Community-based HIV Prevention Program Research Articles

Unit costs of a community-based girl-centered HIV prevention program: a case study of Determined, Resilient, Empowered, AIDS-Free, Mentored, and Safe program.

We compare the unit costs of providing Determined, Resilient, Empowered, AIDS-Free, Mentored, and Safe (DREAMS) interventions to adolescent girls and young women (AGYW) reached across two sites, an urban (Nyalenda A Ward) and peri-urban (Kolwa East Ward) setting, in Kisumu County of Kenya. Micro-costing, using the average cost concept during project initiation and early implementation. Adopting the implementer's (provider's) perspective, we computed and classified costs in the following categories for each sub-implementing partner: medical and professional staff, administrative and support staff, materials and supplies, building space and utilities, equipment, establishment, and miscellaneous. These costs were summed across sub-implementing partners in a site to obtain the site-level total costs. These are then divided by the total number of AGYW reached in each site to obtain the unit costs. Data were collected from July to September 2017. The unit costs in the peri-urban area were about 1.9 times of those in the urban area. It cost about US$67 [or 170 International Dollars] to deliver the DREAMS intervention package to each AGYW reached in the urban area as compared with approximately US$129 (or 327 International Dollars) in the peri-urban area. First, it was generally more expensive to deliver DREAMS interventions in the peri-urban setting as compared with the urban setting. Second, the difference in unit costs was mainly driven by the building space and utilities. Strategies to lower intervention costs are needed in the peri-urban setting, such as using existing infrastructure (either governmental or nongovernmental) or other innovative ways to deliver the services.

Successful integration of HIV pre-exposure prophylaxis into a community-based HIV prevention program for female sex workers in Kolkata, India.

We assessed the impact of pre-exposure prophylaxis (PrEP) in the context of a community-based HIV program among female sex workers (FSWs) in Kolkata, India. This was an open-label, uncontrolled demonstration trial. HIV seronegative FSWs over 18 years were eligible. Participants were administered daily tenofovir/emtricitabine (TDF-FTC) with follow-up visits at months 1, 3, 6, 9, 12, and 15. Drug adherence was monitored by self-report, and a random subset of participants underwent plasma TDF testing. 843 women were screened and 678 enrolled and started on PrEP. Seventy-nine women (11%) did not complete all scheduled visits: four women died of reasons unrelated to PrEP and 75 withdrew, for a 15-month retention rate of 89%. Self-reported daily adherence was over 70%. Among those tested for TDF, the percentage of women whose level reached ≥40 ng/mL was 65% by their final visit. There were no HIV seroconversions, and no evidence of significant changes in sexual behavior. This study demonstrated the feasibility and effectiveness of PrEP for FSWs in Kolkata, with very high levels of adherence to PrEP and no HIV seroconversions. The integration of PrEP into an existing community-based HIV prevention program ensured community support and facilitated adherence.

Determinants of undisclosed HIV status to a community-based HIV program: findings from caregivers of orphans and vulnerable children in Tanzania

