Gertrude Khumalo-Sakutukwa

Community-based intervention to increase HIV testing and case detection in people aged 16–32 years in Tanzania, Zimbabwe, and Thailand (NIMH Project Accept, HPTN 043): a randomised study

BACKGROUND In developing countries, most people infected with HIV do not know their infection status. We aimed to assess whether HIV testing could be increased by combination of community mobilisation, mobile community-based voluntary counselling and testing (VCT), and support after testing. METHODS Project Accept is underway in ten communities in Tanzania, eight in Zimbabwe, and 14 in Thailand. Communities at each site were paired according to similar demographic and environmental characteristics, and one community from each pair was randomly assigned to receive standard clinic-based VCT (SVCT), and the other community was assigned to receive community-based VCT (CBVCT) plus access to SVCT. Randomisation and assignment of communities to intervention groups was done by the statistics centre by computer; no one was masked to treatment assignment because the interventions were community based. Intervention was provided for about 3 years (2006-09). The primary endpoint of HIV incidence is pending completion of assessments after the intervention. In this interim analysis, we examined the secondary endpoint of uptake in HIV testing, differences in characteristics of clients receiving their first HIV test, and repeat testing. Analyses were limited to clients aged 16-32 years. This study is registered with ClinicalTrials.gov, number NCT00203749. FINDINGS The proportion of clients receiving their first HIV test during the study was higher in CBVCT communities than in SVCT communities in Tanzania (2341 [37%] of 6250 vs 579 [9%] of 6733), Zimbabwe (5437 [51%] of 10,700 vs 602 [5%] of 12,150), and Thailand (7802 [69%] of 11,290 vs 2319 [23%] 10,033). The mean difference in the proportion of clients receiving HIV testing between CBVCT and SVCT communities was 40·2% (95% CI 15·8-64·7; p=0·019) across three community pairs (one per country). HIV prevalence was higher in SVCT communities than in CBVCT communities, but CBVCT detected almost four times more HIV cases than did SVCT across the three study sites (952 vs 264; p=0·003). Repeat HIV testing in CBVCT communities increased in all sites to reach 28% of all those testing for HIV by the end of the intervention period. INTERPRETATION CBVCT should be considered as a viable intervention to increase detection of HIV infection, especially in regions with restricted access to clinic-based VCT and support services after testing. FUNDING US National Institute of Mental Health, HIV Prevention Trials Network (via US National Institute of Allergy and Infectious Diseases), and US National Institutes of Health.

Removing barriers to knowing HIV status: Same-day mobile HIV testing in Zimbabwe

Objectives:We developed a mobile HIV voluntary counseling testing (VCT) strategy. Our aims were (1) to describe those using the services, (2) to assess the acceptability of such services, (3) to assess reasons for not testing previously, and (4) to compare those who used the services with those who did not to determine how to increase acceptability. Methods:We provided free anonymous mobile VCT using 2 rapid HIV tests in 12 marketplaces in Epworth and Seke, Zimbabwe. Qualitative interviews were conducted to assess motivations for and barriers to testing. A subsample of HIV testers and individuals near testing vans who declined testing (nontesters) completed a questionnaire. Results:A total of 1099 individuals participated in mobile VCT between March 2002 and August 2003. The proportion of participants infected with HIV was 29.2%. Overall, 98.8% of participants elected to receive HIV test results the same day. Reasons for not testing previously were often logistic (eg, inconvenience of hours [25.6%] and location [20.7%] or cost [8%]). Those who used the same-day mobile testing services (testers vs. nontesters) perceived themselves at higher risk for HIV infection (adjusted odds ratio [AOR] = 1.8) but were less likely to have known people with HIV (AOR = 0.49) or where to get tested (AOR = 0.57). Conclusions:Same-day HIV testing in community settings seems to be acceptable in sub-Saharan Africa. Barriers to HIV testing are often logistic and can be overcome with community-based strategies. These strategies need to be refined to address the needs of those not using mobile testing services.

Project Accept (HPTN 043): a community-based intervention to reduce HIV incidence in populations at risk for HIV in sub-Saharan Africa and Thailand.

