SALDRU project to improve HIV treatment outcomes in South Africa

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In November 2019, a SALDRU-led research team began a project to develop and test a gender-tailored counselling tool to increase demand for rapid HIV treatment uptake and early retention in care among South African men living with HIV. Titled ‘From Now On’, the intervention is a short, powerfully emotive video designed to mitigate men’s psychosocial barriers to treatment initiation and motivate initiation by applying behavioural economics insights to maximise the impact of affect-based messaging. Funded by the Bill and Melinda Gates Foundation, the intervention will be developed in collaboration with Reel Epics Productions, an award-winning South African production company. The project is led by SALDRU’s Dr Brendan Maughan-Brown, and is a collaboration between the University of Cape Town, the University of Pennsylvania and Brown University.

In 2018, an estimated 71,000 people living with HIV (all ages) in South Africa died from AIDS-related illnesses and 240,000 people in the country were newly infected with HIV. Universal access to early antiretroviral therapy (ART) for HIV is central to the global initiative to end AIDS by 2030. ART reduces AIDS-related morbidity and mortality, and treatment-induced viral suppression nearly eliminates HIV transmission between sexual partners.

However, high rates of AIDS-related mortality and HIV incidence in Southern Africa persist due to delayed treatment uptake. The largest gaps in ART coverage are found among men – in 2018, only 56% of adult men living with HIV in South African were on treatment.

Brendan’s previous research has detailed the reasons behind the poor rates of linkage to care following ART-referral in Cape Town. Study results show that several psychosocial factors – including internalised stigma, HIV-status denial, and fear of side effects – are evident immediately after HIV-diagnosis and act as significant barriers to treatment uptake. Compounded by other concerns, such as being seen at clinics, individuals often make decisions about HIV treatment in a context characterised by fear and negative emotions toward themselves. As traditional counselling aspires to motivate treatment initiation by appealing to cognitive factors, this new research seeks to deliver a novel intervention that complements the traditional approach by targeting the affective barriers to care.

The ‘From Now On’ video combines authentic stories of men on ART in local Cape Town communities. These men tell stories of their lives from the moment of HIV-diagnosis to the present time. The video design is informed by insights from behavioural economics and psychology about the role of affect in decision making, specifically that affect has a strong effect on intentions and behaviour. Its potential is also underscored by prior evidence that video-based narratives are effective in increasing health-related knowledge, increasing HIV testing uptake, and improving ART uptake among people living with HIV in the United States. Intervention messaging is informed by prior research on two key motivators for ART initiation: knowledge of other people living healthy, normal lives on ART; and an association between ART and aspirations (e.g., being there for, and with, children).

The aim of ‘From Now On’ is to provide men living with HIV with a reference for what their lives could look like going forward, and create a context in which treatment decisions are made with greater hope and positivity toward ART and the future.

The video intervention will be delivered by counsellors to men who are diagnosed as HIV-positive, and will then be available for replay on their phone or other electronic devices.

‘From Now On’ will start filming in Cape Town in January, 2020. Feasibility and acceptability will be tested among newly-diagnosed men at a clinic-based setting in Cape Town through a pilot randomised controlled trial, and through in-depth interviews with study participants and health care providers. The pilot study aims to collecte data to inform a large randomised controlled trial to test intervention efficacy, and is currently planned for September, 2020.