Flip the Script: Rebranding ART and enhancing the U=U message in Malawi and Zimbabwe

Setting the stage

Since 2009, countries across the world have made substantial progress in identifying undiagnosed People Living with HIV (PLHIV) and initiating them on treatment, with the number of people worldwide increasing from 6 million to 29.8 million by 2022 (UNAIDS, 2023). However, many of those enrolled in ART have not remained on treatment. For example, in Zimbabwe, it is estimated that 20% of all PLHIV enrolled on ART are lost to follow-up, and in Malawi this estimate is 26% (MPHIA 2020-2021; ZIMPHIA, 2020). These losses threaten to undermine the tremendous gains of the HIV response, harming not just the health of PLHIV who stop treatment, but that of their sexual partners and children.

Despite substantial and ever-growing evidence that PLHIV with undetectable viral loads do not infect their sexual partners, very few PLHIV know that being on ART will prevent them from transmitting the virus (Bor et al., 2021; Siegel & Meunier, 2019). Instead, across sub-Saharan Africa, ART is still powerfully associated with HIV itself. Using antiretrovirals has become a source of stigma and shame rather than a source of control, responsibility, or respect (Blake Helms et al., 2017).

"Undetectable = Untransmittable" (U=U) has emerged as a crucial global intervention in HIV management, originated from scientific evidence that people with HIV who maintain an undetectable viral load through adherence to Antiretroviral Therapy (ART) cannot sexually transmit the virus to others (Aoko et al., 2023; Bavinton et al., 2018; Bavinton et al., 2019; Cohen et al., 2011; Loutfy et al., 2013; Rodger et al., 2016; Yombi & Mertes, 2018). The U=U movement, founded by the Prevention Access Campaign in 2016, not only brought forth a new dimension in biomedical HIV prevention but also sought to dismantle HIV-related stigma (Prevention Access Campaign, (n.d.)).

Examples like San Francisco's "Getting to Zero" campaign, which incorporated U=U as a key component, witnessed a substantial reduction in new HIV diagnoses by leveraging the preventive benefits of viral suppression (Buchbinder & Havlir, 2019). Similarly, in Australia, the "Opposites Attract" study substantiated that amongst serodiscordant couples, where the HIV-positive partner maintained viral suppression, there were zero linked HIV transmissions (Bavinton et al., 2014).

Nonetheless, the global understanding of the U=U concept and its policy and programmatic adoption have been imbalanced. In Africa and Asia, awareness, attitudes, and practices regarding U=U have varied starkly, influenced by factors such as socio-cultural norms, healthcare professional knowledge, and government-led HIV initiatives. A systematic review "Changing Knowledge and Attitudes Towards HIV Treatment-as-Prevention and Undetectable=Untransmittable” illuminates a discernible gap in the awareness and acceptance of the U=U message globally, with a notably limited penetration in Sub-Saharan Africa as compared to other regions. The article underscores the imperative to enhance knowledge translation and adoption of U=U, particularly in high HIV burden settings like Zimbabwe and Malawi (Bor et al., 2021).

Addressing the low saturation and comprehension of the U=U message in Malawi and Zimbabwe provides a foundational challenge for our methodology. Infused with key insights from prior programming such as the “Coach Mpilo” project in South Africa, combined with formative qualitative and quantitative data from Malawi and Zimbabwe, our program aimed to develop a marketing and brand strategy that did not merely promote the benefits of ART but aimed to change social and individual perceptions regarding HIV treatment (Hlongwa et al., 2022; The Coach Mpilo Website, n.d.). One of the key insights from the Coach Mpilo program in South Africa was the recognition that the messenger can be as impactful as the message itself (Bruns, 2021; Hlongwa et al., 2022). Therefore, our methodology places strong emphasis on the identification and utilization of a compelling, credible messenger – someone who is capable of connectingthe medical world and the lived experiences of individuals in Sub-Saharan Africa. This "Flip the Script" approach aims to recalibrate ART not as a stigmatizing symbol of infection but as a key that unlocks a pathway to a normalized, healthy life for PLHIV.

“Flip the Script” was established through a unique partnership between private and public sectors, including Ipsos Mori, Fieldstone Helms, TBWA Zimbabwe, Bwanji Malawi, PSI, the Bill & Melinda Gates Foundation, PEPFAR/OGAC, and Johnson & Johnson. The project was initiated to change the narrative around ART and catalyze transformative impact on PLHIV’s lives. PSI and partners acknowledged a significant opportunity for health systems to shift counseling standards, dismantle previous stigmatizing messages, and reintroduce the prospect of sex and intimacy beyond condoms for sexual partners. The initiative aimed to break the cycle of stigma and shame in PLHIV’s lives, fostering a life full of vibrancy, including the possibility of condomless intimacy.

