Abstract
Introduction:
Pre-exposure prophylaxis (PrEP) has the potential to significantly reduce incident HIV globally, especially among individuals in sero-discordant partnerships with repeated HIV exposure and/or whose partners are not virally suppressed (undermining “Undetectable = Untransmittable”). Partner-based referrals may enhance PrEP uptake, yet data on PrEP awareness and willingness among people living with HIV (PLHIV) in east Africa is limited. We assessed PrEP knowledge and willingness to support partner uptake of PrEP among antiretroviral therapy (ART) initiates in Tanzania.
Methods:
Data were from the Afya II cluster RCT, which recruited ART initiates (n=1,990) randomized to usual care or monthly cash incentives for clinic visits. At the twelve-month visit, participants completed a sub-section on PrEP knowledge and attitudes, partner PrEP use, and understanding of U=U. We used multivariable regression to analyze correlates of U=U agreement (linear) and PrEP awareness (logistic).
Results:
Over half (59%) of participants had never heard of PrEP and 52% were in sero-discordant relationships. Among those in sero-discordant relationships, 22% reported their partner PrEP use. Participants showed high support for partner PrEP use (70% very supportive). Median U=U agreement was high (4.0/5.0). Female sex was associated with higher U=U concordance (β=0.84, 95%CI: 0.73–0.97). Among those in sero-discordant relationships, PrEP awareness was higher among those with greater education (AOR=2.91, 95%CI: 1.21–6.98).
Conclusions:
PrEP awareness was low despite over half of participants being in sero-discordant partnerships. Ensuring PrEP promotion during routine HIV care visits, particularly among ART initiates who have yet to achieve viral suppression, may support secondary prevention of HIV efforts.
Keywords: PrEP, U=U, Tanzania, prevention
Introduction
Promoting HIV prevention and treatment via partner-based referrals is a cornerstone of HIV and STI care globally and an effective approach for HIV prevention and treatment.1 Partner-based care’s success is predicated on the idea that engagement in healthcare by one partner can be leveraged to promote linkage to care for the other(s), even amongst discordant couples.2,3 Especially among individuals who are newly initiating antiretroviral therapy (ART) or who have not yet achieved viral load suppression, offering pre-exposure prophylaxis (PrEP) care to HIV seronegative partners can provide protection to “bridge” the gap between treatment initiation and viral suppression.1 Evidence from Kenya and Uganda have demonstrated that this approach is acceptable,3,4 however evidence is lacking from other HIV burdened countries with less robust PrEP delivery systems, such as Tanzania.5 Understanding PrEP awareness among ART initiators is therefore critical for assessing the feasibility of partner-based PrEP referrals as a strategy to reduce onward transmission prior to viral suppression.
Oral daily PrEP, the currently available modality in Western Tanzania, is up to 90% effective at preventing HIV6 and could significantly reduce HIV incidence if used at scale effectively and among key populations.7,8 PrEP awareness is low, underscoring low uptake, and willingness to uptake PrEP is further undermined by anticipated stigma.9 Financial barriers may also play a role: to date, PrEP is predominantly distributed in public health facilities (although differentiated care is on the horizon),3 and transportation costs are a well-documented barrier to seeking preventative care at health facilities in Tanzania, our study’s location.10–12
Tanzania, the site of our study, has made significant progress in reaching the ambitious UNAIDS 95-95-95 goals, having met the second goal of 95% of people living with HIV (PLHIV) on ART.13 Nevertheless, HIV status knowledge and viral load suppression among those PLHIV, the first and third goals, lags behind.14,15 With national estimates at 78% of PLHIV achieving viral suppression, at least 22% of PLHIV may not benefit from Undetectable=Untransmittable (U=U).16 With onward HIV transmission risk highest during the first six months of ART initiation17 or with drug-resistance,18 PrEP can play a role as a bridge strategy among the partners of PLHIV across various stages of their HIV care and treatment journey.1
We sought to understand current knowledge of, engagement in, and correlates of PrEP knowledge among a cohort of ART initiates about their partners, leveraging a study promoting retention in HIV care in four regions of western Tanzania.
Methods
We leveraged data collected from the Afya II type 1 hybrid effectiveness-implementation study. The study design, randomization, and primary outcomes are described in detail elsewhere.19 In brief, the study recruited 1,990 ART initiates (1,059 intervention, 931 control) from 32 clinics across western Tanzania and randomized them 1:1 to usual care or monthly cash incentives (n≤6 possible payments), conditional on clinic attendance over six months.19 The primary outcome was retention on ART with viral suppression at twelve months and has been reported elsewhere.19 Ethical approval was obtained from the Institutional Review Board at the University of California, Berkeley, CA, USA, and the National Institute for Medical Research in Dar es Salaam, Tanzania. Written informed consent was obtained from all participants.
