Evaluation of the Tsima community mobilization intervention to improve engagement in HIV testing and care in South Africa: study protocol for a cluster randomized trial

Abstract Background HIV 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/design Using 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. Discussion Given 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 Registration NCT02197793 Registered July 21, 2014

A cluster randomized-controlled trial of a community mobilization intervention to change gender norms and reduce HIV risk in rural South Africa: study design and intervention

Abstract Background Community mobilization (CM) interventions show promise in changing gender norms and preventing HIV, but few have been based on a defined mobilization model or rigorously evaluated. The purpose of this paper is to describe the intervention design and implementation and present baseline findings of a Cluster Randomized Controlled Trial (RCT) of a two-year, theory-based CM intervention that aimed to change gender norms and reduce HIV risk in rural Mpumalanga province, South Africa. Methods Community Mobilizers and volunteer Community Action Teams (CATs) implemented two-day workshops, a range of outreach activities, and leadership engagement meetings. All activities were mapped onto six theorized mobilization domains. The intervention is being evaluated by a randomized design in 22 communities (11 receive intervention). Cross-sectional, population-based surveys were conducted with approximately 1,200 adults ages 18–35 years at baseline and endline about two years later. Conclusions This is among the first community RCTs to evaluate a gender transformative intervention to change norms and HIV risk using a theory-based, defined mobilization model, which should increase the potential for impact on desired outcomes and be useful for future scale-up if proven effective. Trial registration ClinicalTrials.gov NCT0212953

Gaining traction: Promising shifts in gender norms and intimate partner violence in the context of a community-based HIV prevention trial in South Africa

BACKGROUND: HIV and violence prevention programs increasingly seek to transform gender norms among participants, yet how to do so at the community level, and subsequent pathways to behavior change, remain poorly understood. We assessed shifts in endorsement of equitable gender norms, and intimate partner violence (IPV), during the three-year community-based trial of Tsima, an HIV 'treatment as prevention' intervention in rural South Africa. METHODS: Cross-sectional household surveys were conducted with men and women ages 18-49 years, in 8 intervention and 7 control communities, at 2014-baseline (n = 1,149) and 2018-endline (n = 1,189). Endorsement of equitable gender norms was measured by the GEM Scale. Intent-to-treat analyses assessed intervention effects and change over time. Qualitative research with 59 community members and 38 staff examined the change process. RESULTS: Nearly two-thirds of men and half of women in intervention communities had heard of the intervention/seen the logo; half of these had attended a two-day workshop. Regression analyses showed a 15% improvement in GEM Scale score over time, irrespective of the intervention, among men (p<0.001) and women (p<0.001). Younger women (ages 18-29) had a decreased odds of reporting IPV in intervention vs. control communities (aOR 0.53; p<0.05). Qualitative data suggest that gender norms shifts may be linked to increased media access (via satellite TV/smartphones) and consequent exposure to serial dramas modeling equitable relationships and negatively portraying violence. Tsima's couple communication/conflict resolution skills-building activities, eagerly received by intervention participants, appear to have further supported IPV reductions. CONCLUSIONS: There was a population-level shift towards greater endorsement of equitable gender norms between 2014-2018, potentially linked with rapid escalation in media access. There was also an intervention effect on reported IPV among young women, likely owing to improved couple communication. Societal-level gender norm shifts may create enabling environments for interventions to find new traction for violence and HIV-related behavior change

The power and process of shifting gender norms: Insights from a randomized controlled trial in South Africa

This Project SOAR report summarizes findings from a randomized controlled trial of Tsima ra rihanyu (“working together for health”), a three-year community mobilization program for treatment as prevention that aimed to address the social barriers to HIV testing and treatment in Mpumalanga Province, South Africa. In this report, the authors explore the types of gender norms that are salient for women and men, how these relate to HIV testing and treatment, and the pathways through which gender norms operate to affect women’s and men’s HIV service use and experience and perpetration of intimate partner violence