Grounded in human-centered and co-design approaches, the project ensured host country governments played a vital leadership role, encouraging collaboration between stakeholders, influencers, and the target audience from the outset. This strategy was crucial for crafting a globally resonant brand, while allowing for necessary country-specific adaptations in line with regional and national priorities.

Aiming to transcend geographical boundaries and promote south-to-south learning across the sub-continent, the “Flip the Script” initiative aimed to make the U=U message more routinely communicated by trusted messengers in more comprehensible and resonant ways. Expected outcomes included:

These objectives are addressed through several key intermediate outcomes:

Ultimately, the initiative strived to increase the percentage of PLHIV who achieve & sustain viral suppression and to reduce HIV incidence. The Theory of Change for Flip the Script presented in Figure 1.

Figure 1. Flip the Script Theory of Change.

Formative research and human centered design

Previous methodologies and campaigns. The Flip the Script program leveraged commercial marketing tools—including formative research, strategic marketing campaigns, and human-centered design approaches—and ongoing stakeholder engagement to cultivate an impactful framework rooted in regional lessons learned in the HIV space. Evidence from previous studies indicates that the synergy of social marketing and key stakeholder collaboration has been pivotal in sculpting effective HIV treatment campaigns, with notable achievements in ART adherence and establishing affirmative emotional linkages among PLHIV towards their treatment (Underwood et al., 2014). Applications of social marketing, especially via mass media, have improved understanding and acceptance of ART, and have demonstrated the potential to simultaneously reduce the stigma attached to HIV/AIDS in countries like Malawi, by delivering behavioral programming that is both culturally and emotionally resonant (Rimal & Creel, 2008). This emotional resonance proves to be pivotal in crafting, designing, and implementing impactful HIV-related communication strategies, especially in the context of PLHIV in sub-Saharan Africa (Underwood et al., 2014).

Stakeholder involvement, particularly supporting campaigns focused on HIV treatment and management, is recognized not merely as a procedural formality but as a fundamental element that guarantees the cultural relevance, community acceptance, and effectiveness of the campaign with its target audiences (Babalola et al., 2016).

Formative research. After validating the theoretical underpinnings of our methodology through an extensive literature review, we set out to conduct formative research in Malawi and Zimbabwe to fill gaps from existing literature. The project started with a research phase, investigating both the existing knowledge and emotional resonance that PLHIV and healthcare workers had regarding ART and its benefits. Ipsos MORI led the research through a two-phased approach: a qualitative phase involving in-depth interviews with PLHIV, nurses, and community influencers in Malawi and Zimbabwe; and a quantitative segmentation phase targeting a larger sample of PLHIV and healthcare workers, including nurses, counsellors, and community healthcare workers. This approach aimed to learn from lived experiences, understand current perceptions, and identify strategic insights for the campaign to effectively convey its crucial messages. The interviewers were both males and females.

Key research objectives included:

Qualitative research

We also interviewed 24 HCWs and 24 community influencers to gain insights into the perspectives influencing PLHIV. Key insights revealed that PLHIV trusted HCWs yet perceived a lack of emotional support from them. Both clients and providers had a limited understanding of U=U, and the motivation for PLHIV to adhere often stemmed from a desire to support families and communities.

From PLHIV, we learned that knowledge of treatment benefits was limited, there was a strong negative association between ART and HIV, nurses were credible but often perceived as rushed, medical terminology was confusing, secrecy was a major issue, and there were specific role model preferences for male and female PLHIV. Some key insights included:

From HCWs, we found a disconnect in perceptions of HIV stigma—in clinical settings, judgment often takes precedence over empathy, providers distrust patients, and medical terminology is used to maintain professionalism. Some of the key insights from HCW that informed the design process include:

In exploring attitudes of those not identified as HIV positive, we found a lack of familiarity with U=U, and supportive attitudes towards PLHIV, but a reluctance to engage in romantic or sexual relationships with them, highlighting the need for broader communication about ART's capability to prevent sexual transmission.