This sub-study included a survey section offered one year post enrollment to all parent study participants and timed with their 12-month study visit with questions around PrEP knowledge, use among their primary partners who were HIV seronegative or with an unknown status, and attitudes (Table 1). For U=U, participants were asked how much they agreed with the following statement: “If I take my HIV medicine regularly and my viral load is always suppressed, it is very hard for me to transmit HIV to someone else;” response options were a Likert scale ranging from strongly disagree (1) to strongly agree (5). The sub-section was included after the 12-month visit launched due to IRB approval for the additional sub-section timeline; consequently, 1,276 (64%) of participants completed the questionnaire. IRB approval was received from both the University of California, Berkeley, and the National Institute for Medical Research. The parent study was registered at ClinicalTrials.gov, NCT04201353.
Table 1.
Sociodemographic and PrEP related characteristics of entire sample which completed the PrEP sub-study and the subgroup of participants with a partner not living with HIV, Afya Study, 2022
| Non-HIV seropositive partner sub-sample (n=318) | Overall sample who completed PrEP sub-study (n=1,276) | |
|---|---|---|
| Age at enrollment, yr, median (IQR) | 34.0 (26.8, 41.7) | 34.9 (27.4, 43.2) |
| Sex | ||
| Male | 151 (47.5%) | 506 (39.7%) |
| Female | 167 (52.5%) | 770 (60.3%) |
| Married or partnered | ||
| No | 95 (30.0%) | 496 (39.3%) |
| Yes | 222 (70.0%) | 765 (60.7%) |
| Head of household | ||
| No | 126 (39.7%) | 549 (43.5%) |
| Yes, head of household | 160 (50.5%) | 601 (47.7%) |
| Yes, joint head of household | 31 (9.8%) | 111 (8.8%) |
| Educational attainment | ||
| No formal education | 77 (24.4%) | 318 (25.3%) |
| Some primary | 66 (21.0%) | 213 (17.0%) |
| Completed primary | 131 (41.6%) | 571 (45.5%) |
| More than primary | 41 (13.0%) | 154 (12.3%) |
| Wealth quintile | ||
| 1 | 64 (20.1%) | 253 (19.8%) |
| 2 | 58 (18.2%) | 258 (20.2%) |
| 3 | 69 (21.7%) | 271 (21.2%) |
| 4 | 65 (20.4%) | 245 (19.2%) |
| 5 | 62 (19.5%) | 249 (19.5%) |
| Health Status | ||
| Excellent | 140 (44.0%) | 587 (46.0%) |
| Very Good | 113 (35.5%) | 440 (34.5%) |
| Good | 58 (18.2%) | 207 (16.2%) |
| Fair | 5 (1.6%) | 35 (2.7%) |
| Poor | 2 (0.6%) | 7 (0.5%) |
| Screens for depression (PHQ-2) | 31 (9.7%) | 102 (8.0%) |
| Screens for Anxiety (GAD-2) | 26 (8.2%) | 100 (7.9%) |
| Intervention Assignment | ||
| Control | 156 (49.1%) | 634 (49.7%) |
| Treatment | 162 (50.9%) | 642 (50.3%) |
| Region | ||
| Geita | 104 (32.7%) | 370 (29.0%) |
| Kagera | 71 (22.3%) | 294 (23.0%) |
| Mwanza | 78 (24.5%) | 333 (26.1%) |
| Shinyanga | 65 (20.4%) | 279 (21.9%) |
| Have you ever heard of PrEP? | ||
| No | 186 (58.5%) | 752 (58.9%) |
| Yes | 118 (37.1%) | 465 (36.4%) |
| Not sure | 13 (4.1%) | 28 (2.2%) |
| Prefer not to respond | 1 (0.3%) | 31 (2.4%) |
| Does your partner have HIV, are they HIV negative, do you not know, or would you prefer not to say? | ||
| Partner positive | -- | 349 (47.2%) |
| Partner negative | 203 (63.8%) | 203 (27.4%) |
| Status unknown | 115 (36.2%) | 115 (15.5%) |
| Prefer not to respond | -- | 73 (9.9%) |
| Is your partner currently taking PrEP? | ||
| No | 74 (56.1%) | 83 (53.9%) |
| Yes | 34 (25.8%) | 34 (22.1%) |
| Don't know | 22 (16.7%) | 26 (16.9%) |
| Refuse to answer | 2 (1.5%) | 11 (7.1%) |
| Have you ever talked about PrEP with your partner? | ||
| No | 78 (80%) | 92 (76.7%) |
| Yes | 16 (16%) | 16 (13.3%) |
| Refuse to answer | 4 (4%) | 12 (10.0%) |
| If your partner told you that they wanted to start taking PrEP, how supportive would you be? | ||
| Very unsupportive | 12 (4.2%) | 20 (5.6%) |
| Somewhat unsupportive | 7 (2.5%) | 9 (2.5%) |
| Neither supportive nor unsupportive | 20 (7.1%) | 28 (7.9%) |
| Somewhat supportive | 39 (13.8%) | 50 (14.1%) |
| Very supportive | 205 (72.4%) | 248 (69.9%) |
| How comfortable would you feel discussing PrEP with a partner who you weren’t sure of their status? | ||
