This month, SALDRU researcher Brendan Maughan-Brown completed the development of a video-based intervention titled From Now On, which aims to encourage South African men living with HIV to start, and to stay on, HIV treatment. The 4-minute video weaves together the stories of three men from Cape Town communities as they share how they were able to carry on with their lives and achieve personal goals after HIV diagnosis. From Now On addresses psychosocial barriers and uses affect-based messaging to promote HIV treatment uptake and adherence.
The intervention is motivated by a recognition that merely providing information about the benefits of treatment isn’t enough to promote linkage to care – many men delay starting HIV treatment despite knowing it is effective in slowing disease progression and reducing transmission risk. Research shows that affective factors – the emotions and feelings experienced by individuals – have a strong influence on decision-making. This intervention applies concepts from behavioural economics to create a context in which men’s HIV-treatment decisions are made with greater hope and positivity about the future. From Now On was designed to address fears experienced at the time of HIV diagnosis, and to counter the negative associations people make with HIV treatment.
From Now On was created in collaboration with a multidisciplinary team including Dr Alison Buttenheim, Dr Harsha Thirumurthy and Laura Schmucker (University of Pennsylvania; Indlela: Behavioural Insights for Better Health), and Dr Abigail Harrison and Dr Mark Lurie (Brown University). It was produced by Reel Epics Productions, an award-winning production company based in Cape Town.
From Now On is designed to be viewed by men who have recently received an HIV-positive test result, and to be delivered to mobile devices to reinforce messaging.
Origins and design
The idea for the video emerged during formative research on factors influencing HIV treatment uptake among individuals living with HIV in Cape Town. Findings showed that learning about people living healthy, normal lives while they were on HIV treatment was a powerful motivator for starting treatment, but that this awareness was typically gained by chance, if at all. Researchers also learned that what motivated many men was the positive association they made between treatment and the achievement of special aspirations (e.g., being there for, and with, children; having a family; acquiring or keeping a partner). But it was negative associations with treatment – the way it flagged illness, for example, and the risk it carried of involuntary HIV-status disclosure – that were being made much more readily. Our results aligned with several other studies conducted around the same time, underscoring the need for novel interventions to address these treatment barriers.
From Now On provides men who receive an HIV-positive test result with examples of other men living healthy, ‘normal’ lives on treatment, and creates strong positive associations between treatment and the achievement of life goals and aspirations via emotive images, such as of men with their families. The video narratives also provide a means to counter some of the psychosocial barriers to treatment that our formative research identified at the time of diagnosis, including internalised stigma, fears about treatment side-effects, and an array of fears around loss: loss of normalcy, loss of status, loss of relationships with friends, and loss of loved ones.
The intervention draws on two concepts from behavioural economics to encourage treatment uptake. The ‘affect heuristic’ is a mental shortcut in which emotions influence our judgements: if people’s feelings about something are positive, then people are more likely to judge the risks as low and the benefits high. By shifting associations with HIV treatment from fear and dread, to ones of hope and optimism, From Now On aims to increase the perceived benefits and reduce the perceived risks of HIV treatment. The ‘availability heuristic’ is a mental shortcut that relies on immediate examples that come to mind when evaluating something – the easier something is to recall, the more important and common it is perceived to be. By using striking images of many healthy men on treatment, From Now On aims to provide examples of men on treatment that can be readily recalled when decisions about treatment are made.
Technical aspects of the film (slow paced, soft lighting, gentle transitions between scenes) were designed to ensure From Now On is sensitive to the anticipated emotions of a viewer who has just received an HIV-positive diagnosis. Key messages are provided using visual images: in the immediate aftermath of diagnosis some men will have limited capacity to take in new information.
The careful selection of men to feature in the film – whom we refer to as ‘collaborators’ on the strength of their active involvement in the filming process – was key to the success of the intervention. It was also a challenge as there were several factors that needed to align. Collaborators had to be living openly with HIV and comfortable that their stories could be viewed by anyone. They needed to be likeable and relatable to a wide range of viewers – so we needed diversity in factors such as age and employment. Their stories had to vary, so different viewers could identify with different experiences: one viewer might fear treatment side-effects, while another might be in denial of his HIV status. On top of this, collaborators had to be able to act naturally in front of a camera – which sounds easy until the clapper board snaps shut and the Director says: “Take 1.”
Collaborators were selected in a five-step process. We first advertised information sessions via social media, HIV treatment support groups, organisations providing HIV services, and known networks of people living with HIV. Individuals who attended the information sessions were invited to submit an expression of interest – a short self-filmed video clip of them explaining why they wanted to take part. Individuals without access to a smart phone were filmed by the project team. The project team then conducted a screen test with each individual by having them introduce themselves to camera for 30 seconds. This was used to identify individuals who had good camera presence. The penultimate step, and arguably the most important one, was to run focus group discussions with men in different communities in Cape Town to collect impressions and judgements on the 10 shortlisted candidates.
We based the focus groups on ‘thin-slicing’, a term used in psychology to describe the ability to make a strong judgement, and often accurate assessment, of a person from observing just a few seconds – a ‘thin slice’ – of their behaviour (this is what speed-dating is all about). From Now On is short, so first impressions need to be good ones. During the focus group discussions participants were shown the 30-second screen test videos and then scored the candidate on a range of characteristics, such as likeability, relatability, trustworthiness, sincerity, credibility, and healthy appearance. Participants then had an open discussion about the candidates. Finally, the project team selected three main collaborators, and three secondary characters (who either appeared briefly in the film or who were back-ups for the main collaborators).
A participatory approach was used in the film production. While a story-board was established to outline the broad sweep of the story, the film was shaped around collaborators’ own stories and how they wanted these to be told. Collaborators gave input into aspects such as what supplemental (B-roll) footage to use, what the scene should look like, and where filming should be conducted.
To help ensure that From Now On is impactful, as well as acceptable to implementers and recipients of the intervention, the film development process included two rounds of detailed feedback on rough-cut versions of the film. HIV counsellors from organisations delivering HIV services in different settings (clinic-based, or mobile clinics in communities) provided feedback: initially through focus group discussions, and then through telephonic interviews when COVID-19 prevented gatherings (participants viewed the video prior to the discussion). In-depth interviews were conducted with men living with HIV who had recently (within the previous 6 weeks) received an HIV-positive test result. We also collected feedback from collaborators in the film, from a film expert, from members of four organisations providing HIV services, and from 20 researchers.
The project had to make several adjustments, and was delayed by about a year, due to COVID-19. Some of the adjustments were predictable, but others caught us by surprise. In one instance (which turned into a memorably comedic moment) we realised that what was out of kilter was the collaborator’s hair: he was almost bald before COVID-19, but had a solid growth by the time filming restarted. In the end, we had to refilm all of his scenes.
Rollout and evaluation
We are now rolling out use of the video. If you are interested in using From Now On within your organisation or partnering with our team on an evaluation, please reach out to Brendan.firstname.lastname@example.org.