The key insights from influencers revealed that proximity to PLHIV increases empathy, attitudes towards sex and marriage are exceptions, there's judgment based on perceived causes of HIV, treatment literacy is low, and PLHIV are seen as trusted sources of inspiration. Some of the key insights from influencers that informed the design process include:

Quantitative research

The second component of our formative research was a quantitative survey of n=786 adult PLHIV and n=504 HCWs, including nurses, counsellors, and community healthcare workers, building on pivotal themes distilled from the preceding qualitative research. This survey was key in uncovering the distribution patterns of key beliefs and depth of knowledge across both PLHIV and HCWs, enabling the creation of a psychographic segmentation of each demographic. A post-hoc hybrid cluster methodology was employed in the segmentation analysis for both young PLHIV and HCWs, considering factors such as needs, attitudes, perceptions, behaviors, and approaches towards HIV treatment.

Moreover, the survey provided crucial data from the PLHIV quantitative research which informed both channel selection—based on reach and exposure—and identified trusted sources of information. This PLHIV segmentation allowed PSI and partners to narrow in and prioritize a target audience for the campaign that would ultimately inform the brand architecture, while the healthcare worker segmentation illuminated prevalent misunderstandings and negative attitudes among healthcare workers, thus, shaping the development of counseling tools destined for utilization in clinical settings. This quantitative segmentation was integral to comprehend whom and how to precisely target the campaign and each embedded message. PLHIV segmentation is presented in Figure 2.

Figure 2. PLHIV segment overview.

The five distinct PLHIV segments identified by Ipsos MORI across both countries are differentiated by demographics, adherence levels, information sources, and psychosocial factors.

Segmentation prioritization

Utilizing a set of well-defined segment prioritization criteria, the teams analyzed the research findings to identify the most critical segment for intervention:

Based primarily on these criteria and the guidance of the Ministries of Health, the team prioritized Segment 4, the Apathetic Navigators, as the key demographic for our intervention.

This segment, comprising a significant portion of the population at 22%, is largely male and under 35 (87%), displaying a concerning ART adherence rate of 31% despite an average HIV duration of 7.6 years. Their substantial size and critical health need, paired with their actionability and reachability, make them an optimal target.

The Apathetic Navigators' disconnect between HIV knowledge and treatment action, combined with prevalent misconceptions, positions them as a segment that could benefit significantly from a targeted communications campaign. Their relative indifference to societal perceptions simplifies the intervention framing and messaging.

They were also deemed reachable due to their openness to HIV-related communication. Given that 62% have awareness of HIV/ARVs, strategies can leverage this to convert apathy into action.

In both Zimbabwe and Malawi, Segment 4 offers challenges and opportunities for impactful interventions, from empowering and proactive health management to addressing healthcare access and misinformation. The success in these countries could inform strategies across sub-Saharan Africa, considering the region's shared PLHIV challenges.

While HCWs play a critical role, the team chose not to prioritize one segment of HCWs as a separate focus segment, intending to maximize the use of scarce resources and foster synergies between all HCW segments for health impact.

Intervention design

Design method. Over a period of two months starting in June 2021, the Ministries of Health in Malawi and Zimbabwe, alongside PSI, Fieldstone Helms, TBWA Zimbabwe, Bwanji Malawi, engaged in multiple virtual co-design workshops, led by a human-centered design expert.

The I Can program uses an integrated channel strategy featuring radio, press, digital, print and outdoor as reinforcing mediums that complement interpersonal communication (IPC) as the core intervention. The I Can campaign features testimonial-style executions of people living with HIV who have achieved important romantic, family, work, or educational milestones because of being on treatment. These executions are delivered through a mix of media types and that mix should be informed by evidence about media usage in your target audiences and reflected in a well-considered media plan. Above the line (TV, billboard, radio, and digital) creative materials were developed using formative research, audience insights, and the creative expertise of Fieldstone Helms. Content, tone, visuals, and scripts were pretested iteratively with audience members to ensure resonance, comprehension, and emotional appeal. IPC materials for use by both HCW and ART Champions were both adopted from other successful programs and developed through design workshops with healthcare providers in Malawi and Zimbabwe. These tools, and the training that accompanies them, are the core of the campaign because successfully communicating about treatment as prevention requires one-on-one or small group interactions.

Campaign concepts and tools were subjected to rapid field testing, led by Ipsos MORI, employing a real-world conversation approach to garner immediate and actionable feedback from the target demographic. Ipsos MORI recruited the same respondents from the qualitative and quantitative research components to ensure selection of Segment 4 demographic. This cycle of ideation, development, and field testing is reiterated multiple times, facilitating a continuous loop of feedback and refinement. The intervention design process ensured that the developed initiatives are grounded in theoretical assumptions and constantly informed and validated by real-time user responses.

