Monique A. Wyatt
Harvard University
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PLOS Medicine | 2009
Norma C. Ware; John Idoko; Sylvia Kaaya; Irene Andia Biraro; Monique A. Wyatt; Oche Agbaji; Guerino Chalamilla; David R. Bangsberg
Background Individuals living with HIV/AIDS in sub-Saharan Africa generally take more than 90% of prescribed doses of antiretroviral therapy (ART). This number exceeds the levels of adherence observed in North America and dispels early scale-up concerns that adherence would be inadequate in settings of extreme poverty. This paper offers an explanation and theoretical model of ART adherence success based on the results of an ethnographic study in three sub-Saharan African countries. Methods and Findings Determinants of ART adherence for HIV-infected persons in sub-Saharan Africa were examined with ethnographic research methods. 414 in-person interviews were carried out with 252 persons taking ART, their treatment partners, and health care professionals at HIV treatment sites in Jos, Nigeria; Dar es Salaam, Tanzania; and Mbarara, Uganda. 136 field observations of clinic activities were also conducted. Data were examined using category construction and interpretive approaches to analysis. Findings indicate that individuals taking ART routinely overcome economic obstacles to ART adherence through a number of deliberate strategies aimed at prioritizing adherence: borrowing and “begging” transport funds, making “impossible choices” to allocate resources in favor of treatment, and “doing without.” Prioritization of adherence is accomplished through resources and help made available by treatment partners, other family members and friends, and health care providers. Helpers expect adherence and make their expectations known, creating a responsibility on the part of patients to adhere. Patients adhere to promote good will on the part of helpers, thereby ensuring help will be available when future needs arise. Conclusion Adherence success in sub-Saharan Africa can be explained as a means of fulfilling social responsibilities and thus preserving social capital in essential relationships.
Journal of Acquired Immune Deficiency Syndromes | 2012
Norma C. Ware; Monique A. Wyatt; Jessica E. Haberer; Jared M. Baeten; Alexander Kintu; Christina Psaros; Steven A. Safren; Elioda Tumwesigye; Connie Celum; David R. Bangsberg
Objective:Adherence may be the “Achilles heel” of pre-exposure prophylaxis (PrEP), a promising biomedical approach to HIV prevention. This article presents an explanation of PrEP adherence for African serodiscordant couples derived from qualitative data. Design:Explaining quantitative findings is one way qualitative investigation contributes to research in medicine and public health. This qualitative interview study was nested in the Partners PrEP Study, a phase III randomized trial evaluating oral tenofovir and emtricitabine/tenofovir PrEP to prevent HIV acquisition by HIV-uninfected partners in serodiscordant heterosexual couples. Methods:In-depth qualitative interviews were provided by 60 Partners PrEP Study participants in Uganda. Interviews used open-ended questions eliciting information on adherence experiences, barriers, and facilitators. An inductive approach informed by grounded theory methodology was used to analyze study data. Results:The proposed explanation may be summarized as follows. Serodiscordance destabilizes couples, as the HIV-negative partner reacts with anger, fear, and sadness to the implication of infidelity represented by HIV infection. A “discordance dilemma” ensues, as the desire to avoid acquiring HIV and the advantages of preserving the relationship become competing priorities. PrEP is seen as a solution—a means of safeguarding health without ending the relationship. PrEP users benefit from the support of partners, who reinforce adherence. Where discord in the relationship persists, adherence suffers. Conclusions:PrEP adherence in serodiscordant couples may be understood as a function of the desire to reduce risk although preserving a partnered relationship. PrEP use in stable couples may be associated with improved adherence and thus, greater effectiveness.
Aids Care-psychological and Socio-medical Aspects of Aids\/hiv | 2006
Norma C. Ware; Monique A. Wyatt; Toni Tugenberg
Abstract Research on adherence to combination antiretroviral therapy has up to now focused largely upon problems of definition and measurement, and on the identification of barriers and supports. This paper examines the intersection between taking HAART and building a life with HIV/AIDS. Data consist of 214 qualitative interviews with 52 HIV-positive, active illegal drug users. A interpretive analysis drawing upon stigma and fear of disclosure as analytical constructs was applied to explain working tensions between efforts to develop social relationships on the one hand, and attempts to safeguard health through adherence on the other. The analysis specifies a mechanism through which stigma as a social process results in marginalization and exclusion. The hierarchical organization of multiple stigma is also noted. Loneliness and the desire for relatedness is intensified by drug use. Results suggest that persons with HIV/AIDS will not consistently subordinate other interests to prioritize adherence. Interventions aimed at supporting long-term adherence must address experienced conflicts between ‘health’ and ‘life’.