BackgroundHIV status disclosure facilitates receipt of HIV prevention and treatment services. Although disclosure to sexual partners, family members or friends has been extensively studied, disclosure to community-based HIV programs is missing. This study assesses the magnitude of, and factors associated with undisclosed HIV status to a community-based HIV prevention program among caregivers of orphans and vulnerable children (OVC) in Tanzania.MethodsData are from the USAID-funded Kizazi Kipya project that seeks to increase uptake of HIV, health, and social services by OVC and their caregivers in Tanzania. Data on OVC caregivers who were enrolled in the project during January–March 2017 in 18 regions of Tanzania were analyzed. Caregivers included were those who had complete information on their HIV status disclosure, household socioeconomic status, and sociodemographic characteristics. HIV status was self-reported, with undisclosed status representing all those who knew their HIV status but did not disclose it. Multilevel mixed-effects logistic regression, with caregivers’ HIV status disclosure being the outcome variable was conducted.ResultsThe analysis was based on 59,683 OVC caregivers (mean age = 50.4 years), 71.2% of whom were female. Of these, 37.2% did not disclose their HIV status to the USAID Kizazi Kipya program at the time of enrollment. Multivariate analysis showed that the likelihood of HIV status non-disclosure was significantly higher among: male caregivers (odds ratio (OR) = 1.22, 95% confidence interval (CI) 1.16–1.28); unmarried (OR = 1.12, 95% CI 1.03–1.23); widowed (OR = 1.12, 95% CI 1.07–1.18); those without health insurance (OR = 1.36, 95% CI 1.28–1.45); age 61 + years (OR = 1.72, 95% CI 1.59–1.88); those with physical or mental disability (OR = 1.14, 95% CI 1.04–1.25); and rural residents (OR = 1.58, 95% CI 1.34–1.86). HIV status non-disclosure was less likely with higher education (p < 0.001); and with better economic status (p < 0.001).ConclusionWhile improved education, economic strengthening support and expanding health insurance coverage appear to improve HIV status disclosure, greater attention may be required for men, unmarried, widowed, rural residents, and the elderly populations for their higher likelihood to conceal HIV status. This is a clear missed opportunity for timely care and treatment services for those that may be HIV positive. Further support is needed to support disclosure in this population.

Understanding the costs and the cost structure of a community-based HIV and gender-based violence (GBV) prevention program: the Woza Asibonisane Community Responses Program in South Africa

BackgroundThe Woza Asibonisane Community Responses (CR) Programme was developed to prevent HIV infections and gender-based violence (GBV) within four provinces in South Africa. The Centre for Communication Impact (CCI) in collaboration with six partner non-governmental organizations (NGOs) implemented the programme, which was comprised of multiple types of group discussion and education activities organized and facilitated by each NGO. To date, little information exists on the cost of implementing such multi-objective, multi-activity, community-based programmes. To address this information gap, we estimated the annual cost of implementing the CR Programme for each NGO.MethodsWe used standard methods to estimate the costs for each NGO, which involved a package of multiple activities targeted to distinct subpopulations in specific locations. The primary sources of information came from the implementing organizations. Costs (US dollars, 2017) are reported for each partner for one implementation year (the U.S. Government fiscal year (10/2016–09/2017). In addition to total costs disaggregated by main input categories, a common metric--cost per participant intervention hour--is used to summarize costs across partners.ResultsEach activity included in the CR program involve organizing and bringing together a group of people from the target population to a location and then completing the curriculum for that activity. Activities were held in community settings (meeting hall, community center, sports grounds, schools, etc.). The annual cost per NGO varied substantially, from $260,302 to $740,413, as did scale based on estimated total participant hours, from 101,703 to 187,792 participant hours. The cost per participant hour varied from $2.8–$4.6, with NGO labor disaggregated into salaries for management and salaries for service delivery (providing the activity curriculum) contributing to the largest share of costs per participant hour.ConclusionsThe cost of implementing any community-based program depends on: (1) what the program implements; (2) the resources used; and (3) unit costs for such resources. Reporting on costs alone, however, does not provide enough information to evaluate if the costs are ‘too high’ or ‘too low’ without a clearer understanding of the benefits produced by the program, and if the benefits would change if resources (and therefore costs) were changed.

Evaluation of community-based HIV self-testing delivery strategies on reducing undiagnosed HIV infection, and improving linkage to prevention and treatment services, among men who have sex with men in Kenya: a programme science study protocol

