[dropcap]A[/dropcap]n independent interim review of the Strategic Timing of AntiRetroviral Treatment (START) study findings shows that initializing treatment early improves outcomes for individuals with HIV, according to a May 27, 2015, press release from the National Institutes of Health. START, a major international randomized trial across 215 sites in thirty-five countries, shows that treatment-naive patients have a decreased risk of progressing to serious AIDS-related events or developing other serious non-AIDS-related illnesses if they start a regimen when their CD4 cell counts are 500 cells/mm3 and above rather than when their CD4 cell counts fall below 350, which has been a key time to start treatment if it has been deferred.
Although current U.S. guidelines recommend starting treatment even if asymptomatic and no matter what your CD4 cell count is, the START study is the first study to offer concrete and comprehensive proof that early treatment in treatment-naive individuals confers expansive health benefits.
Along with the data from previous studies, START also showed individuals on antiretroviral treatment have a lower viral load, and therefore a decreased risk of transmitting the virus to uninfected sexual partners, further bolstering the Treatment as Prevention approach.
Treatment and testing access for everyone is essential. But how do we help empower HIV-negative, status-unknown, and HIV-positive individuals to approach sexual health with more forethought than afterthought? One campaign has zeroed in on Mondays.
Web search engines seem to be busier on Mondays, at least when it comes to surfing for health-related information about HIV prevention and testing. According to analysis published in the April 21 edition of the journal AIDS Care, researchers at Johns Hopkins Bloomberg School of Public Health and The Monday Campaigns have found that Monday is the day when many individuals seek out HIV/AIDS information. The analysis, “An exploration of weekly patterns in HIV-related behaviors: implications for successful interventions and future research” by Laura W. Fuentes, Morgan L. Johnson, MPH, and David R. Holtgrave, PhD, builds on other research that suggests that Monday is a reset day, when people look for resources such as informational hotlines, expert advice, and general health information. Researchers in the HIV information study analyzed literature reporting on weekly patterns of HIV information-seeking behaviors; the analysis was restricted to English-language articles.
Along with an increase of HIV-related information searches on Mondays, researchers also found that risky sexual behaviors increase on the weekends, and, for those who are HIV-positive and in treatment, adherence to regimens goes down slightly on weekends.
Additionally, researchers found that innovative care interventions, such as weekly text messages to HIV patients, improve antiretroviral adherence. They suggest, too, that expanding weekend clinic hours can help dismantle a significant barrier to testing and care. Ultimately, the researchers are committed to meeting people where they are and starting the engagement there, instead of asking individuals to adapt to already institutionalized practices and ideals.
Understanding these patterns may help health workers and public-health strategists develop even more new ways to improve HIV-related linkages to testing and care, and therefore reduce transmissions and improve the health of individuals who are positive.
The Monday Campaigns, a nonprofit public health initiative in association with Johns Hopkins Bloomberg School of Public Health, Columbia University Mailman School of Public Health, and the Maxwell School of Syracuse University, is capitalizing on this trend with Man Up Mondays, a cheeky, sex-positive initiative to encourage sexually active men to stay on top of their sexual health and nurture practices, such as reflecting on their sexual health decisions, seeking out HIV and STI testing, and restocking condoms, that will benefit them.
A&U corresponded with Morgan L. Johnson, director of programs and research for The Monday Campaigns and an author of the study, about the ideas behind Man Up Mondays and its early successes.
Chael Needle: Are individuals to some extent trapped by the social construct: Monday as a reset day and Friday as a “party now, worry later” day? Is the ultimate goal to change health decision-making behavior so that any day can be a reset day, if need be, to connect to care?
Morgan L. Johnson: To be clear, though we do advocate for Monday as a “reset” day, we don’t advocate for Friday as a “party now, worry later” day. As mentioned in the study, it may be the case that people treat Friday (and the weekend generally) this way, but what we’d like to see is more people building on their good Monday intentions throughout the week so that by the time the weekend rolls around, they are in the right mindset to protect themselves and make healthy choices.
