Participation and diffusion effects of a peer-intervention for HIV prevention among adults in rural Malawi

Condom use increased after a peer group intervention implemented by community volunteers in Malawi

BACKGROUND

HIV prevention remains a global priority, especially in sub-Saharan Africa. Our research team previously developed an evidence-based peer group program for HIV prevention called Mzake ndi Mzake (Friend to Friend). A community-engaged collaboration adapted the program for community ownership and implementation. Here we report whether this HIV prevention program, implemented by community volunteers, increased condom use among sexually active individuals in rural Malawi.

METHODS

Three communities sequentially rolled out the program. Effectiveness was evaluated using a stepped wedge design. Repeated surveys 11-13 months apart were conducted between 2016 and 2019. At Time 1, no community had offered the intervention. At Time 2, the first community had offered the intervention and two had not (control group). At Time 3, two communities had offered the intervention and one had not (control group). We used two condom use indicators; condom use frequency in the last 2 months (N = 771) and condom use at last sex (N = 880). The analytical sample included all sexually active persons answering that question at one or more time points. Mixed-effects cumulative logit and Generalized Estimating Equation (GEE) models were used to model the two condom indicators over time, controlling for demographic factors, UNAIDS HIV knowledge, safer sex self-efficacy and partner communication.

RESULTS

This peer group intervention implemented by trained community volunteers increased both condom use indicators at Times 2 and 3. In the final adjusted models with non-significant factors removed, condom use in the last two months increased for the intervention group vs. control group [Time 2: Adjusted Odds Ratio (AOR) = 1.59 (1.15, 2.21); Time 3: AOR 2.01 (1.23, 3.30)]. Similarly, condom use at last sex increased for the intervention group vs. control group [Time 2: AOR = 1.48 (1.08, 2.03); Time 3: AOR 1.81 (1.13, 2.90)]. Other significant predictors of greater condom use were also described. Although the intervention increased UNAIDS HIV knowledge, knowledge did not predict condom use.

CONCLUSIONS

In this community-engaged implementation study, an evidence-based peer group program for HIV prevention increased condom use when delivered by trained community volunteers. Community ownership and program delivery by trained volunteers offer an innovative and cost-effective strategy to address ongoing HIV prevention needs without overburdening healthcare systems in sub-Saharan Africa.

TRIAL REGISTRATION

Clinical Trials.gov NCT02765659 Registered May 6, 2016.

Exploring the experiences of peer support participation for HIV peer volunteers: A meta-synthesis of qualitative research

BACKGROUND

Gaining insights and feedback from HIV peer volunteers about their peer support practice is crucial for optimizing and enhancing the effectiveness and sustainability of peer support for people with HIV. There is a dearth of systematic reviews that explore the experiences of HIV peer volunteers about their peer support experience. This study aims to consolidate qualitative research on the experiences of peer support participation for HIV peer volunteers, to provide inspiration and reference for HIV peer support practice.

METHODS

A meta-aggregation approach was employed to synthesize qualitative studies. Electronic databases were searched for peer-reviewed and gray literature published in English and Chinese between 1996 and September 2022. Two independent reviewers assessed the methodological quality and extracted data from the included studies. The meta-aggregation approach developed by the Joanna Briggs Institute (JBI) was utilized to synthesize the findings.

RESULTS

A total of 2610 studies were initially identified through the database search, and twenty-two eligible studies were included in the meta-synthesis. Among the included studies, five presented synthesized findings on the following topics: firstly, taking people with HIV as HIV peer volunteers shows specific motivations and advantages when engaging in peer support practice. Secondly, HIV peer volunteers reinforce the connections between people with HIV and medical institutions, ensuring continuity of care and compensating for the limited availability of medical resources. Thirdly, HIV peer volunteers are capable of providing people with HIV with a higher level of support. Additionally, participating in peer support practice can also yield personal benefits for HIV peer volunteers. Finally, HIV peer support programs face both opportunities and challenges.

