Antiretroviral-based approaches to HIV prevention have been shown to reduce new infections in both clinical trials and demonstration settings. To achieve optimal uptake of these strategies and anticipate barriers to effective rollout, it is critical to understand users’ perspectives on the use of antiretroviral treatment (ART) for prevention of HIV transmission. We explored serodiscordant couples’ understandings of and feelings about treatment as prevention (TasP) using qualitative data from the Partners Demonstration Project (PDP).
The PDP employed an integrated delivery strategy of daily oral pre-exposure prophylaxis (PrEP) and ART for serodiscordant couples in Kenya and Uganda. PrEP use was time-limited and discontinued after HIV-infected partners had been on ART for 6 months. Multiple in-depth interviews were conducted with a subset of 48 couples from the Kampala, Uganda site (N interviews=189). Interview topics included: (a) purpose and meanings of PrEP and ART; (b) adherence; (c) experiences of PrEP discontinuation; and (d) understandings of TasP. Interviews were inductively analyzed to identify themes representing couples’ understandings of and feelings about using ART for prevention of HIV transmission. Categories were developed to represent the themes.
Serodiscordant couples generally understood that ART prevents HIV transmission to uninfected partners. However, some individuals doubted that ART alone was ‘enough’ to protect against HIV acquisition. Lack of confidence in ART for prevention took the following forms: (1) Concerns about the effectiveness of ART for prevention in the absence of other methods of protection (i.e., PrEP, condoms); (2) Misunderstandings about how viral suppression and sustained ART use lead to a reduction in infectiousness and HIV risk; (3) Uncertainty about partners’ adherence to ART stemming from distrust in the relationship; and (4) A preference for multiple methods of protection used simultaneously.
Our findings suggest a lack of confidence in TasP among serodiscordant couples arising from unfamiliarity with new biomedical prevention strategies and reluctance to rely on partners for HIV prevention. Improved messaging about how ART works to achieve viral suppression and reduce transmission, along with supportive counseling, may address underlying concerns about HIV risk, helping to alleviate fears and increase trust in ART to prevent HIV.