Novel community health worker strategy for HIV service engagement in a hyperendemic community in Rakai, Uganda: A pragmatic, cluster-randomized trial

Abstract

Background Effective implementation strategies are needed to increase engagement in HIV services in hyperendemic settings. We conducted a pragmatic cluster-randomized trial in a high-risk, highly mobile fishing community (HIV prevalence: approximately 38%) in Rakai, Uganda, to assess the impact of a community health worker-delivered, theory-based (situated Information, Motivation, and Behavior Skills), motivational interviewing-informed, and mobile phone application-supported counseling strategy called “Health Scouts” to promote engagement in HIV treatment and prevention services. Methods and findings The study community was divided into 40 contiguous, randomly allocated clusters (20 intervention clusters, n = 1,054 participants at baseline; 20 control clusters, n = 1,094 participants at baseline). From September 2015 to December 2018, the Health Scouts were deployed in intervention clusters. Community-wide, cross-sectional surveys of consenting 15 to 49-year-old residents were conducted at approximately 15 months (mid-study) and at approximately 39 months (end-study) assessing the primary programmatic outcomes of self-reported linkage to HIV care, antiretroviral therapy (ART) use, and male circumcision, and the primary biologic outcome of HIV viral suppression (<400 copies/mL). Secondary outcomes included HIV testing coverage, HIV incidence, and consistent condom use. The primary intent-to-treat analysis used log-linear binomial regression with generalized estimating equation to estimate prevalence risk ratios (PRR) in the intervention versus control arm. A total of 2,533 (45% female, mean age: 31 years) and 1,903 (46% female; mean age 32 years) residents completed the mid-study and end-study surveys, respectively. At mid-study, there were no differences in outcomes between arms. At end-study, self-reported receipt of the Health Scouts intervention was 38% in the intervention arm and 23% in the control arm, suggesting moderate intervention uptake in the intervention arm and substantial contamination in the control arm. At end-study, intention-to-treat analysis found higher HIV care coverage (PRR: 1.06, 95% CI: 1.01 to 1.10, p = 0.011) and ART coverage (PRR: 1.05, 95% CI: 1.01 to 1.10, p = 0.028) among HIV–positive participants in the intervention compared with the control arm. Male circumcision coverage among all men (PRR: 1.05, 95% CI: 0.96 to 1.14, p = 0.31) and HIV viral suppression among HIV–positive participants (PRR: 1.04, 95% CI: 0.98 to 1.12, p = 0.20) were higher in the intervention arm, but differences were not statistically significant. No differences were seen in secondary outcomes. Study limitations include reliance on self-report for programmatic outcomes and substantial contamination which may have diluted estimates of effect. Conclusions A novel community health worker intervention improved HIV care and ART coverage in an HIV hyperendemic setting but did not clearly improve male circumcision coverage or HIV viral suppression. This community-based, implementation strategy may be a useful component in some settings for HIV epidemic control. Trial registration ClinicalTrials.gov NCT02556957.

Impact of community health worker intervention on PrEP knowledge and use in Rakai, Uganda: A mixed methods, implementation science evaluation

“…In the intention-to-treat analysis, both current and ever use of PrEP was higher in the intervention group compared to the control, but was not statistically significant; as noted previously, contamination in the control arm may have introduced a null bias to these estimates ( S5 ). 15 Adjusted and unadjusted results showed negligible differences in estimates.…”

“…Intention-to-treat multivariable analyses were conducted using log-linear binomial regression with generalized estimating equation to estimate prevalence risk ratios (PRR) in the intervention versus control. Based on evidence from previous analyses that found substantial contamination in the control arm, 15 as-treated analyses were performed to measure outcomes using Chi-square tests using the exposure variable. Subsequent analyses adjusted for sex and age.…”

“…As previously reported, this trial evaluated the impact of a CHW intervention on HIV care engagement, antiretroviral therapy adherence, male circumcision coverage, and virologic suppression. 14,15 Counseling on PrEP, defined as CHW-led exploration and optimization of related knowledge, motivation, and behavioral skills using motivational interviewing strategies, was added to the original intervention design in 2017 and PrEP-related outcomes have not been previously reported. Using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) implementation science framework and a mixed methods approach, we aimed to now characterize: 1) the impact of CHWs on PrEP knowledge and use in the community; and 2) how and by what mechanisms CHWs may have made an impact on PrEP knowledge and use.…”

Makerere’s contribution to the development of a high impact HIV research population-based cohort in the Rakai Region, Uganda

“…In 2017, the RHSP documented the first population-level impact of combination HIV prevention including a 42% reduction in HIV incidence within about 10 years 34 in the general population and 48% decline (within 5 years) in hyper-endemic fishing communities 35 . The RHSP, based on cohort has conducted multiple implementation research studies to determine how to improve the availability and acceptance of combined HIV prevention 36 , 37 . Since 2016, RHSP has supported a comprehensive HIV service program (beyond VMMC and ART) across 12 districts of the Masaka region (including Rakai) with funding from PEPFAR through CDC-Uganda.…”

Knowledge and attitude of secondary school students in Nakaseke, Uganda towards HIV transmission and treatment

“…Community-based interventions (CBIs) for the prevention and control of HIV allow increased access and ease availability of medical care to populations at risk, or already infected with HIV by reaching individuals in schools, homes or community centers. School-based delivery of HIV prevention education has also been advocated as potential strategies to target high-risk youth groups 8 , 9 . Community engagement activities with Persons Living with HIV in Nakaseke have been utilised to reduce the number of new infections.…”