Transcript Mochudi MP3: An HIV Prevention Program for Mochudi

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
Background
o Botswana – Adult HIV seroprevalence 23.4%
o 9,000 new infections annually
o Early antiretroviral therapy (ART) may:
o Improve outcomes in HIV-infected
o 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 interview
o 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 aim
Context – ‘within the expanded program’
Time period – ‘within 30 days’
An Integrated Model of Behavioral Prediction
Background Influences
Distal variables
Demographics
Culture
Attitudes towards
them (stigma,
stereotypes)
Personality and
Emotions
Other Individual
variables
(perceived risk,
sensationseeking)
Exposure to
media and other
interventions
Behavioral
beliefs and
Outcome
evaluation
Attitude
Injunctive and
Descriptive
Normative
beliefs
Perceived
Norms
Efficacy Beliefs
SelfEfficacy
Skills
Fishbein and Yzer, Communication Theory (2003)
Intention
Behavior
Environmental
Constraints
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: Attitudes
Barriers to ART/TasP:
•
•
•
•
•
Fear of stigma*
Fear of disclosure/shame
Side effects
Cannot be stopped
Cannot take with alcohol or
traditional medicine
“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
Facilitators of ART/TasP:
• Perception of HIV as a
disease like any other*
• Improvement in health
• Knowing someone nonadherent who died
“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 Norms
Barriers 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 Efficacy
Barriers 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
Skills
Barriers 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
Conclusions
• Importance of community sensitization of ART as TasP
• Stigma and shame were key barriers to uptake
“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
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
Acknowledgements
Funding
Fogarty AITRP, NIAID R01AI083036
Sub-Study Principal Investigators
• Dr Rebeca Plank
• Dr Shahin Lockman
Harvard School of Public Health
• Dr Max Essex
• Dr Felton Earls
Harvard School of Medicine
• Dr Laura Bogart
Botswana-Harvard Partnership
• Dr Hermann Bussmann
• Dr Lillian Okui
• Khumoyame Maotonyane
• Keamogetswe Moloi
• Mochudi Prevention Project Team