Experiences of early antiretroviral therapy (art) initiation among people living with HIV in Livingstone district in Zambia

Magister Public Health - MPHBeing healthy (‘feeling fine’) and health deterioration (‘getting sick’) were key health concerns among PLHIV prior to ART initiation. PLHIV often referred living with HIV as ‘being sick’ and experiencing poor health when already infected with HIV as ‘very sick’ and this perception about sickness and wellness partly determined the need and value placed on accessing HIV services. Motivations for starting treatment included needing to maintain or regain health, encouragement from HCWs, relatives and friends and believing in the effectiveness of ART to improve health. Prevention of HIV transmission to others was not cited to influence uptake. The majority of PLHIV reported stringent adherence to ART; even a half-hour delay in taking treatment was sometimes defined by participants as ‘non-adherence’. Initial reminders for taking ART (setting alarm, placing pills where visible) fell away as daily medication became routine. However, daily uptake of treatment had its own psychosocial and economic consequences which PLHIV had to navigate. With few exceptions, when taking the first line regimen, most PLHIV experienced both temporal (hallucinations, vomiting) and long-term (dizziness and irregular heartbeat) side-effects attributed to ART, which although not considered life threatening, could undermine ART adherence. HIV status disclosure was both limited and selective (mainly to spouses, close relatives, friends and co-workers) and deemed as promoting adherence to treatment and access to HIV services. HIV/AIDS stigma persisted even among relatively healthy PLHIV due to links with ‘promiscuity’, hampering disclosure and access to HIV services. Competing demands on participants’ time, especially livelihood activities, also disrupted accessing services. Good relationships between HCWs and PLHIV promoted access to services

Good Health and Moral Responsibility: Key Concepts Underlying the Interpretation of Treatment as Prevention in South Africa and Zambia Before Rolling Out Universal HIV Testing and Treatment.

Gauging community responses to the WHO 2015 recommendation to provide antiretroviral treatment (ART) to all people living with HIV (PLHIV) is critical. There is limited qualitative evidence on the acceptability of this Universal Test and Treat (UTT) strategy or community understanding of the impact of ART on reducing HIV transmission, promoted as Treatment as Prevention (TasP). This article explores early understanding of UTT and TasP in 21 urban communities in South Africa and Zambia in 2013 before a community randomized trial of combination prevention-HPTN 071 (PopART). It draws on participatory research conducted in each community, which carried out group discussions and interviews with 1202 respondents and 203 structured observations. Participants were largely unfamiliar with the concepts of UTT and TasP. They were concerned about an accompanying de-emphasis on sexual behavior change. Treatment and prevention seemed, at first glance, to be experienced separately. With the exception of the prevention of mother-to-child transmission, prevention seldom came into discussions about ART. This was partly because this science had not yet been explained to many and also because it was not an easy fit. Contemplating the link between treatment and prevention, participants emphasized both PLHIV taking care of themselves through good health and preventing disease progression and the moral responsibility of PLHIV to prevent HIV transmission. To avoid igniting moralizing and blaming when introducing UTT and TasP, we should capitalize on the "taking care of yourself" legacy while boosting public responsibility through broad antistigma education and patient empowerment efforts

Adapting community-based sexual and reproductive health services for adolescents and young people aged 15-24 years in response to COVID-19 in Lusaka, Zambia: the implications on the uptake of HIV testing services.