| Very uncomfortable | 18 (6.4%) | 18 (6.4%) |
| Somewhat uncomfortable | 18 (6.4%) | 18 (6.4%) |
| Somewhat comfortable | 51 (18.0%) | 51 (18.0%) |
| Very comfortable | 196 (69.3%) | 196 (69.3%) |
| “If I take my HIV medicine regularly and my viral load is always suppressed, it is very hard for me to transmit HIV to someone else?” 1 | 4.0 (4.0, 5.0) | 4.0 (4.0, 5.0) |
| To whom have you disclosed your HIV status? (select all) | ||
| Spouse/Partner | 126 (39.6%) | 439 (34.4%) |
| Close family | 157 (49.4%) | 691 (54.2%) |
| Friends | 29 (9.1%) | 131 (10.3%) |
| I have not disclosed to anyone. | 26 (8.2%) | 88 (6.9%) |
| Virally suppressed at 12 months | 292 (97.7%) | 1180 (97.4%) |
Range strongly disagree (1) to strongly agree (5)
Potential correlates of PrEP knowledge included biological sex (male [reference] or female), marital status at study baseline (married or unmarried [reference]), educational attainment (no formal education [reference], some primary, completed primary, or more than primary), baseline wealth status (calculated using the Demographic and Health Surveys Wealth and Assets tool); we also controlled for the region of enrollment (the stratification factor in the parent study randomization).
We present descriptive statistics and self-reported data on partner use of PrEP among PLHIV in sero-discordant partnerships. We conducted two sets of regressions to assess socio-demographic correlates of 1) degree of agreement with the U=U statement, and 2) having ever heard of PrEP. For these regressions, we conducted generalized linear models with the Gaussian and binomial family to assess the continuous outcome of U=U agreement and the binary outcome of having ever heard of PrEP, respectively. As a supplementary analysis, we restricted the models to the subset of participants with a partner who was HIV seronegative or of unknown HIV status. As a robustness check, we conducted an additional analysis controlling for the parent study arm, although the intervention had no PrEP or U=U components and the active intervention components ended six months prior to data collection. Robust standard errors to account for clustering at the health facility were included for all models. Analyses were conducted using Stata 16 (College Station, Texas).
Results
The study enrolled 1,990 participants (1,059 intervention, 931 control) from May 28, 2021-March 7, 2022, recruited from 32 clinics; the CONSORT has been published elsewhere.19 Follow-up continued until July 14, 2023. There were no differences between those who completed the sub-section (n=1,276) and those who did not. Among those who completed the PrEP sub-section, the median age was 34.9 (interquartile range [IQR]: 27.2, 43.2), 60.3% were female, 60.7% were married, 67.8% had primary or greater education, and there was equal enrollment by study arm (Table 1). HIV disclosure was high; 6.9% reported never disclosing to anyone; disclosure was most frequent among close family (54.2%), followed by spouse/partner (34.4%) and friends (10.3%). By 12 months, 97.4% of participants achieved viral suppression.
Over half of the participants (58.9%) reported no knowledge of PrEP. Partner HIV status varied: 47.2% reported their partner being a PLHIV, 27.4% reported an HIV-seronegative partner, and 15.5% reported a partner with unknown HIV status (Table 1). Among those not in sero-concordant relationships, 22.1% reported that their partner was currently taking PrEP; over half (53.9%) reported that their partner was not on PrEP. Participants reported that they would be very (69.9%) and somewhat (14.1%) supportive of a partner using PrEP, with fewer reporting hypothetically being somewhat (2.5%) and very (5.6%) unsupportive. Similarly, participants reported being very (69.3%) and somewhat (18.0%) comfortable discussing PrEP with a partner if they were unaware of their partner’s HIV status. In response to the question about U=U, the median concordance with the statement was 4.0 (IQR: 4.0, 5.0), indicating high agreement with U=U.
