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“What is this ‘Universal Test and Treat’ (UTT)?”
Community Understandings of Key Concepts
linked to a Combination HIV Prevention Strategy
in 21 Zambian and South African Communities
Virginia Bond, Graeme Hoddinott, Melvin Simuyaba, Kelly Abrahams,
Helen Ayles, Nulda Beyers, Peter Bock, Bwalya Chiti, Lesley-Ann
Erasmus-Claassen, Sarah Fidler, James Hargreaves, Richard Hayes,
Jabulile Mantantana, Maurice Musheke, Rhoda Ndubani, Janet Seeley,
Musonda Simwinga, & Lario Viljoen
ON BEHALF OF THE HPTN 071 STUDY PROTOCOL TEAM
23 JULY 2014, IAS ORAL
NATIONAL INSTITUTES OF HEALTH:
National Institute of Allergy and Infectious Diseases
National Institute of Mental Health
National Institute on Drug Abuse
The HPTN 071 Study Team, led by:
Dr. Richard Hayes
Dr. Sarah Fidler
Dr. Helen Ayles
Dr. Nulda Beyers
Government Agencies:
PEPFAR Implementing Partners:
With thanks to:
• All research participants and their families
• The 21 research communities and their religious, traditional,
secular and civil leadership structures
• Volunteers in the community advisory board structures
Key Question
How do communities in high HIV
prevalence settings perceive ‘innovative
approaches’ to HIV prevention?
Background: PopART & BBS
• HPTN-071 (PopART):
– large-scale 3-arm, community-randomised
controlled trial of a multi-component HIV prevention
intervention (including earlier access to ART) in 21
community sites in Zambia (12) and South Africa (9)
– built on a Universal Test and Treat (UTT) model,
underscored by Treatment as Prevention paradigm
• Qualitative research in 21 communities
preceded PopART:
– ‘Broad Brush Surveys’ (see poster THPE 214) of
HIV landscape
– November 2012 - May 2013
Methods & Study Population
• Concept mapping used to explore local
understanding of HIV prevention:
•
‘What is HIV Prevention?’ discussed initially with HIV
‘specialists’ then with community member groups (age &
gender specific)
• Key Informant Interviews asked specifically about
HIV Prevention options & ‘Treatment as
Prevention’
• 97 groups (757 participants – 454 women); 65 KIIs
(51 women)
• Data analysis in two phases – rapid (for
implementation feedback) and finer, themed
KEY FINDINGS
CONCEPT MAPPING ACTIVITY: ‘WHAT IS HIV PREVENTION?’
WHAT IS HIV PREVENTION?
Zambia
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Couple counselling
Education – IEC, health
talk, health education,
drama
HIV testing – ‘re-testing’
Couple counselling
Avoid re-infection
Medical Male
Circumcision
Faith healing
Control/reduce alcohol
intake
Fear of God
Avoid sharing sharp
instruments
Avoid sexual cleansing
Common
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Be faithful
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Education/sensitisation
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Condom use
•
Abstinence
HIV testing (‘know your
status’/‘VCT’)
‘Stay HIV negative’
STI treatment
PMTCT (‘start ANC early’)
Traditional medicine/
‘Immune boosters’
Support PLWH to “take
treatment and live healthy
lifestyles” (HCW, S20)
Masturbation
South Africa
Know your partner’s status
Education – radio & library
Stop rape/crimes
Prevention rarely linked to Treatment
• Participants more often used the words ‘reducing
transmission’ rather than ‘HIV prevention’
• Only two (Zambian) sites listed ‘take ARVs’; in relation to
PMTCT and ‘to reduce viral load’ for PLWH’s own health
benefit
• Abstinence, Be Faithful and Condomise (‘ABC’) readily
identified in both countries
•
an HIV specialist in Zambia mentioned ‘D’ had been added to
‘ABC campaign’: “ABCD...[because]...drugs are also used for
HIV prevention these days” (Z3)
• Widely understood to be a combination of approaches &
having shifted from stronger focus on ‘no sex’ (behaviour
change):
•
“it’s a combination of all of them, we can’t really single one
out” (adherence supporter, S15)
Talking about Treatment AS Prevention
• No spontaneous use of the terms ‘UTT’, ‘TasP’, ‘Test
& Treat’
• Spontaneous limited use of:
• ‘PEP’
• ‘Truvada’; heard about “truvada outside Zambia” (HIV
specialists, Z4)
• ‘PWP’ (‘Prevention With Positives’) (one Zambian site)
• Widespread use of ‘PMTCT’
“HAVE YOU HEARD OF ART TREATMENT USED AS
HIV PREVENTION?”
