Browsing by Author "Pisarski, Emily E."

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    Beyond HIV prevention: everyday life priorities and demand for PrEP among Ugandan HIV serodiscordant couples
    (Journal of the International AIDS Society, 2019) Nakku-Joloba, Edith; Pisarski, Emily E.; Wyatt, Monique A.; Muwonge, Timothy R.; Asiimwe, Stephen; Celum, Connie L.; Baeten, Jared M.; Katabira, Elly T.; Ware, Norma C.
    Pre-exposure prophylaxis (PrEP) to prevent HIV infection is being rolled out in Africa. The uptake of PrEP to date has varied across populations and locations. We seek to understand the drivers of demand for PrEP through analysis of qualitative data collected in conjunction with a PrEP demonstration project involving East African HIV serodiscordant couples. Our goal was to inform demand creation by understanding what PrEP means – beyond HIV prevention – for the lives of users. Methods: The Partners Demonstration Project evaluated an integrated strategy of PrEP and antiretroviral therapy (ART) delivery in which time-limited PrEP served as a “bridge” to long-term ART. Uninfected partners in HIV serodiscordant couples were offered PrEP at baseline and encouraged to discontinue once infected partners had taken ART for six months. We conducted 274 open-ended interviews with 93 couples at two Ugandan research sites. Interviews took place one month after enrolment and at later points in the follow-up period. Topics included are as follows: (1) discovery of serodiscordance; (2) decisions to accept/decline PrEP and/or ART; (3) PrEP and ART initiation; (4) experiences of using PrEP and ART; (5) PrEP discontinuation; (6) impact of PrEP and ART on the partnered relationship. Interviews were audio-recorded and transcribed. We used an inductive, content analytic approach to characterize meanings of PrEP stemming from its effectiveness for HIV prevention. Relevant content was represented as descriptive categories. Results: Discovery of HIV serodiscordance resulted in fear of HIV transmission for couples, which led to loss of sexual intimacy in committed relationships, and to abandonment of plans for children. As a result, partners became alienated from each other. PrEP countered the threat to the relationship by reducing fear and reinstating hopes of having children together. Condom use worked against the re-establishment of intimacy and closeness. By increasing couples’ sense of protection against HIV infection and raising the prospect of a return to “live sex” (sex without condoms), PrEP was perceived by couples as solving the problem of serodiscordance and preserving committed relationships. Conclusions: The most effective demand creation strategies for PrEP may be those that address the everyday life priorities of potential users in addition to HIV prevention.
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    Integrated delivery of antiretroviral treatment and pre-exposure prophylaxis to HIV-1 serodiscordant couples in East Africa: a qualitative evaluation study in Uganda
    (Journal of the International AIDS Society, 2018) Ware, Norma C.; Pisarski, Emily E.; Nakku-Joloba, Edith; Wyatt, Monique A.; Muwonge, Timothy R.; Turyameeba, Bosco; Asiimwe, Stephen B.; Heffron, Renee A.; Baeten, Jared M.; Celum, Connie L.; Katabira, Elly T.
    Serodiscordant couples are a priority population for delivery of new HIV prevention interventions in Africa. An integrated strategy of delivering time-limited, oral pre-exposure prophylaxis (PrEP) to uninfected partners in serodiscordant couples as a bridge to long-term antiretroviral treatment (ART) for infected partners has been implemented in East Africa, nearly eliminating new infections. We conducted a qualitative evaluation of the integrated strategy in Uganda, to better understand its success. Methods: Data collection consisted of 274 in-depth interviews with 93 participating couples, and 55 observations of clinical encounters between couples and healthcare providers. An inductive content analytic approach aimed at understanding and interpreting couples’ experiences of the integrated strategy was used to examine the data. Analysis sought to characterize: (1) key aspects of services provided; (2) what the services meant to recipients; and (3) how couples managed the integrated strategy. Themes were identified in each domain, and represented as descriptive categories. Categories were grouped inductively into more general propositions based on shared content. Propositions were linked and interpreted to explain “why the integrated strategy worked.” Results: Couples found “couples-focused” services provided through the integrated strategy strengthened partnered relationships threatened by the discovery of serodiscordance. They saw in services hope for “getting help” to stay together, turned joint visits to clinic into opportunities for mutual support, and experienced counselling as bringing them closer together. Couples adopted a “couples orientation” to the integrated strategy, considering the health of partners as they made decisions about initiating ART or accepting PrEP, and devising joint approaches to adherence. A couples orientation to services, grounded in strengthened partnerships, may have translated to greater success in using antiretrovirals to prevent HIV transmission. Conclusions: Various strategies for delivering antiretrovirals for HIV prevention are being evaluated. Understanding how and why these strategies work will improve evaluation processes and strengthen implementation platforms. We highlight the role of service organization in shaping couples’ experiences of and responses to ART and PrEP in the context of the integrated strategy. Organizing services to promote positive care experiences will strengthen delivery and contribute to positive outcomes as antiretrovirals for prevention are rolled out.
