A Role for Health Communication in the Continuum of HIV Care, Treatment, and Prevention

"The aim of this article is to explore the role of health communication, an approach within the social and behavioral sciences, across the treatment continuum" for HIV. The article is from the JAIDS: Journal of Acquired Immune Deficiency Syndromes supplement addressing clinicians and public health scientists in the field of HIV prevention and treatment who might value information on health communication. (Footnotes removed by the editor.)

The authors "provide illustrative examples of the specific roles that health communication can play in bolstering the continuum of care in low- and middle-income countries... and draw on ...reviews ...and studies ... [of] interventions that incorporate health communication components" in order to approach health communication's potential to improve outcomes across the continuum of care through supporting development of a framework "that translates health communication theories and practices into specific interventions to address each step in the treatment cascade."

The first section discusses linking patients who test positive for HIV to care and treatment. "Current research underlines the importance of interpersonal communication in linkage to care through counseling, both in clinical settings and at patients' homes. For instance, a RCT [randomised controlled trial] in Uganda found that enhanced posttest counseling coupled with home visits and continued counseling support from trained volunteers significantly improves the uptake of pre-ART [anti-retroviral adherence] care." Results of a similar programme in Uganda showed that "the intervention improved HIV clinic attendance by women, but not by men, and reduced the time to initiation of ART for those eligible men, but not for women."

Improving ART studies have shown that "clinics with educational materials and food rations available were significantly associated with lower attrition compared with clinics without these services. Furthermore, clinics with available peer educators, support groups, and adherence reminder tools were associated with lower rates of measured death compared with clinics without these services." Some communication-based strategies for adherence that have been evaluated are:

• A comparison of counseling to counseling with the added use of a reminder alarm for medication adherence alarm, an alarm on its own, and the absence of counseling or an alarm in Kenya found that the counseling interventions increased adherence, while the added alarm had no effect.
• A 4-session comprehensive intervention for couples, delivered by a nurse practitioner, and group counseling and education resulted in increased adherence. "Three cohort studies in sub-Saharan Africa that trained counselors to improve their skills found higher levels of adherence at the study's end than at baseline", suggesting that quality of the counseling matters to the outcomes.
• Due to high caseloads in low- and middle-income countries, "[t]ask shifting, decentralization, and employment of lay health care workers have emerged as promising interventions."
• Two randomised trials in Kenya "provided high-quality evidence that mobile telephone short message service (SMS) consisting of medication reminders, motivational messages, or questions that required a response could improve adherence. The trial..., in which nurses or clinical officers sent SMS messages to inquire about participants' well-being and called unwell patients and nonresponders for additional support, found that SMS support also improved rates of viral suppression.... At the same time, in [a] Cameroon mobile phone SMS study, standardized motivational text messages did not improve adherence outcomes compared with usual care without text messages, suggesting that additional research and the tailoring of messaging to specific populations are necessary to achieve consistently improved outcomes."

Retention in care may be improved through: overall provider-patient communication; psychosocial and organisational support from a community member ("patient navigators" or guides) accompanying the patient to health care visits; and counseling by community health care workers. "For example, a community-based ART program in Rwanda achieved 92.3% retention in care after 24 months from 2005 to 2008" by enrolling patients in education and support groups meeting the same day as clinic appointments and "included daily visits by trained community health workers who directly observed therapy and offered psychosocial support."

The discussion of other communication interventions that might be incorporated into the treatment continuum includes: "mass media, school- or workplace-based education, or entertainment modalities (eg, street theater) in addressing specific steps in the treatment cascade, have been traditionally used in HIV prevention efforts." However, more research is needed. "For instance, there is preliminary evidence from Malawi that provision of a workplace-based clinic and support group can increase the uptake of HIV testing and care, and provide good ART outcomes, but the communication aspects of this intervention were not clearly developed."

Finally: "Although many behavioral intervention efforts clearly incorporate health communication components, a framework that explicitly draws on health communication theories and practices is rarely identified as part of an intervention to improve ART. Such a framework would need to map specific communication theories, proximate determinants, and interventions to specific purposes at each step along the continuum of care in both clinical and nonclinical settings, resulting in a hands-on toolkit for program design. The development of this framework would also facilitate clearer assessment of the health communication components that might be applied within comprehensive models of care."