CONCLUSION

It is necessary to take more flexible and effective approaches to address resource allocation and social support for people with HIV. Peer support presents a mutually beneficial option that holds significant implications for public health systems, clinical healthcare providers, people with HIV, and HIV peer volunteers. It is imperative to develop effective models for HIV peer support practice. Collaborative efforts between relevant departments and personnel, alongside HIV peer volunteers, should be undertaken to formulate support strategies. Additionally, efforts should be made to identify and guide people with HIV into the healthcare system, facilitating comprehensive treatment and care continuity. These measures aim to further reduce HIV transmission, improve the quality of life for people with HIV, and advance the "normalization" of HIV.

Condom use increased after a peer group intervention implemented by community volunteers in Malawi

Background

HIV prevention remains a global priority, especially in sub-Saharan Africa. Our research team previously developed an evidence-based peer group program for HIV prevention called Mzake ndi Mzake (Friend to Friend). A community-engaged collaboration adapted the program for community ownership and implementation. Here we report whether this HIV prevention program, implemented by community volunteers, increased condom use among sexually active individuals in rural Malawi.

Methods

Three communities sequentially rolled out the program. Effectiveness was evaluated using repeated surveys. At Time 1, no community had offered the intervention. At Time 2, the first community had offered the intervention and two had not (control group). At Time 3, two communities had offered the intervention and one had not (control group). We used two condom use indicators; condom use frequency in the last 2 months (N = 776) and condom use at last sex (N = 880). For each indicator, the sample included all sexually active persons answering that question at one or more time points. Regression analyses were used to model the two condom indicators over time, controlling for demographic factors, UNAIDS HIV knowledge, safer sex self-efficacy and partner communication.

Results

This peer group intervention implemented by trained community volunteers increased both condom use indicators at Times 2 and 3. In the final regression models. Other predictors of greater condom use for at least one condom use indicator included younger age group (13-19), male gender, not married/cohabiting, high involvement in religiously affiliated activities, higher safer sex self-efficacy, and greater partner communication. Although the intervention increased UNAIDS HIV knowledge, knowledge did not predict condom use.

Conclusions

This community engaged implementation study found that an evidence-based peer group program for HIV prevention increased condom use when delivered by trained community volunteers. Leveraging community strengths and human capital resources facilitated implementation of this effective HIV prevention program in rural Malawi. Community ownership and program delivery by trained local volunteers offers an innovative and cost-effective strategy to address ongoing HIV prevention needs without overburdening heathcare systems in sub.

Trial registration

Clinical Trials.gov NCT02765659 Registered May 6, 2016.

Evidence and gap map report: Social and Behavior Change Communication (SBCC) interventions for strengthening HIV prevention and research among adolescent girls and young women (AGYW) in low- and middle-income countries (LMICs)

BACKGROUND

Adolescent girls and young women (AGYW), aged 15-24 years, are disproportionately affected by HIV and other sexual and reproductive health (SRH) risks due to varying social, cultural, and economic factors that affect their choices and shape their knowledge, understanding, and practices with regard to their health. Socio-Behavioral Change Communication (SBCC) interventions targeted at strengthening the capabilities of individuals and their networks have supported the demand and uptake of prevention services and participation in biomedical research. However, despite growing global recognition of the domain, high-quality evidence on the effectiveness of SBCC remains scattered. This evidence and gap map (EGM) report characterizes the evidence base on SBCC interventions for strengthening HIV Prevention and Research among AGYW in low- and middle-income countries (LMICs), identifying evidence gaps and outlining the scope of future research and program design.

OBJECTIVES

The objectives of the proposed EGM are to: (a) identify and map existing EGMs in the use of diverse SBCC strategies to strengthen the adoption of HIV prevention measures and participation in research among AGYW in LMICs and (b) identify areas where more interventions and evidence are needed to inform the design of future SBCC strategies and programs for AGYW engagement in HIV prevention and research.

METHODS

This EGM is based on a comprehensive search of systematic reviews and impact evaluations corresponding to a range of interventions and outcomes-aimed at engaging AGYW in HIV prevention and research - that were published in LMICs from January 2000 to April 2021. Based on guidance for producing a Campbell Collaboration EGM, the intervention and outcome framework was designed in consultation with a group of experts. These interventions were categorized across four broad intervention themes: mass-media, community-based, interpersonal, and Information Communication and Technology (ICT)/Digital Media-based interventions. They were further sub-categorized into 15 intervention categories. Included studies looked at 23 unique behavioral and health outcomes such as knowledge attitude and skills, relationship dynamics, household dynamics, health care services, and health outcomes and research engagement. The EGM is presented as a matrix in which the rows are intervention categories/sub-categories, and the columns are outcome domains/subdomains. Each cell is mapped to an intervention targeted at outcomes. Additional filters like region, country, study design, age group, funding agency, influencers, population group, publication status, study confidence, setting, and year of publication have been added.