BackgroundHIV prevalence among men having sex with men (MSM) in Kenya is 18.2%. Despite scale-up of HIV testing services, many MSM remain unaware of their HIV status and thus do not benefit from accessing HIV treatment or prevention services. HIV self-testing (HIVST) may help address this gap. However, evidence is limited on how, when, and in what contexts the delivery of HIVST to MSM could increase awareness of HIV status and lead to early linkage to HIV treatment and prevention.MethodsThe study will be embedded within existing MSM-focused community-based HIV prevention and treatment programmes in 3 counties in Kenya (Kisumu, Mombasa, Kiambu). The study is designed to assess three HIV testing outcomes among MSM, namely a) coverage b) frequency of testing and c) early uptake of testing. The study will adopt a mixed methods programme science approach to the implementation and evaluation of HIVST strategies via: (i) a baseline and endline bio-behavioural survey with 1400 MSM; (ii) a socio-sexual network study with 351 MSM; (iii) a longitudinal qualitative cohort study with 72 MSM; (iv) routine programme monitoring in three sites; (v) a programme-specific costing exercise; and (vi) mathematical modelling. This protocol evaluates the impact of community-based implementation of HIV self-testing delivery strategies among MSM in Kenya on reducing the undiagnosed MSM population, and time for linkage to prevention, treatment and care following HIV self-testing. Baseline data collection started in April 2019 and the endline data collection will start in July 2020.DiscussionThis study is one of the first programme science studies in Sub-Saharan Africa exploring the effectiveness of integrating HIVST interventions within already existing HIV prevention and treatment programmes for MSM in Kenya at scale. Findings from this study will inform national best approaches to scale up HIVST among MSM in Kenya.

This is who we are: building community for HIV prevention with young gay and bisexual men in Beirut, Lebanon

Young gay men in Beirut are at significantly elevated risk of HIV infection compared with the general Lebanese population. Despite nascent HIV prevention efforts in the region, there is a need for effective community-level HIV prevention interventions tailored for young gay men. This qualitative study examined internal dynamics within Beirut’s gay community as a basis for developing community-level interventions. Peer ethnographers were trained to collect field notes on conversations between young gay men in public spaces in Beirut, and conducted follow-up focus groups with young gay men. Analyses revealed three major themes: (1) the need for safe spaces in which to socialise, (2) the importance of being able to locate and connect with other young gay men, and (3) ambivalence regarding a gay community that was supportive in some ways but also fragmented and often judgemental. Study findings also confirm the existence of external threats to community such as stigma, cultural and familial norms regarding heterosexuality and criminalisation of refugee status. Understanding such community dynamics and the environmental context is central to designing effective community-based HIV prevention programmes.

Measurement Noninvariance of Safer Sex Self-Efficacy Between Heterosexual and Sexual Minority Black Youth.

Black and lesbian, gay, bisexual, or questioning (LGBQ) youth in the United States are disproportionately affected by HIV and other sexually transmitted diseases (STDs). Although self-efficacy is strongly, positively associated with safer sex behaviors, no studies have examined the validity of a safer sex self-efficacy scale used by many federally funded HIV/STD prevention programs. This study aims to test factor validity of the Sexual Self-Efficacy Scale by using confirmatory factor analysis (CFA) to determine if scale validity varies between heterosexual and LGBQ Black youth. The study uses cross-sectional data collected through baseline surveys with 226 Black youth (15 to 24 years) enrolled in community-based HIV-prevention programs. Participants use a 4-point Likert-type scale to report their confidence in performing 6 healthy sexual behaviors. CFAs are conducted on 2 factor structures of the scale. Using the best-fitting model, the scale is tested for measurement invariance between the 2 groups. A single-factor model with correlated errors of condom-specific items fits the sample well and, when tested with the heterosexual group, the model demonstrates good fit. However, when tested with the LGBQ group, the same model yields poor fit, indicating factorial noninvariance between the groups. The Sexual Self-Efficacy Scale does not perform equally well among Black heterosexual and LGBQ youth. Study findings suggest additional research is needed to inform development of measures for safer sex self-efficacy among Black LGBQ youth to ensure validity of conceptual understanding and to accurately assess effectiveness of HIV/STD prevention interventions among this population.

Economic Evaluation of Community-Based HIV Prevention Programs in Ontario: Evidence of Effectiveness in Reducing HIV Infections and Health Care Costs.

Investments in community-based HIV prevention programs in Ontario over the past two and a half decades are assumed to have had an impact on the HIV epidemic, but they have never been systematically evaluated. To help close this knowledge gap, we conducted a macro-level evaluation of investment in Ontario HIV prevention programs from the payer perspective. Our results showed that, from 1987 to 2011, province-wide community-based programs helped to avert a total of 16,672 HIV infections, saving Ontario’s health care system approximately $6.5 billion Canadian dollars (range 4.8–7.5B). We also showed that these community-based HIV programs were cost-saving: from 2005 to 2011, every dollar invested in these programs saved about $5. This study is an important first step in understanding the impact of investing in community-based HIV prevention programs in Ontario and recognizing the impact that these programs have had in reducing HIV infections and health care costs.