Background:Changing community norms to increase awareness of HIV status and reduce HIV-related stigma has the potential to reduce the incidence of HIV-1 infection in the developing world. Methods:We developed and implemented a multilevel intervention providing community-based HIV mobile voluntary counseling and testing, community mobilization, and posttest support services. Forty-eight communities in Tanzania, Zimbabwe, South Africa, and Thailand were randomized to receive the intervention or clinic-based standard voluntary counseling and testing (VCT), the comparison condition. We monitored utilization of community-based HIV mobile voluntary counseling and testing and clinic-based standard VCT by community of residence at 3 sites, which was used to assess differential uptake. We also developed quality assurance procedures to evaluate staff fidelity to the intervention. Findings:In the first year of the study, a 4-fold increase in testing was observed in the intervention versus comparison communities. We also found an overall 95% adherence to intervention components. Study outcomes, including prevalence of recent HIV infection and community-level HIV stigma, will be assessed after 3 years of intervention. Conclusions:The provision of mobile services, combined with appropriate support activities, may have significant effects on utilization of voluntary counseling and testing. These findings also provide early support for community mobilization as a strategy for increasing testing rates.

Men's attitudes toward vaginal microbicides and microbicide trials in Zimbabwe

Female-controlled methods of HIV/AIDS and sexually transmitted disease prevention specifically vaginal microbicides may be more successful in Zimbabwe than the male condom. Since in Zimbabwe men make most decisions regarding sex the ultimate acceptability and effectiveness of a vaginal microbicide will depend on mens attitudes and beliefs about the practice. These issues were explored in five focus group discussions with Zimbabwean men. The majority of participants were married taxi drivers and farm workers from the Harare area. They indicated that women can protect themselves from HIV by being hygienic faithful and responsive to their husbands sexual needs; there was no mention of the fact that many women are at risk of acquiring HIV as a result of their partners extramarital sexual activity. Almost all participants said that a woman would need her partners permission to use a microbicide. They were skeptical about product safety concerned that it would lead to infertility or at least prevent pregnancy. They further expressed concerns that a microbicide would cause excessive vaginal lubrication and interfere with sexual pleasure. The discussions indicated that if vaginal microbicides are to find acceptance in Zimbabwe they must neither substantially lubricate the vagina nor act as a contraceptive. If clinical trials are to be conducted both men and women need to be informed about the safety and mechanism of action of the microbicide and assured that treatment for side effects will be available. The study guidelines should be explained to male partners as well as to women enrolled in the trial to minimize domestic conflicts and ensure compliance with the protocol.

Barrier Method Preferences and Perceptions Among Zimbabwean Women and their Partners

In Zimbabwe, adult HIV prevalence is over 25% and acceptable prevention methods are urgently needed. Sixty-eight Zimbabwean women who had completed a barrier-methods study and 34 of their male partners participated in focus group discussions and in-depth interviews to qualitatively explore acceptability of male condoms, female condoms and diaphragms. Most men and about half of women preferred diaphragms because they are female-controlled and do not detract from sexual pleasure or carry stigma. Unknown efficacy and reuse were concerns and some women reported feeling unclean when leaving the diaphragm in for six hours following sex. Nearly half of women and some men preferred male condoms because they are effective and limit womens exposure to semen, although they reportedly detract from sexual pleasure and carry social stigma. Female condoms were least preferred because of obviousness and partial coverage of outer-genitalia that interfered with sexual pleasure.

Vaginal microbicides for HIV / STI prevention in Zimbabwe: what key informants say.

The purpose of this study was to assess the acceptability of vaginal microbicides as prevention methods for heterosexually transmitted HIV. Interviews were conducted with key informants in and around Harare using a semistructured questionnaire with probes. Twenty-seven interviews were conducted with a total of 48 informants. Most women were enthusiastic about the products but had concerns about safety and how the use of these products might affect their relationships with their husbands. Many men were concerned that women would be able to use the products without their consent or knowledge. Several products may be acceptable in this culture but must be introduced within the existing gender power structure. This study provides a model for involving community leaders in the design of culturally appropriate clinical trials.

Understanding and addressing socio-cultural barriers to medical male circumcision in traditionally non-circumcising rural communities in sub-Saharan Africa

Given recent clinical trials establishing the safety and efficacy of adult medical male circumcision (MMC) in Africa, attention has now shifted to barriers and facilitators to programmatic implementation in traditionally non-circumcising communities. In this study, we attempted to develop a fuller understanding of the role of cultural issues in the acceptance of adult circumcision. We conducted four focus-group discussions with 28 participants in Mutoko, Zimbabwe, and 33 participants in Vulindlela, KwaZulu-Natal, South Africa, as well as 19 key informant interviews in both settings. We found the concept of male circumcision to be an alien practice, particularly as expressed in the context of local languages. Cultural barriers included local concepts of ethnicity, social groups, masculinity and sexuality. On the other hand, we found that concerns about the impact of HIV on communities resulted in willingness to consider adult male circumcision as an option if it would result in lowering the local burden of the epidemic. Adult MMC-promotional messages that create a synergy between understandings of both traditional and medical circumcision will be more successful in these communities.