SELECTION CRITERIA

To be eligible, studies must have tested the effectiveness of SBCC interventions at engaging AGYW in LMICs in HIV prevention and research. The study sample must have consisted of AGYW between the ages of 15-24, as defined by UNAIDS. Both experimental (random assignment) and quasi-experimental studies that included a comparison group were eligible. Relevant outcomes included those at the individual, influencer, and institutional levels, along with those targeting research engagement and prevention-related outcomes.

RESULTS

This EGM comprises 415 impact evaluations and 43 systematic reviews. Interventions like peer-led interactions, counseling, and community dialogues were the most dominant intervention sub-types. Despite increased digital penetration use of media and technology-driven interventions are relatively less studied. Most of the interventions were delivered by peers, health care providers, and educators, largely in school-based settings, and in many cases are part of sex-education curricula. Evidence across geographies was mostly concentrated in Sub-Saharan Africa (70%). Most measured outcomes focused on disease-related knowledge dissemination and enhancing awareness of available prevention options/strategies. These included messaging around consistent condom use, limiting sexual partners, routine testing, and awareness. Very few studies were able to include psychographic, social, and contextual factors influencing AGYW health behaviors and decisions, especially those measuring the impact of social and gender norms, relationship dynamics, and household dynamics-related outcomes. Outcomes related to engagement in the research were least studied.

CONCLUSION

This EGM highlights that evidence is heavily concentrated within the awareness-intent spectrum of behavior change and gets lean for outcomes situated within the intent-action and the action-habit formation spectrum of the behavior change continuum. Most of the evidence was concentrated on increasing awareness, knowledge, and building risk perception around SRH domains, however, fewer studies focused on strengthening the agency and self-efficacy of individuals. Similarly, evidence on extrinsic factors-such as strengthening social and community norms, relationships, and household dynamics-that determine individual thought and action such as negotiation and life skills were also found to be less populated. Few studies explore the effectiveness of these interventions across diverse AGYW identities, like pregnant women and new mothers, sex workers, and people living with HIV, leading to limited understanding of the use of these interventions across multiple user segments including key influencers such as young men, partners, families, religious leaders, and community elders was relatively low. There is a need for better quality evidence that accounts for the diversity of experiences within these populations to understand what interventions work, for whom, and toward what outcome. Further, the evidence for use of digital and mass-media tools remains poorly populated. Given the increasing penetration of these tools and growing media literacy on one end, with widening gender-based gaps on the other, it is imperative to gather more high-quality evidence on their effectiveness. Timely evidence generation can help leverage these platforms appropriately and enable intervention designs that are responsive to changing communication ecologies of AGYW. SBCC can play a critical role in helping researchers meaningfully engage and collaborate with communities as equal stakeholders, however, this remains poorly evidenced and calls for investigation and investment. A full list of abbreviations and acronyms are available in Supporting Information: Appendix F.

A peer group intervention implemented by community volunteers increased HIV prevention knowledge

BACKGROUND

HIV prevention knowledge levels are low in sub-Saharan Africa. In our efficacy study, the Mzake ndi Mzake (Friend-to-Friend; hereafter Mzake) 6-session peer group intervention, delivered by health workers, improved HIV prevention knowledge and other outcomes in Malawi. To expand HIV prevention approaches, this implementation study tested whether the intervention remained effective when implemented by trained community volunteers. HIV prevention knowledge findings are presented.

