Stigma and the roll-out of ART regardless of CD4-count: initial insights from HPTN 071 (PopART) Nomsenge, Hoddinott, Bond, Stangl and Hargreaves on Behalf of the HPTN 071 Study Team

Stigma as a barrier to roll-out? **RH: This slide seems to focus on “key populations” – usually meaning sub-populations at especially high risk – but UTT has a more universal target group – why are you focusing on “key populations” here? https://www.fhi360.org/projects/linkages-across-continuum-hiv-services-key-populations-affected-hiv-linkages

Stigma: Attitudes, perceptions and experiences PLWH (I have experienced this) Community members (Perception) Health Workers (Perception) Health workers sometimes talk badly about PLWH 5% 24% 31% (My co-workers) People sometimes talk badly about PLWH 17% 53% 81% Health workers sometimes talk badly about MSM - 57% People sometimes talk badly about MSM 92% (Krishnaratne et al.,)

Health in social context? “There are also letters submitted promoting the stigmatisation of people living with HIV … in July 2013, several letters were published where readers accused young, single women in their communities of purposefully infecting (mostly married) men with HIV. These women were labelled with phrases such as: Vengeful … AIDS-slut … bitch … rotten with AIDS … AIDS-monster … serial killer … emaciated whore … a remorseless murderer … common killer … using her body as weapon of mass destruction of families” (Viljoen et al., in press). Not sure I can approeciate the flow of this slide after the first 3 but I am sure you will be able to link this… **RH: I also found flow a bit unclear – and not sure what “letters submitted” refers to...?

Stigma in health facilities Map of a Zambian Health Facility Physical Infrastructure Material Items Patient Flow Relations Within Living With HIV & Social Identity **RH: Meanings of boxes not that clear but again I assume you will be explaining these verbally. (Bond et al., TUPED388)

Scaling-up ART access “There is some concern amongst HCPs that the scale-up of ART access (regardless of CD4-count) will create an unsustainably overburdened health system. This concern can feed into the normative cognitive processes of patient-blame.” (Hoddinott et al., THPEE440) Defining who us and them are. What if the HCW are also PLWH?

Discussion – Importance of process? Cautious optimism about increasing access to test and ART regardless of CD4-count Health systems should be vigilant about the many ways stigma can act as a barrier We need innovative ways of thinking about how to level change In HPTN 071 (PopART) we will continue to track this process over time **RH: Cautious optimism among whom?? Which slide/finding does this relate to? What does “level change” mean?

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)

The HPTN 071 Study Team, led by: PEPFAR Implementing Partners: 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