arksey and O'Malley methodological framework was carried out. We included all study types describing or reporting on methods to identify, prioritize, and display gaps or priorities in health research. Data synthesis is both quantitative and qualitative.

RESULTS

Among 1,938 identified documents, 139 articles were selected for analysis; 90 (65%) aimed to identify gaps, 23 (17%) aimed to determine research priorities, and 26 (19%) had both aims. The most frequent methods in the review were aimed at gap identification and involved secondary research, which included knowledge synthesis (80/116 articles, 69%), specifically systematic reviews and scoping reviews (58/80, 73%). Among 49 studies aimed at research prioritization, the most frequent methods were both primary and secondary research, accounting for 24 (49%) reports. Finally, 52 (37%) articles described methods for displaying gaps and/or priorities in health research.

CONCLUSION

This study provides a mapping of different methods used to identify, prioritize, and display gaps or priorities in health research.

A review of HIV testing strategies among MSM (2005-2015): Changes and continuities due to the biomedicalization of responses to AIDS

Global AIDS policy points to a new prevention rationale centred on the identification and treatment of people infected with HIV, particularly among the so-called key populations. This study analyses the continuities and changes in HIV testing strategies based on a meta-narrative review of academic output (2005-2015) focusing on men who have sex with men. We reviewed 65 articles based on their prevention approaches, testing strategies and the involvement of non-governmental organisations (NGOs) and community-based organisations. The analysis found continuities in HIV testing strategies in addition to changes. A new focus is reflected in the expansion and diversification of testing offered, the reduced importance of counselling, an emphasis on condom use associated with test results and on the absence of active participation of NGOs in implementing social responses to AIDS. Our findings indicate a systematic lack of problematising the potential ethical, political and cultural issues surrounding HIV testing as a strategy to control the epidemic. The findings of our study reinforce criticisms of the biomedicalization of current HIV-related policies, and reiterate the importance of combining progress achieved in increasing access to diagnosis and treatment with the historical achievements of social responses to AIDS.

Same family, different species: methodological conduct and quality varies according to purpose for five types of knowledge synthesis

OBJECTIVES

The aim of the study was to characterize methodological conduct, reporting, and quality of five knowledge synthesis (KS) approaches.

STUDY DESIGN AND SETTING

Retrospective analysis of a convenience sample of five published databases of KS approaches: overview of reviews (n = 74), scoping reviews (n = 494), rapid reviews (n = 84), systematic reviews (n = 300), and network meta-analyses (NMAs; n = 456). Data in the five published databases were abstracted by two reviewers independently, any missing data for this retrospective analysis were abstracted by one experienced reviewer. Methods were appraised using the A MeaSurement Tool to Assess systematic Reviews (AMSTAR) tool. Descriptive analysis was performed.

RESULTS

Reporting the use of a protocol ranged from 4% for rapid reviews to 32% for systematic reviews. The use of two reviewers for citation and full-text screening ranged from 20% for scoping reviews to 60% for NMAs. Data abstraction was performed in duplicate for 11% of rapid reviews and 54% of NMAs, and for risk of bias appraisal, this ranged from 6% for scoping reviews to 41% for NMAs. NMAs had the highest median percentage of maximum obtainable AMSTAR score (64%; Q1-Q3:45-73%), while scoping reviews had the lowest (25%; Q1-Q3:13-38%).

CONCLUSION

NMAs consistently scored the highest on the AMSTAR tool likely because the purpose is to estimate treatment effects statistically. Scoping reviews scored the lowest (even after adjusting the score for not relevant items) likely because the purpose is to characterize the literature.

Clinical ethics issues in HIV care in Canada: an institutional ethnographic study

BACKGROUND

This is a study involving three HIV clinics in the Canadian provinces of Newfoundland and Labrador, and Manitoba. We sought to identify ethical issues involving health care providers and clinic clients in these settings, and to gain an understanding of how different ethical issues are managed by these groups.

