The Regai Dzive Shiri project: results of a randomized trial of an HIV prevention intervention for youth

Abstract

Background HIV prevention among young people in southern Africa is a public health priority. There is little rigorous evidence of the effectiveness of different intervention approaches. We describe findings of a cluster randomised trial of a community-based, multi-component HIV and reproductive health intervention aimed at changing social norms for adolescents in rural Zimbabwe. Methods Thirty rural communities were randomised to early or deferred implementation of the intervention in 2003. Impact was assessed in a representative survey of 18–22 year olds after 4 years. Participants self-completed a questionnaire and gave a dried blood spot sample for HIV and HSV-2 antibody testing. Young women had a urinary pregnancy test. Analyses were by intention-to-treat and were adjusted for clustering. Findings 4,684 18–22 year olds participated in the survey (97.1% of eligibles, 55.5% female). Just over 40% had been exposed to ≥ 10 intervention sessions. There were modest improvements in knowledge and attitudes among young men and women in intervention communities, but no impact on self-reported sexual behaviour. There was no impact of the intervention on prevalence of HIV or HSV-2 or current pregnancy. Women in intervention communities were less likely to report ever having been pregnancy. Interpretation Despite an impact on knowledge, some attitudes and on reported pregnancy, there was no impact of this intervention on HIV or HSV-2 prevalence, further evidence that behavioural interventions alone are unlikely to be sufficient to reverse the HIV epidemic. The challenge remains to find effective HIV prevention approaches for young people in the face of continued and unacceptably high HIV incidence, particularly among young women.

Behavioral and Biomedical Combination Strategies for HIV Prevention

“…This was similarly shown in HIVserodiscordant couples in Zambia (Fideli et al 2001). Plasma HIV-1 RNA levels generally correlate positively with the concentration of HIV in genital secretions, rectal mucosa, and saliva, although inflammation can stimulate local replication (Cu-Uvin et al 2000;Lampinen et al 2000;Shugars et al 2000). Other studies have shown that transmission events may be observed at a very low plasma HIV-1 RNA level, suggesting that plasma viral load is not the only determinant of transmission (Vernazza et al 2000;Tovanabutra et al 2002).…”

HIV Prevention in Young People in Sub-Saharan Africa: A Systematic Review

“…Five studies reported the impact of interventions on biologically measured outcomes: all measured HIV (A-D, W) [11][12][13][14][15][16]39,40,46,47,[49][50][51][52]; three measured HSV-2 (A-C) [11][12][13][14][15]49]; two measured pregnancy in females (A-B) [11][12][13]; and one measured Chlamydia trachomatis and Neisseria gonorrhoeae (A) [11,12]. Studies measuring HIV and other biological outcomes directly should carry more weight in terms of their strength of evidence than those that used proxy measures, such as reported sexual behavior.…”

“…We identified 11 interventions in schools that had been published in 2005-2008 and met our criteria for inclusion (A, B, E-M) [11,13,[17][18][19][20][21][22][23][24][25]. Of these 11, five were in South Africa, three in Kenya, and there was one intervention each in United Republic of Tanzania, Uganda, and Zimbabwe.…”

“…Nonetheless, overall there was some evidence that interventions in geographically defined communities can have the potential to positively affect several reproductive health outcomes in young people. There were two type 1 (U, V) [37,38], three type 2 (C, D, S) [15,16,34,35,49,51], one type 3 (B) [13,14], and five type 4 interventions (N-P, T, W) [26,30,36,39,40,45,50] (Table 3). The objective of most interventions was to increase knowledge and build skills to promote positive health behavior change.…”

“…Two large CRTs-MEMA kwa Vijana in United Republic of Tanzania (A) [11,12,46,52] and Regai Dzive Shiri in Zimbabwe (B) [13,14]-evaluated multicomponent interventions with activities in schools and health services. Study B also included substantial interventions in geographically defined communities.…”