To the Editors:
In 2011, the landmark HIV Prevention Trials Network (HPTN) 052 trial found that early initiation of antiretroviral treatment (ART) in persons living with HIV (PLHIV) reduced viral transmission to uninfected partners by 96%.1 Treatment as prevention (TasP), whereby HIV transmission is prevented by consistent use of HIV treatment and durable viral suppression, has ushered in a new era in worldwide HIV prevention.2 The combined health benefits of averting new infections and preserving/improving health for PLHIV have translated into rapid scale-up in treatment access across the globe.3
Eight years after the publication of HPTN 052 results and 3 years after the launch of the Undetectable = Untransmittable (U = U) campaign,4 promotion of TasP has largely been adopted into global HIV discourse and policy. However, dissemination of information about TasP/U = U to communities in the most impacted areas of the world has been delayed, incomplete, or ineffective. For example, qualitative research we conducted in 2015 with rural South African men in Mpumalanga Province showed low awareness of the potential of treatment to reduce transmission to partners.5 Moreover, both PLHIV and those at risk of HIV believed this information would have played a significant role in their choices to get tested, initiate treatment, and disclose to their partners.5 The few other studies assessing TasP awareness in sub-Saharan Africa (SSA) have also found levels to be remarkably low.6,7
Health providers are the primary gateway for delivering HIV prevention and treatment information. However, virtually no research has assessed provider knowledge, attitudes, and counseling practices related to TasP/U = U. Therefore, we asked health providers about TasP during a 2018 assessment of 9 health facilities, conducted as part of a cluster-randomized trial underway in South Africa examining community mobilization around improving HIV care and treatment (NCT02197793).8 Interviews were designed to understand provider attitudes, beliefs, and counseling behaviors about the potential of ART to avert new infections.
Primary care facility assessments were undertaken in all 9 public health facilities located within the Agincourt health and socio-demographic surveillance system, a census area in northeast South Africa. We created rosters of all staff in each facility and then randomly selected a sample of 10 staff from each clinic, except for one that had only 9. Of 89 selected staff, 79 providers underwent structured interviews to understand practices related to HIV care provision, 3 failed to participate, and 7 did not provide care and were excluded from this analysis. To assess providers' understanding of TasP, we asked them to agree or disagree with the statement: “Individuals who adhere to ART and are virally suppressed have a very low chance of transmitting HIV to their sex partner during unprotected sex.” We also asked about the frequency (always, sometimes, or never) with which providers told their clients that onward transmission was unlikely if virally suppressed. Finally, we included separate questions about whether providers counsel PLHIV who are virally suppressed that they do not need to use condoms with partners who are HIV-positive, HIV-negative, and unknown status. Questions were pilot tested for clarity at 1 facility before use.
We compared provider characteristics and counseling practices by knowledge of TasP, assessing associations using the F statistic (converted from the χ2 statistic, corrected for survey design) for binary and categorical variables and linear regression for continuous variables. Analyses were clustered by facility and weighted based on sampling probability from the clinic roster. We also calculated the intraclass correlation of responses by clinic using an unadjusted random intercept model to determine to what extent variance was due to within- vs. between-clinic differences. We presented assessment results at study clinics approximately 6 months after the interviews to seek feedback and interpretation of findings.
Table 1 characterizes the 79 providers, most of whom (83%) were women. About half (48%) were professional nurses, followed by staff nurses (19%), home-based care (18%), and lay counselors (14%). On average, the providers had 8 years of professional experience and 5 years in their current clinic.
Providers demonstrated inconsistent knowledge and infrequent counseling on the benefits of TasP. Fewer than half (42%) of providers indicated an awareness of the benefits of TasP. Male providers, and providers who had been at their current clinic longer, were slightly more likely to know about TasP (P = 0.06 and P = 0.05, respectively). Among the providers who knew of TasP, only 61% said they always shared this information with their HIV-positive clients; 20% never shared TasP information with clients. The large majority of providers (78%–79%) reported counseling virally suppressed patients to always use condoms, regardless of their partner's status. Less than 10% of providers who knew about TasP and 31% of providers who did not reported telling virally suppressed clients that they did not need to use condoms with partner of any serostatus, indicating a lack of understanding of TasP among providers and that TasP knowledge had little impact on counseling behavior. The intraclass correlation for TasP knowledge/agreement was 0.076, indicating minimal clustering of responses by clinic.
