Upload
moises-cave
View
215
Download
1
Tags:
Embed Size (px)
Citation preview
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 aim
Context – ‘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 medicine
Facilitators 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 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 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