BACKGROUND: Across Sub-Saharan Africa, adolescents and young people (AYP) aged 15-24 have limited access to sexual and reproductive health (SRH) services, including HIV testing services (HTS). In response, the Yathu Yathu study was implemented in two high-density communities in Lusaka, Zambia. Yathu Yathu provides comprehensive, community-based, peer-led SRH services, including differentiated HTS (finger-prick and HIV self-testing) and comprehensive sexuality education (CSE). We describe adaptations to the Yathu Yathu intervention in response to the COVID-19 epidemic, and implications on uptake of HTS among AYP. METHODS: Yathu Yathu provides SRH services through community-based peer-led spaces. AYP in study communities were offered prevention points cards (PPC), which incentivizes and tracks service use. Social media (WhatsApp©/Facebook©) is used to engage and inform AYP about SRH. Due to COVID-19, hubs closed from April-June 2020. We describe adaptations in response to COVID-19 and, using routinely collected PPC data, describe uptake of HTS before (September 2019-March 2020) and after (July-December 2020) adaptations in response to COVID-19. We describe reach of the Yathu Yathu Facebook page and use qualitative data to describe AYP experiences of SRH service access. RESULTS: During hub closures, CSE was delivered via video on social media, resulting in an increase in Facebook page followers from 539(April) to 891(June). WhatsApp groups evolved as a platform to deliver CSE and COVID-19 information, with higher participation among young people aged 20-24. Key service delivery adaptations included: reducing the number of participants in hubs, mandatory handwashing before entry, use of personal protective equipment by staff and provision of facemasks to AYP. HTS were provided as normal. Adaptations led to fewer AYP attending hubs. Uptake of HTS among AYP visiting hubs for the first time after COVID-19-related closures was higher (73.2%) compared to uptake before adaptations (65.9%; adjOR=1.24 95%CI 0.99, 1.56, p=0.06). Despite disappointments with some aspects of service delivery, AYP expressed happiness that hubs had reopened. CONCLUSIONS: Social media can be a useful additional platform to reach AYP with HIV prevention information during COVID-19. With proper infection control in place, HTS can safely be provided to, accessed and accepted by AYP in community-based settings during COVID-19. TRIAL REGISTRATION: National Clinical Trials NCT04060420,19th August 2019. Current Controlled Trials ISRCTN75609016 , 14th September 2021, retrospectively registered

Spinning plates: livelihood mobility, household responsibility and anti-retroviral treatment in an urban Zambian community during the HPTN 071 (PopART) study.

INTRODUCTION: Qualitative data are lacking on the impact of mobility among people living with HIV (PLHIV) and their decision-making around anti-retroviral treatment (ART). We describe challenges of juggling household responsibility, livelihood mobility and HIV management for six PLHIV in urban Zambia. METHODS: Six PLHIV (three men and three women, aged 21 to 44) were recruited from different geographic zones in one urban community drawn from a qualitative cohort in a social science component of a cluster-randomized trial (HPTN071 PopART). Participants were on ART (n = 2), not on ART (n = 2) and had started and stopped ART (n = 2). At least two in-depth interviews and participant observations, and three drop-in household visits with each were carried out between February and August 2017. Themed and comparative analysis was conducted. RESULTS: The six participants relied on the informal economy to meet basic household needs. Routine livelihood mobility, either within the community and to a nearby town centre, or further afield for longer periods of time, was essential to get by. Although aware of ART benefits, only one of the six participants managed to successfully access and sustain treatment. The other five struggled to find time to access ART alongside other priorities, routine mobility and when daily routines were more chaotic. Difficulty in accessing ART was exacerbated by local health facility factors (congestion, a culture of reprimanding PLHIV who miss appointments, sporadic rationed drug supply), stigma and more limited social capital. CONCLUSIONS: Using a time-space framework illustrated how household responsibility, livelihood mobility and HIV management every day were like spinning plates, each liable to topple and demanding constant attention. If universal lifelong ART is to be delivered, the current service model needs to adjust the limited time that some PLHIV have to access ART because of household responsibilities and the need to earn a living moving around, often away from home. Practical strategies that could facilitate ART access in the context of livelihood mobility include challenging the practice of reprimand, improving drug supply, having ART services more widely distributed, mapped and available at night and weekends, and an effective centralized client health information system

Engaging young people in the design of a sexual reproductive health intervention: Lessons learnt from the Yathu Yathu ("For us, by us") formative study in Zambia.