Longitudinal effects of poverty on men’s perpetration of partner violence in South Africa

Introduction: Although poverty is often viewed as a driver of intimate partner violence (IPV), few studies have examined how changes in poverty influence men’s IPV perpetration over time. One sensitive marker of poverty is food security, or the ability of households to obtain adequate nutrition. The influence of food security has been associated with IPV in cross-sectional studies, but here we examine whether a causal relationship exists. Methods: We followed a cohort of 2,479 men living in a peri-urban settlement near Johannesburg, South Africa during the period of February 2016-August 2018. Using self-completed audio-assisted questionnaires, men responded at baseline (T0), 12 months later (T1), and 24 months later (T2). Questions about current food security, household type, childhood conditions, and past-year IPV perpetration were asked. We used cross-lagged dynamic panel modeling to assess whether food insecurity changes influenced men’s IPV perpetration over time. Results: A large proportion of men (46.9%) reported perpetrating IPV at baseline, but this proportion reduced over time (39.2% and 26.5% reported IPV at midline and endline, respectively). Less than half (41.4%) of participants reported food insecurity at T0, and this stayed consistent at T1 and T2. In cross-sectional bivariate analysis, food insecurity was higher among those men perpetrating IPV than among those who used no violence at all three time-points. In a cross-lagged dynamic panel model, food insecurity predicted men’s use of IPV one year later. Food insecurity was associated with a small, but significant, longitudinal impact on men’s IPV use (standardized coefficient=0.08, p=0.035) and the model fit indices were strong (RMSEA=0.027, CFI=0.993). This longitudinal association between food insecurity and IPV perpetration persisted in a final model controlling for housing status, age at baseline, and childhood exposure to abuse (coef=0.10, p=0.022) that had strong fit (RMSEA=0.015, CFI=0.998). In a separate model, IPV perpetration did not predict later food security, suggesting a causal relationship from poverty to IPV perpetration. Conclusions: Food insecurity and housing, as distinct markers of poverty, had small but persistent longitudinal effects on men’s perpetration of IPV in a peri-urban settlement in South Africa. Addressing IPV perpetration will require examination of broader structural challenges, such as livelihoods and food security, particularly in settings with endemic poverty. Future interventions should consider livelihood strategies to improve health outcomes for both women and men

HIV non-testing, perpetration of violence against women, and sexual risk-behaviour: A cross-sectional analysis of South African peri-urban township men

Despite HIV testing having improved globally, men remain disproportionately less likely to test for HIV. While violence against women (VAW) and HIV risk have a strong association among women, few studies explore men around VAW perpetration, risky-sexual behaviour, and HIV testing. Males aged 18–42 years were recruited from a peri-urban settlement near Johannesburg, South Africa. Data were from an endline of a trial. We used logistic regression to assess odds of non-HIV testing using STATA 13. At endline, 1508 men participated in the study. Of these nearly one-third (31.6%, n = 475) had not tested for HIV in the past year. HIV non-testing was significantly lower among men who were single, older, did not complete high school and were less food secure. VAW perpetration retained a significant association with HIV non-testing after controlling for socio-demographics (AOR = 0.73, 95%CI = 0.58–0.93). In multivariate models, HIV non-testing was also associated with inconsistent condom use (AOR = 0.64, 95%CI = 0.48–0.85), problem drinking (AOR = 0.72, 95%CI = 0.55–0.94) and reporting of all four risky sexual behaviours (AOR = 0.70, 95%CI = 0.49–1.01). Data suggests that one-third of men who never test for HIV in this setting may represent a high-risk group. Future campaigns could consider behaviour change around non-violence, relationship quality, and gender norms alongside HIV testing

Food insecurity and men's perpetration of partner violence in a longitudinal cohort in South Africa.

