Project Shikamana: community empowerment-based combination HIV prevention significantly impacts HIV incidence and care continuum outcomes among female sex workers in Iringa, Tanzania

Abstract

Objective: Determine the impact of a community empowerment model of combination HIV prevention (Project Shikamana) among female sex workers (FSW) in Iringa, Tanzania. Methods: We conducted a two-community randomized trial. Intervention elements included: 1) community drop-in-center; 2) venue-based peer education, condom distribution and HIV testing; 3) peer service navigation; 4) provider sensitivity trainings; and 5) SMS reminders. We utilized time-location-sampling to enroll 496 FSW and conducted a survey and blood draws to screen for HIV and assess viral load at 0 and 18 months. We conducted an intent-to-treat analysis using logistic and Poisson regression and inverse probability weighting for primary outcomes. Results: The analysis included 171 HIV-positive and 216 HIV-negative FSW who completed both the baseline and 18-month study visits. Participants in the intervention were significantly less likely to become infected with HIV at 18-month follow-up (RR 0.38; p=0.047), with an HIV incidence of 5.0% in the intervention vs. 10.4% control. Decreases in inconsistent condom use over time were significantly greater in the intervention (72.0% to 43.6%) vs. control (68.8% to 54.0%; RR 0.81, p=0.042). At follow-up, we observed significant differences in behavioral HIV care continuum outcomes, and positive, but non-significant, increases in viral suppression (40.0% to 50.6%) in the intervention vs. control (35.9% to 47.4%). There was a strong association of between higher intervention exposure and HIV outcomes including viral suppression. Conclusions: Project Shikamana is the first trial of community empowerment-based combination prevention among FSW in Africa to show a significant reduction in HIV incidence warranting its broader implementation and evaluation. Trial registration: Clinicaltrials.gov # NCT02281578.