BACKGROUND: Meeting the sexual and reproductive health (SRH) needs of adolescents and young people (AYP) requires their meaningful engagement in intervention design. We describe an iterative process of engaging AYP to finalise the design of a community-based, peer-led and incentivised SRH intervention for AYP aged 15-24 in Lusaka and the lessons learnt. METHODS: Between November 2018 and March 2019, 18 focus group discussions, eight in-depth interviews and six observations were conducted to assess AYP's knowledge of HIV/SRH services, factors influencing AYP's sexual behaviour and elicit views on core elements of a proposed intervention, including: community-based spaces (hubs) for service delivery, type of service providers and incentivising service use through prevention points cards (PPC; "loyalty" cards to gain points for accessing services and redeem these for rewards). A total of 230 AYP (15 participated twice in different research activities) and 21 adults (only participated in the community mapping discussions) participated in the research. Participants were purposively selected based on age, sex, where they lived and their roles in the study communities. Data were analysed thematically. RESULTS: Alcohol and drug abuse, peer pressure, poverty, unemployment and limited recreation facilities influenced AYP's sexual behaviours. Adolescent boys and young men lacked knowledge of contraceptive services and all AYP of pre and post exposure prophylaxis for HIV prevention. AYP stated a preference for accessing services at "hubs" located in the community rather than the health facility. AYP considered the age, sex and training of the providers when choosing whom they were comfortable accessing services from. PPCs were acceptable among AYP despite the loyalty card concept being new to them. AYP suggested financial and school support, electronic devices, clothing and food supplies as rewards. CONCLUSIONS: Engaging AYP in the design of an SRH intervention was feasible, informative and considered responsive to their needs. Although AYP's suggestions were diverse, the iterative process of AYP engagement facilitated the design of an intervention that is informed by AYP and implementable. TRIAL REGISTRATION: This formative study informed the design of this trial: ClinicalTrials.gov, NCT04060420. Registered 19 August, 2019

Closing the gap: did delivery approaches complementary to home-based testing reach men with HIV testing services during and after the HPTN 071 (PopART) trial in Zambia?

INTRODUCTION: The HPTN 071 (PopART) trial demonstrated that universal HIV testing-and-treatment reduced community-level HIV incidence. Door-to-door delivery of HIV testing services (HTS) was one of the main components of the intervention. From an early stage, men were less likely to know their HIV status than women, primarily because they were not home during service delivery. To reach more men, different strategies were implemented during the trial. We present the relative contribution of these strategies to coverage of HTS and the impact of community hubs implemented after completion of the trial among men. METHODS: Between 2013 and 2017, three intervention rounds (IRs) of door-to-door HTS delivery were conducted in eight PopART communities in Zambia. Additional strategies implemented in parallel, included: community-wide "Man-up" campaigns (IR1), smaller HTS campaigns at work/social places (IR2) and revisits to households with the option of HIV self-testing (HIVST) (IR3). In 2018, community "hubs" offering HTS were implemented for 7 months in all eight communities. Population enumeration data for each round of HTS provided the denominator, allowing for calculation of the proportion of men tested as a result of each strategy during different time periods. RESULTS: By the end of the three IRs, 65-75% of men were reached with HTS, primarily through door-to-door service delivery. In IR1 and IR2, "Man-up" and work/social place campaigns accounted for ∼1 percentage point each and in IR3, revisits with the option of self-testing for ∼15 percentage points of this total coverage per IR. The yield of newly diagnosed HIV-positive men ranged from 2.2% for HIVST revisits to 9.9% in work/social places. At community hubs, the majority of visitors accepting services were men (62.8%). In total, we estimated that ∼36% (2.2% tested HIV positive) of men resident but not found at their household during IR3 of PopART accessed HTS provided at the hubs after trial completion. CONCLUSIONS: Achieving high coverage of HTS among men requires universal, home-based service delivery combined with an option of HIVST and delivery of HTS through community-based hubs. When men are reached, they are willing to test for HIV. Reaching men thus requires implementers to adapt their HTS delivery strategies to meet men's needs. CLINICAL TRIAL NUMBER: NCT01900977

The Broad-Brush Survey Approach. A set of methods for rapid qualitative community assessment