“NO”
WHEN PROBED....
“UTT? What kind of animal is that?” (PLWH, Z8)
“UTT? This is our first time to hear it...we have
heard it [for the first time] today” (PLWH, Z9)
“I say your question’s got me stuck [stumped me]...I
don’t think I have heard of it ha ah I will be lying if I said
[that I did]” (healthcare worker, S13)
Widespread Support for Testing
• Familiar and overall supportive of testing everyone
for HIV and everyone knowing their status
• “we are moving too slowly... if we could test more
people…then we can...get more people on treatment...”
(health worker, S19)
• However, this was NOT talked about as a ‘universal’
approach. More often referred to, especially in
Zambia, as ‘door to door’.
• Mostly supportive of early treatment for PLWH
PMTCT
• Most could relate ‘ART as prevention’ to PMTCT,
considered it to result in ‘HIV-free children’:
• “is really preventing our children from getting HIV…is well
understood because our pregnant clients and I think it’s
because this is a life.. this is a baby.. that one is a
success” (KII, S17)
• In SA, some participants described PMTCT as a
‘secondary’ prevention method:
•
it has not stopped the mother contracting HIV or from
having more children AND the child may well also contract
HIV by “following in her parents’ footsteps” (community
group, S19)
Preventing Illness in PLWH
• With the exception of PMTCT, and a few Zambian
participants in a few sites, prevention in PLWH on
treatment was understood as preventing illness,
‘boosting the immune system’ and ‘re-infection’.
• ART was not often understood to reduce HIV
transmission and condom use for PLWH – even within
HIV-positive partnerships – was advocated.
• Some participants expressed concern that if viral load
was ‘undetectable’ PLWH would stop treatment
At odds with ‘Behaviour Change’,
indicative of ‘improper behaviour’
• Participants quick to link ‘ART as prevention’ to ‘improper’
sex (‘promiscuity’) and other forms of improper
‘behaviour’. This fed a tendency to subsequently highlight
non-sexual HIV transmission.
• Some respondents considered PLWH on ART to be
vindictively spreading HIV. This was sometimes also
levelled at PLWH NOT on ART.
• There was a widespread tendency in both countries to tell
PLWH ‘how’ to live so that THEY prevent the spread of
HIV
• “prevention should start with those who are positive.
Not to infect others who are HIV negative” (HIV
specialists, Z8)
CONCLUSIONS
‘UTT’, ‘TasP’
unfamiliar
Prevention &
Treatment
mostly delinked
‘TasP’ increases
PLWH
responsibility
• Be more cautious about promoting
‘innovative’ approaches through new
acronyms
• Build on old acronyms – e.g. ‘ABCD’ - &
provide detailed information
• Build on support for HIV testing &
treatment and PMTCT
• Put focus on emphasising impact of
treatment on transmission WITHIN
treatment initiatives and WITHIN
prevention initiatives
• Risk that TasP could re-draw the boundary
between ‘us’ and ‘them’ & drive HIV stigma
• The responsibility for prevention is broader
than PLWH
ACKNOWLEDGEMENTS
•
Sponsored by the National Institute of Allergy and Infectious
Diseases (NIAID) under Cooperative Agreements # UM1
AI068619, UM1-AI068617, and UM1-AI068613
•
Funded by:
– The U.S. President's Emergency Plan for AIDS Relief
(PEPFAR)
– The International Initiative for Impact Evaluation (3ie) with
support from the Bill & Melinda Gates Foundation
– NIAID, the National Institute of Mental Health (NIMH), and
the National Institute on Drug Abuse (NIDA) all part of the
U.S. National Institutes of Health (NIH)