You are correct that any day can be a potential reset day and that quick connection to care is critical, but Monday seems to have the most potential as a reset day for coordinated public health communication: More people are paying attention to their health on Monday and are more willing to take action, whether it is getting tested or getting back on track with their medication adherence. Leveraging Monday as a day for communication improves the reach and efficiency of public health campaigns—very important in these times of diminished resources for public health programming.
Even as the campaign has reached out to individuals of all gender identities, the name of the campaign reframes a gendered idea of having courage. Is there evidence that (young) men, culturally, tend to approach health with a sense of bravado, as in “I’ll soldier through the pain”? And is this what you are seeking to disrupt among all individuals?
There are many reasons why men might not seek care, potentially including this “sense of bravado” you’ve described. Certainly there is evidence of there being a culture of prompting men from a young age to “tough it out,” which is often linked in the social sense to “being a man.” As illuminated in a 2014 paper in the American Journal of Public Health, these types of gender norms can ultimately prove harmful if they end up resulting in missed care opportunities. What we’ve tried to do with “Man Up Monday” is to shift the concept of masculinity as “toughing it out” to masculinity as “taking responsibility.” So far, this is indeed how the campaign has worked out, as evidenced by our success with the pilot programs at Planned Parenthood and University of Missouri and Murray State University [where the campaign has been shown to increase STI testing]. That said, we are of course aware of the fact that different populations may not internalize the “Man Up” concept as taking responsibility, so we are careful to monitor how the campaign is doing in all the settings it has been deployed—we certainly want to make sure the campaign is not promoting harmful gender norms.
Is there evidence that these Monday health knowledge-seekers are akin to frantic WebMD searches when one discovers a new mole. If so, I imagine this less-than-calm mindset is anathema to feeling empowered about one’s health, and, in this context, sexual health. Is this what you are offering too—a calmer, destigmatized approach to learning about testing and treatment?
We don’t yet know very much about what people’s specific motivations are for running web searches on health topics on Monday. We have a few theories: that people are generally more motivated to make positive change on Mondays; that people feel guilty about weekend behavior and want to make up for it by doing better on Monday; that Monday serves as a sort of “fresh start” or “mini New Year’s” during which people like to recommit themselves to their health resolutions. We’d love to tease this out a little so that future campaigns can target each of these potential motivations, but for the time being just knowing that there are far more people looking for help on Monday is sufficient justification for getting those messages out there at the beginning of the week.
Indeed, we are keen to de-stigmatize testing and treatment, which is why our creative team went with the strategy of humor over some of the scare tactics you often see used in public health media campaigns. With this lighter approach, we hope that people do see Monday as a day for a fresh start—an opportunity to do better, which is a much more positive and effective way to promote health than telling someone they did something “bad” that they need to “fix.” People are more likely to ignore those stronger admonishments than have an “a-ha” moment that gets them into the clinic for testing and/or treatment.
You’ve seen successful pilot programs at Planned Parenthood of Southeastern Virginia as well as the University of Missouri and Murray State University. What are the campaign’s next steps in terms of research?
As I mentioned, we’d really like to learn more about why people are motivated to take action on their health on Monday as it will help us to refine the messaging for different target populations. We are also interested in continuous quality improvement of our campaigns, so we will continue to collect feedback on the campaign materials themselves from the people that have seen them (i.e., the people that come into the clinic and report doing so because they saw a poster or other piece of creative material). Finally, as the campaign is adopted by other clinics, health departments, universities, etc., we want to make sure to evaluate the impact the campaign is having on actual testing and treatment metrics, or even prevention metrics such as condom usage. Beyond the research, we are also interested in testing out a more women-focused campaign we’re calling “Woman Up Monday” to see if that messaging resonates more with women than the Man Up campaign has, even though we know women have often responded well, even going so far as to accompany their male sexual partners to testing, an ideal outcome if ever there was one!
For more information about Man Up Mondays, visit: www.mondaycampaigns.org/campaigns/man-up-monday.
Chael Needle interviewed researcher Patricia LiWang, PhD, about her silk protein film prevention candidate for the March issue.