METHODS

We used an institutional ethnographic method to investigate ethical issues in HIV clinics. Our researcher conducted in-depth semi-structured interviews, compiled participant observation notes, and studied health records in order to document ethical issues in the clinics, and to understand how health care providers and clinic clients manage and resolve these issues.

RESULTS

We found that health care providers and clinic clients have developed work processes for managing ethical issues of various types: conflicts between client-autonomy and public health priorities ("treatment as prevention"), difficulties associated with the criminalization of nondisclosure of HIV positive status, challenges with non-adherence to HIV treatment, the protection of confidentiality, barriers to treatment access, and negative social determinants of health and well-being.

CONCLUSIONS

Some ethical issues resulted from structural disadvantages experienced by clinic clients. The most striking findings in our study were the negative social determinants of health and well-being experienced by some clinic clients - such as experiences of violence and trauma, poverty, racism, colonization, homelessness, and other factors affecting well-being such as problematic substance use. These negative determinants were at the root of other ethical issues, and are themselves of ethical concern.

Plasma HIV-1 RNA viral load rebound among people who inject drugs receiving antiretroviral therapy (ART) in a Canadian setting: an ethno-epidemiological study

Background

People who inject drugs (PWID) living with HIV often experience sub-optimal antiretroviral therapy (ART) treatment outcomes, including HIV plasma viral load (PVL) rebound. While previous studies have identified risk factors for PVL rebound among PWID, no study has examined the perspectives of PWID who have experienced PVL rebound episodes. We conducted an ethno-epidemiological study to investigate the circumstances surrounding the emergence of rebound episodes among PWID in Vancouver, BC, Canada.

Methods

Comprehensive clinical records linked to a community-based prospective observational cohort of HIV-positive drug users were used to identify PWID who had recently experienced viral rebound. In-depth qualitative interviews with 16 male and 11 female participants explored participant perspectives regarding the emergence of viral rebound. A timeline depicting each participant’s HIV viral load and adherence to ART was used to elicit discussion of circumstances surrounding viral rebound.

Findings

Viral rebound episodes were shaped by interplay between various individual, social, and environmental factors that disrupted routines facilitating adherence. Structural-environmental influences resulting in non-adherence included housing transitions, changes in drug use patterns and intense drug scene involvement, and inadequate care for co-morbid health conditions. Social-environmental influences on ART adherence included poor interactions between care providers and patients producing non-adherence, and understandings of HIV treatment that fostered intentional treatment discontinuation.

Conclusions

This study describes key pathways which led to rebound episodes among PWID receiving ART and illustrates how environmental forces may increase vulnerability for non-adherence leading to treatment failure. Our findings have potential to help inform interventions and supports that address social-structural forces that foster non-adherence among PWID.

Implementation challenges and opportunities for HIV Treatment as Prevention (TasP) among young men in Vancouver, Canada: a qualitative study

BACKGROUND

Despite evidence supporting the preventative potential of HIV Treatment as Prevention (TasP), scientific experts and community stakeholders have suggested that the success of TasP at the population level will require overcoming a set of complex and population-specific implementation challenges. For example, the factors that might influence decisions to initiate 'early' treatment have yet to be thoroughly understood; neither have questions about the factors that enhance or impede their ability to achieve long-term adherence to ARVs or the social norms regarding various treatment regimens been examined in detail. This knowledge gap may hamper opportunities to effectively develop public health practices that are informed by the various challenges and opportunities related to TasP implementation and scale up.

METHODS

Drawing on 50 in-depth, individual interviews with young men ages 18-24 in Vancouver, Canada, this study examines young men's perspectives regarding factors that might affect their engagement with TasP.