We also strategically integrated insights gleaned from Positive Youth Development (PYD) best practices, drawing on the success of prior projects focused on HIV-prevention in sub-Saharan Africa. A notable reference in this regard is the DREAMS initiative, a multi-country project that has significantly contributed to reducing HIV incidences among adolescent girls and young women in the region (Birdthistle et al., 2018; Chimbindi et al., 2020). By fostering an environment that nurtures the inherent strengths and abilities of young people, our initiative aimed to emphasize youth empowerment and the notions of improving social capital to help Segment 4 take control of their health and make informed decisions regarding HIV prevention and treatment.

Additionally, we drew inspiration from the Zvandiri program in Zimbabwe, which combines clinic-based HIV care with community-based support, provided by trained adolescents and young people living with HIV (Busza et al., 2017). This peer-led approach aligns with the PYD framework, emphasizing the role of positive relationships and support networks in fostering resilience and adherence to HIV treatment.

By leveraging these proven strategies and integrating them into our intervention design methodology, we sought to create a supportive and empowering environment for young people living with HIV, encouraging adherence to treatment, reducing stigma, and ultimately contributing to better health outcomes.

Key design insights

The research in Malawi and Zimbabwe uncovered shared challenges among the PLHIV in Segment 4 in both countries. People in this segment experienced life-altering disruptions, with a stark loss of sexual and psychological security due to mandatory condom use, implying risks to partners. This led to strained relationships and weakened community ties. Additionally, while HCWs were trusted for information, their advice often lacked relevance and actionability. Despite hardships, a strong and healthy appearance, equated with societal participation and acceptance, was paramount.

In Malawi, belonging and societal contribution were linked to visible health and strength, crucial in a rural agrarian setting. Thus, "looking good" equated to being healthy and capable. Interventions are needed to address these connotations, reshaping perceptions of strength in the context of HIV. Enhancing HCW communication was essential to align with PLHIV's aspirations.

In Zimbabwe, HIV induced a sense of societal and familial disconnection, resulting in a feeling of apathy. Interventions aimed to foster hope, using success stories to demonstrate that a fulfilling life with HIV is possible were identified as having the highest potential. The introduction of relatable "Champions" in communities sought to shift PLHIV's self-perception from passive to active, addressing the detrimental impacts on treatment adherence and concerns about appearance.

From these insights, four key themes informed our campaign design:

A unifying theme of “strength” emerged as a powerful motivating factor for treatment adherence across both countries, serving as a foundational anchor for our campaign and the overall brand architecture. In Malawi, strength was not merely physical but deeply embedded in societal value and worth. Strength signified one's capacity to contribute to communal life, especially in a predominantly agrarian setting. To be perceived as healthy, and thus strong, was tantamount to being a valuable member of the community, emphasizing the crucial role of appearance as a determinant of social inclusion.

On the other hand, in Zimbabwe, the diminished sense of agency among PLHIV underscored a different dimension of strength. Their pervasive apathy and diminished self-worth were challenged by introducing real-life role models or "Champions", intending to reignite the internal strength, resilience, and belief in their potential. In both contexts, the campaign’s focus on strength sought to redefine and reclaim the inherent power and capability of PLHIV, positioning them not as passive recipients but as empowered individuals with an active role in their communities and lives.

The mapping apathetic navigator insights to brand architecture (Figure 3) highlights how the insights derived from our co-design process played an instrumental role in shaping our brand architecture—a crucial guiding mechanism for the overarching strategy of the initiative, ensuring consistency, relevance, and impact across all program touchpoints or channels. This framework not only serves as the campaign’s backbone, articulating its core identity and value proposition, but also aids in forging a resonant and meaningful connection with our target audience. The insights derived from our co-design process played an instrumental role in shaping this architecture, as they provided a nuanced understanding of the emotional and practical needs of PLHIV.

Figure 3. Mapping apathetic navigator insights to brand architecture.

The theme of "Fitting In" reflects the deep-seated need for social acceptance and the fear of ostracization, highlighting the vital role of social acceptance with regard to personal well-being. This insight aligns with our Overall Equity, which focuses on reclaiming pre-diagnosis freedom and normalcy. The feeling of "In Control" ties directly to our Key Benefits, emphasizing ART's role in reinstating control over one's life and health, counteracting the daily reminder of HIV through medication. The "Missing Out" insight underscores the desire to fully participate in life's precious moments, a yearning addressed by ART's promise to let PLHIV live a full life without missing out. Lastly, the need for "Sexual Freedom" speaks to reclaiming a vital part of personal identity and relationships, aligning with ART's benefit of enabling pre-diagnosis sexual relationships.

