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Implementation challenges and opportunities for HIV Treatment as Prevention (TasP) among young men in… Knight, Rod; Small, Will; Thomson, Kim; Gilbert, Mark; Shoveller, Jean Mar 15, 2016

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RESEARCH ARTICLE Open AccessImplementation challenges andopportunities for HIV Treatment asPrevention (TasP) among young men inVancouver, Canada: a qualitative studyRod Knight1,2,3 , Will Small1,2, Kim Thomson3, Mark Gilbert3,4 and Jean Shoveller3*AbstractBackground: Despite evidence supporting the preventative potential of HIV Treatment as Prevention (TasP),scientific experts and community stakeholders have suggested that the success of TasP at the population level willrequire overcoming a set of complex and population-specific implementation challenges. For example, the factorsthat might influence decisions to initiate ‘early’ treatment have yet to be thoroughly understood; neither havequestions about the factors that enhance or impede their ability to achieve long-term adherence to ARVs or thesocial norms regarding various treatment regimens been examined in detail. This knowledge gap may hamperopportunities to effectively develop public health practices that are informed by the various challenges andopportunities related to TasP implementation and scale up.Methods: Drawing on 50 in-depth, individual interviews with young men ages 18–24 in Vancouver, Canada, thisstudy examines young men’s perspectives regarding factors that might affect their engagement with TasP.Results: While findings from the current study indicate young men generally have a high receptiveness to TasP,our findings also identify key social and structural forces that will warrant ongoing consideration for TasP implementation.For example, participants described how an enhanced awareness regarding treatment (including awareness of theuniversal availability of treatment in Vancouver) would be a necessary, but not sufficient, condition to decide to endorseTasP. Their decisions about engaging in HIV care in the context of TasP (e.g., HIV testing, treatment initiation, long-termadherence) also appear to be contingent on their ability to negotiate or ‘balance’ the risks and benefits to themselves andothers. The findings also offer insight into the complex and sometimes controversial narratives that continue to emergeregarding risk compensation practices in the context of TasP.Conclusion: Based on the results of this study, we identify several areas that hold promise for informing the effectivescale up of TasP, including new information regarding implementation adaptation strategies.Keywords: Treatment as prevention, HIV/AIDS, Young men, Canada* Correspondence: jean.shoveller@ubc.ca3School of Population and Public Health, University of British Columbia, 2206East Mall, Vancouver, British Columbia V6T 1Z3, CanadaFull list of author information is available at the end of the article© 2016 Knight et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Knight et al. BMC Public Health  (2016) 16:262 DOI 10.1186/s12889-016-2943-yBackgroundA growing number of clinical trials, cohort studies andmathematical modeling analyses indicate that antiretro-viral (ARV) treatment is effective in reducing the on-ward transmission of HIV from seropositive toseronegative individuals [1–5]. As a result, regional andglobal HIV prevention efforts are increasingly relyingupon HIV Treatment as Prevention (TasP) approachesas a key component of broader efforts to address theHIV epidemic, as evidenced by the UNAIDS’ [6] recentadoption of the ‘90-90-90’ testing, treatment and viralload suppression targets. Despite evidence supportingthe preventative potential of TasP, scientific experts andcommunity stakeholders have suggested that the successof TasP at the population level will require overcoming aset of complex and population-specific implementationchallenges.Treatment as preventionThe role of TasP within the rapidly transforming ARV-based prevention arena has had a significant impact inre-shaping the broader HIV continuum of care. Today,TasP is being implemented as a means to reduce sexual-and injection-related transmission of HIV among a var-iety of populations. Within the evidence in this area, alandmark clinical trial-HPTN 052-indicated that ‘early’initiation of ARVs can reduce the transmission of theHIV virus among heterosexual serodiscordant couplesby up to 96 % compared to couples who initiate therapyat previously recommended World Health Organizationthresholds (CD4 count < 250 cells/mm3) [5]. More re-cently, the PARTNER Study (an investigation of HIVtransmission through vaginal and anal condomless sexbetween serodiscordant heterosexual and MSM part-ners) reported that, among couples initiating ARV treat-ment, none had transmitted the virus to their partners[7]. Given these promising clinical and epidemiologicalfindings, treatment is now widely accepted as havingboth individual and community health benefits in that itcan prevent both HIV-related morbidity (e.g., progres-sion to AIDS), as well as the onward transmission ofHIV infection [8, 9].