Uptake of voluntary counselling and testing increased dramatically in intervention communities during the first two years of a community-randomised, controlled HIV prevention study in four countries, according to an article in the December 1st edition of the Journal of Acquired Immune Deficiency Syndromes. Project Accept seeks to reduce HIV transmission by changing community norms through a combination of community-mobilisation activities, high quality mobile voluntary HIV counselling and testing (VCT) and post-test support services.
HIV incidence and stigma reduction were endpoints of the three-year study, which is being conducted in 48 communities in South Africa, Tanzania, Thailand and Zimbabwe. In each country, study communities have been paired according to common features, then one community has been randomised to serve as an intervention site and the other, a control site. In the control communities, standard VCT is available, but Project Accept is not staging any special interventions.
The report presented data on the uptake of VCT during the first two years of the study in Tanzania, Thailand, and Zimbabwe. Together, the intervention communities in these countries saw a fourfold higher level of HIV testing than the control communities (Tanzania, 2936 intervention cases of VCT versus 917 control cases of VCT; Thailand, 7526 intervention cases of VCT versus 2210 control cases of VCT; and Zimbabwe, 7251 intervention cases of VCT versus 551 control cases of VCT). The difference in Zimbabwe was greater than tenfold.
The study also examined scores from quality-assurance evaluations of VCT counsellors, support-services facilitators and mobile outreach workers in all four countries. The evaluations, which are conducted by the managers of those teams in each intervention community, indicated a high level of adherence to protocols for implementing VCT and other intervention components.
Cumulative VCT and community mobilisation quality assurance scores were found to be 95% or higher in the first month, and to increase over the course of the first year. Support services' quality-assurance scores were slightly lower for much of the first year, but eventually climbed to the same level as the other quality-assurance scores.
While randomised controlled trials are routinely conducted to obtain the best evidence of the efficacy of biomedical interventions, a study of a community-wide behavioural intervention with 'treatment' and 'control' arms consisting of multiple communities is a complex undertaking. There has been only a small number of community-randomised, controlled HIV prevention studies with HIV incidence as an endpoint, and Project Accept is the first international study of this nature.
One goal of taking a community-level approach to HIV prevention, the researchers explain, is to “tip the scale to establish as the community norm reductions in behaviours and attitudes … which lead to HIV transmission and increases in behaviours that help people maintain health.”
The post-intervention assessment will be performed in the population at large rather than among Project Accept programme participants. That is, a representative sample of adults aged 18 to 32 will be recruited to serve as the study population in each community, so that researchers can measure the impact of the intervention on the community as a whole.
The mobile VCT component of Project Accept is intended to remove barriers to HIV testing while also encouraging more discussion about HIV. Mobile VCT units operate in marketplaces, transport venues, temples and other centres of community life. Services are offered at a variety of times, including evenings and weekends, in an effort to reach working people. Test results are available the same day.
Everyone who undergoes HIV testing at the mobile sites is referred to Project Accept’s post-test support services, and HIV-positive people also receive referrals to other services as needed, including health care. The Project Accept post-test programming includes large meetings to share HIV-related information; psychosocial support groups; crisis counselling for individuals and couples; workshops to build stress-management and coping skills; and workshops to help people cope with HIV-related stigma.
One reason study participants feared receiving HIV-positive test results, the researchers write, was because this was thought to lead to the loss of social support. “The experience of individuals who had tested positive before introduction of the pilot phase of the intervention encouraged this fear. Many study participants described the experiences of HIV-infected individuals being shunned by their friends and family.”
Stigma-reduction efforts are part of the community-mobilisation component, which involves various types of outreach activities.
The full evaluation of Project Accept will include an assessment of cost-effectiveness. The researchers believe that the intervention is designed in a way that will make large-scale implementation relatively inexpensive, in part because some of the human resources come from volunteer and peer support.
Khumalo-Sakutukwa G et al. Project Accept (HPTN 043): a community-based intervention to reduce HIV incidence in populations at risk for HIV in sub-Saharan Africa and Thailand. J Acquir Immune Defic Syndr 49: 422 – 431, 2008.