Acceptability of early initiation of antiretrovirals for treatment as prevention among HIV-infected

persons in Mochudi, Botswana

Andrew Logan, PhD; Rebeca Plank, MD, MPH; Laura M. Bogart, PhD; Keamogetswe Moloi; Khumoyame Maotonyane; Hermann Bussmann, MD, PhD; Lillian Okui, MD, MPH; Felton Earls, MD; Max Essex, DVM,

PhD; Shahin Lockman, MD, MSc

Backgroundo Botswana – Adult HIV seroprevalence 23.4%

o 9,000 new infections annually o Early antiretroviral therapy (ART) may:

o Improve outcomes in HIV-infectedo Decrease risk of HIV transmission

o However, 20% of ART-eligible patients (CD4<200 cells/mm3 or WHO Stage 4) in South Africa declined ART (Katz, AIDS, 2011)

o Key unanswered question:

“Will HIV-infected persons with relatively high CD4 cell count (≥ 350 cells/mm3) want to initiate therapy?”

Background: The ‘Mochudi Prevention Pilot Project’: Community-Wide HIV Testing with Viral-Load-Driven TasP

Background: The ‘Mochudi Prevention Pilot Project’: Community-Wide HIV Testing with Viral-Load-Driven TasP

Community-based study providing package of HIV prevention interventions to 16–64-year-olds in a rural village, Mochudi, in southern Botswana (adult HIV prevalence 25%)

Core components:• Annual door-to-door HIV testing • Identification of individuals with CD4≥350 cells/mm3

and viral load ≥50,000 cp/mL (TasP)• Eligible for ART under study protocol

Objectives and Design of Qualitative Substudy

o To use qualitative methods to identify barriers and facilitators to uptake of TasP in the Mochudi Prevention Pilot Project

o All participants eligible for TasP (ART-naïve adult residents with CD4≥350 cells/mm3 and viral load ≥50,000 copies/mL, excluding PMTCT) were asked to take part:o Individual in-depth interviewo Focus group discussion (FGD)

o Study period: July 2012 - January 2013 – 12 were eligible

Methods• 12 Individual Interviews: To explore intention to

initiate ART • 9 women (24-57 years, mean 37), 3 men (35-64 years,

mean 46)

• 2 Focus Group Discussions (FGDs): To explore intention to initiate ART, separated by gender

• 6 women and 2 men

• Conducted in Setswana by a trained counselor• Based on semi-structured interview guides• Audio recorded, transcribed and translated into English.

Definition of Behavior

Action – ‘Taking ART’Target – ‘Before CD4<350 cells/mm3 or AIDS’

• Specifically with TasP as aimContext – ‘within the expanded program’Time period – ‘within 30 days’

An Integrated Model of Behavioral Prediction

Distal variablesDemographics

CultureAttitudes towards

them (stigma, stereotypes)

Personality and Emotions

Other Individual variables

(perceived risk, sensation-seeking)Exposure to media

and other interventions

Behavioral beliefs and Outcome

evaluation

Injunctive and Descriptive Normative

beliefs

Efficacy Beliefs

Attitude

Perceived Norms

Self-Efficacy

Intention Behavior

Skills

Environmental Constraints

Background Influences

Fishbein and Yzer, Communication Theory (2003)

Data Analysis

• Manual coding to identify data features• Coded iteratively/independently by 2 investigators • Discrepancies resolved through discussion and

consensus

• Thematic analysis to identify and arrange emerging categories according to the Integrated Model of Behavioral Prediction

Results: AttitudesBarriers to ART/TasP:• Fear of stigma* • Fear of disclosure/shame• Side effects• Cannot be stopped• Cannot take with alcohol or

traditional medicineFacilitators of ART/TasP:• Perception of HIV as a disease like

any other*• Improvement in health• Knowing someone non-adherent

who died

“There was one at our work, and it was known that she had this

disease. Then I saw people scorned her... the others no longer used the toilet that she used. They changed

toilets and told her to go to that one... It is still like that” Female,

51yrs

“Oh, the virus these days, I see it as a disease like everything else. It is

the same as just being sick with diabetes. It is no longer feared

today” Female, 31yrs

Injunctive Norms

Barriers to ART/TasP:• Knowing someone on ART -

discriminated against *• Fear of disapproval - church, traditional

healers

Facilitators of ART/TasP:• Approval of ART - churches• Support to start ART* • Knowing someone on ART - adherent

