“Is it making any difference?” A qualitative study examining the treatment‐taking experiences of asymptomatic people living with HIV in the context of Treat‐all in Eswatini

Abstract

IntroductionTreat‐all is being implemented in several African settings, in accordance with 2015 World Health Organisation guidelines. The factors known to undermine adherence to antiretroviral therapy (ART) may change in the context of Treat‐all, where people living with HIV (PLHIV) increasingly initiate ART at earlier, asymptomatic stages of disease, soon after diagnosis. This paper aimed to examine the asymptomatic PLHIV's experiences engaging with early ART initiation under the Treat‐all policy, including how they navigate treatment‐taking over the longer term.MethodsA longitudinal qualitative study was conducted within a Médecins Sans Frontières/Ministry of Health Treat‐all pilot in Shiselweni, southern Eswatini. The Treat‐all pilot began in October 2014, adopted into national policy in October 2016. Participants were recruited purposively to include newly diagnosed, clinically asymptomatic PLHIV with a range of treatment‐taking experiences, and healthcare workers (HCW) with various roles. This analysis drew upon a sub‐sample of 17 PLHIV who had been on ART for at least 12 months, with mean 20 months on ART at first interview, and who undertook three interviews each. Additionally, 20 HCWs were interviewed once. Interviews were conducted from August 2016 to September 2017. Data were analysed thematically using coding, drawing upon principles of grounded theory, and aided by Nvivo 11.ResultsIt was important for PLHIV to perceive the need for treatment, and to have evidence of its effectiveness to motivate their treatment‐taking, thereby supporting engagement with care. For some, coming to terms with a HIV diagnosis or re‐interpreting past illnesses as signs of HIV could point to the need for ART to prevent health deterioration and prolong life. However, others doubted the accuracy of an HIV diagnosis and the need for treatment in the absence of symptoms or signs of ill health, with some experimenting with treatment‐taking as a means of seeking evidence of their need for treatment and its effect. Viral load monitoring appeared important in offering a view of the effect of treatment on the level of the virus, thereby motivating continued treatment‐taking.ConclusionsThese findings highlight the importance of PLHIV perceiving need for treatment and having evidence of the difference that ART is making to them for motivating treatment‐taking. Patient support should be adapted to address these concerns, and viral load monitoring made routinely available within Treat‐all care, with communication of suppressed results emphasized to patients.

Same-day antiretroviral treatment (ART) initiation and associated factors among HIV positive people in Northwest Ethiopia: baseline characteristics of prospective cohort

“…The finding is similar to a study in South Africa which reported that patients who presented with less advanced clinical disease were more likely to accept same-day ART initiation [ 15 ]. However, such findings are in contrast with several qualitative studies that had reported the absence of symptoms or signs of ill health, which is the major reason for differing same-day ART [ 34 – 36 , 58 ]. Moreover, Ethiopian Ministry of Health and WHO guidelines recommended that a rapid approach to ART initiation is particularly relevant to people with advanced HIV disease [ 1 , 2 ] yet CD4 count determination was not available in the study area during the study period.…”

“…Although many qualitative studies have been conducted about the barriers and facilitators to same-day ART initiation [ 12 , 34 – 40 ], there is a paucity of quantitative evidence in this regard. Hence, the current study aimed to address the previous studies’ methodological gaps by applying advanced quantitative statistical analysis.…”

<p>Barriers and Facilitators of Same-Day Antiretroviral Therapy Initiation Among People Newly Diagnosed with HIV in Ethiopia: Qualitative Study Using the Transtheoretical Model of Behavioral Change</p>

“…Repeated HIV testing after receiving a positive result may give insight into reasons for delayed linkage to care. 17 , 36 Fortunately, now there are guidelines recommendation to repeat HIV tests to confirm HIV positivity in the same health facility in Ethiopian that may overcome client-initiated repeat testing in another health facility. 4 Therefore, this is a good opportunity for healthcare workers to teach patients about the testing procedure and its reliability in both hospital and health center settings.…”

“… 16 Besides, they are in doubt about the need for treatment in the absence of symptoms or signs in apparently healthy individuals. 17 Most patients who are in a fairly good physical condition and who feel “healthy” would be in a state of shock to learn about their HIV status and lack readiness to initiate ART. 18 Also, fear of disclosure, lack of social support, prior negative experiences with health services, and perceived drug side effects are potential barriers to early ART initiation.…”

HIV Diagnosis Time Differentiates ART Initiation: Implications from a Prospective Cohort Study in China

“…Previous studies suggested that ART-related perceptions can be modi ed to promote the actual ART initiation behavior [13,14,29,[36][37][38][39][40]. The different perception levels between the two subgroups might primarily contribute to different ART initiations.…”