Sten Vermund, Ed.
Helen Struthers, Ed.
Publication Date
Publication Date: 
December 8, 2016

"Health communication can motivate people to get tested, get treated and stay on treatment for the rest of their lives. That's because health communication seeks to address frankly the complex behaviors that influence HIV-related decision-making in the context of HIV." - Sten Vermund

Effective health communication helps keep people in treatment throughout the HIV continuum of care, thus leading to more positive health outcomes. This is one common thread communicated in the 10 open-source articles that make up the January 2017 Supplement of the Journal of Acquired Immune Deficiency Syndromes (JAIDS). The Supplement is an extension of a July 2014 JAIDS edition (see Related Summaries, below), which provided evidence of health communication's positive impact on HIV prevention, care, and treatment. Both supplements were sponsored by the Health Communication Capacity Collaborative (HC3), a 5-year global communication project funded by the United States (US) Agency for International Development (USAID) through the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) and based at Johns Hopkins Center for Communication Programs (CCP).

According to USAID, health communication is a broad term that applies to the interaction between healthcare providers, policymakers, patients, and community members to facilitate an understanding about health risks, prevention methods and services. It is a critical element in HIV and AIDS testing, prevention, care, and treatment by, for example, being used to encourage behaviour change and affect HIV treatment outcomes. Effective health communication is also instrumental in reducing losses throughout the HIV continuum of care, an essential step in achieving the Joint United Nations Programme on HIV/AIDS (UNAIDS) 90-90-90 treatment targets. The HIV continuum of care begins with HIV testing, linking those who test positive to care, treatment initiation, and ongoing adherence and retention in care with the aim of achieving viral suppression.

In an effort to foster multidisciplinary dialogue, advance global knowledge, and provide guidance to the field, researchers representing multiple sectors, countries, and perspectives contributed their examples of how communication has improved HIV treatment outcomes to the Supplement. Real-world examples from low- and middle-income settings - Kenya, Lesotho, Mozambique, Senegal, South Africa, Tanzania, and Uganda - where health communication made a measureable difference in HIV treatment outcomes are included. In brief, articles in the Supplement are:

