"We are in this together:" dyadic-level influence and decision-making among HIV serodiscordant couples in Tanzania receiving access to PrEP.

BACKGROUND: A substantial number of new HIV infections in sub-Saharan Africa occur within stable couples. Biomedical prevention (pre-exposure prophylaxis, PrEP) and treatment (antiretroviral therapy, ART) can provide benefits to sexual partners and can be used to prevent infection within HIV serodiscordant couples. However, research is typically focused on individuals, not dyads, even when the intervention may directly or indirectly impact sexual partners. Gaps remain in understanding best practices for recruitment, informed consent, and intervention implementation in studies involving HIV prevention and treatment among heterosexual serodiscordant couples. This qualitative study was undertaken to understand and describe decision-making and dyadic-level influence among members of serodiscordant couples regarding (1) participation in a dyadic-based research study involving HIV self-testing and access to PrEP, and (2) utilization of PrEP and ART. METHODS: This qualitative study was nested within an observational cohort study assessing the acceptability of home-based couples' HIV self-testing and uptake of dyadic care for serodiscordant couples involving facilitated referral for HIV-positive partners and access to PrEP for HIV-negative partners. Semi-structured in-depth interviews were conducted among a subset of study participants (n = 22) as well as individuals involved in serodiscordant relationships who chose not to participate (n = 9). Interviews focused on couples' decision-making regarding study participation and dyadic-level influence on medication use. Interviews were transcribed verbatim and translated from Kiswahili into English. Data were analyzed using thematic analysis. RESULTS: Three major themes were identified: (1) HIV as "two people's secret" and the elevated role of partner support in serodiscordant relationships; (2) the intersectional role of HIV-status and gender on decision-making; (3) the relational benefits of PrEP, including psychosocial benefits for the couple that extend beyond prevention. CONCLUSIONS: The study found that couples made joint decisions regarding study participation and uptake of HIV-related medication. Relational autonomy and dyadic-level influence should be considered within research and programs involving HIV serodiscordant couples.

NIMH Project Accept (HPTN 043): results from in-depth interviews with a longitudinal cohort of community members.

INTRODUCTION: NIMH Project Accept (HPTN 043) is a community- randomized trial to test the safety and efficacy of a community-level intervention designed to increase testing and lower HIV incidence in Tanzania, Zimbabwe, South Africa and Thailand. The evaluation design included a longitudinal study with community members to assess attitudinal and behavioral changes in study outcomes including HIV testing norms, HIV-related discussions, and HIV-related stigma. METHODS: A cohort of 657 individuals across all sites was selected to participate in a qualitative study that involved 4 interviews during the study period. Baseline and 30-month data were summarized according to each outcome, and a qualitative assessment of changes was made at the community level over time. RESULTS: Members from intervention communities described fewer barriers and greater motivation for testing than those from comparison communities. HIV-related discussions in intervention communities were more grounded in personal testing experiences. A change in HIV-related stigma over time was most pronounced in Tanzania and Zimbabwe. Participants in the intervention communities from these two sites attributed community-level changes in attitudes to project specific activities. DISCUSSION: The Project Accept intervention was associated with more favorable social norms regarding HIV testing, more personal content in HIV discussions in all study sites, and qualitative changes in HIV-related stigma in two of five sites.

"I pray that they accept me without scolding:" experiences with disengagement and re-engagement in HIV care and treatment services in Tanzania.

HIV care and treatment programs in sub-Saharan Africa have been remarkably successful, but disengagement from care by people living with HIV (PLHIV) remains high. The goal of this study was to explore the experiences of PLHIV who disengaged from HIV care in Iringa, Tanzania. We conducted a series of three longitudinal, semi-structured interviews with 14 PLHIV who had disengaged from ART programs for a total of 37 interviews. Narrative analysis was used to identify key themes. Our findings indicate that an individual's decision to disengage from care often resulted from harsh and disrespectful treatment from providers following missed appointments. Once disengaged, participants reported a strong desire to re-engage in care but also reluctance to return due to fear of further mistreatment. Participants who successfully re-engaged in care during the course of this study leveraged social support networks to facilitate this process, but often felt guilt and shame for breaking clinic rules and believed themselves to be at fault for disengagement. Developing strategies to minimize disengagement and facilitate re-engagement through more flexible attendance policies, improved client-provider interactions, and outreach and support for disengaged clients could increase retention and re-engagement in HIV care and treatment programs.

Using participatory mapping to inform a community-randomized trial of HIV counseling and testing.

Participatory mapping and transect walks were used to inform the research and intervention design and to begin building community relations in preparation for Project Accept, a community-randomized trial sponsored by the U.S. National Institute of Mental Health (NIMH). NIMH Project Accept is being conducted in five sites within four countries including Thailand, Zimbabwe, South Africa and Tanzania. Results from the mapping exercises informed decisions about the research design such as defining community boundaries, and identifying appropriate criteria for matching community pairs for the trial. The mapping also informed intervention related decisions such as where to situate the services. The participatory methods enabled each site to develop an understanding of the communities that could not have been derived from existing data or data collected through standard data collection techniques. Furthermore, the methods lay the foundation for collaborative community research partnerships.

A comparison of HIV stigma and discrimination in five international sites: the influence of care and treatment resources in high prevalence settings.

What accounts for differences in HIV stigma across different high prevalence settings? This study was designed to examine HIV stigma and discrimination in five high prevalence settings. Qualitative data were collected as part of the U.S. National Institute of Mental Health (NIMH) Project Accept, a multi-site community randomized trial of community-based HIV voluntary counseling and testing. In-depth interviews were conducted with 655 participants in five sites, four in Sub-Saharan Africa and one in Southeast Asia. Interviews were conducted in the local languages by trained research staff. Data were audiotaped, transcribed, translated, coded and computerized for thematic data analysis. Participants described the stigmatizing attitudes and behaviors perpetuated against people living with HIV/AIDS (PLWHA). The factors that contribute to HIV stigma and discrimination include fear of transmission, fear of suffering and death, and the burden of caring for PLWHA. The family, access to antiretrovirals and other resources, and self-protective behaviors of PLWHA protected against HIV stigma and discrimination. Variation in the availability of health and socioeconomic resources designed to mitigate the impact of HIV/AIDS helps explain differences in HIV stigma and discrimination across the settings. Increasing access to treatment and care resources may function to lower HIV stigma, however, providing services is not enough. We need effective strategies to reduce HIV stigma as treatment and care resources are scaled up in the settings that are most heavily impacted by the HIV epidemic.