WORLD AIDS DAY | HIV prevention strategies must evolve as ARVs change the perception of risk

Worry about becoming infected with HIV has slipped down young women’s “priority list” as they navigate life, family, children and education.

This is because the availability of antiretrovirals to prevent and control infection means HIV is perceived as a condition that can be controlled and concealed, HIV experts told a webinar on the eve of World Aids Day hosted by the Genital Inflammation Test (Gift) team at the University of Cape Town (UCT).

For this reason, warnings about HIV risks no longer work, they said. Instead, messaging should emphasise the rewards of remaining HIV-negative and healthcare professionals should deliver services more holistically, paying attention to women’s evolving needs and circumstances.

“Pregnancy is a risk that cannot be hidden and can cause big disruption to women’s life trajectory,” said Prof Constance Mackworth-Young from the London School of Hygiene and Tropical Medicine, who leads social science research at The Health Research Unit Zimbabwe (ThruZim).

“In contrast, despite continued stigma, HIV is often viewed as something that can be hidden and controlled through taking pills.”

Prof Nelly Mugo of the Kenya Medical Research Institute said research she conducted with Prof Elizabeth Bukusi found young women at high risk of contracting HIV often have a low perception of that risk, prioritising short-term rewards and assuming they are invulnerable.

“There’s a perception that the consequences of HIV are no longer dire,” Mugo said at the webinar, which focused on understanding women’s awareness of HIV risks and ways to stay safe that are practical for women in their daily lives.

While the HIV risk might be seen as low, about 5,000 women between the ages of 15 and 24 were infected weekly in eastern and southern Africa in 2022, said Prof Sinead Delany-Moretlwe, director of research at the Wits Reproductive Health Institute.

“And the reasons for the higher prevalence of HIV in women have to do with a lack of decision-making power about sexual relations, contraceptive use and access to health care, which really limits people’s ability to protect themselves,” she said.

“HIV continues to be a threat to health for young women and it’s important that we continue to recognise that HIV is unfinished business.”

The webinar was the first of a series planned by the Gift team, which recently conducted clinical studies of a new device designed to screen for vaginal inflammation that puts them at risk for HIV infections, to give women key information about their own risk, and ultimately to improve women’s sexual and reproductive health.

The device, a lateral flow test similar to a pregnancy test, detects vaginal inflammation – often caused by sexually transmitted infections (STIs) and bacterial vaginosis. These conditions are typically treatable with antibiotics, but because most women don’t have symptoms, they are often undiagnosed and untreated. That’s where Gift’s developers believe the test could transform the landscape.

In the clinical studies the device has been tried by nearly 700 women in South Africa, Zimbabwe and Madagascar this year. But Gift team member and webinar facilitator Dr Ramla Tanko from UCT said diagnostic and therapeutic innovations are only part of the solution for reduced HIV risk.

“We need to understand the concerns of women and their challenges to design better intervention strategies,” she said.

Mackworth-Young said “incredible public health efforts and successes” mean HIV is often seen as a condition for which effective treatment is readily available.

“A historically singular and successful focus on HIV has meant antiretroviral therapy and increasingly pre-exposure prophylaxis (PrEP) are accessible at public health facilities,” she said.

The risk perception is therefore lower, and “this is the irony of success in terms of HIV”.

In Zimbabwe, Mackworth-Young said her team had seen an encouraging outcome when it aligned its approach to women’s own priorities, rather than simply telling them about the importance of HIV prevention. Her team at ThruZim recently completed the Chiedza  cluster-randomised trial that offered 12 communities in Zimbabwe an integrated package of sexual and reproductive health services, including HIV and STI testing and treatment, menstrual hygiene products and care, condoms and family planning.

“We found providing free menstrual hygiene products in a context where they are prohibitively expensive to buy was a real draw for young women to attend,” she said.

“It drew them in, and while they were there they would take up other sexual and reproductive health services.

“The key message is about really understanding women’s risks and priorities first, designing programmes and services that address those needs, and only then seeing how they can be integrated or aligned with public health priorities.”

Mugo said her findings in Kenya were similar.

“Young people tend to be biased towards immediate concerns. ‘I need to hustle. I haven’t made any money today. I need to fetch water.’ That’s what we heard. Rarely do young people think about being at risk.

“One young woman told us: ‘ Now people with HIV are much better than us. They’re taken care of in lots of places, they’re the most important people and the pills for treatment are available. It’s not easy for you to just die like that any more. I would not have a problem if I get infected.”

Mugo said since “risk-framing” no longer worked, “gain-framing” is more likely to succeed.

“Very often we’ve sold the fear that you will get HIV, rather than [the message that] protection from HIV will give you a better life and a future,” she said.

Delany-Moretlwe said the uptake of PrEP, with more than a million South Africans initiated on a daily pill, showed a strong appetite for this form of HIV prevention.

“But many people who express huge enthusiasm for taking an oral pill daily struggle with that practice in reality,” she said.

“About two out of five people will likely stop their PrEP within the first six months of starting. And this challenge is probably greater for younger people.”

Risk is also a factor here, she said.

“People self-perceive their risk to be low. Many people articulate concerns about [drug] side-effects particularly. Just taking a pill a day is difficult to remember. And when young people move from home to school or a new job, often that means that their access might be limited.”

Researchers had also uncovered interpersonal factors that undermined PrEP adherence.

“Often, families are suspicious. ‘Why is this person taking these pills? Do they have HIV?’ And the stigma associated with HIV is still prevalent enough that many people don’t feel comfortable to take their pills in public.

“For young women there are also concerns that come with conversations with partners who might think they are trying to protect themselves from other partners. With the high levels of gender-based violence in our region, this is a big concern and may prompt people to stop taking their pills.

“Then there are the social and structural factors which are about cost and access to healthcare. And it’s striking that many of these factors that influence PrEP continuation also influence HIV risk, particularly in young people.”

Mackworth-Young emphasised the importance of involving men in their partners’ sexual health rather than placing all the responsibility on women.

“The biggest way men can support women’s health is for men to go to health services, and that’s something we see as a challenge again and again,” she said.

“We’ve tried offering boxer shorts or haircuts at health services and that has had some impact. But I’d like to go further and meet the need that young men face, which is economic income generation. What can we do to provide something around that which links to health services and will support men to access health services?”

Delany-Moretlwe said she was encouraged by efforts to develop new ways to deliver PrEP.

“We have seen approvals for the vaginal ring and for an eight-weekly injectable PrEP. And there are a number of other studies to evaluate a monthly pill, a six-monthly injection,” she said.

“There is a real desire to increase the range of options that are available because we recognise that oral pills are not feasible for everyone. If we have that expanded choice, we really have an opportunity to change the trajectory of the HIV epidemic.”

* Dave Chambers is a writer for research and communications company Jive Media Africa