‘Fast-tracking’ the response to HIV/AIDS with TasPIn 2014 the UNAIDS called for a global scale-up of TasPand efforts to meet the following ‘90-90-90’ targets by2020: (1) 90 % of all people living with HIV will knowtheir HIV status; (2) 90 % of all people diagnosed withHIV infection will receive antiretroviral therapy (ART),that includes the use of ARVs; and (3) 90 % of all peoplereceiving ART will achieve viral suppression. Thesecommitments established a set of highly ambitious tar-gets regarding the scale-up of TasP that, as indicated inthe ‘90-90-90’ target guidelines, require various globaland local settings to ‘tailor approaches to address theunique challenges in diverse settings and populations’[6].Since 2010, Vancouver’s regional health authority hasimplemented a voluntary routine offer model for HIVtesting in primary and acute care settings, aiming to in-crease HIV testing rates by embedding testing withinroutine care. Funding and policy commitments have alsosupported universal availability of ARVs for HIV-positiveindividuals, ‘earlier’ initiation of ARVs (i.e., as soon aspossible following seroconversion and regardless of anindividual’s CD4 count), and enhanced efforts to treat allclinically eligible HIV-positive persons [10]. As such,Vancouver provides an interesting implementation con-text within which to examine factors that can influencethe scalability of TasP among a variety of key-affectedpopulations.Young men and HIV careScaling up TasP programmes and service delivery prac-tices may present a particularly salient set of implemen-tation issues among young men-a group with high andrising rates of HIV in addition to disproportionately lowlevels of engagement with health care seeking behaviourgenerally and HIV care specifically (e.g., compared toolder men and/or women). In 2012, for example, HIVincidence rates for men between the ages of 20–24 and25–29 in BC were significantly higher than the provin-cial average at 7.7 and 22.0 cases per 100,000 (comparedto the provincial average of 5.2 per 100,000) [11]. More-over, new HIV diagnoses in Vancouver have been in-creasing among younger cohorts of MSM (born 1980–1999), as compared with decreasing numbers of newHIV diagnoses among MSM cohorts born pre-1980 [12].As a result, HIV transmission in BC has been describedas a ‘re-emerging epidemic’ among young men, particu-larly in marginalized subgroups of men including MSMand men who inject drugs [12].Previous work has shown how socio-cultural influ-ences affect young men’s (non) participation in HIV test-ing [13–16], particularly through social norms regardingmasculinity, stigma and wait times [15, 17]. Young menalso face challenges when accessing sexual health ser-vices, including barriers to effective communication withhealth professionals, that can be exacerbated throughenactments of hegemonic masculinity [13, 14, 18–20].Furthermore, theories of gender relations, masculinitiesand men’s health behaviour suggest that men’s health ex-periences are influenced by the wider set of social rela-tions [21–24] that vary across other aspects of the socialhierarchy (e.g., socio-economic status). In general, menare less likely than women to seek care from health careprofessionals and more likely to engage in medium- tolong-term self-treatment strategies, as well as positionKnight et al. BMC Public Health  (2016) 16:262 Page 2 of 10‘help-seeking’ behaviour as potentially emasculating [22,23, 25, 26].While there is a growing empirical and theoretical lit-erature related to young men’s health-related practicesregarding their (non)participation with HIV testing, farless is known about how young men perceive otherlevels of the HIV continuum of care, particularly in therapidly evolving context of TasP. Previous research intovarious levels of the HIV cascade of care, however, havebeen extremely helpful at identifying how structural in-fluences, including HIV stigma, can have vast implica-tions for particular experiences with the HIV cascade ofcare that hold relevance for the imperatives of TasP (e.g.,barriers and facilitators to: HIV testing patterns; risk-reduction practices; capacity for long-term adherence toART) [27]. With respect to TasP, a recent review [28] ofempirical literature investigating the acceptability ofARV-based prevention strategies (specifically, TasP andPre-Exposure Prophylaxis-PrEP) found that only three of33 relevant articles focused on TasP. Furthermore,among the three TasP-related articles [29–31], none fo-cused on the needs or perceptions of young menspecifically.There is currently a dearth of information related tohow young men might respond to or perceive the evolv-ing HIV continuum of care in the context of TasP andgiven the universal availability of treatment in some set-tings, including what TasP means for evolving ‘risk land-scapes’ and testing practices of young men who are atrisk of contracting HIV, as well as those who may not beaware of their serostatus. Moreover, the factors thatmight influence young men’s decisions to initiate ‘early’treatment have yet to be thoroughly understood; neitherhave questions about the factors that enhance or impedetheir ability to achieve long-term adherence to ARVs orthe social norms regarding various treatment regimensbeen examined in detail. To date, these and other issues,including young men’s perspectives on other potentialunanticipated consequences that may arise in the con-text of TasP (e.g., risk compensation practices, such asreduced rates of sustained condom and/or sterile syringeuse), remain largely unknown. This knowledge gap mayhamper opportunities