Applying Qualitative Data Derived from a Rapid Assessment and Response (RAR) Approach to Develop a Community-based HIV Prevention Program for Adolescents in Thailand

HIV education programs are needed to address risk-taking behavior for adolescents. The purpose of our study was to use the World Health Organization's Rapid Assessment and Response (RAR) method to design a community-based, cultural- and age-appropriate HIV prevention program for adolescents in Bangkok, Thailand. Adolescent single-gender-specific focus groups (n = 3; 28 participants) were used to gather reactions/ideas about program topics/approaches. An adult, mixed-gender group was held to review information identified by adolescents. Sessions were audiotaped and transcribed verbatim. Themes regarding HIV content and the process of implementation emerged from a qualitative content analysis of the data. Community representatives recommended incorporation of HIV information and risk-prevention skills. Information delivery suggestions included small group discussions, interactive games/role-playing, program materials/terminology, and HIV-infected program facilitators. Community members provided critical input toward an HIV prevention program tailored to meet adolescents' unique needs/interests. The RAR model provides opportunities to engage communities in developing health-related interventions.

How do community-based HIV prevention programmes for men who have sex with men ‘travel’? Lessons from the Ukwazana/Zwakalani journey in South Africa

Research reveals how homophobia and stigma link closely to HIV among men who have sex with men in sub-Saharan Africa. This paper considers the varying impact of homophobic stigma on HIV prevention programmes among men who have sex with men in South Africa. It explores how a community-based HIV prevention programme based in the peri-urban townships of Cape Town was ‘translated’ to peri-urban Johannesburg. Drawing on interviews with volunteers and programme facilitators in Johannesburg, it argues that an altered homophobic environment to that found in Cape Town gave different opportunities to engage both with other men who have sex with men and the broader community. It also argues that programme facilitators should be mindful of how varying degrees of homophobic stigma may relate to broader theoretical debates about sexual binary relationships, which can help us understand why particular programmes choose to focus on certain activities rather than others.

Barbershop Talk With Brothers: using community-based participatory research to develop and pilot test a program to reduce HIV risk among Black heterosexual men.

There is a need for feasible, evidence-based interventions that support HIV risk reduction among heterosexual Black men. In this article, we describe the process for development of the Barbershop Talk With Brothers (BTWB) program and evaluation. The BTWB program is a theoretically grounded and community-based HIV prevention program that seeks to improve individual skills and motivation to decrease sexual risk, and that builds men's interest in and capacity for improving their community's health. Formative data collection included barbershop observations and barber focus groups, brief behavioral risk assessments of men in barbershops, and focus groups and individual interviews. Based on this information and in consultation with our steering committee, we developed the BTWB program and accompanying program evaluation. From April through November 2011, 80 men were recruited and completed a baseline assessment of a pilot test of the program; 78 men completed the program and 71 completed a 3-month assessment. The pilot evaluation procedures were feasible to implement, and assessments of pre- and post-test measures indicate that key behavioral outcomes and proposed mediators of those outcomes changed in hypothesized directions. Specifically, attitudes and self-efficacy toward consistent condom use improved, and respondents reported lower levels of sexual risk behavior from baseline to follow-up (all p < 0.05). Perceptions of community empowerment also increased (p = 0.06). While HIV stigma decreased, this difference did not reach statistical significance. Our approach to community-engaged program development resulted in an acceptable, feasible approach to reaching and educating heterosexual Black men about HIV prevention in community settings.

Integration of Screening for Syphilis, Hepatitis C, and Other Sexually Transmitted Infections with HIV Testing in a Community-Based HIV Prevention Program in Miami, Florida.

