Addressing disengagement from HIV care amongst vulnerable populations with a focus on mobile fishing communities in Malawi

Background Fishing is important in Africa for income and survival. It is estimated that 20.6 million Africans will be engaged in fishing activities by 2030. Fishing communities in Africa have one of the highest HIV prevalence estimates (up to 37%) due to complex 'fish for sex trade', alcohol use and ART sharing. Fishing communities are also poorly engaged in HIV services; many studies report that even after starting treatment a low proportion achieve viral suppression (~73%), unacceptable both for their own health and for community transmission. High rates of mobility, essential to sustain successful fishing and fish trading, are associated with disengagement from HIV care leading to treatment interruption, viral non-suppression and increased risk of developing ART resistance. Existing ART adherence interventions do not address the unique ART needs and lifestyles of mobile fishing communities, who have little control over where they will be day to day. Fishing in 'boat teams' while living with HIV is often highly stigmatised, is associated with risk of inadvertent disclosure, and now compounded by climate change. There is a dearth of interventions tailored to the unique health, economic and social priorities of fishing communities. Research question How can gendered understanding of disengagement from HIV care be leveraged to co-develop with stakeholders an acceptable, sustainable and affordable intervention that can increase HIV viral suppression among mobile fishing communities to meet global targets? Aim To identify, co-develop with stakeholders and test for feasibility an intervention to support ART continuation that can increase rates of viral suppression among mobile fishing communities. Objectives Understand how mobile fishing communities navigate the complexity of HIV care and how this understanding may lead to better models of care that are responsive to their unique and gendered needs. Identify a preferred intervention through a discrete choice experiment. Co-produce a gender responsive intervention with stakeholders (mobile fishing communities, health care workers and policy makers). Pilot final intervention to assess acceptability, efficacy, gender responsiveness, feasibility, affordability and sustainability. Methods A mixed-methods project with five work packages that will recruit men and women in fishing communities in Mangochi, Malawi. First, a formative phase involving social science (in-depth interviews with 30 men, 30 women from mobile fishing communities and 5 policy makers; 3 focus group discussions with health care workers). Second, a discrete choice experiment (N=250; 125 men and 125 women). Third, 3 intervention co-development workshops with stakeholders. Fourth, piloting the intervention (N=200; 100 men and 100 women). Finally, evaluation of implementation guided by the RE-AIM framework using semi-structured interviews (50 men and 50 women from mobile fishing community, n=10 health care workers) and a costing study using an Ingredients Cost Method. Anticipated impact and dissemination Key outputs include: a feasible and acceptable intervention for improving viral suppression among mobile fishing communities; one PhD thesis; one scoping review; peer-reviewed papers and policy briefs. Timelines for delivery Years 1-2 will focus on completing the research components with ongoing policy and community stakeholder engagement. Translation of findings will be in year 3.