to effectively develop public healthpractices that are informed by the various challengesand opportunities related to TasP implementation andscale up among young men who are at risk for HIV and/or may not be aware of their serostatus.PurposeThe purpose of this study is to examine the knowledge,attitudes and normative understandings of young menwho are at risk for HIV acquisition, including those whomay not be aware of their serostatus, regarding the test-ing, treatment and long-term suppression imperatives ofTasP. To do so, we draw on data gathered through semi-structured, in-depth individual interviews with 50 youngmen (ages 18–24) in Vancouver, Canada.MethodsFor the reader, it is helpful to consider our motivationsfor conducting this analysis. The current analysis wasconducted as a part of a larger program of researchidentifying the structural and socio-cultural determi-nants of young men’s sexual health, with particular at-tention on the ethical and implementation factorsassociated with Vancouver’s evolving HIV intervention‘landscape’. Our analysis is grounded within a criticalrealist perspective [32, 33] that hypothesizes that socio-structural features of implementation context are dia-lectically interrelated with both the outcomes of anintervention (in this case, TasP) and the experiences ofthe intervention ‘targets’ (in this case, both young menwho do and do not know their serostatus, and/or are atrisk of HIV). For example, we aim to identify how fea-tures of contemporary socio-cultural contexts (e.g.,norms about young people’s sexual health practices) in-fluence young men’s perspectives and experiences re-garding the testing, treatment and preventionimperatives of TasP.Recruitment and data collectionData were collected between June and November 2013in Vancouver, British Columbia (BC) in Canada, whichprovides an ideal setting to examine perspectives aboutTasP. We drew on a stratified purposeful approach tosampling in order to capture variation within and acrossvarious sub-groups of young men (e.g., various lived ex-periences; social identities; behavioural, social and struc-tural HIV risk profiles). In total, fifty young men ages18–24 were recruited to participate in the study throughadvertisements at clinical sites (e.g., posters at youth sex-ual health clinics) and non-clinical settings (e.g., youthcenters; bus stops), as well as online (e.g., Facebook ad-vertisements; Craigslist). Participants also were recruitedfrom the At-Risk Youth Study (ARYS), a prospective co-hort of Vancouver youth who are or have previouslybeen street-involved and used illicit drugs (other thanmarijuana) (see Wood et al. [34] for more informationon the ARYS cohort). Eligibility criteria include: ages18–24; ability to speak and understand English; identifyas a man (including cisgender and/or trans* identifiedmen); currently sexually active or have been sexually ac-tive previously.Participants completed an informed consent form anda 9-item socio-demographic questionnaire, prior to par-ticipating in an in-depth, semi-structured, individualinterview (see Table 1 for additional information on thequestions and probes used during our interviews toKnight et al. BMC Public Health  (2016) 16:262 Page 3 of 10discuss some of the tenets of TasP). All interviews wereaudio-recorded and were conducted within our team re-search offices. Participants were offered the choice to beinterviewed by a male interviewer (co-author RK) or afemale interviewer (a research assistant), though noneexpressed a preference. Interviews lasted 1 to 1.5 h induration and were conducted by interviewers with train-ing in qualitative health research methods, as well as ex-tensive experience conducting interviews with youngmen regarding sexual health. Participants were asked todescribe their thoughts regarding HIV treatment (e.g.,availability; effectiveness) in Vancouver (and elsewhere).They also were asked to describe their perceptions re-garding the effectiveness of HIV treatment in terms ofthe prognoses for HIV-positive individuals as well astheir opinions regarding the capacity of TasP to protectseronegative partners (e.g., partners with whom theyshare drugs; sex partners). Participants were providedwith a description of TasP and asked to describe the ex-tent to which they felt these approaches were ‘fair’ and‘justifiable’. Participants also were asked to explainwhether or not they perceived TasP to be somethingthey might consider for themselves (i.e., would theychoose to initiate treatment in the event of an HIV posi-tive diagnosis for either or both treatment and preven-tion reasons?).We did not ask participants to disclose their HIV sta-tus, a decision we arrived at only after considerable dis-cussion and debate within our team. In the end, wechose not to ask interview participants to disclose theirstatus for the following reasons. Firstly, the legal systemin Canada currently adopts a “criminalization” approach.A 2012 ruling by the Supreme Court of Canada hasupheld the criminalization of HIV non-disclosure exceptwhere both a condom is used and the person has a ‘low’HIV viral load. A conviction of aggravated sexual assaultcould result if these requirements are not followed.Bearing all this in mind, we thought that it was notwarranted from an ethical perspective to ask studyparticipants to disclose their serostatus to us. Instead,we have