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 Botswana – Adult HIV seroprevalence 23.4% 9,000 new infections annually Early antiretroviral therapy (ART) may: Improve outcomes in HIV-infected Decrease risk of HIV transmission However, 20% of ART-eligible patients (CD4<200 cells/mm3 or WHO Stage 4) in South Africa declined ART (Katz, AIDS, 2011) Key unanswered question: “Will HIV-infected persons with relatively high CD4 cell count (≥ 350 cells/mm3) want to initiate therapy?” UNAIDS 2011, 15-49 Swaziland 26%, Botswana 23.4%, Lesotho 23.3% CD4

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 To use qualitative methods to identify barriers and facilitators to uptake of TasP in the Mochudi Prevention Pilot Project 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: Individual in-depth interview Focus group discussion (FGD) Study period: July 2012 - January 2013 – 12 were eligible Sub Study Background Statement of importance of the topic Background from literature, with citations Theoretical approach (unless you prefer to include this in Methods) Research question or objective of the study or paper

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 variables Demographics Culture Attitudes 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 Discrepancies were resolved through discussion and consensus

Results: Attitudes Barriers to ART/TasP: Facilitators of ART/TasP: “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 Barriers 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

Injunctive Norms Barriers to ART/TasP: “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 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

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

“There is nothing that would prevent me… I am talking about my health” 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: Facilitators of ART/TasP: “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 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

Environment Barriers to ART/TasP: Facilitators of ART/TasP: “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 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

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 Based on the fact that all interviews Shame

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