BackgroundAlthough food insecurity has been associated with intimate partner violence (IPV), few studies examine it longitudinally or among male perpetrators.MethodsWe used secondary data from a trial that followed 2479 men in a peri-urban settlement in South Africa (February 2016-August 2018). Men self-completed questionnaires at baseline (T0), 12 months (T1) and 24 months (T2) on food security, household type, relationship status, childhood abuse exposure, alcohol use, and perpetration of physical and/or sexual IPV. Cross-lagged dynamic panel modelling examines the strength and direction of associations over time.ResultsAt baseline, rates of IPV perpetration (52.0%) and food insecurity (65.5%) were high. Food insecure men had significantly higher odds of IPV perpetration at T0, T1 and T2 (ORs of 1.9, 1.4 and 1.4, respectively). In longitudinal models, food insecurity predicted men's IPV perpetration 1 year later. The model had excellent fit after controlling for housing, relationship status, age, childhood abuse and potential effect of IPV on later food insecurity (standardised coefficient=0.09, p=0.031. root mean squared error of approximation=0.016, comparative fit index=0.994). IPV perpetration did not predict later food security (p=0.276).ConclusionFood insecurity had an independent, longitudinal association with men's IPV perpetration in a peri-urban South African settlement. These findings suggest food security could be a modifiable risk factor of partner violence.Trial registration numberNCT02823288

Community mobilization for HIV testing uptake: Results from a community randomized trial of a theory-based intervention in rural South Africa

Background: HIV testing uptake in South Africa is below optimal levels. Community mobilization (CM) may increase and sustain demand for HIV testing, however, little rigorous evidence exists regarding the effect of CM interventions on HIV testing and the mechanisms of action. Methods: We implemented a theory-driven CM intervention in 11 of 22 randomly-selected villages in rural Mpumalanga Province. Cross-sectional surveys including a community mobilization measure were conducted before (n = 1181) and after (n = 1175) a 2-year intervention (2012–2014). We assessed community-level intervention effects on reported HIV testing using multilevel logistic models. We used structural equation models to explore individual-level effects, specifically whether intervention assignment and individual intervention exposure were associated with HIV testing through community mobilization. Results: Reported testing increased equally in both control and intervention sites: the intervention effect was null in primary analyses. However, the hypothesized pathway, CM, was associated with higher HIV testing in the intervention communities. Every standard deviation increase in village CM score was associated with increased odds of reported HIV testing in intervention village participants (odds ratio: 2.6, P = \u3c0.001) but not control village participants (odds ratio: 1.2, P = 0.53). Structural equation models demonstrate that the intervention affected HIV testing uptake through the individual intervention exposure received and higher personal mobilization scores. Conclusions: There was no evidence of community-wide gains in HIV testing due to the intervention. However, a significant intervention effect on HIV testing was noted in residents who were personally exposed to the intervention and who evidenced higher community mobilization. Research is needed to understand whether CM interventions can be diffused within communities over time

Understanding men’s networks and perceptions of leadership to promote HIV testing and treatment in Agincourt, South Africa

Understanding informal leadership in high HIV prevalence settings is important for the success of popular opinion leader (POL) and other HIV testing and treatment promotion strategies which aim to leverage the influence of these leaders. We conducted a study in Mpumalanga province, South Africa, in which we aimed to: (1) describe men's personal networks and key social relationships; and (2) describe the types of individuals men identify as leaders. We administered a structured questionnaire with 45 men (15 HIV-positive and 30 HIV-negative) in which men enumerated and described characteristics of individuals they share personal matters with, and people they considered as leaders. We further conducted in-depth interviews with 25 of these men to better understand men's conceptualisation of leadership in their community. Family members were prominent in men's personal networks and among the leaders they nominated. Men living with HIV were much more likely to know others living with HIV, and described friendships on the basis of the shared experience of HIV treatment. Future POL interventions aiming to promote HIV testing and care among men in rural South Africa should consider the importance of family in community leadership, and seek to leverage the influence of connections between men living with HIV