In adjusted models examining correlates of U=U agreement, sex was the only correlate associated with higher U=U concordance, with 0.84 (95% confidence interval [CI]: 0.73, 0.97) units higher on the scale (range 1–5) among all women with a partner who was HIV negative or unknown status compared to their male counterparts; results were similar when study arm was included in models (0.86, 95% CI: 0.74, 0.99) (Table 2).
Table 2:
Socio-demographic correlates of U=U and PrEP knowledge, Afya II Study, 2022
| U=U (continuous)1 | U=U + arm | PrEP knowledge2 | PrEP knowledge + arm | |||||
|---|---|---|---|---|---|---|---|---|
| Full sample | Non- HIV seropositive partner | Full sample | Non- HIV seropositive partner | Full sample | Non- HIV seropositive partner | Full sample | Non- HIV seropositive partner | |
| Beta, 95% CI, p-value | AOR, 95% CI, p-value | |||||||
| Female sex (ref male) | 0.78 | 0.84 | 0.81 | 0.86 | 0.78 | 0.63 | 0.79 | 0.68 |
| (0.60, 1.01) | (0.73, 0.97) | (0.70, 0.94) | (0.74, 0.99) | (0.60, 1.01) | (0.39, 1.02) | (0.60, 1.04) | (0.41, 1.14) | |
| (0.0022) | (0.021) | (0.0060) | (0.035) | (0.060) | (0.059) | (0.092) | (0.15) | |
| Married at baseline (ref no) | 1.19 | 1.18 | 1.08 | 1.18 | 1.19 | 0.95 | 1.16 | 0.93 |
| (0.88, 1.60) | (0.91, 1.53) | (0.93, 1.24) | (0.91, 1.52) | (0.88, 1.60) | (0.58, 1.54) | (0.87, 1.55) | (0.55, 1.56) | |
| (0.25) | (0.21) | (0.30) | (0.21) | (0.25) | (0.83) | (0.30) | (0.78) | |
| Education (ref none) | ||||||||
| Some primary | 0.88 | 1.00 | 0.91 | 1.01 | 0.88 | 1.82 | 0.91 | 1.99 |
| (0.61, 1.27) | (0.76, 1.31) | (0.73, 1.13) | (0.76, 1.34) | (0.61, 1.27) | (0.89, 3.70) | (0.64, 1.28) | (0.94, 4.18) | |
| (0.29) | (0.99) | (0.37) | (0.94) | (0.48) | (0.10) | (0.58) | (0.071) | |
| Completed primary | 0.87 | 1.16 | 1.07 | 1.15 | 0.87 | 1.46 | 0.90 | 1.49 |
| (0.64, 1.19) | (0.90, 1.49) | (0.90, 1.28) | (0.89, 1.49) | (0.64, 1.19) | (0.75, 2.87) | (0.67, 1.20) | (0.78, 2.85) | |
| (0.38) | (0.25) | (0.44) | (0.28) | (0.39) | (0.27) | (0.47) | (0.23) | |
| More than primary | 0.90 | 1.20 | 0.90 | 1.18 | 0.90 | 2.91 | 0.91 | 2.85 |
| (0.51, 1.60) | (0.86, 1.68) | (0.69, 1.18) | (0.86, 1.62) | (0.51, 1.60) | (1.21, 6.98) | (0.54, 1.55) | (1.22, 6.64) | |
| (0.57) | (0.27) | (0.45) | (0.30) | (0.73) | (0.017) | (0.74) | (0.016) | |
| Baseline wealth | 1.01 | 1.00 | 1.00 | 1.00 | 1.01 | 0.97 | 1.01 | 0.97 |
| (0.99, 1.03) | (0.98, 1.01) | (0.99, 1.01) | (0.98, 1.01) | (0.99, 1.03) | (0.93, 1.02) | (0.99, 1.03) | (0.93, 1.02) | |
| (0.71) | (0.57) | (0.96) | (0.58) | (0.20) | (0.30) | (0.32) | (0.30) | |
| Age (year) | 0.99 | 1.00 | 1.00 | 1.00 | 0.99 | 0.98 | 0.99 | 0.98 |
| (0.98, 1.00) | (0.99, 1.01) | (1.00, 1.01) | (0.99, 1.01) | (0.98, 1.00) | (0.96, 1.00) | (0.98, 1.00) | (0.96, 1.00) | |
| (0.30) | (0.63) | (0.40) | (0.73) | (0.073) | (0.061) | (0.062) | (0.025) | |
| Region (ref: Geita) | ||||||||
| Kagera | 4.53 | 1.04 | 1.28 | 1.07 | 4.53 | 3.96 | 4.50 | 4.91 |
| (2.69, 7.65) | (0.78, 1.39) | (0.88, 1.85) | (0.84, 1.36) | (2.69, 7.65) | (2.30, 6.82) | (2.63, 7.70) | (2.86, 8.42) | |
| (0.21) | (0.76) | (0.19) | (0.58) | (<0.0001) | (<0.0001) | (<0.0001) | (<0.0001) | |
| Mwanza | 4.42 | 0.78 | 1.10 | 0.80 | 4.42 | 3.46 | 4.71 | 4.12 |
| (1.97, 9.93) | (0.55, 1.11) | (0.80, 1.52) | (0.55, 1.15) | (1.97, 9.93) | (1.10, 10.90) | (2.03,10.95) | (1.24,13.6) | |
| (0.72) | (0.16) | (0.53) | (0.22) | (0.00030) | (0.034) | (0.0003) | (0.020) | |
| Shinyanga | 2.96 | 0.80 | 1.07 | 0.81 | 2.96 | 2.06 | 2.90 | 2.25 |
