Community Mobilization Approaches for Large-Scale Public Health Surveys: Experiences from the Population-based HIV Impact Assessment (PHIA) Project.

Community mobilization is an integral process of raising awareness and increasing participation in a specific program. Communities with long-standing mistrust of health research may otherwise be reluctant to participate in surveys originating outside of their locality, particularly when asked to share personal information, provide blood samples, or undergo medical examinations. Here we discuss the community mobilization approaches undertaken by the Population-based HIV Impact Assessment (PHIA) project to optimize participation in surveys across 13 countries of sub-Saharan Africa. The PHIA Project developed a community mobilization strategy to address anticipated community concerns. In each country, a trained cadre of Community Mobilization Coordinators (CMCs) facilitated (1) ongoing communication with leadership and stakeholders at national, provincial/district and local levels; (2) door-to-door visits and group meetings; (3) promotional material dissemination through radio and television jingles and mass social/community media; and (4) the use of public address systems to enhance survey awareness and promote participation. Response rates (RR) were recorded from each survey. The PHIA surveys' mobilization efforts cultivated a receptive environment for data collection. The average household response rate for 13 PHIA surveys was 90.4% and interview RR were consistently over 80%, with women more likely to conduct an interview in all countries except Cote d'Ivoire. 89% of eligible women consented to a blood draw and 81.1% of eligible men consented. The robust and contextualized community mobilization approaches in PHIA were critical for engaging communities in large-scale public health surveys and contributed to high RR in participant interviews and blood draw.

Prevalence, patterns, and correlates of HIV disclosure among TB-HIV patients initiating antiretroviral therapy in Lesotho.

Disclosure of HIV-positive status has important implications for patient outcomes and preventing HIV transmission, but has been understudied in TB-HIV patients. We assessed disclosure patterns and correlates of non-disclosure among adult TB-HIV patients initiating ART enrolled in the START Study, a mixed-methods cluster-randomized trial conducted in Lesotho, which evaluated a combination intervention package (CIP) versus standard of care. Interviewer-administered questionnaire data were analyzed to describe patterns of disclosure. Patient-related factors were assessed for association with non-disclosure to anyone other than a health-care provider and primary partners using generalized linear mixed models. Among 371 participants, 95% had disclosed their HIV diagnosis to someone other than a health-care provider, most commonly a spouse/primary partner (76%). Age, TB knowledge, not planning to disclose TB status, greater perceived TB stigma, and CIP were associated with non-disclosure in unadjusted models (p < .1). In adjusted models, all point estimates were similar and greater TB knowledge (adjusted odds ratio [aOR] 0.59, 95% confidence interval [CI] 0.39-0.90) and CIP (aOR 0.20, 95% CI 0.05-0.79) remained statistically significant. Among 220 participants with a primary partner, 76% had disclosed to that partner. Significant correlates of partner non-disclosure (p < .1) in unadjusted analyses included being female, married/cohabitating, electricity at home, not knowing if partner was HIV-positive, and TB knowledge. Adjusted point estimates were largely similar, and being married/cohabitating (aOR 0.03, 95% CI 0.01-0.12), having electricity at home (aOR 0.38, 95% CI 0.17-0.85) and greater TB knowledge (aOR 0.76, 95% CI 0.59-0.98) remained significant. In conclusion, although nearly all participants reported disclosing their HIV status to someone other than a health-care provider at ART initiation, nearly a quarter of participants with a primary partner had not disclosed to their partner. Additional efforts to support HIV disclosure (e.g., counseling) may be needed for TB-HIV patients, particularly for women and those unaware of their partners' status.

'Men usually say that HIV testing is for women': gender dynamics and perceptions of HIV testing in Lesotho.