The South Beach AIDS Project (SoBAP) in Miami, Florida, is a nonprofit community-based organization that recently began offering syphilis, chlamydia and gonorrhea, and hepatitis C screening along with confidential HIV screening to its clients. We retrospectively reviewed data from SoBAP collected from January 2011 to June 2012 to describe the prevalence of sexually transmitted infections (STIs) among persons seeking testing services. Our findings are in line with national data demonstrating that men who have sex with men (MSM) of color are disproportionately affected by STIs, especially Latino MSM. Integrating HIV, STI, and hepatitis C screening in community-based testing programs is feasible and an important means to identify infected persons.

에티오피아 농촌지역 여자청소년을 위한 HIV 예방프로그램 개발

Objectives: The objective of this study was developing a community-based HIV prevention program to enhance the safe sexual behavior among rural Ethiopian female youth. Methods: A community-based HIV prevention program was developed using the Cox's Interaction Model of Client Health Behavior. The program development was carried out in four phases using a mixed research method: need-assessment which consisted of three steps (secondary-data analysis, key-informant interview, and focused-group interview); identification of preliminary program contents; expert's review of the program contents for the validity and cultural acceptability of the program; and refinement of the proposed program contents. Results: The HIV prevention program developed in this study consisted of three modules; the first module was for enhancing the youth's self-esteem, the second was for providing the youth with information regarding HIV/AIDS and safe sexual behavior, and the third was for improving the youth's communication skills and refusing skills. Conclusions: The need assessment and expert's review was very effective way to reflect sociocultural factors of rural Ethiopia for developing HIV prevention program for female youth. Further research is desirable for verifying the effectiveness of the developedprogram.

Collaboration With Urban Parents to Deliver a Community-Based Youth HIV Prevention Program.

This article draws on the unified theory of behavior change to examine adult community members' participation in a collaborative, community-based HIV prevention program for inner-city youth. Specifically, the impact of a training and mentorship process is examined with a sample of parent facilitators hired to deliver an evidence-based HIV prevention program in Bronx, New York. Findings indicate that the training program impacted four of five key constructs (environmental constraints, habitual behavior, social norms, and self-concept) expected to be related to parents' ability to deliver the program constructs significantly beyond any increase evidenced by the control group (HIV knowledge increased in both groups). Community-level training programs may therefore be an effective medium for increasing caregivers' intention to collaborate in community-based prevention programs.

Subtypes of Alcohol Dependence and Their Effect on Sexual Behavior Change

This study utilized data from a National Institute on Drug Abuse and National Institute on Alcohol Abuse and Alcoholism funded community-based HIV prevention program in the Midwest in 2000. We categorized women who met lifetime criteria for alcohol dependence (using the DIS) and who also had used cocaine (n = 324) into four alcohol typologies based on onset of regular drinking and the length of time to dependence. The Risk Behavior Assessment measured sex behaviors, combined into a risk index, before and after the program. Generalized linear modeling compared decreases over time. Women who began drinking regularly later and became dependent more slowly significantly decreased risky sex behaviors. Tailored prevention protocols may more effectively decrease HIV risk.

Differences in substance use and sexual partnering between men who have sex with men, men who have sex with men and women and transgender women

Men who have sex with men (MSM), men who have sex with men and women (MSM/W) and transgender women (TGW) remain the populations most severely and disproportionately impacted upon by HIV in Los Angeles County. Baseline data from community-based HIV-prevention programmes serving these populations were analysed to explore differences in demographic characteristics, substance use and sexual partnering between the three groups. Despite high HIV prevalence overall (MSM 34.7% versus MSM/W 16.1% versus TGW 21.9%, p < .001), there were striking differences in risk behaviours. Higher rates of homelessness were reported by MSM/W compared to MSM and TGW. Lower rates of education and less substance use were reported by TGW (62.2%), compared to MSM (79.7%) and MSM/W (92.6%). A much higher number of male sexual exchange partners were reported by TGW (MSM 1.04 [SD = 4.8] versus MSM/W 1.54 [SD = 10.3] versus TGW 12.37 [SD = 23.9], p < .001). Findings support the need for HIV-prevention interventions that specifically address the unique risk patterns among each population in order to curb HIV acquisition and transmission.