provided context regarding various aspects ofHIV-related risk at the individual level (e.g., use ofcondoms; injection drug use) as well as at the structurallevel (e.g., recent experiences with being street-entrenchedor homeless).Participants received a CDN$25 honorarium to com-pensate them for their participation. Ethics approval wasobtained from the University of British Columbia’s Be-havioural Research Ethics Board (#H12-01936).Data analysisInterviews were transcribed and accuracy checked andthen uploaded to Nvivo10. First, co-authors RK and KTread and re-read the transcripts, assigning initial codesthat were then grouped thematically. Next, we used anopen-coding approach in which coding was first orga-nized into ‘trees’ to group the codes thematically. Theemergent thematic codes focused on capturing the mi-cro- (e.g., previous experiences), meso- (e.g., interper-sonal relations) and macro (e.g., socio-cultural) factorsthat shape men’s opinions and behaviour related to HIV,with a specific focus on ARV treatment initiation andlong-term adherence (e.g., successes, challenges). Dis-crepancies between codes and coders were resolvedthrough discussion and re-visiting the raw data at codingduring team meetings. Next, each thematic was exploredfurther by asking three key analytic questions: (a) Howdo men perceive HIV care in Vancouver in the contextof universally available treatment, and how might thisinfluence their engagement with TasP programmes andservice delivery practices?; (b) What are the factors thatinfluence men’s perceptions regarding HIV treatmentand TasP?; and (c) What do participants raise as import-ant challenges or opportunities for young men’s engage-ment with TasP? Thus, as we conducted our thematicanalysis, we employed both inductive and deductive ap-proaches by continually comparing our emergent themesTable 1 Questions and probes to specifically discuss TasP during the interviewsQuestions ProbesSome people have told us that because there are more advancedHIV treatment opportunities, some of the concerns related to HIV areno longer as important.a. What do you know about HIV treatment?b. Providing treatment to people who are HIV+ can also make themless infectious-in other words, if somebody who is HIV+ is receivingtreatment, they will not be as likely to give HIV to someone else.This has been referred to as ‘treatment as prevention’, because thetreatment is offered to patients to prevent HIV transmission, regardlessof whether or not the individual is at a stage of HIV infection thatrequires treatment for their individual benefit (e.g., so they don’tbecome sick). What are your thoughts on offering treatment toindividuals who are HIV+ in order to prevent them from transmitting HIV?• Tell me how the availability of HIV treatment might influence your decisionto go for HIV testing? How might the availability of treatment affect thetesting decisions of your friends (guys/girls)?• How acceptable do you think it would be if you were HIV+ and youwere offered treatment so that you would not be infectious, ratherthan for your own health-related concerns?• Some have argued that it might be unfair to treat an HIV-infected personin order to prevent them from infecting others because it places anotherdemand on people who might be very vulnerable people (e.g., poor people;people who use injection drugs). Can you tell me what your thoughts areon the ‘fairness’ of this approach?Knight et al. BMC Public Health  (2016) 16:262 Page 4 of 10with the existing literature in this area with our empir-ical data [35].ResultsStudy participantsA total of 50 young men completed interviews. Partici-pants ranged in age from 18 to 24 (mean age: 21.7).Thirty-two percent (n = 16) of participants identified asgay, bisexual or Two-Spirit, 68 % (n = 34) as straight.Forty-eight percent (n = 24) were recruited from theARYS cohort, with the remaining 52 % (n = 26) recruitedeither through online advertising or posters. Table 2provides additional socio-demographic information ofour sample.Overview of findingsWe report our findings using two thematic categoriesregarding the participants’ perceptions of TasP: (1) Re-flections about treatment and treatment initiation in thecontext of TasP; and (2) Perceived challenges and oppor-tunities regarding long-term viral load suppression.Quotations from participants’ transcripts are presentedto illustrate the various themes that arose during our in-terviews and related to each thematic. Each quotation ispreceded by a short description of each participant’ssocio-demographic profile and a researcher-assigned nu-meric code follows each quote.Reflections about treatment and treatment initiation inthe context of TasPOur interviews began by asking participants to describehow their understandings of contemporary HIV treat-ment regimens might influence their engagement withHIV care. Within this conversation, some participantsexplained that they had limited knowledge regardingHIV treatment and asked our interviewers for some add-itional information. We explained to the participantsthat, when effectively treated and diagnosed early, HIVseropositive individuals can expect a near normal qualityof life and longevity. Upon reflecting on this informa-tion, several participants indicated that knowing moreabout the availability and effectiveness of HIV treatmentmight make them more likely to access HIV