Activating Treatment as Prevention through Community Mobilization in South Africa (Tsima)

Rationale HIV transmission can be decreased substantially by reducing the proportion of undiagnosed infections and expanding early and consistent use of antiretroviral therapy (ART). Treatment as Prevention (TasP) has been proposed as key to ending the HIV epidemic. Community Mobilisation (CM) has significant potential to improve testing, uptake and linkage to and retention in care, by addressing the primary social barriers to engagement with HIV care.

SPECIFIC AIMS Implement and evaluate a theory-based CM intervention (Tsima) with the specific target of decreasing undiagnosed infections and improving linkage to and retention in care: Aim 1, TESTING: determine whether uptake of HIV testing among residents of communities receiving the intervention is higher than residents of control communities. Aim 2, LINKAGE: determine whether linkage to care is higher among residents of intervention versus control communities. Aim 3, RETENTION: determine whether retention in care is higher among residents of intervention versus control communities. Aim 4, MECHANISMS: explore changes in CM domains as well as how differences in each domain associate with changes in individual outcomes (testing, linkage, and retention) over time. Aim 2: linkage to care  a) proportion of those testing HIV positive who complete CD4 staging within 3 months of diagnosis; b) proportion of those eligible for treatment who initiate ART within 3 months of CD4 staging Aim 3: retention in care  a) proportion of ART initiated patients still in care at 12 months; b) those ineligible for ART returning for scheduled CD4 staging at 12 months)

Conceptual framework

Who will do this work? CM TasP is a partnership between… The MRC/Rural Public Health and Health Transitions Research Unit of the University of the Witwatersrand 2 Universities in the US: University of California, San Francisco University of North Carolina, Chapel Hill 2 local organizations: Sonke Gender Justice Right to Care (RTC)

STUDY SITE & POPULATION The Agincourt sub-District of Bushbuckridge is covered by a health and socio-demographic surveillance system (HDSS) established in 1992 by the MRC/Wits University Rural Public Health and Health Transitions Research Unit. Through the annual census, the Unit maintains a detailed database of all 16,000 households and 90,000 individuals living in the 27 villages. 15 villages participate in our study (8 intervention, 7 control). The MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt) has already established the Clinic Link Data System to link clinic records to the HDSS. Clinics located in the immediate study area offer HIV testing and HIV Care (including ART) where members of the HDSS receive care. We monitor all attendance and services provided at study-participating clinics.

The Tsima Intervention Implemented by Sonke Gender Justice : 15 villages: 8 intervention, 7 control. Intervention: Huntington, Ireagh B, Lillydale A, Dumphries, Belfast, Makaringe, MP Stream, Rolle C Control: Agincourt, Croquetlawn, Ireagh A, Lillydale B, Newington B, Xanthia, Kumani Target groups: Men and women ages 18-49 years of age living in the intervention village. Tsima uses activities, workshops, leadership engagement meetings, stakeholder meetings, and Community Action Teams (CATs, comprised of community volunteers) to educate the community about HIV treatment as prevention (TasP). 18 community mobilisers (CMs) implement the intervention on a daily basis in the intervention villages. Sonke Gender Justice works across Africa to strengthen government, civil society and citizen capacity to promote gender equality, prevent domestic and sexual violence, and reduce the spread and impact of HIV and AIDS.

Data SYSTEMS & collection (1 of 2) Monitoring of Tsima CMs’ work in the 8 intervention villages occurs on a daily basis via monitoring forms subsequently entered into a monitoring database. Monitoring and data collection of HIV-testing and care delivery occurs on a daily basis using the Clinic Link data management system at the 9 participating clinics: Agincourt, Belfast, Bhubezi/Lillydale, Cunningmore, Kildare, Justicia, Thulamahashe, Rolle, Xanthia To measure coverage of Tsima, 2 cross-sectional population-based samples of 1,200 adults (approx. half men and women) will be selected for interview from each of the randomized villages. Baseline survey was completed in November 2014 Endline survey will take place after 3 years of intervention (in July – Nov 2018) Qualitative component: In-depth interviews and focus groups 3 rounds: mid-way through intervention, intervention end, post-endline

Data SYSTEMS & collection (2 OF 2)

Project Clinic set-up (1 OF 4) Participating Clinics: Agincourt, Belfast, Bhubezi/Lillydale, Cunningmore, Justicia, Kildare, Rolle, Thulamahashe, Xanthia Staffing: 1 Research Assistant (RA) and 1 Data Typist (DT) each at the smaller clinics (Belfast, Cunningmore, Justicia, Kildare, Rolle and Xanthia) 2 RAs and 3 DTs each at the health centers (Agincourt, Bhubezi, and Thulamahashe)

TSIMA team Sheri Lippman, PhD, MPH – Principal Investigator Audrey Pettifor, PhD, MPH – Principal Investigator Kathleen Kahn, MD, PhD – Principal Investigator F. Xavier Gómez-Olivé, MD, PhD – Wits/Agincourt Research Manager Rhian Twine, MPH – Manager Public Engagement Wits/Agincourt Unit Aimée Julien Suárez, MPH – Tsima Project Manager (UNC) Rebecca West, MPH – Tsima Project Manager (UCSF) Dumisani Rebombo – Tsima Community Mobilization Manager Rhandzekile Mathebula – Tsima Community Mobilization Coordinator Brian Khosa – Tsima Logistician Annah Hlatshwayo – Tsima Data Typist Nkonzo Khanyile – Sonke Capacity Building & Technical Assistant 18 Community Mobilisers & 42 CAT volunteers Chodziwadziwa Kabudula, MSc – Senior Data Scientist Nkosinathi Masilela – Junior Data Scientist 32 Clinic Link staff: Data Typists & Research Assistants