Contingency management among homeless, out-of-treatment men who have sex with men

Homeless men who have sex with men are a particularly vulnerable population with high rates of substance dependence, psychiatric disorders, and HIV prevalence. Most need strong incentives to engage with community-based prevention and treatment programs. Contingency management (CM) was implemented in a community HIV prevention setting and targeted reduced substance use and increased health-promoting behaviors over a 24-week intervention period. Participants in the CM condition achieved greater reductions in stimulant and alcohol use ( χ 2 = 27.36, p < .01) and, in particular, methamphetamine use ( χ 2 = 21.78, p < .01) and greater increases in health-promoting behaviors ( χ 2 = 37.83, p < .01) during the intervention period than those in the control group. Reductions in substance use were maintained to 9- and 12-month follow-up evaluations. Findings indicate the utility of CM for this high-risk population and the feasibility of implementing the intervention in a community-based HIV prevention program.

The Change Approach to Capacity-Building Assistance

The CHANGE approach to capacity-building assistance (CBA), developed over 4 years by the Latino Commission on AIDS Manos Unidas' Program to assist Latino-serving community-based HIV prevention programs in eight northern U.S. states, Puerto Rico, and the U.S. Virgin Islands, is a system for providing community-based organizations (CBOs) with not only the skills to implement interventions from the Centers for Disease Control and Prevention's Diffusion of Effective Behavioral Interventions (DEBI) project, but also the capacity to reorient to the disruptive innovation of the DEBIs. The CHANGE (customized, holistic, analytical, network-building, grassroots, evaluatory) approach entails an integrated CBA-model emphasizing community and programmatic diagnosis and reflection and the enhancement of staff skills through tailored curricula in six areas: community-assessment, target-refinement, recruitment and retention, basic skills, program implementation, and evaluation. The CHANGE model encourages active CBO participation in the learning process rooted in the experiences of the organization as a member of its community.

Gender differences in intention to remain a virgin until marriage among school pupils in rural northern Tanzania

Abstinence is often promoted in HIV-prevention programmes for adolescents, but little is known about the factors that influence adolescents' intentions to abstain from sex until marriage. This study was conducted in ten districts in the Kilimanjaro, Arusha, and Manyara regions of northern Tanzania, in July 2005. Out of 65 villages, four were randomly selected. In total, 953 primary school pupils, aged 10 to 14 years, participated in an interview and questionnaire: about 54% were girls and 41% were aged 12 to 13. Thirty-four percent of boys and 28.5% of girls said they had the intention to remain a virgin until marriage. Among the male respondents, having the intention to remain a virgin until marriage was associated with sharing a bedroom with a brother under age 18 years (odds ratio [OR] = 3.19, 95% confidence interval [CI] 1.48-6.87) and with saying that girls have the right to say ‘no’ to sex (OR = 8.51, 95% CI 2.93-24.72); among males, the intention was also negatively associated with saying they had the confidence to refuse sex with someone they had known for less than three months (OR = 0.12, 95% CI 0.04-0.32). Among the female respondents, having the intention to remain a virgin until marriage was associated with living with both parents (OR = 2.60, 95% CI 1.23-5.50) and saying that they had the confidence to refuse sex with someone who has authority or power (OR = 3.69, 95% CI 1.31-10.48). The findings highlight that young adolescents may benefit from community-based HIV-prevention programmes that include building lifeskills and increasing one's confidence to abstain from sex or delay sexual debut until marriage.

A Dynamic Model of Client Recruitment and Retention in Community-Based HIV Prevention Programs

The study used system dynamics modeling computer simulations to gain a better understanding of the process of delivering small-group, evidence-based HIV prevention programs in the community and to explore implications for public health practice. A model was developed to explain provider-reported challenges associated with recruiting, retaining, and graduating people from small-group workshop programs. The model simulations revealed the difficulty in sustaining high rates of recruitment and retention in small-group programs over time. The model simulations provided insight into what processes may lead to suboptimal numbers of people being recruited and positively influenced by these programs.