MEN’S PERCEPTIONS OF TREATMENT AS PREVENTION IN SOUTH AFRICA: IMPLICATIONS FOR ENGAGEMENT IN HIV CARE AND TREATMENT

MEN’S PERCEPTIONS OF TREATMENT AS PREVENTION IN SA 275 as prevention (TasP) among rural South African men. Narratives emphasized the known value of ART for individual health, but none were aware of its preventive effects. Many expressed that preventing transmission to partners would incentivize testing, earlier treatment, and adherence in the absence of symptoms, and could reduce the weight of a diagnosis. Doubts about TasP impacts on testing and care included enduring risks of stigma and transmission. TasP information should be integrated into clinic-based counseling for those utilizing services, and community-based education for broader reach. Pairing TasP information with alternative testing options may increase engagement among men reluctant to be seen at clinics. Early and consistent use of antiretroviral therapy (ART) by people living with HIV substantially minimizes transmission by reducing the viral load in blood and genital secretions (Cohen et al., 2011). Treatment as prevention (TasP) has significant potential to reduce the incidence of HIV in high-prevalence countries like South Africa (Cohen et al., 2011; Granich, Gilks, Dye, De Cock, & Williams, 2009; Padian et al., 2011), where observational research has found lower HIV incidence in communities with higher ART coverage (Tanser, Barnighausen, Grapsa, Zaidi, & Newell, 2013). Optimizing the HIV prevention benefits of ART requires a high level of engagement in HIV testing and care (Granich et al., 2009). This has not been achieved in South Africa; less than one third of people living with HIV are receiving treatment (Shisana et al., 2014), despite the country’s large ART program. Achieving high HIV service and treatment utilization has been particularly challenging among men, who access HIV testing and ART at a far lower rate than do women, and are less likely to be retained in care and to achieve viral suppression (Cornell, McIntyre, & Myer, 2011; Lippman et al., 2016). Given that treatment prevents transmission to HIV-negative partners, awareness of TasP may alter the meaning of an HIV diagnosis and influence testing and treatment choices. A recent randomized controlled trial (RCT) in Malawi involving TasP promotion found a 60% increase in testing in intervention communities (Derksen et al., 2015), suggesting that community education about TasP may have the potential to improve HIV service uptake. In September 2016, the South African Department of Health introduced universal HIV treatment access, which includes free ART through the public health system regardless of CD4 count. While access to ART is expanding, there are few mechanisms through which information about TasP is being disseminated. Current national HIV counseling and testing policy guidelines (Department of Health, Republic of South Africa, 2015) contain no mention of treatment as prevention, and instruct HIV service providers to counsel patients in “how to reduce the risk of HIV transmission (i.e. abstinence, correct and consistent use of condoms, starting treatment if pregnant, not sharing needles, etc.)” (p. 33). Community perceptions about TasP and effects on decision-making remain underexplored in South Africa. The literature on barriers to HIV testing and treatment emphasizes the impact of social and structural factors such as HIV-related stigma and fear of disclosure, lack of knowledge about treatment, and male gender norms that discourage men from engaging in care (Govindasamy, Ford, & Kranzer, 2012). The broad use of ART has reduced self-stigmatization through physical recovery and spaces for support that normalize the disease (Russell et al., 2016; Zuch & Lurie, 2012). However, the association drawn between HIV, promiscuity and infidelity, and the anticipation of gossip, rejection, and the loss of dignity if a person is revealed to be HIV-positive remain major barriers to HIV serv