Study shows community-based HIV-prevention efforts increase testing rates, reduce HIV incidence

In Africa and Thailand, communities that worked together on HIV-prevention efforts saw not only a rise in HIV screening but a drop in new infections, according to a new study presented this week at the Conference on Retroviruses and Opportunistic Infections in Atlanta.

The U.S. National Institute of Mental Health's Project Accept - a trial conducted by the HIV Prevention Trials Network to test a combination of social, behavioral and structural HIV-prevention interventions - demonstrated that a series of community efforts was able to boost the number of people tested for HIV and resulted in a 14 percent reduction in new HIV infections, compared with control communities.

"These study results clearly demonstrate that high rates of testing can be achieved by going into communities and that this strategy can result in increased HIV detection, which makes referral to care possible," said Project Accept's overall principal investigator, Thomas J. Coates, who directs UCLA's Center for World Health and is an associate director of the UCLA AIDS Institute. "This has major public health benefit implications by not only linking infected individuals to care but also by encouraging testing in entire communities and therefore also reducing further HIV transmission."

The trial was conducted in 34 communities in South Africa, Tanzania and Zimbabwe and in 14 communities in Thailand. It consisted of mobile HIV testing, post-test support services and real-time feedback.

The aim of the intervention was four-fold: (1) to increase access to voluntary counseling and testing, as well as post-test services; (2) to change community attitudes about HIV awareness and particularly about the benefit of knowing one's HIV status; (3) to remove barriers to knowing one's HIV status; and (4) to increase the safety of testing and minimize the potential negative consequences of testing by providing various forms of support.

Communities were matched into pairs based on sociodemographic, cultural and infrastructure characteristics, with one community randomly assigned to the intervention and one serving as a control for comparison. (The randomization was performed centrally, and the assignment was not blinded, due to the nature of the intervention.)

Among the findings:

• Rates of testing were 45 percent higher in intervention communities than control communities, especially among men and young people.

• Individuals in intervention communities, particularly those infected with HIV, reported a lower number of sexual partners and fewer multiple partners. This was particularly true among HIV-positive men, who reported 18 percent fewer sexual partners overall and 29 percent fewer concurrent sexual partners than those in control communities.

• Diagnoses of HIV infection were higher in intervention communities.

• Social acceptance of the importance of testing was higher in intervention communities.

• Modest reductions in HIV incidence occurred in the intervention communities, compared with the control communities, particularly among women in the 25-to-32 age range.

Study participants who learned they were infected with HIV were directed to the study's post-test services, which included counseling and referrals to health and social services assistance. Those who tested negative were also directed to post-test services for further counseling, referrals and support to help ensure they remained uninfected. Local health authorities were thoroughly briefed on the study findings and encouraged to continue the implementation efforts.

Individuals need to be made aware of their HIV status through testing in order to receive the necessary care and treatment and learn how to prevent infection, said Dr. Wafaa El-Sadr, principal investigator of the HIV Prevention Trials Network, under whose auspices the trial was conducted.

"These study findings provide clear and compelling evidence that the provision of mobile services, combined with appropriate support activities, is a strategy that can increase testing rates and also reduce HIV incidence," she said.