ART diversion in Rakai, Uganda

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Summary Drug sharing is commonly reported for other prescription medications, but to date, no studies have examined antiretroviral drug diversion (buying, selling, borrowing, or lending) for therapeutic use among people living with HIV. We previously conducted qualitative interviews with people living with HIV in high-prevalence fishing communities (hotspots) along Lake Victoria in the Rakai region, Uganda. Participants reported frequent, short- term sharing of antiretroviral treatment (ART) with coworkers/friends that was motivated by the desire to keep taking drugs despite challenges to regular clinic attendance and adherence. However, we do not know how common ART diversion is at the population-level, who is most likely to divert antiretroviral drugs, or whether ART diversion affects HIV treatment outcomes such as HIV viral suppression. We therefore propose a mixed methods study to better understand ART diversion and whether it can be leveraged to reach and support sub-optimally adherent, hard-to-reach individuals living with HIV. The study will be conducted through the Rakai Community Cohort Study, a population-based cohort study conducted among all residents aged 15-49 in 40 communities in southcentral Uganda. Aim 1 will measure the prevalence, distribution, and factors associated with ART diversion in this representative sample. Aim 2 will assess the association between ART diversion and HIV viral suppression. Aim 3 will explore acceptability and feasibility of a novel intervention among ART-sharing dyads that builds upon these existing networks of social trust to reach sub-optimally adherent, hard-to-reach HIV patients.