By weaving these insights into our Brand Architecture, we've crafted a campaign that resonates on a personal level with PLHIV, guiding them on a journey from fear and uncertainty to empowerment, control, and full participation in life.

“I Can” campaign development and communication strategy

With a clear brand architecture in place, our next phase delved into the design of the insights-driven brand campaign strategy, ensuring that every component of the approach was finely tuned to resonate with our audience. By leveraging the insights uncovered from our co-design process, we worked on communication objectives and messages that spoke directly to the hearts and minds of people living with HIV, addressing their deep-seated needs, aspirations, and challenges.

This approach necessitated the establishment of a key umbrella message, serving as a guiding star for all our communication efforts. In the creation of the campaign, the central theme "seeing is believing" emerged from a common sentiment among PLHIV: skepticism about maintaining a fulfilling life on ART. This insight brought to life the concept that showing could be more impactful than merely telling. Thus, the campaign introduced the idea of featuring “ART Champions," PLHIV who would exemplify the potential of life with ART adherence. These champions, sourced from varied backgrounds, would share their inspiring stories, not only chronicling their personal experiences but also providing vital treatment information.

Research from countries like South Africa, Malawi, and Zimbabwe confirmed that PLHIV were more receptive to messages when relayed by someone who shares their journey (Birdthistle et al., 2018; Busza et al., 2017; Hlongwa et al., 2022). The authenticity of a messenger who's traversed the same challenges was unparalleled in enacting behavior change. This underscored the importance of having a diverse range of ART Champions to ensure an inclusive and broad-reaching impact, resonating with PLHIV across different backgrounds and experiences.

To ensure the key insights are linked to the desired health outcomes, the communication objectives were established as follows to reinforce and support the key messages:

Once the communication objectives were established, the strategy partner Fieldstone Helms alongside creative partner TBWA Zimbabwe developed the “I Can” creative concept as an umbrella campaign idea that would tie together all campaign messaging into a positive reinforcing message to encourage and celebrate individual agency amongst PLHIV. This campaign slogan directly responds to the apathy and low self-esteem expressed by PLHIV respondents in Zimbabwe.

Channel mix

The campaign's channel mix was selected to ensure that each mode of communication served a distinct purpose, dovetailing with the overall strategy of enhancing ART adherence among PLHIV in Malawi and Zimbabwe. The selection of channels was a deliberate process, steered by in-depth analysis of media habits and preferences within the target demographics, facilitated by our creative partner TBWA. Their assessment was informed by historical data, insights into the audience's lifestyle, and measurable outcomes from previous campaigns.

Interpersonal communication. On the ground, the campaign's heartbeat was its "ART Champions" and healthcare workers, who were the focal point of community engagement. ART Champions, thriving on treatment themselves, offered one-on-one coaching and shared the empowering message of U=U, fostering a strong motivation for ART adherence and viral load testing.

Tools like the Bead Bottles and the Viral Load Explainer were cleverly designed to bridge the communication gap between healthcare providers and PLHIV, making the concept of viral load tangible and understandable.

The Treatment Journey Flipchart and related materials served as visual aids to further demystify the treatment process, anchoring group discussions and promoting literacy about the journey to undetectable viral loads.

The campaign's informational print materials—the Fact Sheet and FAQ Brochure—targeted literacy enhancement, ensuring that PLHIV were well-informed about the implications of their diagnosis and the pathway to suppression.

Mass media. Radio and television were pivotal in harnessing the emotional connection with our audience, capturing the attention of men and HIV-negative individuals who play a supportive role in the treatment journey. These mediums allowed for a broad reach, instilling the campaign's branding and emotional resonance into the daily lives of the community. Billboards complemented this effort, offering a visual anchor for the campaign's identity in high-traffic areas, serving as constant reminders of the campaign's presence and message.

Digital platforms. By deploying targeted ads on Google and Facebook, we reached PLHIV where they were most comfortable, ensuring confidentiality and convenience. Social media's daily content, from posts to polls and webinars, aimed to engage the audience featuring ART champions and routinely updated content, while the campaign microsite provided more in-depth educational resources. This site was not just a hub for information but intended to be a connective thread for community and guidance, directing users towards additional support systems, including a dedicated call center.