PLOS Medicine | 2013
Norma C. Ware; Monique A. Wyatt; Elvin Geng; Sylvia Kaaya; Oche Agbaji; Winnie Muyindike; Guerino Chalamilla; Patricia A. Agaba
Norma Ware and colleagues conducted a large qualitative study among patients in HIV treatment programs in sub-Saharan Africa to investigate reasons for missed visits and provide an explanation for disengagement from care.
PLOS Medicine | 2016
Jared M. Baeten; Renee Heffron; Lara Kidoguchi; Nelly Mugo; Elly Katabira; Elizabeth A. Bukusi; Stephen Asiimwe; Jessica E. Haberer; Jennifer Morton; Kenneth Ngure; Nulu Bulya; Josephine Odoyo; Edna Tindimwebwa; Craig W. Hendrix; Mark A. Marzinke; Norma C. Ware; Monique A. Wyatt; Susan Morrison; Harald Haugen; Andrew Mujugira; Deborah Donnell; Connie Celum
Background Antiretroviral-based interventions for HIV-1 prevention, including antiretroviral therapy (ART) to reduce the infectiousness of HIV-1 infected persons and pre-exposure prophylaxis (PrEP) to reduce the susceptibility of HIV-1 uninfected persons, showed high efficacy for HIV-1 protection in randomized clinical trials. We conducted a prospective implementation study to understand the feasibility and effectiveness of these interventions in delivery settings. Methods and Findings Between November 5, 2012, and January 5, 2015, we enrolled and followed 1,013 heterosexual HIV-1-serodiscordant couples in Kenya and Uganda in a prospective implementation study. ART and PrEP were offered through a pragmatic strategy, with ART promoted for all couples and PrEP offered until 6 mo after ART initiation by the HIV-1 infected partner, permitting time to achieve virologic suppression. One thousand thirteen couples were enrolled, 78% of partnerships initiated ART, and 97% used PrEP, during a median follow-up of 0.9 years. Objective measures of adherence to both prevention strategies demonstrated high use (≥85%). Given the low HIV-1 incidence observed in the study, an additional analysis was added to compare observed incidence to incidence estimated under a simulated counterfactual model constructed using data from a prior prospective study of HIV-1-serodiscordant couples. Counterfactual simulations predicted 39.7 HIV-1 infections would be expected in the population at an incidence of 5.2 per 100 person-years (95% CI 3.7–6.9). However, only two incident HIV-1 infections were observed, at an incidence of 0.2 per 100 person-years (95% CI 0.0–0.9, p < 0.0001 versus predicted). The use of a non-concurrent comparison of HIV-1 incidence is a potential limitation of this approach; however, it would not have been ethical to enroll a contemporaneous population not provided access to ART and PrEP. Conclusions Integrated delivery of time-limited PrEP until sustained ART use in African HIV-1-serodiscordant couples was feasible, demonstrated high uptake and adherence, and resulted in near elimination of HIV-1 transmission, with an observed HIV incidence of <0.5% per year compared to an expected incidence of >5% per year.
AIDS | 2016
Jessica E. Haberer; Angella Musiimenta; Esther C. Atukunda; Nicholas Musinguzi; Monique A. Wyatt; Norma C. Ware; David R. Bangsberg
Objective:To explore the effects of four types of short message service (SMS) plus real-time adherence monitoring on antiretroviral therapy (ART) adherence: daily reminders, weekly reminders, reminders triggered after a late or missed dose (delivered to patients), and notifications triggered by sustained adherence lapses (delivered to patient-nominated social supporters). Design:Pilot randomized controlled trial. Methods:Sixty-three individuals initiating ART received a real-time adherence monitor and were randomized (1 : 1 : 1): (1) Scheduled SMS reminders (daily for 1 month, weekly for 2 months), then SMS reminders triggered by a late or missed dose (no monitoring signal within 2 h of expected dosing); SMS notifications to social supporters for sustained adherence lapses (no monitoring signal for >48 h) added after 3 months. (2) Triggered SMS reminders starting at enrolment; SMS notifications to social supporters added after 3 months. (3) Control: No SMS. HIV RNA was determined at 9 months. Percentage adherence and adherence lapses were compared by linear generalized estimating equations and Poisson regression, respectively. Results:Median age was 31 years, 65% were women, and median enrolment CD4+ cell count was 322 cells/&mgr;l 97% took once daily tenofovir/emtricitabine/efavirenz. Compared to control, adherence was 11.1% higher (P = 0.04) and more than 48-h lapses were less frequent (IRR 0.6, P = 0.02) in the scheduled SMS arm. Adherence and more than 48-h lapses were similar in the triggered SMS arm and control. No differences in HIV RNA were seen. Conclusion:Scheduled SMS reminders improved ART in the context of real-time monitoring. Larger studies are needed to determine the impact of triggered reminders and role of social supporters in improving adherence.