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    PrEP Discontinuation and Prevention-Effective Adherence: Experiences of PrEP Users in Ugandan HIV Serodiscordant Couples
    (Journal of acquired immune deficiency syndromes, 2019) Gilbert, Hannah N.; Wyatt, Monique A.; Pisarski, Emily E.; Muwonge, Timothy R.; Heffron, Renee; Katabira, Elly T.; Celum, Connie L.; Baeten, Jared M.; Haberer, Jessica E.; Ware, Norma C.
    Optimal adherence to oral pre-exposure prophylaxis (PrEP) for HIV prevention involves aligning consistent PrEP use with periods of risk to achieve prevention-effective adherence. Prevention-effective adherence is predicated on individuals discontinuing PrEP during periods without expected risk. For stable, serodiscordant couples, ART adherence by the HIV-positive partner markedly decreases HIV transmission risk, potentially obviating the need for continued PrEP use; yet little is known about actual lived experiences of discontinuing PrEP. Methods: In-depth qualitative interviews were carried out with HIV-uninfected PrEP users in serodiscordant couples taking part in the Partners Demonstration Project at IDI-Kasangati, Kampala, Uganda. Open-ended interviews elicited information on the partnered relationship; understandings of PrEP; prevention strategies; and experiences of PrEP discontinuation. An inductive, thematic, content-analytic approach was used to analyze study data. Results: Uninfected partners experienced PrEP as a valued resource for preventing HIV acquisition. Despite ongoing ART use by HIV-positive partners for a period of time consistent with viral suppression, discontinuation of PrEP was experienced as a loss of protection and a corresponding increase in risk of HIV acquisition. Uninfected partners responded with strategies aimed at offsetting this subjective sense of increased risk, specifically: (1) changing sexual practices; (2) prioritizing fidelity in the relationship; (3) increasing reliance on condoms; and (4) seeking evidence of partners’ ART adherence. Conclusions: These experiences highlight the challenges PrEP users in serodiscordant couples face in discontinuing PrEP for prevention-effective adherence. Flexible interventions that support individuals during this transition may increase comfort with discontinuing PrEP when alternative prevention strategies provide protection, such as a partner’s consistent adherence to ART.
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    Understanding PrEP Acceptability Among Priority Populations: Results from a Qualitative Study of Potential Users in Central Uganda
    (AIDS and Behavior, 2022) Sundararajan, Radhika; Wyatt, Monique A.; Muwonge, Timothy R.; Pisarski, Emily E.; Mujugira, Andrew; Haberer, Jessica E.; Ware, Norma C.
    Daily oral pre-exposure prophylaxis (PrEP) can safely and effectively prevent HIV acquisition in HIV-negative individuals. However, uptake of PrEP has been suboptimal in sub-Saharan Africa. The goal of this qualitative study was to identify facilitators of and barriers to PrEP acceptability among target users not taking PrEP. Fifty-nine individuals belonging to Ugandan priority populations participated in a single in-depth interview. Participants perceived themselves as being at high risk for HIV acquisition, and expressed interest in PrEP as an HIV prevention strategy. Two forms of stigma emerged as potential barriers to PrEP use: (1) misidentification as living with HIV; and (2) disclosure of membership in a priority population. Acceptability of PrEP was dampened for this sample of potential PrEP users due to anticipated stigmatization. Mitigating stigma should be a key component of effective PrEP delivery to reach UNAIDS goal of ending the AIDS epidemic by 2030.
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    Users May Lack Confidence in ART for HIV Prevention: A Qualitative Analysis
    (Conference on retroviruses and opportunistic infections (CROI), 2017) Wyatt, Monique A.; Pisarski, Emily E.; Baeten, Jared M.; Heffron, Renee; Nakku-Joloba, Edith; Muwonge, Timothy R.; Katabira, Elly T.; Celum, Connie L.; Ware, Norma C.
    Antiretroviral-based approaches to HIV prevention have been shown to reduce new infections in clinical trials and demonstration settings. To optimize uptake and anticipate barriers to effective rollout, we must understand users’ perspectives on antiretroviral treatment (ART) for prevention of HIV transmission. We explored serodiscordant couples’ understandings of and feelings about treatment as prevention using qualitative data from the Partners Demonstration Project. The Partners Demonstration Project 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 HIVinfected partners had been on ART for 6 months. Multiple in-depth qualitative interviews were conducted with a subset of 48 couples from the Kampala, Uganda Partners Demonstration Project site (N interviews=195). Interview topics included: (a) perceived purpose and meanings of PrEP and ART; (b) adherence; (c) experiences of PrEP discontinuation; and (d) understandings of antiretroviral treatment as prevention. Interviews were audio-recorded, transcribed into English and coded using Atlas.ti software by two trained analysts. Coded data 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.