| (1.16, 7.54) | (0.60, 1.08) | (0.76, 1.51) | (0.60, 1.10) | (1.16, 7.54) | (0.68, 6.27) | (1.19, 7.07) | (0.89, 5.68) | |
| (0.68) | (0.14) | (0.670) | (0.17) | (0.023) | (0.20) | (0.019) | (0.087) | |
| Intervention | 0.74 | 0.84 | 0.59 | 0.39 | ||||
| (0.55, 0.98) | (0.65, 1.07) | (0.30, 1.17) | (0.17, 0.86) | |||||
| (0.035) | (0.15) | (0.13) | (0.020) | |||||
| Observations | 1,199 | 315 | 912 | 315 | 1,199 | 301 | 1,199 | 301 |
“How much do you agree with the following statement: If I take my HIV medicine regularly and my viral load is always suppressed, it is very hard for me to transmit HIV to someone else.” Options: Strongly disagree (1), disagree, neither agree nor disagree, agree, strongly agree (5)
Have you ever heard of PrEP? (Yes = 1, No =0)
In adjusted models examining correlates of PrEP awareness among those with a partner who was HIV negative or of unknown status, greater than primary level educational attainment was consistently associated with knowledge of PrEP in the primary model (adjusted odds ratio [AOR] 2.91, 95% CI: 1.21, 6.98) and in the model adjusting for study arm (AOR: 2.85, 95% CI: 1.22, 6.64; Table 2). Moreover, two regions (Kagera and Mwanza) were significantly associated with increased PrEP knowledge (Table 2) compared to the reference region (Geita).
Discussion
In this sub-study of PLHIV newly initiated in care, over half (59%) of participants had never heard of PrEP despite having partners who could potentially benefit from PrEP, highlighting the potential to expand PrEP delivery through partner programs for PLHIV. Our study also documented general knowledge of U=U, with 90% of participants demonstrating some level of agreement with the concept as stated to them. Taken together, while PrEP could be a bridge to viral suppression among sero-discordant couples, it may be underutilized due to low awareness, despite high awareness of U=U. This study builds upon previous literature demonstrating low knowledge of PrEP among PLHIV, while highlighting gaps in the literature surrounding the potential of PLHIV to support HIV prevention, especially in the era of newer PrEP products and U=U.20,21
Engaging partners in HIV sero-discordant sexual relationships is considered among the more logistically feasible approaches to HIV prevention care globally, with logical extensions to PrEP provision.9,22 Current screening approaches hinges on an HIV seronegative individual being aware of, choosing to use, and seeking out PrEP, and overcoming the numerous documented barriers to do so.9,12,23 Conversely, treatment via partner tracing, such as expedited partner therapy, is a cornerstone of STI surveillance globally and is a feasible approach for HIV treatment for potentially exposed and/or newly acquired HIV cases.1 For HIV prevention among discordant couples, engagement in HIV care by one partner can overcome barriers such as awareness and seeking healthcare, as the index partner’s engagement in care can be leveraged to promote linkage to care for the other(s).3,24,25 A small body of recent partner-based studies in the United States among men who have sex with men and transgender women found that partner referral programs resulted in higher proportions of individuals at risk of HIV acquisition linking to and engaging in PrEP care.26 While PrEP education and promotion among PLHIV are part of the standard HIV care visit in Tanzania, in this study only 1 in 3 participants had heard of PrEP, raising questions about the occurrence and effectiveness of the education and promotion.