testing ser-vices. For example, a 24-year-old straight man described:I think knowing what it would be like if I testedpositive would make me more prone to get tested,‘cause, like, I don’t know how justified this is, but I hadthis idea that the prognosis is pretty bad. Maybe that’sjust ignorance, I don’t know. But I think if people knewwhat happens next more, it would make testing moreeasy to decide to do. (#020)After reflecting on how available and highly effective HIVtreatment might influence their HIV testing practices, sev-eral participants expressed concern that, despite the effect-iveness of treatment, there would likely be ‘insurmountable’economic barriers to acquiring treatment that they wouldnot be able to overcome – and these concerns were par-ticularly salient among men experiencing multiple andintersecting forms of disadvantage (e.g., living on thestreets; addiction issues). For example, after being informedthat treatment can greatly improve an HIV seropositive in-dividual’s quality and length of life, a 22-year-old bisexualman and a 20-year-old straight man expressed concern:But I don’t know if that [information about HIVtreatment and prognoses] makes me any lessconcerned about certain aspects of the disease justbecause I also know that it’s [treatment] expensive,and that definitely plays into me, ‘cause I know that ifI needed to afford expensive medication, I just couldn’tright now. (#018)Table 2 Socio-demographic characteristics of study sampleEthnicity (n) (%)Aboriginal 6 12African-Canadian 1 2Euro-Canadian 26 52Latin 2 4South East Asian 7 14Middle Eastern 1 2Other 7 14Living arrangementWith parents 9 18With friends or partner 22 44Alone 7 14In a shelter or on the street 11 22In a recovery house 1 2Sexual OrientationBisexual 8 16Gay 7 14Heterosexual/straight 34 68Two-Spirit 1 2Gender IdentityTransgender man 1 2Cisgender man 49 98Recruitment mechanismOnline advertising 23 46Posters 2 4ARYS study (see recruitment detailsfor information on the ARYS study)24 48Other 1 2Knight et al. BMC Public Health  (2016) 16:262 Page 5 of 10You’re still fucked [in the event of an HIV diagnosis]. Idon’t even know if it’s covered by MSP [MedicalServices Plan, the provincial health care plan in theprovince of British Columbia]. I highly doubt it. So ifyou’re on welfare and you have HIV, I think you’repretty fucking screwed. And I would not want to haveto figure it out, either. (#041)During this part of our interviews, we explained thatHIV treatment is universally available free-of-chargethrough the medical services plan in BC to clinically eli-gible patients. We also described to participants thatthere are preventative benefits associated with HIVtreatment by explaining that HIV seropositive individualswho achieve viral suppression are less likely to transmitHIV to their uninfected partners. Upon reflecting on thisinformation, most participants were eager to learn moreabout a variety of aspects of HIV treatment. For ex-ample, when we asked them to consider the differentpieces of information that they would need to know inorder to inform their decision about treatment initiation,the majority of participants described that they wouldwant to learn more about the various potential sideeffects associated with HIV treatment. For instance, a23-year-old straight participant explained how hisdecision-making about treatment initiation would re-quire a careful balance of the health benefits versus thepotential side effects associated with drug toxicity:Participant: It [initiating ARVs] all depends on theside effects of the treatment. If the side effects werereally serious, I probably would not want to do it,because side effects from drugs, from treatment likethat, could be very serious. So, yeah, I probably wouldnot do it if the side effects were too serious.Interviewer: Okay. And, if the side effects weren’t toobad?Participant: I would be very glad to do it so I don’tspread it to other people. (#028)At this point in our interviews, we provided partici-pants with some additional information regarding HIVtreatment, including a description of how treatment isnow generally considered to be safe if treatment regimesare effectively followed. As participants reflected on HIVtreatment and whether they might consider initiatingtreatment, two dominant themes emerged from theirnarratives about why they would consider initiatingtreatment immediately following an HIV diagnosis. First,participants described how preventing future harm (i.e.,transmitting HIV) to their sex partners would representan important consideration. For example, one 22-year-old bisexual participant described:Personally, I’d go on that sort of treatment just tomake sure that it is safe for my partners. (#018)The preventative benefits of treatment were also posi-tioned as constituting a “public safety” measure in the par-ticipants’ narratives about HIV treatment. For example,another 22-year-old bisexual participant described:If the medicine is destructive on the body then thereare certain compromises that can’t be made. But froma point of public safety, I think it is important forsomebody to take it if they’re gonna be puttingthemselves at risk of spreading it. (#007)Similarly, among a small sub-set of participants, someelaborated how treatment would also be a beneficialmeans to protect the partners with whom they exchangeor share injection drug