In Lesotho, men have lower HIV testing rates, less contact with HIV clinical settings and less knowledge of HIV prevention than women. However, women's HIV prevalence has consistently remained higher than men's. This paper explores gender norms, sexual decision-making and perceptions of HIV among a sample of Basotho men and women in order to understand how these factors influence HIV testing and prevention. A total of 200 women and 30 men were interviewed in Lesotho between April and July 2011. Participants reported reluctance among women to share information about HIV prevention and testing with men, and resistance of men to engage with testing and/or prevention services. Findings demonstrate a critical need for educational initiatives for men, among other strategies, to engage men with HIV testing and prevention. This study highlights how gender issues shape perceptions of HIV and sexual decision-making and underlines the importance of engaging men along with women in HIV prevention efforts. More studies are needed to determine the most effective strategies to inform and engage men.

"They are our eyes outside there in the community": Implementing enhanced training, management and monitoring of South Africa's ward-based primary healthcare outreach teams.

INTRODUCTION: In 2018, South Africa's National Department of Health provided additional resources for ward-based primary healthcare outreach teams (OT) with support from the U.S. President's Emergency Plan for AIDS Relief. The intervention package included a new training curriculum, enhanced staffing, revised management and supervisory structures, and more intensive monitoring and evaluation (M&E). The goal was to strengthen OT and their impact on both primary healthcare and HIV-specific services. We conducted a process evaluation of this intervention package during its second year and examined implementation successes and challenges. METHODS: We conducted a mixed-methods evaluation at 20 purposively selected facilities in Bojanala and City of Tshwane districts, including surveys with 222 community health workers (CHWs) and outreach team leaders (OTLs); key informant interviews and online surveys with 28 policy and program stakeholders; 70 in-depth interviews with health facility staff; 20 focus group discussions with 194 CHWs; 20 structured health facility assessments; directly-observed time-motion studies; and review of program documents. RESULTS: Most participants highlighted the hiring and training of CHWs and OTLs as a key implementation success because this had partially alleviated staffing shortages and helped clarify CHWs' and OTLs' responsibilities and supervisory structures. The new monitoring tools were welcomed for their potential to improve data collection and program tracking. However, participants highlighted many program challenges: short-lived gains in CHWs' knowledge and skills due to lack of ongoing training and mentoring; insufficient integration of OT into health facility management structures; persistent shortages of equipment, supplies, transportation, and workspace for CHWs; and insufficient remuneration for staff. CONCLUSION: Strengthening and expanding CHW programs, such as OT, requires intensive support and continuous investments. To sustain improvements in training, supervision, and job satisfaction, CHWs must be equipped with needed resources, provided with ongoing supportive supervision, and strengthened by optimized program management, monitoring and processes.

Reaching the end of the line: Operational issues with implementing phone-based unannounced pill counts in resource-limited settings.

INTRODUCTION: Accurate measurement of adherence is necessary to ensure that therapeutic outcomes can be attributed to the recommended treatment. Phone-based unannounced pill counts were shown to be feasible and reliable measures of adherence in developed settings; and have been further used as part of medication adherence interventions. However, it is not clear whether this method can be implemented successfully in resource-limited settings, where cellular network and mobile phone coverage may be low. Our objective is to describe operational issues surrounding the use of phone-based unannounced pill counts in Lesotho and Ethiopia. METHODS: Phone-based monthly unannounced pill counts, using an adaptation of a standardized protocol from previous US-based studies, were utilized to measure anti-TB and antiretroviral medication adherence in two implementation science studies in resource-limited settings, START (Lesotho) and ENRICH (Ethiopia). RESULTS: In START, 19.6% of calls were completed, with 71.9% of participants reached at least once; majority of failed call attempts were due to phones not being available (54.8%) or because participants were away from the pills (32.7%). In ENRICH, 33.5% of calls were completed, with 86.7% of participants reached at least once; the main reasons for failed call attempts were phones being switched off (31.5%), participants not answering (27.3%), participants' discomfort speaking on the phone (15.4%), and network problems (13.2%). Structural, facility-level, participant-level, and data collection challenges were encountered in these settings. DISCUSSION: Phone-based unannounced pill counts were found to be challenging, and response rates suboptimal. While some of these challenges were specific to local contexts, most of them are generalizable to resource-limited settings. In a research study context, a possible solution to ease operational challenges may be to focus phone-based unannounced pill count efforts on a randomly selected sample from participants who are provided with study phones and rigorously ensure that call attempts are made for these participants.