'Why Would You Promote Something That Is Less Percent Safer Than a Condom?': Perspectives on Partially Effective HIV Prevention Technologies Among Key Populations in South Africa

"Global policy-level recommendations advocate the development of 'clear communications about the pros and cons' of NPTs (AIDS Vaccine Advocacy Coalition, 2012); however, there remain a dearth of specific guidelines as to how this can be achieved..."

The effectiveness of new biomedical prevention technologies (NPTs) for HIV, including oral pre-exposure prophylaxis (PrEP), vaginal and rectal microbicides, and HIV vaccines, is contingent on product acceptability and adherence. A general understanding of the fact that NPTs are only partially efficacious supports the need to combine different methods of prevention (including biomedical, behavioural, and structural). Partial efficacy could signify that the product may offer substantial protection to some people in a population, but that not all people may benefit; or that the product may protect against HIV acquisition in a certain percentage of cases overall; or that the product may reduce the severity of HIV infection but not prevent it entirely; or some combination of these different types of efficacy.

Existing studies document challenges with understanding the concept of partial efficacy and highlight the importance of sound communication, education, and community engagement efforts with key populations in planning for product implementation. To better inform efforts to communicate risks and benefits of NPTs to potential users and other stakeholders, this study investigates perceptions and understandings of partial effectiveness of NPTs among key populations in South Africa.

Key populations - adolescents, men who have sex with men (MSM), and heterosexual adults - were selected and recruited from Masiphumelele and Gugulethu, 2 informal peri-urban communities located outside Cape Town, South Africa. From October 2013 to February 2014, the researchers conducted 6 focus group discussions (FGDs) and 18 in-depth interviews (IDIs) with members of these communities, including Xhosa-speaking adolescents (n=14), adult MSM (n=15), and adult heterosexual men (n=9) and women (n=10), as well as 8 key informant (KI) interviews with healthcare workers (HCWs).

In line with the push by the Global Network of People Living with HIV (GNP+) for "biobehavioural" interventions to promote HIV prevention, facilitators of all FGDs and IDIs framed the concept of partial efficacy in a positive light, explaining that these different prevention methods can be used as a "toolkit" for prevention, along with fewer partners, condoms, and regular health check-ups, to reduce the risk of HIV acquisition. Nevertheless, this positive framing was picked up and reflected back by only a minority of participants.

Specifically, participants and KIs indicated scepticism about NPTs that were not 100% efficacious. Some participants equated not being 100% effective with not being completely safe, and thus not appropriate for dissemination. A woman expressed discomfort with HIV vaccines, for example: "I think I would use it, but then the problem I have, I think the percentage stated here, I think it's too little; so I'm not sure how it would work because its percentage is too small." KIs expressed concerns that promoting partially effective NPTs would encourage substitution of a more effective with a less effective method or encourage risk compensation.

The data suggest that the concept of partial effectiveness is still understood in largely negative terms. Participants raised several key framings which, taken together, suggest that work remains for those tasked with promoting the uptake of NPTs:

• Some participants advised that rather than rushing to promote a product with only partial efficacy, scientists and public health officials should wait for a more efficacious product, endorsing the belief that a completely efficacious product just required more time to develop. Given the current consensus that achieving a completely efficacious NPT in the near future is unlikely, the researchers call for the development of evidence-informed education and social marketing campaigns to shift perceptions around partially effective products.
• The conflation of "partial effectiveness" with "partial safety" raises considerations for future NPT promotion efforts. These data do not reflect whether participants are aware of previous terminated NPT trials, such as one in which the investigational HIV vaccine increased susceptibility to HIV infection for some recipients. However, given how news of these events evolves and is interpreted through different communication channels, it may be important for future outreach and advocacy efforts to address past events that may exacerbate confusion or mistrust of NPTs.
• HCWs shared misgivings about the promotion of partially efficacious NPTs, but their support is crucial to the dissemination of these products. Tailored training for frontline HCWs could help those who might otherwise feel overwhelmed by another new technology or intervention they are required to become familiar with and explain to their clients. Such training could also address concerns that partially effective NPTs may encourage risk compensation behaviour or that NPTs may specifically discourage condom use.

In conclusion, the researchers stress "the importance of engagement with community concerns and priorities through social marketing and education campaigns tailored for key populations and frontline service providers. The time prior to the availability of particular NPTs provides a rich opportunity to foster understanding and acceptance of partially effective HIV prevention technologies that can, when used in combination, comprise a formidable toolkit for combination HIV prevention."