Partner-based referrals for PrEP predicates some degree of HIV status disclosure by the PLHIV and is most urgent among individuals newly diagnosed, those with adherence or drug resistance challenges, and those with unsuppressed viral load, all of whom may experience heightened stigma or psychosocial challenges.5,27 In our study, 80% of those in sero-non-concordant relationships had never discussed PrEP, and 40% reported disclosing their HIV status to their partners. Structural barriers, such as stock-outs or long laboratory testing times, may undermine adherence and viral suppression and promote resistance, potentially undermining U=U.28–30 There is little evidence on how U=U is being communicated to PLHIV, particularly in lesser-resourced settings where these barriers persist. Preliminary research among serodiscordant couples around safer conception reveal that even when the partner was virally suppressed, partners chose PrEP and ART adherence as methods for safer conception.31 Studies among providers in other settings have reported challenges, including provider and patient skepticism of U=U.32 As such, there remains a critical role for PrEP, particularly in response to patient preference and choice, beyond a typical ridge” period from HIV incidence to viral suppression. Nevertheless, a study among 2,389 PLHIV from 25 predominantly high-income countries found that two-thirds had ever discussed U=U, and that those who had discussed U=U had higher odds of adherence, viral suppression, and HIV status disclosure.33 Our research aligns with these findings around demonstrating relatively high degrees of agreement with U=U, although this did not translate to adherence or viral suppression. Guidelines for discussing U=U in different settings, which take into account status disclosure and structural (e.g., stock-outs), individual (e.g., resistance, suppression) dynamics for settings where these factors are more prevalent, combined with partner PrEP usage, may facilitate this patient-provider discussion.
Our study’s findings must be interpreted within its limitations and strengths. We observed statistically significant differences in PrEP knowledge by region and study assignment, where participants from some regions had more than four times the odds of hearing about PrEP and participants from intervention clinics were less likely to have PrEP and U=U knowledge. PLHIV are exposed to the same standards of care nationally and we would not expect non-random differences; nevertheless, regional heterogeneity may be explained by non-clinic-based programs. Finally, we do not have data on the sero-discordant partners of the study participants who may use PrEP or be PrEP aware.
Conclusions
HIV prevention and care for sero-discordant couples has served as a cornerstone for STI and HIV prevention and care for decades. While there are numerous studies citing low PrEP awareness among potential PrEP users, there are fewer studies ascertaining PrEP knowledge among PLHIV. Engaging PLHIV, particularly ART initiates, in PrEP promotion can support primary HIV prevention through secondary prevention, especially as a bridge strategy while they achieve viral suppression. In turn, U=U may motivate individuals in serodiscordant partnerships to maintain adherence. Our study identified low PrEP knowledge among newly diagnosed PLHIV and among those in sero-discordant relationships. Renewed efforts to promote PrEP to PLHIV during routine HIV care visits and to evaluate the efficacy of provided tools may serve to reduce HIV incidence.
Acknowledgements
We acknowledge the study participants who shared their time and lived experiences with our study team. We also acknowledge the support of the National AIDS, STIs and Hepatitis Control Programme of the Ministry of Health, as well as the Regional Medical Officers and other national and regional leaders in Geita, Kagera, Mwanza, and Shinyanga who supported the project. We appreciate the many individuals who served as research assistants and/or provided valuable input at various points throughout the project: Agatha Mnyippembe, Lisa Richard, Joan Mneney, Elizabeth Mzobora, Krisha Shrestha, Puspa Raj Bhattarai, David Temba, Noela John, Eddastella Wilson, Mashaka Leonard, Samuel Masasi, Pooja Chitle, Sydney Tucker, Jacqueline Kunesh, and Natalia Msami. This study was supported by a grant from the US National Institutes of Health, National Institute of Mental Health (R01MH112432). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Mental Health.
Footnotes
Clinical Trial Number: NCT04201353
Competing interests
The authors have no COI to report. SIM is an employee of Gilead Sciences, however this affiliation is outside the scope of the submitted work.
Data Availability Statement:
The data that support the findings of this study are available from the corresponding author upon reasonable request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.