equipment. For example, a 24-year-old straight man who had previously injected drugsdescribed how he would expect others who seroconvertand inject drugs to initiate treatment in order to helpprevent the likelihood of onward transmission throughcontaminated equipment:I couldn’t imagine being like, “No, I don’t want togo through treatment,” and just, like then beingcompletely sloppish about disposing of anythingwith blood on it or like needles. I just don’t knowwhy someone would want to run the risk of infectingsomeone. Like, why wouldn’t you want to gettreatment and just try to nip it in the bud as quickas you can? (#031)We also asked them to consider how they would wantto be offered treatment in the event of an HIV diagnosis.Some of the participants expressed concern that clinicalcommunication strategies would need to be tailored in away that transparently delineates the various risks andbenefits associated with ‘early’ treatment initiation. Forexample, one 23-year-old straight man explained:I think if it’s [clinical recommendations regardingARV initiation] sort of proposed in the form of aquestion or as a sort of an option amongst several,right? Then I think those sorts of things continue torespect the autonomy of other people. Whereas if it’skind of, you know, strongly recommended or, you know,bordering on coercive, then I would question thelegitimacy of that kind of approach. (#013)Some participants described how seropositive individ-uals could feel ‘targeted’ within clinical encounters ifthey perceived that their clinician was emphasizingpublic health benefits (e.g., prevention of onwardKnight et al. BMC Public Health  (2016) 16:262 Page 6 of 10transmission) over clinical concern for the individualpatient being recommended for treatment. For ex-ample, one participant described:The person may feel like, ‘Well, you’re only making meundergo treatment because you just wanna protectthose around me and decrease their chance ofcontracting the infection, as opposed to treating meand being concerned about me.’ So I can see theperson viewing the measure as ‘all but me.’ (#001)Thus, within our interviews regarding treatment initi-ation, participants’ responses underscored how their de-cision making regarding the initiation of treatment inthe context of TasP would be contingent on their abilityto negotiate or ‘balance’ the risks and benefits to others(e.g., preventing transmission of the virus) with the risksand benefits to themselves (e.g., potential side effects oftreatment vs. personal ‘peace of mind’). Taken as awhole, these narratives reveal that, despite having limitedawareness regarding TasP (e.g., the preventative capacityof treatment; understandings about the universal avail-ability of treatment in the Vancouver setting), participantsgenerally responded with high levels of acceptability andreceptiveness towards the approach.Perceived challenges and opportunities regardinglong-term viral load suppressionWe asked participants to reflect on the various chal-lenges that young men who choose to initiate treat-ment might face with regards to achieving long-termadherence to treatment (and therefore be more likelyto achieve viral load suppression). Participants de-scribed an array of different challenges, including howvarious social and structural conditions could serve toeither positively or negatively impact young men’scapacity to adhere to a treatment regimen. For in-stance, a 20-year-old gay man described how theplaces where one lives, and their socio-economic sta-tus, would differentially influence one’s prospects forsuccessful adherence and health outcomes in theevent of an HIV diagnosis:Even within Vancouver, I know that like if I’m ahomeless person with intravenous drug use on theDowntown Eastside [an inner-city neighbourhood]and I’m not eating right because I’m homeless and Idon’t have a job and I’ve been mentally ill, life isgoing to be hard [in the event of an HIV diagnosis].Whereas, if I’m a gay man on Davie Street [Vancou-ver’s ‘gay village’] with a nice middle-class job, life isgoing to be liveable. So I think even within Vancouverthere’s like, it depends on a lot, you know, your placein society. (#014)A sub-set of participants who had reported a historyof being street-entrenched also described how the vari-ous hardships that they experience in ‘street life’ wouldinfluence their capacity to adhere to treatment. For ex-ample, a 24-year-old straight man and a 19-year-oldstraight man who both were living on the street at thetime of our interview described how the challenges ofdrug use and street life would likely influence adherencerates:I would think if you’re sharing rigs and out havingmultiple partners and all that […] I can’t imaginesomeone keeping up with the upkeep of doing that kindof treatment or something, you know? […] That’s just, Ican’t see them having too much of a structure in theirlife where they would have a daily routine to dosomething like that. (#031)Because, like, some people won’t take their pill. Theymight be high, they might be sleeping, they might justforget about it. (#040)As the interviews progressed, some participantsexpressed concern that individuals who choose to initi-ate treatment might reduce their use of other HIV pre-vention strategies. For example, a 23-year-old straightman described how he worried condom use would de-crease among those who choose to