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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

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
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
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
hiv, incidence, project accept, Africa, hptn 043
2214-109X
e267-e277
Coates, Thomas J.
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Kulich, Michal
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Celentano, David D.
70098ee6-c3ea-445d-811a-0b80b60a734a
Zelaya, Carla E.
abd3944a-5a8c-459d-aff0-920de8a97369
Chariyalertsak, Suwat
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Chingono, Alfred
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Gray, Glenda
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Mbwambo, Jessie K.K.
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Morin, Stephen F.
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Richter, Linda
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Sweat, Michael
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van Rooyen, Heidi
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McGrath, Nuala
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Fiamma, Agnes
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Laeyendecker, Oliver
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Piwowar-Manning, Estelle
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Szekeres, Greg
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Donnell, Deborah
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Eshleman, Susan H.
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Coates, Thomas J.
966ae7da-ddce-4a8a-a614-859df1a2d244
Kulich, Michal
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Celentano, David D.
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Zelaya, Carla E.
abd3944a-5a8c-459d-aff0-920de8a97369
Chariyalertsak, Suwat
a0df138d-f778-48fd-b49d-170efeaaf828
Chingono, Alfred
0e6fb05b-d92d-4435-9cd2-8735923b051d
Gray, Glenda
8884167a-c074-4a4c-95b7-880035252892
Mbwambo, Jessie K.K.
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Morin, Stephen F.
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Richter, Linda
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Sweat, Michael
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van Rooyen, Heidi
19159681-0f8c-42da-8c8b-3001d4ada200
McGrath, Nuala
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Fiamma, Agnes
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Laeyendecker, Oliver
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Piwowar-Manning, Estelle
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Szekeres, Greg
afd2d785-de63-4274-8142-20a2f5562479
Donnell, Deborah
716487e6-9bc9-4d47-a758-8cb11858517f
Eshleman, Susan H.
eb088987-f205-4d64-8913-5775561c7725

Coates, Thomas J., Kulich, Michal, Celentano, David D., Zelaya, Carla E., Chariyalertsak, Suwat, Chingono, Alfred, Gray, Glenda, Mbwambo, Jessie K.K., Morin, Stephen F., Richter, Linda, Sweat, Michael, van Rooyen, Heidi, McGrath, Nuala, Fiamma, Agnes, Laeyendecker, Oliver, Piwowar-Manning, Estelle, Szekeres, Greg, Donnell, Deborah and Eshleman, Susan H. (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, 2 (5), e267-e277. (doi:10.1016/S2214-109X(14)70032-4).

Record type: Article

Abstract

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

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Accepted/In Press date: 17 February 2014
Published date: May 2014
Keywords: hiv, incidence, project accept, Africa, hptn 043
Organisations: Primary Care & Population Sciences

Identifiers

Local EPrints ID: 373617
URI: https://eprints.soton.ac.uk/id/eprint/373617
ISSN: 2214-109X
PURE UUID: c06f8503-bff8-4cef-8d54-6f5373f0f38f
ORCID for Nuala McGrath: ORCID iD orcid.org/0000-0002-1039-0159

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Date deposited: 26 Jan 2015 14:34
Last modified: 15 Oct 2019 00:35

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Contributors

Author: Thomas J. Coates
Author: Michal Kulich
Author: David D. Celentano
Author: Carla E. Zelaya
Author: Suwat Chariyalertsak
Author: Alfred Chingono
Author: Glenda Gray
Author: Jessie K.K. Mbwambo
Author: Stephen F. Morin
Author: Linda Richter
Author: Michael Sweat
Author: Heidi van Rooyen
Author: Nuala McGrath ORCID iD
Author: Agnes Fiamma
Author: Oliver Laeyendecker
Author: Estelle Piwowar-Manning
Author: Greg Szekeres
Author: Deborah Donnell
Author: Susan H. Eshleman

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