Viral load monitoring motivates HIV treatment adherence in eSwatini
The Treat-All policy will only succeed if people keep taking their HIV treatment. It is important to motivate people who started treatment while they were still feeling well.
People on ART in eSwatini are motivated when they see evidence of their treatment effectiveness, and engage better in their HIV care.
In a longitudinal qualitative study, which comprised of several in-depth interviews with people living with HIV and healthcare workers, researchers sought to understand how people who start HIV treatment with no symptoms felt about their treatment-taking over time.
In the era of ‘Treat-all’ – where every person living with HIV starts ART soon after diagnosis and regardless of disease stage progression – getting people to keep taking their treatment remains a significant challenge. A range of individual, social, structural and environmental factors can influence engagement in the HIV treatment and care cascade.
Many of the people starting antiretroviral treatment under a Treat-All policy will not have any HIV symptoms and will generally feel well. In the past, people would have to wait until they were feeling sick to start treatment, which in turn acted as a powerful motivator for treatment adherence, as people saw the effectiveness of taking their treatment as their health improved. We do not yet know how well people will engage with their HIV care when they begin their treatment without any symptoms.
This analysis was drawn from in-depth interviews conducted with 17 people living with HIV, who started treatment when they were clinically asymptomatic, and who had been on treatment for at least 12 months (with an overall mean of 22 months of treatment). They were interviewed three times, to build trust and rapport with the interviewer but also to understand their experiences over time. Twenty healthcare workers were also interviewed once.
They found that it was very important for people living with HIV to be conscious of their need for treatment and to have evidence of its effectiveness to support care engagement. Even when people did not have clinical symptoms, re-interpreting past signs of illness as signs of HIV, or noticing positive physical changes such as increased energy, weight gain, or lack of headaches following ART initiation, supported treatment-taking in this group.
“Before I started taking the treatment, I would feel that my body is going down, like when you wake-up you’d find that the body is very tired most of the time. But then since I started the treatment, I feel much better and healthier, and my body is energetic.” (Mandla, man, 36 years)
But many people still felt doubtful about their need for treatment, as they did not have any signs of ill-health or symptoms. This was related to the fact that individuals felt that ART was making no difference to their lives, this could lead to treatment fatigue over time.
“I used to just get tired and I would sometimes skip some days and not go to collect them… there were times I just would be quiet and not take it, no because there is no food or something, I would just feel annoyed that why am I taking this treatment and what is it for?” (Khanyisile, woman, 24 years)
All those interviewed acknowledged the importance of seeing the difference that ART was making to their health over time, particularly those who did not have symptoms at the time of treatment initiation.
“I want them to tell me is there something that it is doing, is there a difference. Even no, I wasn’t them to tell me how my CD4 is doing, my CD4 was this much and now that I am continuing with the treatment, is it making any difference?” (Celiwe, woman, 40 years)
“[When told suppressed] it made me to feel free and to continue emphatically taking the treatment, because it means it is working.” (Vusi, man, 49 years)
Alarmingly, some participants had indicated that they themselves had experimented with their treatment to see if it was making a difference or not to their health, as proof of evidence for effectiveness.
Health workers also underlined the value of monitoring, and particularly viral load monitoring, as a tool to keep people adhering to their treatment.
“These patients are patients who came in healthy, they had no symptoms, so they are going to continue being healthy… they are not going to see what is better for them. So viral suppression is important… It would be good to have an initial baseline viral load and then you do monitoring following.”
Understanding patient motivations to keep taking their HIV treatment in the long term is critical as we roll-out ‘treat all’ across sub-Saharan Africa. Particular attention needs to be given to those who may not experience the transformational effects of HIV treatment. Those who start treatment while they are well, may need further motivation and increased access to point-of-care viral load monitoring across sub-Saharan Africa.