Impact and process evaluation of integrated community and clinic-based HIV-1 control: a cluster-randomised trial in eastern Zimbabwe.
BACKGROUND
HIV-1 control in sub-Saharan Africa requires cost-effective and sustainable programmes that promote behaviour change and reduce cofactor sexually transmitted infections (STIs) at the population and individual levels.


RESULTS
We measured the feasibility of community-based peer education, free condom distribution, income-generating projects, and clinic-based STI treatment and counselling services and evaluated their impact on the incidence of HIV-1 measured over a 3-y period in a cluster-randomised controlled trial in eastern Zimbabwe. Analysis of primary outcomes was on an intention-to-treat basis. The income-generating projects proved impossible to implement in the prevailing economic climate. Despite greater programme activity and knowledge in the intervention communities, the incidence rate ratio of HIV-1 was 1.27 (95% confidence interval [CI] 0.92-1.75) compared to the control communities. No evidence was found for reduced incidence of self-reported STI symptoms or high-risk sexual behaviour in the intervention communities. Males who attended programme meetings had lower HIV-1 incidence (incidence rate ratio 0.48, 95% CI 0.24-0.98), and fewer men who attended programme meetings reported unprotected sex with casual partners (odds ratio 0.45, 95% CI 0.28-0.75). More male STI patients in the intervention communities reported cessation of symptoms (odds ratio 2.49, 95% CI 1.21-5.12).


CONCLUSIONS
Integrated peer education, condom distribution, and syndromic STI management did not reduce population-level HIV-1 incidence in a declining epidemic, despite reducing HIV-1 incidence in the immediate male target group. Our results highlight the need to assess the community-level impact of interventions that are effective amongst targeted population sub-groups.
Gregson
Simon
S
Department of Infectious Disease Epidemiology, Faculty of Medicine, Imperial College London, London, United Kingdom. s.gregson@imperial.ac.uk
Adamson
Saina
S
Papaya
Spiwe
S
Mundondo
Jephias
J
Nyamukapa
Constance A
CA
Mason
Peter R
PR
Garnett
Geoffrey P
GP
Chandiwana
Stephen K
SK
Foster
Geoff
G
Anderson
Roy M
RM
D000554:Ambulatory Care Facilities; D003153:Community Health Services; D005260:Female; D015658:HIV Infections / Q000517:prevention & control*; D006266:Health Education / Q000379:methods; D006801:Humans; D015994:Incidence; D008297:Male; D016017:Odds Ratio; D017063:Outcome Assessment, Health Care; D012725:Sexual Behavior; D012749:Sexually Transmitted Diseases / Q000517:prevention & control; D013997:Time Factors; D016896:Treatment Outcome; D015030:Zimbabwe