Universal HIV testing and treatment and HIV stigma reduction: a comparative thematic analysis of qualitative data from the HPTN 071 (PopART) trial in South Africa and Zambia

Viljoen, Lario; Bond, Virginia; Reynolds, Lindsey; Mubekapi-Musadaidzwa, Constance; Baloyi, Dzunisani; Ndubani, Rhoda; Stangl, Anne; Seeley, Janet; Pliakas, Triantafyllos; Böck, Peter; Fidler, Sarah; Hayes, Richard; Ayles, Helen; Hargreaves, James; Hoddinott, Graeme; Team, Hptn Study

doi:10.1111/1467-9566.13208

Cited by 13 publications

(21 citation statements)

References 67 publications

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“…While many participants view HIV as “normal”, due to the availability of life-saving ART and increased visibility of PLHIV, transmission-related stigma still remains pervasive. Our findings echo those of other studies that have found that stigma remains prevalent despite the scale up of treatment [31, 32]. This is particularly concerning as studies have shown that stigma negatively impacts testing for HIV, a barrier to ART adherence and is associated with depression among PLHIV [33, 34].…”

Section: Discussionsupporting

confidence: 88%

“I was scared dating… who would take me with my status?”- Living with HIV in the UTT era in Johannesburg, South Africa

Sineke

Onoya

Mokhele

et al. 2022

Preprint

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BACKGROUND South Africa rolled out Universal Test-and-Treat (UTT) in 2016, extending treatment eligibility to all persons living with HIV (PLHIV). Through this study, we sought to understand the experience of people living with HIV in the UTT era in South Africa. METHODS In May 2021, we conducted in-depth interviews (IDI) (N = 27) with adult (18 years and older) 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, to gain a deeper understanding of their journey living with HIV. Participants were asked to reflect on their HIV diagnosis, what their HIV status meant to them in light of the UTT era 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 thematically. RESULTS The study included 4 men and 23 women recruited from clinics and 12 men and 16 women recruited from civil society (total N= 54). Participants reported that PLHIV could live a long life with antiretroviral therapy (ART) and that ART was widely accessible. However, they reported that 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 a responsibility to avoid transmission. To manage transmission anxieties, participants avoided sexual relationships, chose HIV-positive partners, and/or insisted on using condoms. Many participants feared – or had previously experienced – rejection by their partners due to their HIV status and reported hiding their medication, avoiding disclosure to their partners, or avoiding relationships altogether. Most participants also reported having low to no knowledge about treatment-as-prevention (TasP). Participants who were aware of TasP expressed less anxiety about transmitting HIV to others and greater confidence in having relationships. CONCLUSION Despite the normalization of HIV as a chronic disease, PLHIV still experience transmission anxiety and fears of rejection by their partners. Disseminating information on treatment-as-prevention 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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Section: Discussionsupporting

confidence: 88%

“I was scared dating… who would take me with my status?”- Living with HIV in the UTT era in Johannesburg, South Africa

Sineke

Onoya

Mokhele

et al. 2022

Preprint

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“…However, emerging evidence suggests that interventions explicitly aimed at achieving 'zero discrimination' may produce greater population health benefits in jurisdictions with highly unequal access to care [170,171]. Such evidence will be important because integration could plausibly reduce discrimination by 'normalising' HIV services [172], but it may also cause discrimination, e.g., by reducing the privacy of vulnerable people [173,174]. Only 22 out of the 114 studies reported outcomes for key populations, demonstrating important knowledge gaps [159,[175][176][177][178][179][180][181].…”

Section: Plos Medicinementioning

confidence: 99%

Integrating HIV services and other health services: A systematic review and meta-analysis

