 Shona is going, she just told me she came back from Swaziland actually yesterday. She is going to present some qualitative research on viral load and how viral load could possibly improve or potentially less improve the feeling of patients towards their treatment and do they actually really understand the results of a viral load. Thank you very much. Thank you. Good morning everyone. Sani Bonani Gulaba Bugalago Gangwane, which should mean hello to everyone watching in Swaziland as well. As was just mentioned I'm going to present a qualitative study that was conducted on viral load monitoring in Swaziland. How do HIV positive patients on antiretroviral therapy interpret and understand their results? So firstly to introduce the study setting, Swaziland is reported as having the highest HIV prevalence rate in the world with 31% of those aged 15 to 49 years being HIV positive. MSF in collaboration with the Ministry of Health have been providing decentralized HIV and TB care in the Shisawini region which is in southern Swaziland. Within this project a viral load monitoring pilot program was started in 2012 and this is now routinely offered for all patients on ART with additional support for adherence. So why was it decided to conduct this qualitative study? Well while we know that viral load monitoring can help prevent treatment failure through earlier identification of adherence challenges or need for treatment regimen changes, we still don't really know how patients feel about viral load monitoring and what effect viral load monitoring has on their experiences for example with treatment taking. Concerns were raised within the project as to the potential disinhibitory effect of having a known undetectable viral load, i.e. could those patients engage in risky or sexual practices as a result? And there was also anecdotal information about certain patients stopping treatment early or lost to follow up and also retesting for HIV through interpreting their undetectable result to mean that they had cured. So therefore we decided to do this study to describe patients' views and experiences regarding viral load monitoring. The methods that were adopted participants were recruited from a larger quantitative viral load monitoring study sample stratified for their viral load result in order to be able to explore a range of different experiences with different results. So therefore there were those who were suppressed, who were initially detectable who then resuppressed and those who remained detectable that were included in the study. 22 interviews were conducted in total and interview transcripts were analysed thematically using coding to identify emergent themes, patterns and concepts that came from the participant responses. Deviant cases or discrepancies from the majority themes were also actively sought. Now to the interesting part, what did we find from these interviews? Well, four main themes emerged around treatment literacy, support for adherence to ART, sexual practices and patient non-compliance. And I'll now go into these in more detail. So the first key finding was on viral load monitoring and enhanced treatment literacy. And when we talk about treatment literacy, what we mean by that is patients' overall health knowledge about their treatment. So all participants found viral load monitoring to be positive, useful, and it also reassured them that they were being taken care of. Some said that they preferred it to CD4 count monitoring because it enabled them to have a direct view of what was happening with the level of the virus in their body. An undetectable viral load result brought feelings of happiness, hope and encouragement for the future. But on the other hand, having a detectable result could bring fear, sadness and confusion. Viral load monitoring provided patients with a sense of ownership and control over their treatment and also over their health. And they said it is important for me to know about my life and how I am living. Some participants still had limited understanding about viral load and they said that they hadn't been given much information during visits to the clinics and they really expressed a strong desire to know more. So they said that they wanted more knowledge and more information about viral load monitoring. The participants that had lower understanding confused CD4 count and viral load monitoring. The second finding was that viral load monitoring supported adherence to ART and how was that the case? Well, viral load monitoring was said to, or the process of having your viral load monitored, was said to motivate adherence to ART through patients being able to see the effects that treatment had on the level of the virus. And that was particularly for those who had had a gap in their treatment taking when their viral load had subsequently increased so they could really see what effects that had on the viral load. And this increased their trust and belief in the treatment and therefore their motivation for continuing to take it. So you can see here one patient said, it encourages me to hold on and to take my treatment as prescribed. The point on stress or emotional difficulties has two parts to it. Some patients had periods of time where they stopped taking their treatment as a result of going through stress or emotional problems. Some also saw stress as directly causing their viral load to increase. The third finding is around viral load monitoring and sexual practices. So I mentioned earlier that there were concerns about whether having a known undetectable viral load result could increase unprotected sexual practices. We didn't find that to be the case. Viral load monitoring was said to motivate condom use but with an emphasis on self-protection. So these participants said that they were more motivated to use condoms because they either wanted to protect their undetectable viral load status or those that had a higher viral load they wanted to use condoms to try and lower their viral load. And that's linked to the health messaging within the project, where by patients are told that it's essential for them to use condoms to avoid their viral load from increasing. The connection between ART, viral load suppression and HIV transmission, particularly in terms of reinfection with resistant HIV, are still not well understood by patients. The difficulties that women face in negotiating condom use has been reported before. We also found that women can have severe difficulties on condom use negotiation, including experiencing abuse on suggesting condoms to their partners. And you can see here that one female participant said, at times you would say, here is a condom and he refuses to use them and then you'd be beaten. I have experienced such problems. So that really highlights the complexity of the reality. The last key finding is all about the interaction between health practitioners and patients and the effects that that has. Practitioners are said to assume that patients have done something wrong to cause their viral load to increase. For example, not adhering to treatment or having unprotected sex. Participants describe feeling blamed, abused, interrogated and judged by practitioners. This adds to their confusion and upset over receiving a detectable result. And it also makes it difficult for them to come forwards with potential challenges that they're facing because they're afraid of being reprimanded by health staff. This therefore undermines a supportive practitioner-patient relationship. In conclusion, this study found that viral load monitoring has a positive impact on adherence to ART, potentially also on treatment outcomes. And what can we take away from this? Well, there's a real need for increased patient information and knowledge about viral load monitoring in order to maximize the potential benefits that it can bring. For example, for treatment literacy and support for adherence to ART. We also need careful training of health practitioners to avoid viral load monitoring being used to reinforce those hierarchical practitioner-patient relationships. And we also need to consider the messaging around viral load monitoring that is disseminated, for example, on viral load monitoring and sexual practices. So I'd like to thank all of the patients and the staff members within the Schittelweeney Project who participated and contributed to this study. And also thanks to all of you for listening.