Using a combination of qualitative data collection methods to collect data rapidly from a place on a particular topic is not a novel idea. Rapid participatory and qualitative appraisal approaches have been used in many different settings for the past 40 years, with the influential scholar Robert Chambers, and those he worked with, doing much to shape the practice from the 1970s. The methods spread beyond a rural, agriculture focus (Chambers, 1994) to embrace urban settings and the assessment of health and other areas of interest as well as settings in the Global North as well as South (Annett and Rifkin, 1995, Murray et al., 1994). I first used these approaches in the 1980s, while working in the Annapurna foothills in Nepal at an agricultural research station. We established the practice of a one week data collection exercise, which we called a `Combined Trek’ where a group of scientists from different disciplines, including me – a social anthropologist – systematically collected information using interviews, observations and discussions in a village and the surrounding area – working closely with the local people. Our purpose was to inform future agricultural interventions, building from what people were already doing. Cecilia Vindrola-Padros and Ginger Johnson (2020) detail in a review article how different qualitative methods have been adapted to be used to collect data rapidly. The need for speed, as they explain, has been a response to the increasing pressure many of us are under to deliver study findings quickly. Their review sets out how conventional methods have been adapted to be used rapidly in different settings. Among the combination of methods that they describe is the `rapid ethnographic assessment’. This assessment approach has grown as a response of anthropologists to pressure to produce results far more quickly that more conventional ethnographic approaches would allow. This set of methods is described in detail in the recent manual produced by Sangaramoorthy and Kroeger (2020). We are not, therefore, claiming that the approach set out in this manual is particularly novel nor indeed unique. The Broad Brush Survey, described in this manual is an approach originally developed by Valdo Pons (1993, 1996) and further developed and popularized through the work of Sandra Wallman (1996), which can be used to capture both the landscape and ‘feel’ of a community and the people in it. The research findings can be used to shape further investigators or interventions to address the problem at hand in a useful and practical manner rapidly, succinctly and systematically. This `Broad Brush Survey’ approach manual is, therefore, a contribution to the burgeoning literature on methods for rapid qualitative data collection methods and assessment. The use of the word ‘survey’ in the title of the set of methods may be perplexing to those who consider the term to be synonymous with `questionnaire’. This 6 is not the way we use the word – the Oxford English Dictionary offers several definitions of word `survey’, which include `the act of viewing, examining, or inspecting in detail [...] for some specific purpose’ and `the, or an, act of looking at something as a whole from a commanding position; a general or comprehensive look’. Both definitions convey the sense of our intention: to engage with, and in, a community for a short but concentrated period of time, seeking quickly, but thoroughly, to take a comprehensive look at the place for a specific purpose, and document the place at that moment in time. As we explain in the first chapter, the approach is systematic with a defined sequence of qualitative data collection methods, which gradually allows the user to build an understanding of place and people. The combination of methods used, however, is not set in stone and can be adapted to suit the purpose at hand. As such we hope that this manual serves as a guide to the possibilities which using this approach can offer both for those working in interdisciplinary projects as well as those from anthropology and sociology, for example, laying the groundwork for in-depth longitudinal research

How 'place' matters for addressing the HIV epidemic: evidence from the HPTN 071 (PopART) cluster-randomised controlled trial in Zambia and South Africa.

BACKGROUND: In a cluster-randomised trial (CRT) of combination HIV prevention (HPTN 071 (PopART)) in 12 Zambian communities and nine South African communities, carried out from 2012 to 2018, the intervention arm A that offered HIV treatment irrespective of CD4 count did not have a significant impact on population level HIV incidence. Intervention arm B, where HIV incidence was reduced by 30%, followed national guidelines that mid trial (2016) changed from starting HIV treatment according to a CD4 threshold of 500 to universal treatment. Using social science data on the 21 communities, we consider how place (community context) might have influenced the primary outcome result. METHODS: A social science component documented longitudinally the context of trial communities. Data were collected through rapid qualitative assessment, interviews, group discussions and observations. There were a total of 1547 participants and 1127 observations. Using these data, literature and a series of qualitative analysis steps, we identified key community characteristics of relevance to HIV and triangulated these with HIV community level incidence. RESULTS: Two interdependent social factors were relevant to communities' capability to manage HIV: stability/instability and responsiveness/resistance. Key components of stability were social cohesion; limited social change; a vibrant local economy; better health, education and recreational services; strong institutional presence; established middle-class residents; predictable mobility; and less poverty and crime. Key components of responsiveness were community leadership being open to change, stronger history of HIV initiatives, willingness to take up HIV services, less HIV-related stigma and a supported and enterprising youth population. There was a clear pattern of social factors across arms. Intervention arm A communities were notably more resistant and unstable. Intervention arm B communities were overall more responsive and stable. CONCLUSIONS: In the specific case of the dissonant primary outcome results from the HPTN 071 (PopART) trial, the chance allocation of less stable, less responsive communities to arm A compared to arm B may explain some of the apparently smaller impact of the intervention in arm A. Stability and responsiveness appear to be two key social factors that may be relevant to secular trends in HIV incidence. We advocate for a systematic approach, using these factors as a framework, to community context in CRTs and monitoring HIV prevention efforts. TRIAL REGISTRATION: ClinicalTrials.gov NCT01900977 . Registered on July 17, 2013

