Testing when I know my status: The social dynamics of household HIV testing in HPTN 071 (PopART) trial communities, South Africa

Landmark studies demonstrating a reduction in onward HIV transmission and improved survival have informed a shift in global antiretroviral therapy policy to a ‘treat all’ approach. Global HIV stakeholders have called on countries to urgently scale up their HIV programs, involving responsibilities for various health system actors for accelerating HIV epidemic control. In this article we explore how community members in South Africa who were part of a large-scale ‘Universal Testing and Treatment’ trial made decisions around taking up home-based HIV testing, a major component of the trial's intervention and the entry point to a comprehensive continuum of HIV prevention and care. Drawing on data collected with a qualitative cohort of purposively selected households in the study intervention communities between 2016 and 2018 we describe how the goal of achieving HIV epidemic control was internalized, enacted, and potentially transformed in the interactions between community members and health workers in high HIV burden community settings. Further, we consider the implications for how community members related to their individual health and a collective responsibility to a broader public health good (in this case HIV epidemic control). Our findings suggest that in contexts of precarity – where there is low social cohesion – a community-wide health intervention can create an avenue for people to perform being good, moral citizens. Our findings reveal how complex community and social dynamics inform decisions to take up health interventions, rather than purely ‘rational’ understandings of individual and collective health benefit.