HIV/AIDS

Low Knowledge of ‘Treatment as Prevention’ among University Students in South Africa

Although antiretroviral therapy leading to viral suppression eliminates the risk of HIV transmission during sex, South African university students perceived this risk of transmission to be as high as 73 percent.

Antiretroviral therapy (ART) has been one of the most important breakthroughs in the global effort to end the HIV/AIDS epidemic since the first cases of the virus were recorded 40 years ago. The multi-drug treatment regimen drastically improves and extends the lives of people living with HIV—and it nearly eliminates the sexual transmission of HIV if the HIV-positive partner is virally suppressed.

Despite the overwhelming efficacy of this “treatment as prevention” (TasP) approach to reduce HIV transmission in mixed-status relationships, many young adults—particularly those who live in areas where HIV is endemic—remain largely unaware of the benefits of ART. A new study led by a School of Public Health researcher has found a significant knowledge gap on ART efficacy among university students in South Africa, where young adults are at high risk of HIV infection.

Published in the journal Sexually Transmitted Infections, the study examined beliefs about TasP and HIV transmission among first-year students at a large urban university in Johannesburg. The authors found that the students substantially overestimated the risk of HIV transmission by a person on ART who has attained viral suppression. The 2011 HIV Prevention Trials Network-052 trial and several large cohort studies have shown that the true risk of transmission is close to zero. Despite receiving standard HIV education in their primary and secondary schooling, students perceived a 73 percent annual HIV sexual transmission risk between a mixed-status couple, even if the HIV-positive partner was on ART and virally suppressed.

“These findings are concerning,” says study lead author Jacob Bor, assistant professor of global health and epidemiology. “HIV treatment is one of the most effective strategies to reduce transmission, but our findings highlight low knowledge about TasP among an educated, urban population with access to health services.”

These knowledge gaps are not limited to South Africa, Bor adds. “There are large disparities in access to accurate information about HIV treatment-as-prevention, including within the US,” he says.

The findings were based on survey responses from 363 first-year students, ages 18-25, at a large university in Johannesburg between August and October 2017. The students answered questions about their perceptions of the likelihood of HIV transmission among a heterosexual mixed-status couple in four real-world scenarios: in 1 sex act versus 52 sex acts; and with and without virally-suppressive ART.

On average, students perceived that HIV treatment reduced transmission by only 17 percent, compared to the 96 percent efficacy that the 2011 trial concluded. More than 40 percent of students did not believe that ART reduced the risk of HIV transmission at all. The researchers found no distinctions in TasP efficacy beliefs by demographic characteristics, socioeconomic status, HIV testing history, or HIV knowledge.

As advocates mark World AIDS Day on December 1 with a focus on ending inequalities, the researchers emphasize the critical need to address knowledge disparities around TasP and reevaluate historical messaging around HIV transmission that exaggerates the risk and severity of the virus.

“Traditionally, HIV campaigns used fear to motivate people to avoid infection, but fear of the virus can easily become fear of intimacy with people with HIV,” Bor says. “This is a rational response, but a highly stigmatizing one. Even today, many people are hesitant to test for HIV, start treatment, and disclose to partners because they fear stigma and rejection.”

The power of treatment-as-prevention, he says, is that “you can have intimate relationships without fear of transmission and with less of the stigma that comes with an infectious disease. That’s a powerful motivator, especially for young people, to find out their status and start treatment right away. This message has been effectively communicated by the Undetectable=Untransmittable campaign and is now being embraced more widely. We have been excited to learn that South Africa is planning to launch a U=U campaign in 2022.”

The study was co-authored by Nozipho Musakwa, Dorina Onoya, and Denise Evans, all of the Health Economics and Epidemiology Research Office for the City of Johannesburg, the Wits Health Consortium, and the University of the Witwatersrand, Johannesburg. Bor and Onoya are currently working on an NIH-funded project to develop an intervention to integrate information on HIV TasP into HIV counseling in South Africa.