Bulstra

Hontelez²,

Otto³

et al. 2021

PLoS Med

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Background Integration of HIV services with other health services has been proposed as an important strategy to boost the sustainability of the global HIV response. We conducted a systematic and comprehensive synthesis of the existing scientific evidence on the impact of service integration on the HIV care cascade, health outcomes, and cost-effectiveness. Methods and findings We reviewed the global quantitative empirical evidence on integration published between 1 January 2010 and 10 September 2021. We included experimental and observational studies that featured both an integration intervention and a comparator in our review. Of the 7,118 unique peer-reviewed English-language studies that our search algorithm identified, 114 met all of our selection criteria for data extraction. Most of the studies (90) were conducted in sub-Saharan Africa, primarily in East Africa (55) and Southern Africa (24). The most common forms of integration were (i) HIV testing and counselling added to non-HIV services and (ii) non-HIV services added to antiretroviral therapy (ART). The most commonly integrated non-HIV services were maternal and child healthcare, tuberculosis testing and treatment, primary healthcare, family planning, and sexual and reproductive health services. Values for HIV care cascade outcomes tended to be better in integrated services: uptake of HIV testing and counselling (pooled risk ratio [RR] across 37 studies: 1.67 [95% CI 1.41–1.99], p < 0.001), ART initiation coverage (pooled RR across 19 studies: 1.42 [95% CI 1.16–1.75], p = 0.002), time until ART initiation (pooled RR across 5 studies: 0.45 [95% CI 0.20–1.00], p = 0.050), retention in HIV care (pooled RR across 19 studies: 1.68 [95% CI 1.05–2.69], p = 0.031), and viral suppression (pooled RR across 9 studies: 1.19 [95% CI 1.03–1.37], p = 0.025). Also, treatment success for non-HIV-related diseases and conditions and the uptake of non-HIV services were commonly higher in integrated services. We did not find any significant differences for the following outcomes in our meta-analyses: HIV testing yield, ART adherence, HIV-free survival among infants, and HIV and non-HIV mortality. We could not conduct meta-analyses for several outcomes (HIV infections averted, costs, and cost-effectiveness), because our systematic review did not identify sufficient poolable studies. Study limitations included possible publication bias of studies with significant or favourable findings and comparatively weak evidence from some world regions and on integration of services for key populations in the HIV response. Conclusions Integration of HIV services and other health services tends to improve health and health systems outcomes. Despite some scientific limitations, the global evidence shows that service integration can be a valuable strategy to boost the sustainability of the HIV response and contribute to the goal of ‘ending AIDS by 2030’, while simultaneously supporting progress towards universal health coverage.

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“…Further, when explicitly probed on HIV prevention methods, participants only mentioned condoms. Findings from a seperate analysis showed that participants in trial communities had limited awareness of TasP [ 55 ]. Similarly, this analysis showed that treatment-based prevention methods and UTT as a strategy to avoid HIV transmission were not acknowledged by any of the women.…”

Section: Discussionmentioning

confidence: 99%

Women’s sexual scripting in the context of universal access to antiretroviral treatment—findings from the HPTN 071 (PopART) trial in South Africa

et al. 2021

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Background HIV treatment-based prevention modalities present new opportunities for women to make decisions around sex, intimacy, and prevention. The Universal test and treat (UTT) strategy, where widespread HIV testing is implemented and all people with HIV can access treatment, has the potential to change how sex is understood and HIV prevention incorporated into sexual relationships. We use the frame of sexual scripting to explore how women attribute meaning to sex relative to UTT in an HIV prevention trial setting. Exploring women’s sexual narratives, we explored how HIV prevention feature in the sexual scripts for women who had access to UTT in South Africa (prior to treatment guideline changes) and increased HIV prevention messaging, compared to places without widespread access to HIV testing and immediate access to treatment. Methods We employed a two-phased thematic analysis to explore longitudinal qualitative data collected from 71 women (18–35 years old) between 2016 and 2018 as part of an HIV prevention trial in the Western Cape Province, South Africa. Of the participants, 58/71 (82%) were from intervention communities while 13/71 (18%) lived in control communities without access to UTT. Twenty participants self-disclosed that they were living with HIV. Results We found no narrative differences between women who had access to UTT and those who did not. HIV and HIV prevention, including treatment-based prevention modalities, were largely absent from women’s thinking about sex. In their scripts, women idealised romantic sex, positioned sex as ‘about relationships’, and described risky sex as ‘other’. When women were confronted by HIV risk (for example, when a partner disclosed his HIV-positive status) this created a point of disjuncture between this new perception of risk and their accepted relationship scripts. Conclusion These findings suggest that HIV-negative women did not include their partners’ use of antiretroviral therapy in their sexual partnership choices. For these women, the preventive benefits of UTT are experienced passively—through community-wide viral suppression—rather than through their own behaviour change explicitly related to the availability of treatment as prevention. We propose that prevention-based modalities should be made available and supported and framed as an intervention to promote relationship well-being.

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Universal HIV testing and treatment and HIV stigma reduction: a comparative thematic analysis of qualitative data from the HPTN 071 (PopART) trial in South Africa and Zambia

Cited by 13 publications

References 67 publications

“I was scared dating… who would take me with my status?”- Living with HIV in the UTT era in Johannesburg, South Africa

“I was scared dating… who would take me with my status?”- Living with HIV in the UTT era in Johannesburg, South Africa

Integrating HIV services and other health services: A systematic review and meta-analysis

Women’s sexual scripting in the context of universal access to antiretroviral treatment—findings from the HPTN 071 (PopART) trial in South Africa

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