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      Test but not treat: Community members’ experiences with barriers and facilitators to universal antiretroviral therapy uptake in rural KwaZulu-Natal, South Africa

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          Abstract

          Introduction

          Antiretroviral therapy (ART) has revolutionised the care of HIV-positive individuals resulting in marked decreases in morbidity and mortality, and markedly reduced transmission to sexual partners. However, these benefits can only be realised if individuals are aware of their HIV-positive status, initiated and retained on suppressive lifelong ART. Framed using the socio-ecological model, the present study explores factors contributing to poor ART uptake among community members despite high acceptance of HIV-testing within a Treatment as Prevention (TasP) trial. In this paper we identify barriers and facilitators to treatment across different levels of the socio-ecological framework covering individual, community and health system components.

          Methods

          This research was embedded within a cluster-randomised trial (ClinicalTrials.gov, number NCT01509508) of HIV treatment as Prevention in rural KwaZulu-Natal, South Africa. Data were collected between January 2013 and July 2014 from resident community members. Ten participants contributed to repeat in-depth interviews whilst 42 participants took part in repeat focus group discussions. Data from individual interviews and focus group discussions were triangulated using community walks to give insights into community members’ perception of the barriers and facilitators of ART uptake. We used thematic analysis guided by a socio-ecological framework to analyse participants’ narratives from both individual interviews and focus group discussions.

          Results

          Barriers and facilitators operating at the individual, community and health system levels influence ART uptake. Stigma was an over-arching barrier, across all three levels and expressed variably as fear of HIV disclosure, concerns about segregated HIV clinical services and negative community religious perceptions. Other barriers were individual (substance misuse, fear of ART side effects), community (alternative health beliefs). Facilitators cited by participants included individual (expectations of improved health and longer life expectancy following ART, single tablet regimens), community (availability of ART in the community through mobile trial facilities) and health system factors (fast and efficient service provided by friendly staff).

          Discussion

          We identified multiple barriers to achieving universal ART uptake. To enhance uptake in HIV care services, and achieve the full benefits of ART requires interventions that tackle persistent HIV stigma, and offer people with HIV respectful, convenient and efficient services. These interventions require evaluation in appropriately designed studies.

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          Most cited references51

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            Prevention of HIV-1 infection with early antiretroviral therapy.

            Antiretroviral therapy that reduces viral replication could limit the transmission of human immunodeficiency virus type 1 (HIV-1) in serodiscordant couples. In nine countries, we enrolled 1763 couples in which one partner was HIV-1-positive and the other was HIV-1-negative; 54% of the subjects were from Africa, and 50% of infected partners were men. HIV-1-infected subjects with CD4 counts between 350 and 550 cells per cubic millimeter were randomly assigned in a 1:1 ratio to receive antiretroviral therapy either immediately (early therapy) or after a decline in the CD4 count or the onset of HIV-1-related symptoms (delayed therapy). The primary prevention end point was linked HIV-1 transmission in HIV-1-negative partners. The primary clinical end point was the earliest occurrence of pulmonary tuberculosis, severe bacterial infection, a World Health Organization stage 4 event, or death. As of February 21, 2011, a total of 39 HIV-1 transmissions were observed (incidence rate, 1.2 per 100 person-years; 95% confidence interval [CI], 0.9 to 1.7); of these, 28 were virologically linked to the infected partner (incidence rate, 0.9 per 100 person-years, 95% CI, 0.6 to 1.3). Of the 28 linked transmissions, only 1 occurred in the early-therapy group (hazard ratio, 0.04; 95% CI, 0.01 to 0.27; P<0.001). Subjects receiving early therapy had fewer treatment end points (hazard ratio, 0.59; 95% CI, 0.40 to 0.88; P=0.01). The early initiation of antiretroviral therapy reduced rates of sexual transmission of HIV-1 and clinical events, indicating both personal and public health benefits from such therapy. (Funded by the National Institute of Allergy and Infectious Diseases and others; HPTN 052 ClinicalTrials.gov number, NCT00074581.).
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              Initiation of Antiretroviral Therapy in Early Asymptomatic HIV Infection

              New England Journal of Medicine, 373(9), 795-807
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                Author and article information

