Kawichai S, Celentano D, Srithanaviboonchai K, Wichajarn M, Pancharoen K, Chariyalertsak C, Visrutaratana S, Khumalo-Sakutukwa G, Sweat M, Chariyalertsak S; and The Project Accept Study Team. NIMH Project Accept (HPTN 043) HIV/AIDS Community Mobilization (CM) to Promote Mobile HIV Voluntary Counseling and Testing (MVCT) in Rural Communities in Northern Thailand: Modifications by Experience. AIDS Behav. 2012 Jul;16(5):1227-37.
The overall study goals were to test the efficacy of community mobilization (CM), community-based, mobile voluntary counseling and testing (MVCT), and post-test support services (PTSS) in reducing HIV incidence in the intervention communities of the in rural northern Thailand.
Fourteen rural communities in six districts (Chaiprakarn, Chiang Dao, Fang, Mae-Ai, Mae-tang, and Praow) of northern Chiang Mai province, Thailand. Each community was comprised of 8-23 villages; estimated community sizes at baseline ranged from about 5000 to about 9200.
This is a pre- post-intervention evaluation of the intervention arm, which was part of a larger cluster-randomized trial.
Four-component intervention comprised of CM (community engagement and education); MVCT (free counseling and testing, same-day test results); PTSS (improving support systems and quality of life for people testing HIV-infected); and quality assurance.
Adults (>16 years old), predominantly farmers and farm-workers, but also including students, merchants, government employees, housewives and other occupations. Slightly more than half were female. About half were ethnic minorities (e.g. Hmong, Karen, Lahu, Lisu, Shan and Yao).
Overall study outcomes of interest were change in HIV incidence, change in sexual risk behavior, change in rates of HIV testing, change in social norms regarding HIV testing and disclosure of HIV status, and change in attitudes in regard to HIV stigma. This paper provides data on CM and the uptake of MVCT services.
Four communities were chosen from Fang district; two communities were chosen from each of the other districts. Communities were paired within each district to intervention or control. Control communities received standard voluntary counseling and testing (VCT), performed at district hospitals. Intervention communities received CM, MVCT, and PTSS.
There were a total of seven community pairs. The intervention was conducted sequentially in rounds, conducting CM and MVCT in each of the seven intervention communities before initiating the next round. For the first three rounds, CM teams would enter scheduled villages, going door-to-door and holding small group meetings. Three to five days later, MVCT teams would arrive to deliver VCT.
Beginning with the fourth round, in response to decreasing MVCT uptake in some communities and experience at a large community event commemorating World AIDS Day, researchers modified their approach. They adopted an "edutainment" strategy, in which CM and MVCT staff combined to provide evening entertainment together with HIV education and services. Entertainment consisted of karaoke, movies, prize give-aways and various amusements; HIV services included MVCT, interactive HIV education games, interactive group education and other means of educating and raising awareness about HIV prevention and transmission.
Each intervention community received the same intervention strategy in each round, and was similar demographically and with regard to MVCT access.
In all rounds, clients desiring MVCT were given cards with unique numbers. Each client was assigned to a counselor. After consent was given and pre-test counseling was provided, the counselor led the client to a staff member who performed a finger-prick for rapid HIV testing. Two HIV rapid test kits, Bioline HIV-1/2 and Determine HIV-1/2, were used in parallel. In cases where both test kits gave the same result, the client's HIV status was determined accordingly. If the results were discordant, a third kit (either ACON HIV-1/2 Clearview HIV 1/2 STAT-PAK) was used to confirm test results. Individual clients kept their numbered cards while awaiting test results (usually provided within 30 minutes), and met with the same counselors for post-test counseling as had provided them with pre-test counseling. Only the unique number on the client's card was recorded, and it was not possible to identify individual clients. Clients testing positive were referred for medical care and support.
Pre- and post-test counseling chart notes were created to facilitate individual counseling and to collect data. Data collected included demographic characteristics, history of prior VCT, and HIV risk behaviors. The analysis was restricted to the intervention communities only.
Seven rounds of CM and MVCT activities were conducted between January 2006 and March 2009. A total of 57,007 persons participated in CM activities, of whom 55.8% were female. There were 17,785 clients who participated in MVCT services; 48% were men and 52% women. Forty percent of MVCT clients reported having previously had HIV testing; 632 (3.6%) of the 17,785 clients receiving MVCT services declined to be tested. A total of 17,153 clients were tested (p=0.53). Close to 99% of MVCT participants received their test results. One hundred sixty-four (1%) MVCT clients were found to be HIV-infected; of these, 161 (98.1%) received their test results. Of those 161, 136 (84%) were newly detected cases. and 91 (57%) had never previously had an HIV test. Of those testing HIV-positive and receiving test results, 32.3% (n=52) were symptomatic.
