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 RegistrationNCT02197793 Registered July 21, 2014.
Highlights
HIV transmission can be decreased substantially by reducing the burden of undiagnosed HIV infection and expanding early and consistent use of antiretroviral therapy (ART)
This 90-90-90 framework was largely the result of ground breaking research demonstrating that HIV transmission can be decreased substantially by reducing the burden of undiagnosed HIV infection and expanding early and consistent use of ART. [2, 3] Treatment as prevention (TasP), or treating an HIV-positive person with ART to reduce their HIV viral load and reduce the risk of forward transmission of the virus to a negative partner, is the key to ending the HIV epidemic [4, 5]
HIV testing and clinical care for health and demographic surveillance site (HDSS) residents is provided by nine public health facilities and one public-private-partnership community health center located within the study area
Summary
HIV transmission can be decreased substantially by reducing the burden of undiagnosed HIV infection and expanding early and consistent use of antiretroviral therapy (ART). The targets dictate that by 2020, 90% of all people living with HIV should know their HIV status, 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy (ART), and 90% of all people receiving ART will achieve viral suppression [1] This 90-90-90 framework was largely the result of ground breaking research demonstrating that HIV transmission can be decreased substantially by reducing the burden of undiagnosed HIV infection and expanding early and consistent use of ART. To activate TasP in high prevalence settings and reach 90-90-90 targets, communities must have access to HIV testing and treatment and be motivated to know their status, engage in care if they test HIV positive, and remain in care, including medication adherence to ensure viral suppression. At current rates of testing and treatment coverage, South Africa will fall far short of meeting the 90-90-90 goals
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