METHODS

Using a stepped wedge design, three communities implemented the Mzake program sequentially in randomly assigned order. Repeated surveys assessed outcomes, and participants served as controls until they completed the program. At Time 2, Community 1 became the intervention group, and at Time 3, Communities 1 and 2 were the intervention group. HIV prevention knowledge, the primary outcome, was assessed through two indicators: UNAIDS comprehensive knowledge (UNAIDS Knowledge), defined as correctly answering five HIV prevention questions (Yes/No), and a 9-item HIV/PMTCT Knowledge Index (number correct). Multivariate generalized estimating equation logistic regression (UNAIDS Knowledge) and mixed-effects regression models (HIV/PMTCT Knowledge Index) were used to assess knowledge controlling for five sociodemographic factors.

RESULTS

In bivariate analyses of UNAIDS Knowledge, more persons answered correctly in the intervention group than the control group at Time 2 (56.8% vs. 47.9%, p  < 0.01), but the difference was not significant at Time 3. In logistic regression, there was a significant linear increase in the proportion who correctly answered all questions in the control group, but the increase was significantly higher in the intervention group (log-odds estimate = 0.17, SE = 0.06, p-value < 0.01). The HIV/PMTCT Knowledge Index scores increased over time for both groups, but in the intervention group the increase was significantly higher than the control group (0.11 at Time 2; 0.21 at Time 3). In youth and adult subsamples analyses, the intervention was highly effective in increasing knowledge for youth, but not for adults.

CONCLUSION

This implementation study showed that Mzake was effective in increasing HIV prevention knowledge when delivered by community members. Community approaches offer an important strategy to increase HIV prevention in rural communities without burdening healthcare systems.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02765659. Registered 06/05/2016.

Comment on Alharbi et al. Adoption of Health Mobile Apps during the COVID-19 Lockdown: A Health Belief Model Approach. Int. J. Environ. Res. Public Health 2022, 19, 4179

Alharbi and colleagues' article, "Adoption of health mobile apps during the COVID-19 lockdown: a Health Belief Model approach", was interesting, well-written, and informative [...].

The Characteristics and Risk Factors of Web-Based Sexual Behaviors Among Men Who Have Sex With Men in Eastern China: Cross-sectional Study

Background

Finding casual sex partners on the internet has been considered a huge challenge for HIV transmission among men who have sex with men (MSM) in China.

Objective

This study aimed to identify the characteristics and risk factors of finding causal sex partners on the internet among MSM in Zhejiang Province, China.

Methods

This was a cross-sectional study. Participants were enrolled by 4 community-based organizations (CBOs) and 10 Voluntary Counselling and Testing (VCT) clinics through advertisements in bathrooms, bars, and gay hook-up apps from June to December 2018. A CBO- or physician-assisted survey was conducted to collected information on finding casual sex partners, perceived HIV infection, and HIV risk behaviors.

Results

Among 767 participants, 310 (40.4%) reported finding causal sex partners on the internet. Factors associated with finding casual sex partners on the internet included watching pornographic videos on the internet more than once a week (adjusted odds ratio [aOR]=1.881, 95% CI 1.201-2.948), discussing “hooking-up online” with friends (aOR=4.018, 95% CI 2.910-5.548), and perceiving that the likelihood of HIV infection among casual sex partners sought on the internet was “medium” (aOR=2.034, 95% CI 1.441-2.873) or “low” (aOR=2.548, 95% CI 1.524-4.259). Among the participants who reported finding casual sex partners on the internet, 30.2% (91/310) reported having unprotected sex with casual sex partners encountered on the internet in the past 6 months. On multivariate logistic regression analyses, knowing the HIV infection status of casual sex partners sought on the internet was significantly associated with performing inserted intercourse (aOR=1.907, 95% CI 1.100-3.306) and a decreased risk of inconsistent condom use (aOR=0.327, 95% CI 0.167-0.642).

Conclusions

Web-based casual sexual behavior is becoming more prevalent, and the rate of unprotected sex among MSM in Zhejiang Province is high. Future HIV prevention approaches should emphasize the importance for MSM to proactively determine the HIV infection status of potential casual sex partners sought on the internet.

Women report sustained benefits from attending group-based education about pelvic floor muscles: a longitudinal qualitative study

QUESTION

Among women who have participated in group-based education about the pelvic floor, what are their perceptions of the program and the group format?

DESIGN

Exploratory longitudinal qualitative study.

PARTICIPANTS

Community-dwelling women aged ≥ 18 years who participated in three or four sessions of pelvic floor education in a group format at a university clinic.