The Importance of Discreet Use of the Diaphragm to Zimbabwean Women and their Partners

We conducted a 6-month acceptability study of diaphragms as a potential HIV/STI prevention method among Zimbabwean women. We examined partner involvement in diaphragm use, and importance of discreet use (use without partner awareness). Of the 181 women who completed the study, 45% said discreet use was “very or extremely important” and in multivariate logistic regression, women were more likely to value discretion if their partners: had other partners; drank alcohol; or were believed to prefer condoms to diaphragms. Qualitative data confirmed these findings. Both women and their partners reported that diaphragms can be used discreetly and saw this as advantageous, for both sexual pleasure and female control. However, many were concerned that use without partner approval could lead to marital problems. Discreet use should be considered in development of barrier methods and in diaphragm promotion, if proven effective against HIV/STI.

Only skin deep: limitations of public health understanding of male circumcision in South Africa

To the Editor: The recent randomised controlled trials in South Africa, Uganda and Kenya which showed the dramatic impact of adult male circumcision (MC) on HIV transmission have dominated HIV/AIDS public health discourse over the past few years.1–3 Several authors in the October 2008 SAMJ cautioned against widespread implementation of MC as a prevention intervention. More evidence on the acceptability and effectiveness of male circumcision is required to support the scale-up effort. Particularly in non-circumcising communities, traditional cultural views will influence circumcision’s uptake and acceptability.4 Following the WHO/UNAIDS announcement promoting widespread MC,5 we conducted a pilot study as part of an ongoing community-based voluntary counselling and testing trial (Project Accept) to assess potential challenges to promoting male circumcision in a rural community in KwaZulu-Natal, South Africa. We conducted four age-segregated, gender-specific (i.e. younger men and women and older men and women) focus group discussions of up to 10 individuals per group. We also interviewed 8 key informants, including community leaders, traditional healers and health workers regarding the feasibility and acceptability of male circumcision in this community. Our study revealed rich traditional understandings of male circumcision. Participants had strong negative views regarding the practice of male circumcision (ukusoka), involving the removal of the foreskin. These perceptions seem to originate in historical tensions between Zulus and the Xhosas regarding MC. In contrast to the Xhosa practice of full circumcision, Zulus traditionally promoted partial circumcision (ukugweda). Here, the foreskin is not removed, but an elastic band of tissue under the penis glans is cut, allowing the foreskin to move easily back and forth. Participants understood the difference between full and partial circumcision but ukugweda was preferred. Men and women felt that partial circumcision (i) helped to prevent infections and (ii) helped to avoid sensitivity and pain during sexual intercourse, as the external foreskin remains intact. Further, participants reported that the full removal of the foreskin kills certain cells and this may lower sexual pleasure. On the other hand, participants felt that if the tissue under the penis glans is uncut, the foreskin is not able to move back and forth easily, which interferes with erection and causes the penis to bend downward painfully. A partial cut is believed to allow sperm to move freely and to enhance pleasure for men and women. Male circumcision is being widely promoted on the assumption that the term is unambiguous. Our pilot study shows a widely held alternative meaning among a rural community in KwaZulu-Natal. Public health messages have to be clear and precise, and specifically adapted for different cultural contexts. Information and education materials are needed to distinguish between medical MC (and its benefits) and ukugweda, whose HIV-protective benefits are unknown. For successful uptake in these contexts, strategies to overcome historically negative cultural perceptions of MC among Zulus, as well as positive associations of partial circumcision with enhanced sexual pleasure, are required.

Fixed-Choice and Open-Ended Response Formats: A Comparison from HIV Prevention Research in Zimbabwe

This article examined similarities and differences in responses to open-ended and fixed-choice question formats gathered from Zimbabwean women participating in an HIV intervention study ( n = 227). Specifically, the authors compared the responses of women to two questions (one open-ended and one fixed-choice) about male condom negotiation strategies used with their partners. Comparisons across formats revealed that the definitions of negotiation categories coded from openended responses overlapped only moderately with categories used for the fixed-choice checklist. Fixed-choice reports of negotiation strategies were not statistically associated with reported condom use, but a statistically significant association was obtained with a category derived from open-ended questions. Although these results may be specific to this study and its specific study question, the data suggest that asking key study questions in both open-ended and fixed-choice formats may provide a valuable form of perspective for social and behavioral data.