advanced search

<< Back To Home

EFFECT OF COMMUNITY-BASED VOLUNTARY COUNSELLING AND TESTING ON HIV INCIDENCE AND SOCIAL AND BEHAVIOURAL OUTCOMES

Monday, 14th of April 2014

EFFECT OF COMMUNITY-BASED VOLUNTARY COUNSELLING AND TESTING ON HIV INCIDENCE AND SOCIAL AND BEHAVIOURAL OUTCOMES (NIMH PROJECT ACCEPT; HPTN 043): A CLUSTER-RANDOMISED TRIAL

The Lancet Global Health, Early Online Publication, 9 April 2014

doi:10.1016/S2214-109X(14)70032-4Cite or Link Using DOI

This article can be found in the following collections: Global Health; Infectious Diseases (HIV/AIDS)

Copyright © 2014 Coates et al. Open Access article distributed under the terms of CC BY Published by Elsevier Ltd. All rights reserved.

 

Prof Thomas J Coates PhD a , Michal Kulich PhD b, Prof David D Celentano ScD c, Carla E Zelaya PhD c, Prof Suwat Chariyalertsak MD d, Alfred Chingono MSc e, Glenda Gray MBBCH f, Jessie K K Mbwambo MD g, Prof Stephen F Morin PhD h, Prof Linda Richter PhD i, Michael Sweat PhD j, Heidi van Rooyen PhD k, Nuala McGrath ScD l, Agnès Fiamma MIPH a, Oliver Laeyendecker PhD m o, Estelle Piwowar-Manning BS n, Greg Szekeres BA a, Deborah Donnell PhD p, Prof Susan H Eshleman MD n, the NIMH Project Accept (HPTN 043) study team†

Summary below; full text, with figures, is at

http://www.thelancet.com/journals/langlo/article/PIIS2214-109X%2814%2970032-4/fulltext

 

Background

Although several interventions have shown reduced HIV incidence in clinical trials, the community-level effect of effective interventions on the epidemic when scaled up is unknown. We investigated whether a multicomponent, multilevel social and behavioural prevention strategy could reduce HIV incidence, increase HIV testing, reduce HIV risk behaviour, and change social and behavioural norms.

Methods

For this phase 3 cluster-randomised controlled trial, 34 communities in four sites in Africa and 14 communities in Thailand were randomly allocated in matched pairs to receive 36 months of community-based voluntary counselling and testing for HIV (intervention group) or standard counselling and testing alone (control group) between January, 2001, and December, 2011. The intervention was designed to make testing more accessible in communities, engage communities through outreach, and provide support services after testing. Randomisation was done by a computer-generated code and was not masked. Data were collected at baseline (n=14 567) and after intervention (n=56 683) by cross-sectional random surveys of community residents aged 18—32 years. The primary outcome was HIV incidence and was estimated with a cross-sectional multi-assay algorithm and antiretroviral drug screening assay. Thailand was excluded from incidence analyses because of low HIV prevalence. This trial is registered at ClinicalTrials.gov, number NCT00203749.

Findings

The estimated incidence of HIV in the intervention group was 1·52% versus 1·81% in the control group with an estimated reduction in HIV incidence of 13·9% (relative risk [RR] 0·86, 95% CI 0·73—1·02; p=0·082). HIV incidence was significantly reduced in women older than 24 years (RR=0·70, 0·54—0·90; p=0·0085), but not in other age or sex subgroups. Community-based voluntary counselling and testing increased testing rates by 25% overall (12—39; p=0·0003), by 45% (25—69; p<0·0001) in men and 15% (3—28; p=0·013) in women. No overall effect on sexual risk behaviour was recorded. Social norms regarding HIV testing were improved by 6% (95% CI 3—9) in communities in the intervention group.

Interpretation

These results are sufficiently robust, especially when taking into consideration the combined results of modest reductions in HIV incidence combined with increases in HIV testing and reductions in HIV risk behaviour, to recommend the Project Accept approach as an integral part of all interventions (including treatment as prevention) to reduce HIV transmission at the community level.

Funding

US National Institute of Mental Health, the Division of AIDS of the US National Institute of Allergy and Infectious Diseases, and the Office of AIDS Research of the US National Institutes of Health.

a University of California, Los Angeles, UCLA Center for World Health, Los Angeles, CA, USA

b Charles University, Faculty of Mathematics and Physics, Prague, Czech Republic

c Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology, Baltimore, MD, USA

d Chiang Mai University, Research Institute for Health Sciences, Chiang Mai, Thailand

e University of Zimbabwe, College of Health Sciences, Harare, Zimbabwe

f University of the Witwatersrand, Chris Hani Baragwanath Hospital, Faculty of Health Sciences, Perinatal HIV Research Unit, Soweto, South Africa

g Muhimbili University of Health and Allied Sciences, Muhimbili University Teaching Hospital, Dar es Salaam, Tanzania

h University of California, San Francisco, Center for AIDS Prevention Studies, San Francisco, CA, USA

i Human Sciences Research Council, Dalbridge, South Africa

j Medical University of South Carolina, Family Services Research Center, Charleston, SC, USA

k Human Sciences Research Council, Durban, South Africa

l University of Southampton, Southampton General Hospital, Southampton, UK

m Johns Hopkins University School of Medicine, Department of Medicine, Baltimore, MD, USA

n Department of Pathology, Baltimore, MD, USA

o The National Institutes of Health, Bethesda, MD, USA

p Fred Hutchinson Cancer Research Center, Seattle, WA, USA

Correspondence to: Prof Thomas J Coates, University of California, Los Angeles, UCLA Center for World Health, Los Angeles, CA 90095, USA

† Members listed at end of report