DATA EXTRACTION AND ANALYSIS

Semi-structured group or individual interviews were conducted at three time points: 1 week, 3 months and ≥ 5 months after the education activity. Data were inductively content analysed and independently coded, with iterative theme development.

RESULTS

Women considered the content and delivery appropriate and useful. New knowledge was assimilated and shared with others, and many tried to adopt pelvic floor muscle training in daily life. The women felt that the education sessions might benefit other women, with and without pelvic floor dysfunction symptoms, and that such education would ideally be more widely available. A perception of the value of the education persisted over time, even though maintenance of some health-promoting behaviours, such as pelvic floor muscle training, decreased.

CONCLUSION

The pelvic floor group education sessions appeared to fulfil the purpose of increasing knowledge about pelvic floor (dys)function and applying this in daily life. Overall, the participants, who had completed three or four of the four sessions, found the program to be useful. A unique feature of this study was longitudinal data collection and it seemed that the perception of value persisted over time.

Community-level spillover effects of an intervention to prevent intimate partner violence and HIV transmission in rural Ethiopia

Background

Intimate partner violence (IPV) is associated with adverse health and psychosocial outcomes. We analysed the spillover effects of Unite for a Better Life (UBL), an intervention evaluated in a cluster randomised controlled trial using a double-randomised design; previous evidence suggests UBL reduced IPV in rural Ethiopia among direct beneficiaries.

Methods

Villages (n=64) were randomly allocated to control, or to receive UBL delivered to men, women or couples. Each cluster comprised 106 surveyed households, including 21 randomly selected indirect beneficiary households who were not included in the intervention. Primary and secondary IPV outcomes included women’s experience and men’s perpetration of past-year physical or sexual IPV 24 months postintervention. An intention-to-treat analysis was conducted comparing indirect beneficiaries to sampled households in control communities. The analysis includes 2516 households surveyed at baseline in 2014–2015 (1680 households in the control arm, 258 indirect beneficiary households in the couples’ arm, 287 indirect beneficiary households in the women’s arm and 291 indirect beneficiary households in the men’s arm). Follow-up data were available from 88% of baseline respondents and 86% of baseline spouses surveyed in 2017–2018, a total of 4379 individuals.

Results

Among indirect beneficiaries, there was no statistically significant intervention effect on women’s past-year experience of physical or sexual IPV, while men’s UBL significantly reduced reported perpetration of past-year sexual IPV (Adjusted Odds Ratio: 0.55; 95% CI 0.38 to 0.80, p=0.002). The intervention effects among indirect beneficiaries were statistically similar to those reported for the direct beneficiaries. In general, the hypothesis of equal effects cannot be rejected.

Conclusion

A gender-transformative intervention delivered to men was effective in reducing reported IPV even among indirect beneficiaries, suggesting that the programme had positive spillover effects in diffusing information and changing behaviours within the broader community.

Trial registration numbers

NCT02311699 and American Economic Association Registry (AEARCTR-0000211).

Social, Behavioral, and Cultural factors of HIV in Malawi: Semi-Automated Systematic Review

BACKGROUND

Demographic and sociobehavioral factors are strong drivers of HIV infection rates in sub-Saharan Africa. These factors are often studied in qualitative research but ignored in quantitative analyses. However, they provide in-depth insight into the local behavior and may help to improve HIV prevention.

OBJECTIVE

To obtain a comprehensive overview of the sociobehavioral factors influencing HIV prevalence and incidence in Malawi, we systematically reviewed the literature using a newly programmed tool for automatizing part of the systematic review process.

METHODS

Due to the choice of broad search terms ("HIV AND Malawi"), our preliminary search revealed many thousands of articles. We, therefore, developed a Python tool to automatically extract, process, and categorize open-access articles published from January 1, 1987 to October 1, 2019 in the PubMed, PubMed Central, JSTOR, Paperity, and arXiV databases. We then used a topic modelling algorithm to classify and identify publications of interest.

