Research Article: Impact and Process Evaluation of Integrated Community and Clinic-Based HIV-1 Control: A Cluster-Randomised Trial in Eastern Zimbabwe

Date Published: March 27, 2007

Publisher: Public Library of Science

Author(s): Simon Gregson, Saina Adamson, Spiwe Papaya, Jephias Mundondo, Constance A Nyamukapa, Peter R Mason, Geoffrey P Garnett, Stephen K Chandiwana, Geoff Foster, Roy M Anderson, Joep M. A Lange

Abstract: BackgroundHIV-1 control in sub-Saharan Africa requires cost-effective and sustainable programmes that promote behaviour change and reduce cofactor sexually transmitted infections (STIs) at the population and individual levels.Methods and FindingsWe measured the feasibility of community-based peer education, free condom distribution, income-generating projects, and clinic-based STI treatment and counselling services and evaluated their impact on the incidence of HIV-1 measured over a 3-y period in a cluster-randomised controlled trial in eastern Zimbabwe. Analysis of primary outcomes was on an intention-to-treat basis. The income-generating projects proved impossible to implement in the prevailing economic climate. Despite greater programme activity and knowledge in the intervention communities, the incidence rate ratio of HIV-1 was 1.27 (95% confidence interval [CI] 0.92–1.75) compared to the control communities. No evidence was found for reduced incidence of self-reported STI symptoms or high-risk sexual behaviour in the intervention communities. Males who attended programme meetings had lower HIV-1 incidence (incidence rate ratio 0.48, 95% CI 0.24–0.98), and fewer men who attended programme meetings reported unprotected sex with casual partners (odds ratio 0.45, 95% CI 0.28–0.75). More male STI patients in the intervention communities reported cessation of symptoms (odds ratio 2.49, 95% CI 1.21–5.12).ConclusionsIntegrated peer education, condom distribution, and syndromic STI management did not reduce population-level HIV-1 incidence in a declining epidemic, despite reducing HIV-1 incidence in the immediate male target group. Our results highlight the need to assess the community-level impact of interventions that are effective amongst targeted population sub-groups.

Partial Text: HIV-1–prevalence declines may now be occurring in some sub-Saharan African countries [1]. However, there remains little direct evidence that prevention measures—rather than natural HIV-1 epidemic dynamics [2] or behaviour change prompted by mortality [3]—have contributed to the slowing of HIV-1 epidemics [4,5]. Syndromic management of sexually transmitted infections (STIs) proved effective early in an HIV-1 epidemic in north-west Tanzania [6]. Peer education to promote safe behaviours showed promise in early process evaluations [7], but a randomised controlled trial (RCT) of factory workers in Harare, Zimbabwe, done in the mid-1990s, proved inconclusive [8]. Subsequent RCTs of syndromic management [9] and mass treatment of STIs [10], together with an information, education, and communication (IEC) behaviour-change programme [9], showed no effect in more mature epidemics.



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