initiate ARVs:Condom use would definitely go down without adoubt, just because people would be, I think peoplewould contract HIV […] Like, “I can’t give somebodyHIV now, so there’s no need to use a condom”. Unlessthey can still get them pregnant or something like that.So, I think it would go down, and I don’t think that’s agood thing. (#029)Some participants described how ongoing publichealth efforts might be able to mitigate these con-cerns. For example, one 23-year-old bisexual partici-pant described how a set of tailored clinicalcommunication strategies should be developed to in-form men that TasP is not 100 % effective at pre-venting HIV transmission:I think it’s [TasP] good. But I think that, with it,there should be a statement that says to peoplethat you’re not completely risk free. You are not100 % risk free. […] I think there should be like,at least fail-proof prevention that comes with themedication to say that it would help protectyourself and other people, but also, however, youare not 100 % risk free so always advise yourpartner that you’re HIV positive. (#038)Knight et al. BMC Public Health  (2016) 16:262 Page 7 of 10While most participants tended to position TasP ashaving an added benefit to individual HIV preventionrepertoires (e.g., how young men engage with testing,treatment and prevention practices), one 20-year-old gayparticipant expressed frustration that, as an HIV sero-negative individual, he perceived that TasP puts the re-sponsibility of HIV prevention largely in the hands ofseropositive individuals, as he described:As a prevention strategy, I’m like, okay, that’s focusingon the people who have HIV and could transmit itwhich makes sense, I guess? But as it’s like mepersonally as someone who would be getting the HIV,it doesn’t do anything for me. […] Maybe that’s justme being really self-interested in that I don’t see myselfas a gay men represented there-as an HIV negativegay man. […] Yeah, cause it’s not ‘prevention asprevention’, it’s ‘treatment as prevention’. But it takestwo people to transmit HIV, right? And [TasP is] onlydealing with half those people. (#014)These findings begin to reveal how some men mayascribe complex social meanings to TasP, where it mightsimultaneously be perceived as over-emphasizing per-sonal responsibility, while also being linked with riskcompensation practices that have negative connotationsin terms of social responsibility.DiscussionOverall, knowledge levels regarding ARV treatment andTasP were low. Most participants suggested that in-creased awareness regarding ARV treatment (includingawareness of the universal availability of treatment inthe Vancouver setting) would be a necessary, but not asufficient condition to inform their decision-making re-garding the use of ARVs for prevention or treatment. In-stead, these decisions would more likely be contingenton their ability to negotiate or ‘balance’ the risks andbenefits to themselves and others (e.g., preventing trans-mission of the virus; potential side effects of ARVs; per-sonal desires to know one’s HIV status). The currentstudy reveals how decisions to initiate TasP may bestrongly influenced by both the ability to keep one’s selfhealthy, as well as the ability to protect others from in-fection. Furthermore, the findings offer insight into thecomplex and sometimes controversial narratives thatcontinue to emerge regarding risk compensation prac-tices in the context of TasP [36, 37]. This remains anarea that requires more investigation to fully inform eth-ical approaches to implementing and scaling up TasP inways that do not exacerbate ‘victim blaming’ [38].The findings also highlight how the successful imple-mentation of TasP will require a sophisticated set ofclinical communication strategies-even in settings whereARVs are available universally-thereby underscoring theextent to which TasP educational and communication ef-forts should not be based solely at ‘target’ populations(e.g., young men), but also to those tasked with imple-menting TasP at the patient-clinician interface [39]. Forexample, clinicians require the resources and skill sets toprovide knowledge that patients require to make in-formed decisions regarding TasP-including the side ef-fects associated with initiating ARVs and their capacityto reduce onward disease transmission. Excellent com-munication strategies are particularly salient given thatnew evidence regarding the risks and benefits of ‘early’initiation of treatment (i.e., immediately following sero-conversion) is rapidly unfolding. Rapidly changing infor-mation ‘landscapes’ pose significant challenges to clinicaldiscussions and demand a high level of commitment tostaying current and remaining open to change as newevidence emerges regarding best clinical practice. Forexample, while some have expressed concern that earlyinitiation of ARVs may lead to an increase in potentialside effects, including reduced bone density and kidneydamage as well as the potential for an individual’svirus to develop resistance to ARVs [40], emergingevidence indicates the individual benefits (e.g., de-creased incidence of primary and secondary infec-tions) associated with early uptake may outweigh thenegative side effects [41, 42].We were also struck by the concerns expressed by sev-eral participants that TasP strategies could tend to disre-gard the interests of HIV-negative individuals