  1. Health Communication and the HIV Continuum of Care, by Sten H. Vermund, Elizabeth C. Mallalieu, Lynn M. Van Lith, and Helen E. Struthers. This introductory piece provides a foundation for understanding why health communication leads to successful outcomes along the HIV continuum of care.
  2. A Framework for Health Communication across the HIV Continuum of Care, by Stella Babaloa, Lynn M. Van Lith, Elizabeth C. Mallalieu, Zoe R. Packman, Emily Myers, Kim Siefert Ahanda, Emily Harris, Tilly Gurman, and Maria-Elena Figueroa. This manuscript introduces a conceptual framework to guide the development of effective health communication interventions and activities that aim to impact behaviours across the HIV treatment continuum in low- and medium-income countries. The framework includes HIV testing and counseling (HCT), linkage to care, and retention in pre-antiretroviral therapy (ART) and ART initiation. Behavioural determinants are presented at several levels of the social-ecological model: intrapersonal, interpersonal, health services, community, and policy. Highlighted are the most common health communication interventional approaches, including mHealth, interpersonal communication through service providers and peers, community support groups, and treatment supporters. The remaining articles share data on the communication agenda for different elements of the care cascade.
  3. Counseling Framework for HIV-Serodiscordant Couples on the Integrated Use of Antiretroviral Therapy and Pre-exposure Prophylaxis for HIV Prevention, by Jennifer F. Morton, Connie Celum, John Njoroge, Agnes Nakyanzi, Imeldah Wakhungu, Edna Tindimwebwa, Snaidah Ongachi, Eric Sedah, Emmanuel Okwero, Kenneth Ngure, Josephine Odoyo, Nulu Bulya, Jessica E. Haberer, Jared M. Baeten, and Renee Heffron. Within the Partners Demonstration Project, a prospective interventional project among 1,013 serodiscordant couples in Kenya and Uganda, ART was offered to eligible HIV-positive partners and Pre-exposure Prophylaxis (PrEP) to HIV-negative partners prior to ART initiation and through the HIV-positive partner's first 6 months of ART use. Individual and group discussions were conducted with counseling staff to elicit the health communication framework and key messages about ART and PrEP delivered to couples. The authors conclude that the counseling agenda was all-important for programmatic success in the treatment-as-prevention arena, even as infected persons are nurtured to reduce HIV pathogenesis with the use of ART.
  4. Effective Interpersonal Health Communication for Linkage After HIV Diagnosis in South Africa, by Tonderai Mabuto, Salome Charalambous, and Chris Hoffmann. This article describes how a strategy of interpersonal communication allows for precision health communication to influence behaviour regarding care engagement. The team analysed transcripts from 28 clients from a communication strategy arm of a randomised trial to accelerate care initiation in South Africa. The authors identified key themes of interpersonal communication between client and counselor specific to the client's background, including healthy pregnancy issues, potential barriers to entry into care, and partnering with the client to consider how to overcome challenges in accessing and continuing in care. The authors highlight how this alliance, reminiscent of the information-motivation-behavioural skills model, can increase receptiveness to messages by focusing on individual client concerns.
  5. Feasibility and Acceptability of Health Communication Interventions Within a Combination Intervention Strategy for Improving Linkage and Retention in HIV Care in Mozambique, by Roberta B. Sutton, Maria Lahuerta, Fatima Abacassamo, Laurence Ahoua, Maria Tomo, Matthew Lamb, and Batya Elul. The Engage4Health study assessed the effectiveness of a combination intervention strategy to increase linkage and retention among adults newly diagnosed with HIV in Mozambique. The study included 2 health communication interventions (a modified delivery approach for pre-ART counseling sessions and SMS (text message) reminders) and 3 structural interventions. The authors used a process evaluation framework to report the success of delivering pre-ART counseling and SMS reminder dissemination, with somewhat lower success in coverage with the structural intervention elements. Participants reported pre-ART counseling and CD4 testing as the most useful and noncash incentives as the least useful for linkage and retention.
  6. Using mHealth for HIV/TB Treatment Support in Lesotho: Enhancing Patient-Provider Communication in the START Study, by Yael Hirsch-Moverman, Amrita Daftary, Katharine A. Yuengling, Suzue Saito, Moeketsi Ntoane, Koen Frederix, Llang B. Maama, and Andrea A. Howard. The START study used real-time adherence support by means of SMS messaging and trained village health workers to maximise ART initiation and retention. The authors evaluated the use of mHealth tools from process data, including assessing acceptability via monthly follow-up interviews with all participants, and qualitative interviews with a subset of patients and health care providers. Over 28 months, the automated SMS system delivered 39,528 messages to 633 patients and 202 treatment supporters. Uptake was 92.1% among 713 eligible patients. The authors perceived this low-technology user-friendly mHealth intervention for HIV/tuberculosis (TB) treatment support to be highly acceptable to both patients and health care providers.