During feedback meetings, 3 of 9 clinic operational managers (who are also providers) stated no knowledge of TasP; providers in 2 clinics disputed the idea of counseling on TasP because of concerns around reduced condom use.
Less than half of the providers we surveyed in rural South Africa in 2018 were knowledgeable about TasP, and even fewer understood the nuances of counseling around undetectable viral load and HIV transmission. Even those who agreed with TasP infrequently shared this information with patients. The findings indicate that Tasp/U = U messaging is not routinely reaching PLHIV and that providers themselves are not fully informed about the public health benefits of TasP. This is a small study with and collected from 9 clinics in a single rural area of Mpumlanga; as such, findings cannot be generalized to other facilities and areas of the country. However, this is also among the first inquiries into provider knowledge and counseling behavior around TasP in a high prevalence region where inroads with U = U messaging could have large implications.
There is little published research on providers' attitudes toward TasP or U = U in low- and middle-income countries to date. Work in SSA around safe conception in discordant couples has found that providers often have inadequate knowledge of discordance9 and/or may choose to withhold information about HIV transmission risks when virally suppressed due to concerns that clients would make poor choices if they had this information.9,10 Researchers have also reported that providers prioritize minimizing risk (eg, condoms-only prevention messaging) and have a high degree of discomfort providing information about ART use for safer conception to clients living with HIV.11,12 Similarly, research on pre-exposure prophylaxis in SSA has found that providers are far more comfortable with condom promotion and have concerns around increases in risk behavior associated with reduced perceptions of transmissibility.13,14 Our findings that providers rarely counsel patients about TasP may be attributed to similar concerns about behavioral disinhibition, with some providers stating as much during feedback discussions.
Although providers may have doubts about engaging with TasP messaging, there are numerous reasons why patients should be informed about the clinical and public health benefits of viral suppression. Most importantly, individuals have the right to understand and be able to make informed decisions about their health and treatment choices. In addition, research has indicated that knowledge about TasP could encourage people to seek HIV testing and adhere to treatment, particularly to prevent transmission to their partners.5 Understanding TasP can also address stigma, minimize fears about transmissibility to partners, and allow partners to have sexual relationships and achieve their fertility intentions free of the fear of onward transmission.15,16
Ensuring widespread, accurate messaging about TasP/U = U may require multiple steps. First, language around TasP/U = U needs to be incorporated into relevant policy documents and training programs for providers. Current policy, including the South African HIV service delivery guidelines,17 more recent directives on Test and Treat,18 and the National Strategic Plan,19 has no guidance for counseling around TasP; TasP is mentioned only as a component of combination prevention and again in the glossary.19 Without specific guidance, simple messaging, and training, providers may not be aware of TasP or, as found in our data, not share TasP information even when they are aware. Second, providers need additional training on the topics of serodiscordance, safer contraception, and behavioral disinhibition to deter sharing obsolete prevention messages. Third, it is critical that viral load monitoring be conducted regularly and that results are returned promptly to inform HIV clinical management, ensuring that patients on treatment are, in fact, suppressed. TasP counseling requires a nuanced understanding of transmission dynamics and consistent clinical monitoring,16 a challenge in settings such as South Africa with no linked national medical record system and high levels of labor migration. Finally, successful TasP/U = U messaging has often been led by civil society. Although a small number of South African non-governmental organizations have signed on to the U = U consensus statement,20 further advocacy and leadership in vocalizing patients' rights to TasP information and its potential for supporting HIV service uptake could help stimulate government and provider attention.
Informing patients and communities about TasP can ultimately help South Africa and other highly impacted countries meet their HIV treatment targets and get closer to ending the epidemic. Moving forward we recommend more in-depth monitoring of TasP/U = U counseling behaviors among providers, not only through validating this tool or others, but also through more detailed assessments of provider behaviors (eg, direct observation or standardized patients). It may take time for providers to internalize new, evidence-informed messaging around TasP, and this is unlikely to occur until national guidance and training programs provide direction and support to providers. Progress may also require civil society to champion this critical issue.
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