                Contributors
                Role: ConceptualizationRole: Formal analysisRole: Funding acquisitionRole: MethodologyRole: Writing – original draft
                Role: Formal analysisRole: Writing – original draft
                Role: ConceptualizationRole: Formal analysisRole: Writing – original draft
                Role: Writing – review & editing
                Role: ConceptualizationRole: Formal analysisRole: MethodologyRole: Writing – review & editing
                Role: ConceptualizationRole: Formal analysisRole: Writing – review & editing
                Role: ConceptualizationRole: Writing – review & editing
                Role: Writing – review & editing
                Role: SupervisionRole: Writing – review & editing
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                24 September 2020
                2020
                : 15
                : 9
                : e0239513
                Affiliations
                [1 ] Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Falmer, United Kingdom
                [2 ] Africa Health Research Institute, Berea, KwaZulu-Natal, South Africa
                [3 ] Univ. Bordeaux, Inserm, Bordeaux Population Health Research Center, Bordeaux, France
                [4 ] Institut de Recherche pour le Développement(IRD), Centre Population et Développement (Ceped), Paris, France
                [5 ] Harvard Medical School, Boston, Massachusetts, United States of America
                [6 ] Institute for Global Health, University College London, London, United Kingdom
                [7 ] London School of Hygiene and Tropical Medicine, London, United Kingdom
                Albert Einstein College of Medicine, UNITED STATES
                Author notes

                Competing Interests: I have updated the competing interest statement in the text of the manuscript. Revised text below I have read the journal's policy and the authors of this manuscript have the following competing interests: CI received research grants, honoraria for consulting services and conference attendance support from Gilead Sciences. All other authors declare that they have no conflicts of interest. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

                Author information
                http://orcid.org/0000-0003-2045-1717
                http://orcid.org/0000-0001-7097-700X
                Article
                PONE-D-19-24632
                10.1371/journal.pone.0239513
                7514038
                32970730
                bb3b9113-f31f-4e22-ad1d-1919b5172aac
                © 2020 Iwuji et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 24 September 2019
                : 8 September 2020
                Page count
                Figures: 1, Tables: 0, Pages: 14
                Funding
                Funded by: funder-id http://dx.doi.org/10.13039/501100003323, Agence Nationale de Recherches sur le Sida et les Hépatites Virales;
                Award ID: ANRS 2011-375
                Award Recipient :
                Funded by: funder-id http://dx.doi.org/10.13039/501100003323, Agence Nationale de Recherches sur le Sida et les Hépatites Virales;
                Award ID: ANRS 2011-375
                Award Recipient :
                Funded by: funder-id http://dx.doi.org/10.13039/501100011099, Deutsche Gesellschaft für Internationale Zusammenarbeit;
                Award ID: GIZ 81151938
                Award Recipient :
                Funded by: funder-id http://dx.doi.org/10.13039/501100010275, Deutsche Gesellschaft für Muskelkranke;
                Award ID: GIZ 81151938
                Award Recipient :
                Funded by: International Initiative for Impact Evaluation Inc
                Award Recipient :
                Funded by: International Initiative for Impact Evaluation Inc
                Award Recipient :
                Funded by: Academy of Medical Sciences
                Award Recipient :
                Funded by: funder-id http://dx.doi.org/10.13039/100004440, Wellcome Trust;
                Award ID: 201433/Z/16/Z
                The French National Agency for Aids and Viral Hepatitis Research (ANRS) is the sponsor and co-funder of the trial; http://www.anrs.fr (ANRS 12249). The study received additional support from the Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH; https://www.giz.de/en/ html/index.html (81151938). The research was also co-funded by the International Initiative for Impact Evaluation, Inc. (3ie), a grantee of the Bill & Melinda Gates Foundation; http://www.3ieimpact.org. The trial is conducted with the support of Merck & Co. Inc and Gilead Sciences that provided the Atripla® drug supply. The Africa Health Research Institute receives core funding from the Wellcome Trust, https://wellcome.ac.uk/ which provides the platform for the population- and clinic based research at the Centre. The analysis addressed within this manuscript was funded by the Academy of Medical Sciences, Grand Challenges Research Fund Networking Grant; https://acmedsci.ac.uk, awarded to Deenan Pillay and Collins Iwuji in support of the HIV-Drug Resistance Elimination and Management (H-DREAM) Network. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
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