Good Health and Moral Responsibility: Key Concepts Underlying the Interpretation of Treatment as Prevention in South Africa and Zambia Before Rolling Out Universal HIV Testing and Treatment

Abstract

Gauging community responses to the WHO 2015 recommendation to provide antiretroviral treatment (ART) to all people living with HIV (PLHIV) is critical. There is limited qualitative evidence on the acceptability of this Universal Test and Treat (UTT) strategy or community understanding of the impact of ART on reducing HIV transmission, promoted as Treatment as Prevention (TasP). This article explores early understanding of UTT and TasP in 21 urban communities in South Africa and Zambia in 2013 before a community randomized trial of combination prevention—HPTN 071 (PopART). It draws on participatory research conducted in each community, which carried out group discussions and interviews with 1202 respondents and 203 structured observations. Participants were largely unfamiliar with the concepts of UTT and TasP. They were concerned about an accompanying de-emphasis on sexual behavior change. Treatment and prevention seemed, at first glance, to be experienced separately. With the exception of the prevention of mother-to-child transmission, prevention seldom came into discussions about ART. This was partly because this science had not yet been explained to many and also because it was not an easy fit. Contemplating the link between treatment and prevention, participants emphasized both PLHIV taking care of themselves through good health and preventing disease progression and the moral responsibility of PLHIV to prevent HIV transmission. To avoid igniting moralizing and blaming when introducing UTT and TasP, we should capitalize on the “taking care of yourself” legacy while boosting public responsibility through broad antistigma education and patient empowerment efforts.

“I just believe there is a risk” understanding of undetectable equals untransmissible (U = U) among health providers and HIV‐negative partners in serodiscordant relationships in Kenya

“…Although a majority of HIV-negative partners were aware of the concepts underlying U = U, there were some who had not heard the message, and many did not believe it. Our findings are comparable to a study conducted in Zambia and South Africa that reported that people were largely unfamiliar with the prevention benefits of HIV treatment [14] and with studies done among gay men who expressed reluctance for condomless sex even after viral suppression [12,13]. Awareness and acceptance of the additional HIV prevention benefit of ART needs to go beyond targeting HIV-positive partners; including HIV-negative partners in U = U discussions could provide motivation for HIV-positive people to adhere to ART.…”

Understanding the Time Needed to Link to Care and Start ART in Seven HPTN 071 (PopART) Study Communities in Zambia and South Africa

“…Despite community engagement and messaging on the benefits of immediate ART, many people had internalised previous health messaging about treatment being appropriate only for those who were sick, and were cautious about accepting the change in advice [ 38 ]. Therefore, some considered immediate treatment appropriate for those who are ill , pregnant or in a discordant relationship.…”

“…The communities included have a total population of ~ 200,000 in the four Zambian communities, and ~ 100,000 in the three South African communities. The social context and HIV services in all the communities in both countries have been described elsewhere [ 38 ]. An ancillary study on stigma was undertaken, which provides additional information on stigma experiences in health facilities and levels of stigma in different communities, also described elsewhere [ 35 , 39 , 40 ].…”

Qualitative research on community experiences in large HIV research trials: what have we learned?

“…In 2013, during the initial selection of the 21 communities in Zambia and South Africa for HPTN 071, rapid qualitative research (termed a Broad Brush Survey [26]) was conducted to gather data on each community, prior to the implementation of the trial intervention. While the results of this work are drawn on in a number of publications [27][28][29][30], this example focuses on the work published by Bond and colleagues in 2016 [31]. For the rapid assessment, a small team of social science researchers spent about two weeks staying in each study community to undertake data collection, using group discussions, key informant interviews and observations.…”