Evaluation of the Tsima community mobilization intervention to improve engagement in HIV testing and care in South Africa: study protocol for a cluster randomized trial

Abstract

BackgroundHIV transmission can be decreased substantially by reducing the burden of undiagnosed HIV infection and expanding early and consistent use of antiretroviral therapy (ART). Treatment as prevention (TasP) has been proposed as key to ending the HIV epidemic. To activate TasP in high prevalence countries, like South Africa, communities must be motivated to know their status, engage in care, and remain in care. Community mobilization (CM) has the potential to significantly increase uptake testing, linkage to and retention in care by addressing the primary social barriers to engagement with HIV care—including poor understanding of HIV care; fear and stigma associated with infection, clinic attendance and disclosure; lack of social support; and gender norms that deter men from accessing care.Methods/designUsing a cluster randomized trial design, we are implementing a 3-year-theory-based CM intervention and comparing gains in HIV testing, linkage, and retention in care among individuals residing in 8 intervention communities to that of individuals residing in 7 control communities. Eligible communities include 15 villages within a health and demographic surveillance site (HDSS) in rural Mpumalanga, South Africa, that were not exposed to previous CM efforts. CM activities conducted in the 8 intervention villages map onto six mobilization domains that comprise the key components for community mobilization around HIV prevention. To evaluate the intervention, we will link a clinic-based electronic clinical tracking system in all area clinics to the HDSS longitudinal census data, thus creating an open, population-based cohort with over 30,000 18–49-year-old residents. We will estimate the marginal effect of the intervention on individual outcomes using generalized estimating equations. In addition, we will evaluate CM processes by conducting baseline and endline surveys among a random sample of 1200 community residents at each time point to monitor intervention exposure and community level change using validated measures of CM.DiscussionGiven the known importance of community social factors with regard to uptake of testing and HIV care, and the lack of rigorously evaluated community-level interventions effective in improving testing uptake, linkage and retention, the proposed study will yield much needed data to understand the potential of CM to improve the prevention and care cascade. Further, our work in developing a CM framework and domain measures will permit validation of a CM conceptual framework and process, which should prove valuable for community programming in Africa.Trial Registration NCT02197793 Registered July 21, 2014.

Gaining traction: Promising shifts in gender norms and intimate partner violence in the context of a community-based HIV prevention trial in South Africa

“…The study described in this paper was part of a community RCT to test the effects of 'Community Mobilization for Treatment as Prevention', a three-year intervention to increase HIV testing, linkage to and retention in care and treatment among men and women ages 18-49, by addressing key social barriers to service uptake-including inequitable gender attitudes and norms. For the trial, eight communities were randomized to receive the intervention, and seven to control/no intervention [15]. Results regarding intervention effects on the primary trial endpoints (i.e., HIV testing, linkage to and retention in care) are forthcoming.…”

“…The community mobilization intervention, Tsima ("working together"), was based on a defined mobilization model [29] and has been described in detail elsewhere [15]. Tsima was implemented by Sonke Gender Justice, a South African NGO.…”

“…Each model included intervention status (intervention or control), timepoint (baseline or endline), and the interaction between intervention and timepoint. The resulting coefficients included the effect estimate for timepoint (i.e., change over time regardless of intervention status) and the coefficient for intervention status by time, which reflects the additional difference in changes over time by study arm (i.e., intervention effect) [7,15]. Robust standard errors were used (via the SVY command in Stata) to account for any clustering by community [35].…”

“…Systematic reviews of these evaluations have concluded that the interventions hold promise in shifting gender norms and, in many cases behaviors, among men and women in the areas of IPV and HIV prevention as well as reproductive and child health [11][12][13]. Recently, interventions are also seeking to shift gender attitudes and norms as one pathway to reach the UNAIDS goals for HIV testing, treatment and viral suppression [14][15][16][17][18].…”

Providers' Definitions of Quality and Barriers to Providing Care: a Qualitative Study in Rural Mpumalanga Province, South Africa

“…(27) This research on quality of care was nested within a larger study being conducted in the site on community mobilization for HIV treatment as prevention, described elsewhere. (30) We conducted a crosssectional qualitative study among health care workers active in public health facilities within the Agincourt HDSS study area.…”