“In my own family, I see it with my sister, it entered, then we were

separated in the home. ‘Hey this person has a disease’... then you find you are given insults… It means that we made a mistake and it was better

that some did not know what had happened” Female, 51yrs

“They would be happy. Isn’t it they don’t want to see me sick, because

they know that this disease belittles people right?” Female, 57yrs

Descriptive NormsBarriers to ART/TasP:

• Avoidance of local ART collection sites

• Alcohol use affecting ART adherence*

• Non-adherence of those on ART as health improves

Facilitators of ART/TasP:• Knowing someone on ART• Side effects are short-term• Improvement to health*

“He (partner) drinks (takes) them (ART). He didn’t drink (takes) them well... he is

a drunkard... he will be gone and the time will come and he doesn’t drink

them (ART)” Female, 30yrs

“You see that a person will not now be sick day after day, and they walk… they

work… they were a patient who was sleeping in blankets”

Male, 61yrs

Self EfficacyBarriers to ART/TasP:• Fear of non-adherence*• Distance to travel for ART

Facilitators of ART/TasP:• Personal health*• Ability to work• Prolonging life

“It is very difficult, I don’t know if I will manage… I am not used to it...

And to forget them… I am not used to drinking tablets”

Female, 30yrs

“There is nothing that would prevent me… I am talking about my health”

Female, 57yrs

SkillsBarriers to ART/TasP:• Side effects on ART• Fear of non-adherence*

Facilitators of ART/TasP:• Previously taking tablets for

TB or PMTCT*• Coping strategies for travel

and forgetfulness

“I was able to forget them, you know that you are not used to it

when you are doing it, you find that forgetting happens often”

Female, 36yrs

“They gave me the tablets of IPT to stop the big cough (TB) for six

months and I drank them”Female, 51yrs

Environment

Barriers to ART/TasP:• Distance to travel for ART• Stigma at clinic, hospital*

Facilitators of ART/TasP: • Media• HIV/ART lessons at clinics*• ART availability

“Now if there is a hospital, being a hospital for everything, we

know that all go to that hospital. But when you go to the hospital

you know that you are given tablets that are for you (HIV+)”

Male, 38yrs

“I was able to enter the programs at clinic where we

were taught about suppressants” Female, 31yrs

Intentions specific to TasP

• Baseline knowledge of TasP was limited• Once information was provided, all participants

stated prevention of transmission to partner would be a motivator for ART initiation

Limitations

• Constraints of the larger study protocol• Small sample size• Due to changes in CD4 ART initiation threshold in

National Program• Disease progression to treatment eligibility

• Findings may not be generalizable to programmatic settings which are influenced by provider and delivery systems

“I would say to people that they should stop being ashamed, but stand on their feet, and fight this disease. Everybody must stand up and fight this disease so that it

finishes. We should take suppressants… the virus will reduce, and its spread. We should all be of the same

mind” Female, 57yrs

Conclusions

• Importance of community sensitization of ART as TasP• Stigma and shame were key barriers to uptake

Future Directions

Need to capitalize on identified determinants of behavior to successfully implement TasP

Next steps:• Develop and test quantitative survey in persons

offered TasP in Botswana• Measure predictors associated with TasP initiation and

retention in treatment• Design and test interventions to improve TasP uptake

AcknowledgementsFundingFogarty AITRP, NIAID R01AI083036Sub-Study Principal Investigators• Dr Rebeca Plank• Dr Shahin LockmanHarvard School of Public Health• Dr Max Essex • Dr Felton EarlsHarvard School of Medicine• Dr Laura BogartBotswana-Harvard Partnership• Dr Hermann Bussmann• Dr Lillian Okui• Khumoyame Maotonyane• Keamogetswe Moloi• Mochudi Prevention Project Team