  7. Community Mobilization for HIV Testing Uptake: Results from a Community Randomized Trial of a Theory-Based Intervention in Rural South Africa, by Sheri Lippman, Torsten Neilands, Catherine MacPhail, Dean Peacock, Suzanne Maman, Dumisani Rebombo, Rhian Twine, Amanda Selin, Hannah Leslie, Kathleen Kahn, and Audrey Pettifor. HIV testing uptake in South Africa is below optimal levels. Community mobilisation (CM) may increase and sustain demand for HIV testing, however, little rigorous evidence exists regarding the effect of CM interventions on HIV testing and the mechanisms of action. The 22 communities were randomised into a theory-driven multifaceted 2-year CM intervention or into standard activities (control). Testing improved with time in all communities, and the intervention did not seem to matter. However, within the intervention communities and not the control communities, testing was more common among persons exposed to the CM intervention. These results illustrated the difficulty in diffusing impact within communities beyond the individuals actually exposed to the intervention.
  8. Potential Impact of Integrated Stigma Mitigation Interventions in Improving HIV/AIDS Service Delivery for Key Populations in Senegal, by Carrie Lyons, Sosthenes Ketende, Daouda Diouf, Fatou M. Drame, Benjamin Liestman, Karleen Coly, Cheikh Ndour, Gnilane Turpin, Souleymane Mboup, Karim Diop, Coumba Toure-Kane, Delivette Castor, Nafissatou Leye-Diouf, and Stefan Baral. Men who have sex with men (MSM) and female sex workers (FSW) are consistently shown to have a higher burden of HIV compared with other adults in Senegal. This study, HIV Prevention 2.0, evaluates the impact of the 3-tiered integrated stigma mitigation interventions (ISMIs) approach to optimising HIV service delivery for key populations in Senegal. Over 24 months, 758 FSW and 724 MSM participated in the baseline assessment. Among MSM, fear of seeking health services declined with time, though biased retention may have contributed to this. Similarly, this fear declined among FSW over time, though loss to follow-up again may have biased this finding, i.e., more willing persons persisting in the study. Most MSM (63.9% of 97) and FSW (82.5% of 143) reported that the intervention helped in mitigating stigma.
  9. Project Shikamana: Baseline Findings from a Community Empowerment-Based Combination HIV Prevention Trial Among Female Sex Workers in Iringa, Tanzania, by Deanna Kerrigan, Jessie Mbwambo, Samuel Likindikoki, Sarah Beckham, Ard Mwampashi, Catherine Shembilu, Andrea Mantsios, Anna Leddy, Wendy Davis, and Noya Galai. Community empowerment approaches have been found to be effective in corresponding to HIV among FSWs in South Asia and Latin America. To date, limited rigorous evaluations of these approaches have been conducted in sub-Saharan Africa. A phase II community randomised controlled trial (RCT) is being conducted in Tanzania to evaluate the effectiveness of a community-empowerment-based combination HIV prevention model among a stratified sample of HIV-infected and HIV-uninfected FSWs. A cohort of 496 FSW is being followed. Despite very high (40.9%) baseline HIV prevalence, only 30.5% of 203 HIV-infected women were previously aware of their HIV status, 21.2% were on ART, and only 14.8% were virally suppressed. Among the many factors predicting infection and/or coverage within the continuum of care, social cohesion was beneficial for viral suppression, suggesting a novel avenue for peer-based health communication among FSW themselves.
  10. Development of a National Campaign Addressing South African Men's Fears about HIV Counseling and Testing and Antiretroviral Treatment, by Neil Orr, Helen Hajiyiannis, Laura Myers, Mzamani Benjamin Makhubele, Tselisehang Matekane, Richard Delate, Lusanda Mahlasela, and Brenda Goldblatt. South African men are less likely to get tested for HIV than women and are more likely to commence ART at later stages of disease, default on treatment, and to die from AIDS compared with women. The purpose of this study was to conduct formative research into the ideational and behavioural factors that enable or create obstacles to men's uptake of HCT and ART. The study consulted men with a goal of developing a communication campaign aimed at improving the uptake of HIV testing and ART initiation among men. In their qualitative interviews, avoidance of both HIV testing and, if HIV infected, initiation of ART were strongly anchored in fear of compromised masculinity, the potential for rejection within their communities, and the stress of knowing that they had a stigmatising and potentially fatal infectious disease. The urgency to engage men as to the benefits of knowing one's status and life-saving qualities of ART will be anchored on better health communication strategies.

Sten H. Vermund, Elizabeth C. Mallalieu, Lynn M. Van Lith, and Helen E. Struthers write: "As evidenced in these articles, combinations of effective health communication with skill building and structural interventions are immensely promising lines for implementation science research and ultimate service delivery....This JAIDS supplement underscores the need for studies with coherent counterfactual comparisons to be published to move the health communication field forward toward greater impact and potential for scale-up."

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JAIDS Journal of Acquired Immune Deficiency Syndromes: 1 January 2017 - Volume 74 - Supplement 1 pp. S1–S73 doi: 10.1097/QAI.0000000000001211 - sent via email from HC3 to The Communication Initiative on December 9 2016; "Health Communication Leads to Better Outcomes for Those Receiving HIV Treatment", by Kim Martin, HC3, December 9 2016; USAID website, and "Health Communication and the HIV Continuum of Care", by Sten H. Vermund, Elizabeth C. Mallalieu, Lynn M. Van Lith, and Helen E. Struthers - all accessed on December 13 2016. Image caption/credit: "A woman reads the local language version of the Patient's Charter at a medical camp in Bushenyi, Uganda supported by the USAID-funded Advocacy for Better Health project." PATH