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

Virginia Bond, Graeme Hoddinott, Lario Viljoen, Melvin Simuyaba, Maurice Musheke, Janet Seeley, Virginia Bond, Graeme Hoddinott, Lario Viljoen, Melvin Simuyaba, Maurice Musheke, Janet Seeley

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.

Conflict of interest statement

Author Disclosure Statement No competing financial interests exist.

References

    1. Ross F. Raw Life, New Hope: Decency, Housing and Everyday Life in a Post-Apartheid Community. Cape Town: UCT Press, 2010
    1. World Health Organisation. Guideline on When to Start Antiretroviral Therapy and on Pre-Exposure Prophylaxis for HIV. Geneva: WHO; September 2015, Report No: ISBN 978 92 4 150956 5
    1. Nguyen V-K, O'Malley J, Pirkle CM. Remedicalizing an epidemic: From HIV treatment as prevention to HIV treatment is prevention. AIDS 2011;25:1435.
    1. Kalichman SC. The TasP Revolution. HIV Treatments as Prevention (TasP). New York: Springer; 2013, pp. 61–92
    1. Wilton J, Broeckaert L. Treatment as prevention: Do the individual prevention benefits translate to the population level? 2013; Available at: (Last accessed March26, 2014)
    1. Fowler N, Arkell P, Abouyannis M, James C, Roberts L. Attitudes of serodiscordant couples towards antiretroviral-based HIV prevention strategies in Kenya: A qualitative study. AIDS Patient Care STDs 2015;29:33–42
    1. Vernooij E, Mehlo M, Hardon A, Reis R. Access for all: Contextualising HIV treatment as prevention in Swaziland. AIDS Care 2016;28(Suppl 3):7–13
    1. Young I, McDaid L. How acceptable are antiretrovirals for the prevention of sexually transmitted HIV?: A review of research on the acceptability of oral pre-exposure prophylaxis and treatment as prevention. AIDS Behav 2014;18:195–216
    1. Young I, Flowers P, McDaid L. Key factors in the acceptability of treatment as prevention (TasP) in Scotland: A qualitative study with communities affected by HIV. Sex Transm Infect 2015;91:269–274
    1. Kippax S, Stephenson N. Beyond the distinction between biomedical and social dimensions of HIV prevention through the lens of a social public health. Am J Public Health 2012;102:789–799
    1. Vermund SH, Fidler SJ, Ayles H, Beyers N, Hayes RJ, Team HS. Can combination prevention strategies reduce HIV transmission in generalized epidemic settings in Africa? The HPTN 071 (PopART) study plan in South Africa and Zambia. J Acquir Immune Defic Syndr 2013;63:S221.
    1. Sismanidis C, Moulton LH, Ayles H, et al. . Restricted randomization of ZAMSTAR: A 2 × 2 factorial cluster randomized trial. Clin Trials 2008;5:316–327
    1. Stringer JS, Chisembele-Taylor A, Chibwesha CJ, et al. . Protocol-driven primary care and community linkages to improve population health in rural Zambia: The Better Health Outcomes through Mentoring and Assessment (BHOMA) project. BMC Health Serv Res 2013;13(Suppl 2):S7.
    1. Wallman S, Bond VA, Montouri MA, Vidali M, Conte RL. The Capability of Places: Methods for Modelling Community Response to Intrusion and Change. London: Pluto Press, 2011.
    1. Bond V, Chiti B, Hoddinott G, et al. . “The difference that makes a difference”: Highlighting the role of variable contexts within an HIV Prevention Community Randomised Trial (HPTN 071/PopART) in 21 study communities in Zambia and South Africa. AIDS Care 2016;28(Suppl 3):99–107
    1. Kielmann K, Cataldo F, Seeley J. to Qualitative Research Introduction Methodology. London: Evidence for Action, 2011.
    1. Burke JG, O'Campo P, Peak GL, Gielen AC, McDonnell KA, Trochim WM. An introduction to concept mapping as a participatory public health research method. Qual Health Res 2005;15:1392–1410
    1. Abrahams K, Baleni J, Hoddinott G, et al. . Intruders with questions and justified fears—reflections on the experiences of research staff implementing rapid, qualitative research in 9 HPTN 071 (PopART) community sites in Western Cape Province, South Africa. Melbourne, Australia: 20th International AIDS Conference; July20–25, 2014