Journal of Acquired Immune Deficiency Syndromes | 2006
Norma C. Ware; Monique A. Wyatt; David R. Bangsberg
Summary:Mortality and morbidity for HIV-infected patients in resource-limited settings have declined markedly with increased access to combination antiretroviral therapy. One explanation for this is the high rates of adherence that patients in these settings have achieved. To help patients sustain early successes, detailed understanding of adherence processes in these locales is needed. This understanding is best arrived at using socioculturally valid theoretic models as a guide. This article introduces a heuristic schema for examining the validity of conceptual models of adherence in resource-limited settings. The schema consists of 4 analytic questions to be asked of a model being considered for use in a sociocultural context other than the one in which it was developed. To demonstrate use of the schema, an illustrative validation exercise in which the 4 questions are applied to the information-motivation-behavioral skills model of behavioral change is carried out. Examples for the illustrative exercise come from preliminary qualitative research in HIV/AIDS treatment settings in Mbarara, Uganda and Jos, Nigeria.
AIDS | 2016
Norma C. Ware; Emily E. Pisarski; Melanie Tam; Monique A. Wyatt; Esther C. Atukunda; Angella Musiimenta; David R. Bangsberg; Jessica E. Haberer
Objective:To understand how a pilot intervention combining SMS reminders with real-time adherence monitoring improved adherence to HIV antiretroviral therapy (ART) for adults initiating treatment in rural Uganda. Design:Qualitative study, conducted with a pilot randomized controlled trial. Methods:Sixty-two pilot intervention study participants took part in qualitative interviews on: preferences for content; frequency and timing of SMS adherence reminders; understandings and experiences of SMS reminders; and understandings and experiences of real-time adherence monitoring. Analysis of interview data was inductive and derived categories describing how participants experienced the intervention, and what it meant to them. Results:SMS reminders prompted taking individual doses of antiretroviral therapy, and helped to develop a ‘habit’ of adherence. Real-time adherence monitoring was experienced as ‘being seen’; participants interpreted ‘being seen’ as an opportunity to demonstrate seriousness of commitment to treatment and ‘taking responsibility’ for adherence. Both SMS reminders and real-time monitoring were interpreted as signs of ‘caring’ by the healthcare system. Feeling ‘cared about’ offset depressed mood and invigorated adherence. Conclusion:Although serving as reminders, SMS messages and real-time adherence monitoring also had larger emotional and moral meanings for participants that they felt improved their adherence. Understanding the larger ‘meanings in the messages,’ as well as their more literal content and function, will be central in delineating how SMS reminders and other adherence interventions using cellular technology work or do not work in varying contexts.
Aids Care-psychological and Socio-medical Aspects of Aids\/hiv | 2013
Ingrid T. Katz; Michele L. Ybarra; Monique A. Wyatt; Julius Kiwanuka; David R. Bangsberg; Norma C. Ware
Abstract With more than half of new infections occurring among youth, HIV/AIDS remains a major contributor to morbidity and mortality in Uganda. Semi-structured interviews were performed with 48 adolescents and 15 adult key informants in a rural Ugandan community to identify influences on adolescent sexual decision-making. Inductive data analytic methods revealed five thematic influences: (1) social pressure, (2) decline of the Senga (a familial figure who traditionally taught female adolescents about how to run a household), (3) cultural barriers to condom use, (4) knowledge of HIV transmission and modes of prevention, and (5) a moral injunction against sex before marriage. Influences were classified as HIV/AIDS risk and protective factors and organized to form an explanatory framework of adolescent sexual risk-taking. Risk factors pull youth toward risky behavior, while protective factors push them away. Predominance of risk over protective influences explains persistent sexual risk-taking by Ugandan youth. HIV prevention programs designed for Ugandan adolescents should take competing factors and sociocultural and economic influences into account.
Journal of the International AIDS Society | 2016
Norma C. Ware; Monique A. Wyatt; Stephen Asiimwe; Bosco Turyamureeba; Elioda Tumwesigye; Heidi van Rooyen; Ruanne V. Barnabas; Connie Celum
The successes of HIV treatment scale‐up and the availability of new prevention tools have raised hopes that the epidemic can finally be controlled and ended. Reduction in HIV incidence and control of the epidemic requires high testing rates at population levels, followed by linkage to treatment or prevention. As effective linkage strategies are identified, it becomes important to understand how these strategies work. We use qualitative data from The Linkages Study, a recent community intervention trial of community‐based testing with linkage interventions in sub‐Saharan Africa, to show how lay counsellor home HIV testing and counselling (home HTC) with follow‐up support leads to linkage to clinic‐based HIV treatment and medical male circumcision services.