During rounds 1-3 (original approach) there was a decreasing trend in the mean number of clients accessing MVCT each day (n=18, 95% confidence interval [CI] 16 to 19, p<0.0001). During rounds 4-7 ("edutainment" approach), there was an increasing trend in the mean number (n=28, 95% CI 26 to 30, p<0.0001). The median client age declined between rounds 1-3 and rounds 4-7 from 38 years (95% CI 26 to 46, p<0.0001) to 35 years (95% CI 23 to 46, p<0.0001). The mean number of clients per 100 counselor/hours also increased between rounds 1-3 and rounds 4-7 from 20 hours (95% CI 18 to 22, p<0.0001) to 30 hours (95% CI 28 to 33, p<0.0001).
The authors conclude that locally appropriate strategies can be used to promote MVCT and that integrating entertainment with HIV/AIDS community mobilization can help to increase HIV knowledge and awareness; this in turn can lead to increases in HIV testing and potentially to stigma reduction.
This study has a moderate risk of bias. Using a nine-point scale to assess the study rigor, the study received six points. The study included pre/post intervention data; it included a comparator; comparator groups were equivalent socio-demographically and at baseline on outcome measures. The authors conducted statistical tests to control for potential confounders in the analysis. The study's follow-up rate was well over the rigor scale's specification of 75%. Data for several outcomes were obtained through participant self-report, which adds some potential for bias. Outcome reporting compares favorably to the study protocol.(2)
Project Accept's primary objective, to test the hypothesis that communities receiving community-based MVCT will have significantly lower HIV incidence after three years than similar communities receiving standard VCT, is not addressed in this paper. Data on this outcome have not yet been published. Several other papers have already been published on Project Accept's behavioral outcomes.(3, 4, 5,6 ,7, 8, 9) The take-home lesson from this particular paper is that modifying and adapting a community-based VCT intervention to the local cultural context can improve rates of VCT uptake and HIV case detection.
Community-based VCT programs, particularly those in which participation has been waning, might consider tailoring and enhancing these programs with "edutainment" or in other ways that will lead to greater community engagement and increased testing.
- Higgins JPT, Green S eds. Cochrane Handbook for Systematic Reviews of Interventions. Chichester (UK): John Wiley & Sons, 2008.
- Project Accept (HPTN 043): A Phase III Randomized Controlled Trial of Community Mobilization, Mobile Testing, Same-Day Results, and Post-Test Support for HIV in Sub-Saharan Africa and Thailand [Protocol]. [Accessed 21 June 2012]. Short version of protocol available from: http://www.clinicaltrials.gov/ct2/show/NCT00203749[Accessed 21 June 2012]
- Tedrow VA, Zelaya CE, Kennedy CE, Morin SF, Khumalo-Sakutukwa G, Sweat MD, Celentano DD. No "Magic Bullet": Exploring Community Mobilization Strategies Used in a Multi-site Community Based Randomized Controlled Trial: Project Accept (HPTN 043). AIDS Behav. 2012 Jul;16(5):1217-26.
- Sweat M, Morin S, Celentano D, Mulawa M, Singh B, Mbwambo J, Kawichai S, Chingono A, Khumalo-Sakutukwa G, Gray G, Richter L, Kulich M, Sadowski A, Coates T; Project Accept study team. 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. Lancet Infect Dis. 2011 Jul;11(7):525-32. Epub 2011 May 3.
- Young SD, Hlavka Z, Modiba P, Gray G, Van Rooyen H, Richter L, Szekeres G, Coates T. HIV-related stigma, social norms, and HIV testing in Soweto and Vulindlela, South Africa: National Institutes of Mental Health Project Accept (HPTN 043). J Acquir Immune Defic Syndr. 2010 Dec 15;55(5):620-4.
- McGrath N, Hosegood V, Chirowodza A, Joseph P, Darbes L, Boettiger M, van Rooyen H. Recruiting heterosexual couples from the general population for studies in rural South Africa--challenges and lessons (Project Accept, HPTN 043). S Afr Med J. 2010 Oct 1;100(10):658, 660.
- Wong LH, Rooyen HV, Modiba P, Richter L, Gray G, McIntyre JA, Schetter CD, Coates T. Test and tell: correlates and consequences of testing and disclosure of HIV status in South Africa (HPTN 043 Project Accept). J Acquir Immune Defic Syndr. 2009 Feb 1;50(2):215-22.
- Khumalo-Sakutukwa G, Morin SF, Fritz K, Charlebois ED, van Rooyen H, Chingono A, Modiba P, Mrumbi K, Visrutaratna S, Singh B, Sweat M, Celentano DD, Coates TJ; NIMH Project Accept Study Team. Project Accept (HPTN 043): a community-based intervention to reduce HIV incidence in populations at risk for HIV in sub-Saharan Africa and Thailand. J Acquir Immune Defic Syndr. 2008 Dec 1;49(4):422-31.
- Genberg BL, Kulich M, Kawichai S, Modiba P, Chingono A, Kilonzo GP, Richter L, Pettifor A, Sweat M, Celentano DD; NIMH Project Accept Study Team (HPTN 043). HIV risk behaviors in sub-Saharan Africa and Northern Thailand: baseline behavioral data from Project Accept. J Acquir Immune Defic Syndr. 2008 Nov 1;49(3):309-19.