Community mobilization programme to increase HIV testing – more work is necessary

Community mobilization for HIV testing uptake: results from a community randomized trial of a theory-based intervention in rural South Africa.

Lippman SA, Neilands TB, MacPhail C, Peacock D, Maman S, Rebombo D, Twine R, Selin A, Leslie HH, Kahn K, Pettifor A. J Acquir Immune Defic Syndr. 2017 Jan 1;74 Suppl 1:S44-S51.

Background: HIV testing uptake in South Africa is below optimal levels. Community mobilization (CM) may increase and sustain demand for HIV testing, however, little rigorous evidence exists regarding the effect of CM interventions on HIV testing and the mechanisms of action.

Methods: We implemented a theory-driven CM intervention in 11 of 22 randomly-selected villages in rural Mpumalanga Province. Cross-sectional surveys including a community mobilization measure were conducted before (n = 1181) and after (n = 1175) a 2-year intervention (2012-2014). We assessed community-level intervention effects on reported HIV testing using multilevel logistic models. We used structural equation models to explore individual-level effects, specifically whether intervention assignment and individual intervention exposure were associated with HIV testing through community mobilization.

Results: Reported testing increased equally in both control and intervention sites: the intervention effect was null in primary analyses. However, the hypothesized pathway, CM, was associated with higher HIV testing in the intervention communities. Every standard deviation increase in village CM score was associated with increased odds of reported HIV testing in intervention village participants (odds ratio: 2.6, P = <0.001) but not control village participants (odds ratio: 1.2, P = 0.53). Structural equation models demonstrate that the intervention affected HIV testing uptake through the individual intervention exposure received and higher personal mobilization scores.

Conclusions: There was no evidence of community-wide gains in HIV testing due to the intervention. However, a significant intervention effect on HIV testing was noted in residents who were personally exposed to the intervention and who evidenced higher community mobilization. Research is needed to understand whether CM interventions can be diffused within communities over time.

Abstract [1]  Full-text [free] access  [2]

Editor’s notes: HIV testing is an integral component of HIV prevention strategies, and essential for achieving the UNAIDS 90-90-90 treatment target. However, testing coverage in many parts of sub-Saharan Africa remains low, particularly among men. Stigma, gender norms, and lack of ‘buy in’ about the benefits of early testing and treatment remain major barriers to testing. 

This cluster-randomised trial of a community mobilization (CM) approach for HIV prevention in South Africa is one of the first to be based around an explicit theoretical model of community change. CM is designed to engage community members and motivate people to achieve a common goal, and has been used successfully in some HIV prevention programmes. The programme focused on young men aged 18-35 years, with an aim to build community support for normative changes that are necessary to tackle social barriers to HIV testing and care. Trial outcomes included gender norms, sexual behaviour and HIV testing uptake. The trial found no overall effect on the uptake of HIV testing – self-reported HIV testing increased significantly in both arms over the two year observation period, with no difference between the programme and control communities. However, CM scores, used to quantify the degree of community engagement, were higher in the programme communities. In addition, individuals with greater exposure to the programme were more likely to report HIV testing. These findings suggest that although the CM programme did have an impact on the individuals exposed to it, the effect did not filter through to the wider community.  

CM strategies are used increasingly in public health programmes, and can be a powerful tool for increasing community awareness and engagement with HIV prevention. The benefit of CM is its ability to diffuse beyond the immediate participants to the community as a whole, to bring about the greatest possible change. However, little is known about why and how these approaches work. As this study illustrates, there is a need to understand more about the underlying mechanisms of change associated with CM, and the factors that contribute to its success.

Gender [4], HIV testing [5], Stigma and social exclusion [6]
Africa [7]
South Africa [8]
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