Tailored outcomes. Each channel within our mix was chosen not only for its reach but also for its ability to establish a connection with the audience, instill brand recognition, and ultimately, influence behavior. The campaign capitalized on the strengths of each medium—the emotive power and privacy of radio, the visual impact of billboards, or the interactive and supportive environment created by digital platforms and interpersonal communication—to address behavioral objectives.

Evaluation and assessment

The campaign's deployment across mass and mid-media has achieved substantial outreach and engagement in its mission to enhance ART adherence among PLHIV in Zimbabwe and Malawi. The campaign commenced with a robust mass media launch on September 15th, 2021, marking its presence with over 175 TV and 2605 radio spots broadcasting crucial messaging across the airwaves in Malawi and Zimbabwe.

Digital channels commenced on November 15th and have shown promising engagement, indicating that the campaign's messages are resonating with the audience. Accompanying campaign landing pages have been established, providing pivotal information and resources to PLHIV. While the official launch in Zimbabwe aligned with World AIDS Day, garnering significant attention, Malawi's launch was strategically deferred by two weeks to ensure clear and focused messaging.

In terms of reach, the campaign's impact has been impressive. Zimbabwe has seen a remarkable radio reach of over 5 million, a TV audience of nearly 1.75 million, and substantial digital engagement with a Facebook reach of over 1.4 million, a staggering 13 million Google display impressions, and landing page visits surpassing 32,000. Malawi, not to be outdone, boasted radio numbers reaching over 9.5 million, a TV reach of nearly 7.8 million, Facebook reach of over 1.2 million, Google display impressions of over 4.4 million, and landing page visits of more than 56,000.

On the interpersonal front, the ART Champions' impact has been deeply felt, engaging directly with over 4000 individuals through IPC interventions. This ground-level engagement has been pivotal, leading to 227 new individuals taking up ART, 1629 returning to treatment, and an additional 1,088 engaging in viral load testing. These numbers transcend mere statistics; they represent individual lives positively impacted by the campaign's efforts, fostering a significant stride towards HIV management and treatment adherence in the region.

Champion integration within health systems

Future iterations of the campaign will delve deeper into optimizing the integration of champion cadres within local health system realities. The selection and recruitment process will be fine-tuned to ensure that our champions not only possess the necessary skill set and empathy but also harmonize with the current health cadre structure. We aim to define the roles and responsibilities clearly, considering the workload and the level of effort to ensure longevity and prevent burnout. There is also a commitment to reinforcing the champions' sense of ownership and belonging within the health system framework, which is crucial for the sustainability of their impact.

Communication channel optimization

Multiple channels were used in the program, in line with best practices in social and behavior change. Mass and digital media were used to address emotional and social factors, and interpersonal communication was used within clinic and community settings to improve client-provider interactions and increase understanding of viral load suppression and the benefit of ART to prevent onward transmission.

Strengthening MOH partnerships

Recognizing that enduring health interventions are invariably tied to the support and stewardship of local Ministries of Health, future phases will aim to strengthen these partnerships. Enhancing the MOH's capacity to manage and implement these interventions will be pursued through capacity-building initiatives and continuous dialogue to ensure alignment with national health objectives and integration into existing public health frameworks.

Scalability and the minimum viable intervention

A key next step involves crystallizing the 'minimum viable intervention' that can be scaled up effectively. This task will require identifying the core components of the campaign that are critical to its success, which may involve a closer analysis of existing Randomized Controlled Trial (RCT) data. The insights gleaned will aid in developing an adaptable model that can be customized to different contexts while maintaining the integrity and effectiveness of the intervention.

Data-driven decision-making and research

Continuing to build on the evidence base is essential. Planned research efforts, including further RCTs, will provide robust data to guide future directions. The findings will be pivotal in refining our intervention strategies to ensure they are both impactful and efficient in resource utilization.

Sustainability and legacy planning

Lastly, a concerted effort will be made in planning for the sustainability and legacy of the campaign. This will involve laying down a clear roadmap for transition, ensuring that the systems and structures put in place can be maintained by local entities and integrated seamlessly into ongoing health promotion efforts.

By adhering to these strategic focal points, the 'Flip the Script' campaign aims not only to maintain its current momentum but to expand its reach and efficacy, thereby contributing to lasting change in the health outcomes for PLHIV in Malawi, Zimbabwe, and beyond.

Researchers intending to adopt this approach can replicate it but should carefully consider the study design and the campaign’ sustainability.