 All right, good evening everyone today I'm going to be presenting about a study that I've conducted as part of my PhD thesis in health psychology So this is a study where we looked at using an active visualization device to try and improve adherence to antiretroviral therapy within South Africa Before I move on to talk about the study that we conducted I thought I'd give a bit of background about my PhD topic My thesis is looking at this idea of visualization and how we can use visualizations of medical disease and treatment to improve adherence So the idea here is that we show patients what's going on inside their body Both in terms of how their illness might have occurred but also how treatment might help to try and control that So we do that through using a number of things such as 3d modeling or animations Images that can show patients these processes that are occurring inside More recently we've been interested in this concept called active visualization So the distinction here is that instead of using these static kind of images or 3d models We instead use animations or even live demonstrations And the idea here is that these things can actually show more of a process of what's going on inside the body Instead of just a still snapshot of one point in time So we use one of these active visualizations within the study that I'm going to talk about today And this is the device in certain stages as we were going through development What it ended up looking like was this picture here So it's basically a human-shaped body made of perspex and what we wanted to do was to really clearly demonstrate What happens when patients take their antiretroviral therapy versus when they don't and Unlike other treatments with antiretroviral therapy if patients don't adhere the treatment actually becomes less effective over time So we have this liquid inside which is pink and we say that that represents the presence of the virus within the body And we change the color of the liquid inside from pink to clear We do that through changing the pH balance of the liquid inside So we add in a tablet that represents their medicine, but it's actually just an aspirin tablet So the body always starts pink and we explained that this represents the presence of your HIV infection However, when you take your tablet each day This fizzes around and the liquid inside eventually turns clear This represents that the HIV viral load is under control and it's not able to replicate So that's what occurs on day one, but we wanted to explain the purpose of consistent adherence over time So even though on day one your viral load is under control because you've taken your medicine on day two You then need to take it again So we add in some more of this virus solution which changes the color inside back to pink And then again we add another tablet that fizzes around and changes it back to clear So helping patients to understand that the infection isn't reversible, but by taking their medicine each day They can control the level of viral load inside their body We then show patients what happens if they are consistently not adherent over time So they keep missing doses over and over again, and we just have our virus solution going into the body The color inside becomes more and more and more pink and this time when the person forgets Sorry, remembers to take their medicine. It's dropped into the body and it fizzes around, but the color remains pink So helping patients to understand that if they consistently miss doses Their treatment is actually going to become ineffective at controlling the level of virus within their body That was a pretty quick run through of the methodology we used But we have published this editorial which does explain it in a bit more detail in AIDS and behavior So moving on to the randomized controlled trial This was a study that we conducted as I mentioned in South Africa And we wanted to use this device to see if we could improve adherence within a group of non-adherent patients And our primary outcome measure here was change in viral load Which we measured from looking at patients blood tests So if viral load should decrease as patients are more adherent to their treatment That's kind of the direct association between those two things Just a bit about the context. So we conducted the study in collaboration with Stellenbosch University That's about 30 minutes outside of Cape Town in South Africa And you can see here the kinds of clinics that we're working in are quite different to what we might see when we're working Within clinics here in New Zealand and of course South Africa has a very Large HIV epidemic and the number one reason for treatment failure is actually non-adherence to treatment The study itself we ended up recruiting a hundred and eleven HIV patients So these were patients who were failing on their regimen one or two treatment They're recruited from two sites a peri-urban hospital and a community clinic They completed a baseline assessment and then were randomized into one of two conditions the control and intervention group I just thought I'd point out that in this context standard care, which was received by all Participants includes adherence counseling So that's the doctor actually talking to the patient about their non-adherence Explaining the problems with it and trying to encourage them to change their behavior So all patients receive that but our intervention patients also saw our active visualization device And we collected follow-up data anywhere from two months after they saw the intervention And then retrospectively went back and got a baseline level of viral load from their blood test data as well Just a bit about the sample I think it's important to point out the differences between our sample and what we might see if we're working within chronic illness here in New Zealand And that's really a quite low level of education a high rate of unemployment and low levels of monthly family income So it's a really low socioeconomic status group and I think that's something to remember when thinking about working within this context So moving on to the results This was our primary outcome change in viral load over time from baseline to follow-up And this is the raw level of viral load within their blood test So you can see here that the intervention condition decreases significantly more than the control group over time You can see however that these numbers are really large when you look at what viral load is and how it's calculated So more commonly we report the log transform score, which is an expression of these numbers to the power of 10 You can see here again that the intervention condition significantly Sorry marginally significantly improved at point oh six Versus the control group and that's actually a clinically significant reduction So any change of point five or more in log viral load is associated with a 30% decrease in the risk of clinical progression And I think it's important again to remember that we'd expect everyone to get better because everyone had adherence counseling But it's great that our brief intervention was able to improve it to a clinically significant amount even above that And just a bit of psychological data that we collect we always ask our Participants what thoughts ran through your mind when you saw the device obviously these things are quite abstract So it's interesting to see the ideas that people take away And we coded these thoughts and found that more than half of the sample actually had a thought relating to adherence Which was really good. They were taking away the message that we wanted them to So thoughts such as my adherence beforehand was poor I now see how important the treatment is so that was really encouraging to see What can we conclude from this study well our device was highly accepted and it seems to highlight the importance of adherence to our group of participants our device was brief portable and it's very easy to use and It resulted in a clinically significant change in viral load for this really high need group of Non-adherent patients within this context of South Africa There are of course some limitations to what we found the first would be the viral load data that we had available This was quite messy We just looked at the records that patients had from naturally coming in and and having their routine blood test appointments Of course that meant there was a lot of missing data and a lot of variability and when they actually showed up for testing But we figured that was better and less influential than asking them to come in and have another blood test Which could also be interfering with their behavior change that we want to see There may have been other contextual factors going on that affected patients adherence to appointments and Adherence to their medicine as well and they may have been language barriers as our session was only conducted in Africans and English I Think there are significant strengths of our study though and one would be that ecological validity So we went into this context and we delivered this session alongside the patients speaking to their doctor So it could easily be incorporated into standard care as a sort of adjunct to this adherence counseling Where do we go from here? Well, I think there's a lot of applications for this device It could be used at treatment initiation So helping patients to understand the need for treatment in the first place so they don't become non-adherent It could be used with children It's a nice easy educational tool to understand this quite difficult and abstract process with pregnant women So they understand the need to be adherent to their treatment and they don't pass on infection to their unborn child And obviously it could be used within remote communities, which is really important within South Africa It doesn't rely upon technology. It's very cheap Which means it could be taken to these hard-to-reach communities and there is also some application to use this device within prep So to help patients to understand the purpose of pre-exposure prophylaxis Which helps to prevent HIV infection from being contracted So that's all from me, just some acknowledgements to my supervisors Our collaborators at Stelenbosch University and some other people who are instrumental in helping us create this device Thank you