    1. Hoddinott G, Viljoen L, Baleni J, et al. . When your life is threatened, HIV is a peripheral concern; qualitative perceptions of crime/violence in 9 HPTN 071 (PopART) community sites in South Africa. Melbourne, Australia: 20th International AIDS Conference; July20–25, 2014
    1. Seeley J. HIV and East Africa: Thirty Years in the Shadow of an Epidemic. Basingstoke: Routledge, 2014.
    1. Cataldo F. New forms of citizenship and socio-political inclusion: Accessing antiretroviral therapy in a Rio de Janeiro favela. Sociology of Health and Illness 2008;30:900–912
    1. Squire C. Living with HIV and ARVs: Three-Letter Lives New York: Palgrave Macmillan, 2013; p. 4
    1. Holt M. The undiagnosed and untreated: The ‘unhealthy others’ of the HIV treatment as prevention era. Stellenbosch, South Africa: The 3rd International Association for the Social Sciences and Humanities in HIV; July6–9, 2015
    1. Davis M, Squire C, Davis M, Squire N. HIV Technologies. New York: Palgrave MacMillan; 2010, pp. 8–28
    1. Russell S, Seeley J, Ezati E, Wamai N, Were W, Bunnell R. Coming back from the dead: Living with HIV as a chronic condition in rural Africa. Health Policy Plan 2007;22:344–347
    1. van Loggerenberg F, Gray D, Gengiah S, et al. . A qualitative study of patient motivation to adhere to combination antiretroviral therapy in South Africa. AIDS Patient Care STDs 2015;29:299–306
    1. Musheke M, Bond V, Merten S. Deterrents to HIV-patient initiation of antiretroviral therapy in urban Lusaka, Zambia: A qualitative study. AIDS Patient Care STDs 2013;27:231–241
    1. Chileshe M, Bond VA. Barriers and outcomes: TB patients co-infected with HIV accessing antiretroviral therapy in rural Zambia. AIDS Care 2010;22(S1):51–59
    1. Simpson A, Bond V. Narratives of nationhood and HIV/AIDS: Reflections on multidisciplinary research on the HIV/AIDS epidemic in Zambia over the last 30 years. J South Afr Stud 2014;40:1065–1089
    1. Simpson A. Boys to Men in the Shadow of AIDS: Masculinities and HIV Risk in Zambia. New York: Palgrave Macmillan, 2009.
    1. Gray RH, Li X, Wawer MJ, et al. . Stochastic simulation of the impact of antiretroviral therapy and HIV vaccines on HIV transmission; Rakai, Uganda. AIDS 2003;17:1941–1951
    1. Adams A, Moyer E. Sex is never the same: Men's perspectives on refusing circumcision from an in-depth qualitative study in Kwaluseni, Swaziland. Global Public Health 2015;10:721–738
    1. Bond V, Dover P. Men, women and the trouble with condoms: Problems associated with condom use by migrant workers in rural Zambia. Health Transit Rev 1997;7 Suppl:377–391
    1. Bayer R. Private Acts, Social Consequences. New York: Simon and Schuster, 2010.
    1. Parker R. Why Social Science Matters Now More than Ever in HIV Research. St John's, Newfoundland, Canada: 23rd Annual Canadian Conference on HIV/AIDS Research; May1–4, 2014
    1. Vonn M. British Columbia's ‘seek and treat’ strategy: A cautionary tale on privacy rights and informed consent for HIV testing. HIV AIDS Policy Law Rev 2012;16:1–4
    1. Nyblade L, Pande R, Mathur S, et al. . Disentangling HIV and AIDS Stigma in Ethiopia, Tanzania and Zambia. Washington, DC: ICRW, 2003.
    1. Nguyen V-K. Counselling against HIV in Africa: A genealogy of confessional technologies. Cult Health Sex 2013;15(S4):S440–S452
    1. Philbin MM, Fortenberry JD, Ellen JM, Leonard L. HIV stops with me: Helping HIV-positive adolescents become responsible citizen-patients under a regimen of treatment as prevention. 2014. Population Association of America Conference Boston, MA April 29–May 3, 2014
    1. Mykhalovskiy E. Integrating HIV treatment and prevention: Shifts in community based organising and biopolitics in the canadian context. In: Davis M, Squire C, eds. HIV Treatment and Prevention Technologies in International Perspective. New York: Palgrave MacMillan; 2010, pp. 61–86
    1. Hanefeld J, Bond V, Seeley J, Lees S, Desmond N. Considerations for a human rights impact assessment of a population wide treatment for HIV prevention intervention. Dev World Bioethics 2013;15:115–124

Source: PubMed

Patrocinadores y Colaboradores

Condiciones médicas

Intervenciones de drogas

3
Suscribir