title: Perspectives on use of oral and vaginal antiretrovirals for HIV prevention: the VOICE-C qualitative study in Johannesburg, South Africa.
abstract: BACKGROUND
  Antiretroviral (ARV)-based pre-exposure prophylaxis (PrEP) is a promising new HIV prevention strategy. However, variable levels of adherence have yielded mixed results across several PrEP trials and populations. It is not clear how taking ARV - traditionally used for HIV treatment - is perceived and how that perception may affect the use of these products as preventives. We explored the views and experiences of VOICE participants, their male partners and community members regarding the use of ARV as PrEP in the VOICE trial and the implications of these shared meanings for adherence.
  
  
  METHODS
  VOICE-C was a qualitative ancillary study conducted at the Johannesburg site of VOICE, a multisite, double-blind, placebo-controlled randomised trial testing tenofovir gel, oral tenofovir and oral Truvada for HIV PrEP. We interviewed 102 randomly selected female VOICE participants, 22 male partners and 40 community members through in-depth interviews, serial ethnography, or focus group discussions. All interviews were audiotaped, transcribed, translated and coded thematically for analysis.
  
  
  RESULTS
  The concept of ARV for prevention was understood to varying degrees across all study groups. A majority of VOICE participants understood that the products contained ARV, more so for the tablets than for the gel. Although participants knew they were HIV negative, ARV was associated with illness. Male partners and community members echoed these sentiments, highlighting confusion between treatment and prevention. Concerned that they would be mistakenly identified as HIV positive, VOICE participants often concealed use of or hid their study products. This occasionally led to relationship conflicts or early trial termination. HIV stigma and its association with ARV, especially the tablets, was articulated in rumour and gossip in the community, the workplace and the household. Although ARV were recognised as potent and beneficial medications, transforming the AIDS body from sickness to health, they were regarded as potentially harmful for those uninfected.
  
  
  CONCLUSIONS
  VOICE participants and others in the trial community struggled to conceptualise the idea of using ARV for prevention. This possibly influenced willingness to adopt ARV-based prevention in the VOICE clinical trial. Greater investments should be made to increase community understanding of ARV for prevention and to mitigate pervasive HIV stigma.
authors.affiliation: Women's Global Health Imperative, RTI International, San Francisco, CA, USA; Department of Medicine, Center for AIDS Prevention Studies, University of California San Francisco, San Francisco, CA, USA; ariane@rti.org.
authors.forename: Ariane
authors.initials: A
authors.lastname: van der Straten
authors.affiliation: Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Stadler
authors.affiliation: Women's Global Health Imperative, RTI International, San Francisco, CA, USA.
authors.forename: Ellen
authors.initials: E
authors.lastname: Luecke
authors.affiliation: Women's Global Health Imperative, RTI International, San Francisco, CA, USA.
authors.forename: Nicole
authors.initials: N
authors.lastname: Laborde
authors.affiliation: Women's Global Health Imperative, RTI International, San Francisco, CA, USA.
authors.forename: Miriam
authors.initials: M
authors.lastname: Hartmann
authors.affiliation: Women's Global Health Imperative, RTI International, San Francisco, CA, USA.
authors.forename: Elizabeth T
authors.initials: ET
authors.lastname: Montgomery
mesh_terms: D000282:Administration, Intravaginal; D000284:Administration, Oral; D000328:Adult; D044966:Anti-Retroviral Agents / Q000008:administration & dosage*; D018890:Chemoprevention / Q000379:methods* / Q000523:psychology; D018562:Disease Transmission, Infectious / Q000517:prevention & control*; D005260:Female; D015658:HIV Infections / Q000517:prevention & control* / Q000523:psychology; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D055118:Medication Adherence; D008875:Middle Aged; D010342:Patient Acceptance of Health Care; D065129:Pre-Exposure Prophylaxis / Q000379:methods*; D013019:South Africa; D055815:Young Adult
chemical_list: D044966:Anti-Retroviral Agents
keywords: HIV prevention; HIV stigma; South Africa; adherence; antiretroviral; microbicides; pre-exposure prophylaxis; qualitative methods