1. NATIONAL INSTITUTES OF HEALTH: National Institute of Allergy and Infectious Diseases National Institute of Mental Health National Institute on Drug Abuse “What is this ‘Universal Test and Treat’ (UTT)?” Community Understandings of Key Concepts linked to a Combination HIV Prevention Strategy in 21 Zambian and South African Communities Virginia Bond, Graeme Hoddinott, Melvin Simuyaba, Kelly Abrahams, Helen Ayles, Nulda Beyers, Peter Bock, Bwalya Chiti, Lesley-Ann Erasmus-Claassen, Sarah Fidler, James Hargreaves, Richard Hayes, Jabulile Mantantana, Maurice Musheke, Rhoda Ndubani, Janet Seeley, Musonda Simwinga, & Lario Viljoen ON BEHALF OF THE HPTN 071 STUDY PROTOCOL TEAM 23 JULY 2014, IAS ORAL

2. The HPTN 071 Study Team, led by: Dr. Richard Hayes Dr. Sarah Fidler Dr. Helen Ayles Dr. Nulda Beyers PEPFAR Implementing Partners: Government Agencies:

3. 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 With thanks to:

4. Key Question How do communities in high HIV prevalence settings perceive ‘innovative approaches’ to HIV prevention?

5. HPTN-071 (PopART): –large-scale 3-arm, community-randomised controlled trial of a multi-component HIV prevention intervention (including earlier access to ART) in 21 community sites in Zambia (12) and South Africa (9) –built on a Universal Test and Treat (UTT) model, underscored by Treatment as Prevention paradigm Qualitative research in 21 communities preceded PopART: –‘Broad Brush Surveys’ (see poster THPE 214) of HIV landscape –November 2012 - May 2013 Background: PopART & BBS

7. Concept mapping used to explore local understanding of HIV prevention: ‘What is HIV Prevention?’ discussed initially with HIV ‘specialists’ then with community member groups (age & gender specific) Key Informant Interviews asked specifically about HIV Prevention options & ‘Treatment as Prevention’ 97 groups (757 participants – 454 women); 65 KIIs (51 women) Data analysis in two phases – rapid (for implementation feedback) and finer, themed Methods & Study Population

8. CONCEPT MAPPING ACTIVITY: ‘WHAT IS HIV PREVENTION?’ KEY FINDINGS

9. WHAT IS HIV PREVENTION? South AfricaZambiaCommon Couple counselling Education – IEC, health talk, health education, drama HIV testing – ‘re-testing’ Couple counselling Avoid re-infection Medical Male Circumcision Faith healing Control/reduce alcohol intake Fear of God Avoid sharing sharp instruments Avoid sexual cleansing Be faithful Education/sensitisation Condom use Abstinence HIV testing (‘know your status’/‘VCT’) ‘Stay HIV negative’ STI treatment PMTCT (‘start ANC early’) Traditional medicine/ ‘Immune boosters’ Support PLWH to “take treatment and live healthy lifestyles” (HCW, S20) Masturbation Know your partner’s status Education – radio & library Stop rape/crimes

10. Participants more often used the words ‘reducing transmission’ rather than ‘HIV prevention’ Only two (Zambian) sites listed ‘take ARVs’; in relation to PMTCT and ‘to reduce viral load’ for PLWH’s own health benefit Abstinence, Be Faithful and Condomise (‘ABC’) readily identified in both countries an HIV specialist in Zambia mentioned ‘D’ had been added to ‘ABC campaign’: “ABCD...[because]...drugs are also used for HIV prevention these days” (Z3) Widely understood to be a combination of approaches & having shifted from stronger focus on ‘no sex’ (behaviour change): “it’s a combination of all of them, we can’t really single one out” (adherence supporter, S15) Prevention rarely linked to Treatment

11. No spontaneous use of the terms ‘UTT’, ‘TasP’, ‘Test & Treat’ Spontaneous limited use of: ‘PEP’ ‘Truvada’; heard about “truvada outside Zambia” (HIV specialists, Z4) ‘PWP’ (‘Prevention With Positives’) (one Zambian site) Widespread use of ‘PMTCT’ Talking about Treatment AS Prevention

12. WHEN PROBED.... “HAVE YOU HEARD OF ART TREATMENT USED AS HIV PREVENTION?” “NO” “UTT? What kind of animal is that?” (PLWH, Z8) “UTT? This is our first time to hear it...we have heard it [for the first time] today” (PLWH, Z9) “ I say your question’s got me stuck [stumped me]...I don’t think I have heard of it ha ah I will be lying if I said [that I did]” (healthcare worker, S13)

13. Familiar and overall supportive of testing everyone for HIV and everyone knowing their status “we are moving too slowly... if we could test more people…then we can...get more people on treatment...” (health worker, S19) However, this was NOT talked about as a ‘universal’ approach. More often referred to, especially in Zambia, as ‘door to door’. Mostly supportive of early treatment for PLWH Widespread Support for Testing

14. Most could relate ‘ART as prevention’ to PMTCT, considered it to result in ‘HIV-free children’: “is really preventing our children from getting HIV…is well understood because our pregnant clients and I think it’s because this is a life.. this is a baby.. that one is a success” (KII, S17) In SA, some participants described PMTCT as a ‘secondary’ prevention method: it has not stopped the mother contracting HIV or from having more children AND the child may well also contract HIV by “following in her parents’ footsteps” (community group, S19) PMTCT

15. With the exception of PMTCT, and a few Zambian participants in a few sites, prevention in PLWH on treatment was understood as preventing illness, ‘boosting the immune system’ and ‘re-infection’. ART was not often understood to reduce HIV transmission and condom use for PLWH – even within HIV-positive partnerships – was advocated. Some participants expressed concern that if viral load was ‘undetectable’ PLWH would stop treatment Preventing Illness in PLWH

16. Participants quick to link ‘ART as prevention’ to ‘improper’ sex (‘promiscuity’) and other forms of improper ‘behaviour’. This fed a tendency to subsequently highlight non-sexual HIV transmission. Some respondents considered PLWH on ART to be vindictively spreading HIV. This was sometimes also levelled at PLWH NOT on ART. There was a widespread tendency in both countries to tell PLWH ‘how’ to live so that THEY prevent the spread of HIV “prevention should start with those who are positive. Not to infect others who are HIV negative” (HIV specialists, Z8) At odds with ‘Behaviour Change’, indicative of ‘improper behaviour’

17. Be more cautious about promoting ‘innovative’ approaches through new acronyms Build on old acronyms – e.g. ‘ABCD’ - & provide detailed information ‘UTT’, ‘TasP’ unfamiliar Build on support for HIV testing & treatment and PMTCT Put focus on emphasising impact of treatment on transmission WITHIN treatment initiatives and WITHIN prevention initiatives Prevention & Treatment mostly delinked Risk that TasP could re-draw the boundary between ‘us’ and ‘them’ & drive HIV stigma The responsibility for prevention is broader than PLWH ‘TasP’ increases PLWH responsibility CONCLUSIONS

18. 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)