Cross sectional survey data for self-reported ever and recent (last 12 months) STI testing

Data collected as part of a self-reported survey on sexual behaviour and sexually transmitted infection (STI) testing. The cross-sectional survey was conducted with adolescents and young people aged 15 to 24 in two communities of Lusaka, Zambia

Does distribution of menstrual products through community-based, peer-led sexual and reproductive health services increase use of appropriate menstrual products? Findings from the Yathu Yathu trial

Abstract Background Globally, millions of adolescent girls and young women (AGYW) who menstruate have limited access to appropriate and comfortable products to manage their menstruation. Yathu Yathu was a cluster randomised trial (CRT) that estimated the impact of community-based, peer-led sexual and reproductive health (SRH) services on knowledge of HIV status among adolescents and young people aged 15–24 (AYP). Among the services offered through Yathu Yathu were free disposable pads and menstrual cups. This study aimed to investigate whether the availability of free menstrual products through Yathu Yathu increased AGYW’s use of an appropriate menstrual product at their last menstruation and explored the characteristics of AGYW who accessed menstrual products through Yathu Yathu. Methods Yathu Yathu was conducted between 2019 and 2021 in 20 zones across two urban communities of Lusaka, Zambia. Zones were randomly allocated to the intervention or standard-of-care arm. In intervention zones, a community-based hub, staffed by peers, was established to provide SRH services. In 2019, a census was conducted in all zones; all consenting AYP aged 15–24 were given a Yathu Yathu Prevention Points Card, which allowed AYP to accrue points for accessing services at the hub and health facility (intervention arm), or the health facility only (control arm). Points could be exchanged for rewards, thus acting as an incentive in both arms. We conducted a cross-sectional survey in 2021 to estimate the impact of Yathu Yathu on the primary outcome (knowledge of HIV status) and secondary outcomes. Sampling was stratified by sex and age group; we analysed data from AGYW only to estimate the impact of Yathu Yathu on use of an appropriate menstrual product (disposable or reusable pad, cup, tampon) at last menstruation. We analysed data at zone-level using a two-stage process recommended for CRTs with < 15 clusters/arm. Results Among 985 AGYW participating in the survey who had experienced menarche, the most commonly used products were disposable pads (88.8%; n = 875/985). At their last menstruation, 93.3% (n = 459/492) of AGYW in the intervention arm used an appropriate menstrual product compared to 85.7% (n = 420/490) in the control arm (adjPR = 1.09 95%CI 1.02, 1.17; p = 0.02). There was no evidence for interaction by age (p = 0.20), but use of appropriate products was higher among adolescents in the intervention arm relative to control (95.5% vs 84.5%, adjPR = 1.14 95%CI 1.04, 1.25; p = 0.006) with no evidence for a difference among young women (91.1% vs 87.0%, adjPR = 1.06 95%CI 0.96, 1.16, p = 0.22). Conclusions Delivering community-based peer-led SRH services increased the use of appropriate menstrual products among adolescent girls aged 15–19 at the start of the Yathu Yathu study. With less economic independence, the free provision of appropriate menstrual products is critical for adolescent girls to access materials that allow them to effectively manage their menstruation