People With HIV on Medicare Have Surprisingly Large Gaps in Treatment
Over a Quarter had a 30-day Gap or Longer in Antiretroviral Treatment and 10% had Continuous Gaps of 90 Days or More, LDI Fellows Find
Population Health
Brief
Research Brief: Simple Visual Aids Raise Awareness and Knowledge About HIV Treatment
Bead-Filled Bottles May Change Attitudes and Help Prevent HIV Transmission, LDI Fellows Show in Philadelphia Studies
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Bottles filled with red and black beads representing the HIV virus among healthy cells improve understanding of terminology, attitudes toward living with HIV, and the intention to take medication to prevent transmission. People living with HIV in Philadelphia interacted with B-OK bottles (Figure 1) while a researcher explained that they show the amount of virus in the body when HIV is diagnosed, if HIV is untreated, and with daily antiretroviral therapy. B-OK increased understanding that medication prevents dying from HIV and reduces the risk of transmitting the virus to others. The bottles could support a U.S. initiative to cut new HIV diagnoses, currently stuck at 38,000 per year, by 90% by 2030.
Research Question
Can a simple, visual, tactile communication tool help people living with HIV in Philadelphia improve knowledge about and intentions to take anti-HIV medication?
By taking daily medication, people living with HIV can suppress the virus so it becomes undetectable in a blood test and, therefore, untransmittable. In Philadelphia, a 2020 report estimated that 61% of new HIV transmissions were from people living with HIV but not taking sufficient medication. Medical case manager support improves medication adherence but communicating the benefits of medication remains challenging. LDI Senior Fellows Alison Buttenheim and Harsha Thiramurthy learned about the B-OK intervention through work in South Africa where B-OK was developed. Based on promising results there, the researchers brought B-OK to Philadelphia, where LDI Senior Fellow Aaron Richterman launched what is likely the first U.S. study of the nonproprietary innovation. At four case management agencies, 118 clients took surveys before and after a five-minute individual educational session using the B-OK bottles, with 57 clients interviewed before or afterward. In focus groups, 29 case managers discussed B-OK.
The Findings
The B-OK intervention was associated with progress in several areas (Figure 2). Surveys of client participants showed significantly increased knowledge about the terms “viral suppression” and “Undetectable = Untransmittable.” Focus groups with medical case managers and interviews with clients also demonstrated that understanding Undetectable = Untransmittable as an HIV prevention concept might motivate medication adherence. Client attitudes toward HIV improved, with a significant change in the belief that having HIV means eventually dying from it. The intention to act on the knowledge that treating HIV prevents transmission improved significantly, based on a question about HIV transmission during sex with someone with undetectable status.
However, other answers suggested lingering concerns that HIV medications might not completely eliminate risks to themselves or others. Interview and focus group participants were enthusiastic about B-OK. Medical case managers expressed high levels of acceptability, feasibility, and appropriateness of B-OK for explaining HIV treatment and prevention. They said they had no similar tools for medication adherence support.
The Implications
B-OK tells people living with HIV they can “be OK” by taking medication. The bottles are inexpensive and easy to incorporate into case managers’ conversations with clients. Case managers and clients found B-OK to be helpful conversation starters and useful in both group and individual settings, including people with limited English proficiency. B OK may work by creating accurate mental models about how antiretroviral medications stop HIV progression and transmission.
It may empower people with a stigmatizing condition by changing their focus from loss of health to the preventive benefits for others of viral suppression. This immediate, achievable goal may motivate people who, at diagnosis, may not feel sick. At a time when the value of international collaborations is in question, B-OK shows that an innovation developed in a low- or middle-income country could help people in the U.S. Although study participants were representative of people living with HIV in Philadelphia and case management is standardized across the type of case management agency used in this study, the preliminary results are from a single intervention with participants during agency visits. Longer-term and clinical effects are currently unknown. The researchers plan to systematically test B-OK in a multistage intervention comparing standard case management to the simple, low-cost addition of B-OK. Clients who need more help with medication adherence will be further randomized to receive additional assistance.
The Study
Study participants were from four case management agencies in Philadelphia: 29 case managers in focus groups and 118 English- or Spanish-speaking clients, median age 55 years, 65% male, 96% cisgender, 72% non-Hispanic Black, with 99% receiving antiretroviral therapy but 33% reporting suboptimal adherence in the past 30 years. From March to April 2023, researchers recruited clients for pre- and post-B-OK surveys, with 57 also giving in-depth interviews, 20 before intervention and 37 after. This research was supported by a grant from the Penn Center for AIDS Research (CFAR), an NIH-funded program (P30 AI 045008).
Source Publications: Richterman, A., Klaiman, T., Palma, D., Ryu, E., Schmucker, L., Villarin, K., Grosso, G., Brady, K. A., Thirumurthy, H., & Buttenheim, A. (2025). B-OK: A Visual and Tactile Tool for Improving HIV Mental Models in a United States Urban Center. AIDS Care 1–12.; and, Richterman, A., Klaiman, T., Connelly, R., Palma, D., Ryu, E., Schmucker, L., Villarin, K., Grosso, G., Brady, K. A., Thirumurthy, H., Buttenheim, A. (2024). Acceptability, Feasibility, and Appropriateness of the B-OK Bottles as an Implementation Strategy for Treatment Adherence Support by Medical Case Managers. Global Implementation Research and Applications, 4(4), 433–445.
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