RESULTS

While findings from the current study indicate young men generally have a high receptiveness to TasP, our findings also identify key social and structural forces that will warrant ongoing consideration for TasP implementation. For example, participants described how an enhanced awareness regarding treatment (including awareness of the universal availability of treatment in Vancouver) would be a necessary, but not sufficient, condition to decide to endorse TasP. Their decisions about engaging in HIV care in the context of TasP (e.g., HIV testing, treatment initiation, long-term adherence) also appear to be contingent on their ability to negotiate or 'balance' the risks and benefits to themselves and others. The findings also offer insight into the complex and sometimes controversial narratives that continue to emerge regarding risk compensation practices in the context of TasP.

CONCLUSION

Based on the results of this study, we identify several areas that hold promise for informing the effective scale up of TasP, including new information regarding implementation adaptation strategies.

Ethical Implications of Social Stigma Associated with the Promotion and Use of Pre-Exposure Prophylaxis for HIV Prevention

Identifying sources of and eliminating social stigma associated with the promotion and use of pre-exposure prophylaxis (PrEP) for the prevention of sexually acquired HIV infection among men who have sex with men (MSM) is both a moral imperative and necessary requirement to ensure that public health objectives of HIV prevention can be met. This article will examine and address ethical concerns and criticisms regarding the use of PrEP, barriers to its promotion, and use among MSM and examine the types of social stigma associated with PrEP. An ethical justification for both healthcare and LGBT communities to address and overcome social stigma regarding the use of PrEP among MSM is offered.

Complex and Conflicting Social Norms: Implications for Implementation of Future HIV Pre-Exposure Prophylaxis (PrEP) Interventions in Vancouver, Canada

BACKGROUND

HIV Pre-Exposure Prophylaxis (PrEP) has been found to be efficacious in preventing HIV acquisition among seronegative individuals in a variety of risk groups, including men who have sex with men and people who inject drugs. To date, however, it remains unclear how socio-cultural norms (e.g., attitudes towards HIV; social understandings regarding HIV risk practices) may influence the scalability of future PrEP interventions. The objective of this study is to assess how socio-cultural norms may influence the implementation and scalability of future HIV PrEP interventions in Vancouver, Canada.

METHODS

We conducted 50 interviews with young men (ages 18-24) with a variety of HIV risk behavioural profiles (e.g., young men who inject drugs; MSM). Interviews focused on participants' experiences and perceptions with various HIV interventions and policies, including PrEP.

RESULTS

While awareness of PrEP was generally low, perceptions about the potential personal and public health gains associated with PrEP were interconnected with expressions of complex and sometimes conflicting social norms. Some accounts characterized PrEP as a convenient form of reliable protection against HIV, likening it to the female birth control pill. Other accounts cast PrEP as a means to facilitate 'socially unacceptable' behaviour (e.g., promiscuity). Stigmatizing rhetoric was used to position PrEP as a tool that could promote some groups' proclivities to take 'risks'.

CONCLUSION

Stigma regarding 'risky' behaviour and PrEP should not be underestimated as a serious implementation challenge. Pre-implementation strategies that concomitantly aim to improve knowledge about PrEP, while addressing associated social prejudices, may be key to effective implementation and scale-up.

HIV stigma and the experiences of young men with voluntary and routine HIV testing

As routine HIV testing approaches are implemented to enhance participation rates in HIV testing, it is often widely believed that these approaches are socially and ethically justifiable given the underlying assumption that these practices will result in the widespread reduction of HIV-related stigma. Nonetheless, a variety of empirical and theoretical gaps on how HIV testing practices may impact on HIV stigma remain, raising questions about the social underpinnings of the public health rationale. We draw on 50 interviews with 18-24 year-old men to determine how HIV-related stigma is experienced differentially across subgroups of young men in relation to both voluntary and routine testing practices. The men's experiences with routine testing highlight how (mis)interpretations of universal, routine testing practices may serve to (unintentionally) burden disadvantaged subgroups of men; however, when these practices are adequately explicated, the universal dimension of a routine offer greatly diminished these concerns. These findings also show that, under the right conditions, a routine offer can provide transformative opportunities for individuals to reconceptualise their expectations over HIV and HIV-related stigma.