by notaffording them enhanced agency or opportunity to en-gage in individual risk-reduction practices. While at firstthese concerns seemed to contradict the acknowledge-ment that TasP can have community-wide benefits byreducing the incidence of HIV, it is worth reflecting,however, the extent to which these concerns are es-poused from within a socio-historical context in whichpublic health has largely placed the responsibility of HIVprevention at the level of the individual, rather than viabroad, structural and population-level interventions. In-deed, the young men in this study recognized the pre-ventative capacity of TasP, while not privileging it as theonly way to prevent HIV transmission or acquisition. Indoing so, these narratives tended to align more closelywith the messaging within contemporary cascades ofcare that emphasize combination approaches to HIV riskreduction.Sampling (e.g., due to under-coverage, some popula-tion sub-groups of young men may not be adequatelyrepresented) and participation bias (e.g., men whochoose to volunteer for a study about HIV may tend tohave a similar set of experiences or beliefs about HIV)may have influenced the sample composition and do notfully reflect all variations of young men’s perspectivesKnight et al. BMC Public Health  (2016) 16:262 Page 8 of 10regarding TasP. As such, the findings are not claimed as‘representative’ or generalizable to all young men. More-over, the potential amplification of response biases (e.g.,social desirability bias) may have also influenced thesorts of responses participants felt appropriate in thecontext of an interview about young men’s sexual health.While, towards the end of our data collection activities(i.e., after the 40th interview), new insights were no lon-ger generated regarding TasP (thereby indicating theor-etical saturation was attained), the findings are notclaimed as ‘representative’ or generalizable to all youngmen. Nonetheless, our study provides rich insights intothe perspectives of a diverse group of young men withinVancouver (including those from population sub-groupsof men who have historically been characterized as being‘high risk’ for HIV acquisition), thereby revealing a set ofimplementation challenges and opportunities for scalingup TasP programs and service delivery practices in thissetting.ConclusionOverall, these findings provide important opportunitiesfor those charged with implementing and scaling upTasP efforts, including achieving the 90-90-90 testing,treatment and adherence targets. Clinicians and publichealth campaigners alike may benefit from better under-standings of key target populations’ perspectives regardingTasP (e.g., perceptions about the availability of treatment;their perspectives on treatment initiation and long-termadherence). While findings from the current study indi-cate young men generally have a high receptiveness toTasP, our findings also identify key social and structuralforces that will warrant ongoing consideration for TasPimplementation.AbbreviationsARYS: at-risk youth study; ARV: antiretorivral; CD4: cluster of differentiationantigen 4; HIV: human immunodeficiency virus; MSM: men who have sexwith men; MSP: medical services plan; TasP: treatment as prevention.Competing interestsThe authors declare that they have no competing interests.Authors’ contributionsRK, JS and KT analyzed the data and developed the thematic findings. RKdrafted the first version of the manuscript with subsequent contributionsfrom all co-authors. All authors read and approved the final manuscript.AcknowledgementsThis study was supported by the Canadian Institutes of Health Research(HHP-123778 and EPP-122906) and the US National Institutes of Health(R01DA033147, R01DA028532, U01DA038886). We are thankful to the youngmen who took part in this study, as well as the current and past researchersand staff involved with these studies. Knight is supported by a Post-DoctoralFellowship from CIHR. Small is supported by a Career Scholar Award fromthe Michael Smith Foundation for Health Research. Thomson is supported bya Canada Graduate Scholarship from CIHR.Author details1Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada. 2BritishColumbia Centre for Excellence in HIV/AIDS, Vancouver, Canada. 3School ofPopulation and Public Health, University of British Columbia, 2206 East Mall,Vancouver, British Columbia V6T 1Z3, Canada. 4Ontario HIV TreatmentNetwork, Toronto, Canada.Received: 18 January 2016 Accepted: 8 March 2016References1. Chang LW, Serwadda D, Quinn TC, Wawer MJ. Combinationimplementation for HIV prevention: moving from clinical trial evidence topopulation-level effects. Lancet Infect Dis. 2013;13(1):65–76.2. 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End of the debate about antiretroviral treatment initiation.Lancet Infect Dis. 2014;14(4):258–9.•  We accept pre-submission inquiries •  Our selector tool helps you to find the most relevant journal•  We provide round the clock customer support •  Convenient online submission•  Thorough peer review•  Inclusion in PubMed and all major indexing services •  Maximum visibility for your researchSubmit your manuscript atwww.biomedcentral.com/submitSubmit your next manuscript to BioMed Central and we will help you at every step:Knight et al. BMC Public Health  (2016) 16:262 Page 10 of 10

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