RESULTS

Our tool extracted 22,709 unique articles; 16,942 could be further processed. After topic modelling, 519 of these were clustered into relevant topics, of which 20 were kept after manual screening. We retrieved 7 more publications after examining the references so that 27 publications were finally included in the review. Reducing the 16,942 articles to 519 potentially relevant articles using the software took 5 days. Several factors contributing to the risk of HIV infection were identified, including religion, gender and relationship dynamics, beliefs, and sociobehavioral attitudes.

CONCLUSIONS

Our software does not replace traditional systematic reviews, but it returns useful results to broad queries of open-access literature in under a week, without a priori knowledge. This produces a "seed dataset" of relevance that could be further developed. It identified known factors and factors that may be specific to Malawi. In the future, we aim to expand the tool by adding more social science databases and applying it to other sub-Saharan African countries.

A hybrid design testing a 3-step implementation model for community scale-up of an HIV prevention intervention in rural Malawi: study protocol

BACKGROUND

Scaling-up evidence-based behavior change interventions can make a major contribution to meeting the UNAIDS goal of no new HIV infections by 2030. We developed an evidence-based peer group intervention for HIV prevention and testing in Malawi that is ready for wider dissemination. Our innovative approach turns over ownership of implementation to rural communities. We adapted a 3-Step Implementation Model (prepare, roll-out and sustain) for communities to use. Using a hybrid design, we simultaneously evaluate community implementation processes and program effectiveness.

METHODS

Three communities in southern Malawi begin implementation in randomly-assigned order using a stepped wedge design. Our evaluation sample size of 144 adults and 144 youth per community provides sufficient power to examine primary outcomes of condom use and HIV testing. Prior to any implementation, the first participants in all three communities are recruited and complete the Wave 1 baseline survey. Waves 2-4 surveys occur after each community completes roll-out. Each community follows the model's three steps. During Prepare, the community develops a plan and trains peer group leaders. During Roll-Out, peer leaders offer the program. During Sustain, the community makes and carries out plans to continue and expand the program and ultimately obtain local funding. We evaluate degree of implementation success (Aim 1) using the community's benchmark scores (e.g, # of peer groups held). We assess implementation process and factors related to success (Aim 2) using repeated interviews and observations, benchmarks from Aim 1 and fidelity assessments. We assess effectiveness of the peer group intervention when delivered by communities (Aim 3) using multi-level regression models to analyze data from repeated surveys. Finally, we use mixed methods analyses of all data to assess feasibility, acceptability and sustainability (Aim 4).

DISCUSSION

The project is underway, and thus far the first communities have enthusiastically begun implementation. We have had to make several modifications along the way, such as moving from rapid-tests of STIs to symptoms screening by a nurse due to problems with test reliability and availability. If successful, results will provide a replicable evidence-based model for future community implementation of this and other health interventions.

TRIAL REGISTRATION

Clinical Trials.gov NCT02765659 Registered May 6, 2016.

Representation of People's Decisions in Health Information Systems.* A Complementary Approach for Understanding Health Care Systems and Population Health

OBJECTIVES

In this study, we aimed: 1) to conceptualize the theoretical challenges facing health information systems (HIS) to represent patients' decisions about health and medical treatments in everyday life; 2) to suggest approaches for modeling these processes.

METHODS

The conceptualization of the theoretical and methodological challenges was discussed in 2015 during a series of interdisciplinary meetings attended by health informatics staff, epidemiologists and health professionals working in quality management and primary and secondary prevention of chronic diseases of the Hospital Italiano de Buenos Aires, together with sociologists, anthropologists and e-health stakeholders.

RESULTS

HIS are facing the need and challenge to represent social human processes based on constructivist and complexity theories, which are the current frameworks of human sciences for understanding human learning and socio-cultural changes. Computer systems based on these theories can model processes of social construction of concrete and subjective entities and the interrelationships between them. These theories could be implemented, among other ways, through the mapping of health assets, analysis of social impact through community trials and modeling of complexity with system simulation tools.

CONCLUSIONS

This analysis suggested the need to complement the traditional linear causal explanations of disease onset (and treatments) that are the bases for models of analysis of HIS with constructivist and complexity frameworks. Both may enlighten the complex interrelationships among patients, health services and the health system. The aim of this strategy is to clarify people's decision making processes to improve the efficiency, quality and equity of the health services and the health system.