How place matters for addressing the HIV epidemic : evidence from the HPTN 071 (PopART) cluster-randomised controlled trial in Zambia and South Africa
Date
2021-04-06
Journal Title
Journal ISSN
Volume Title
Publisher
BMC
Abstract
Background: In a cluster-randomised trial (CRT) of combination HIV prevention (HPTN 071 (PopART)) in 12
Zambian communities and nine South African communities, carried out from 2012 to 2018, the intervention arm A
that offered HIV treatment irrespective of CD4 count did not have a significant impact on population level HIV
incidence. Intervention arm B, where HIV incidence was reduced by 30%, followed national guidelines that mid trial
(2016) changed from starting HIV treatment according to a CD4 threshold of 500 to universal treatment. Using
social science data on the 21 communities, we consider how place (community context) might have influenced the
primary outcome result.
Methods: A social science component documented longitudinally the context of trial communities. Data were
collected through rapid qualitative assessment, interviews, group discussions and observations. There were a total
of 1547 participants and 1127 observations. Using these data, literature and a series of qualitative analysis steps, we
identified key community characteristics of relevance to HIV and triangulated these with HIV community level
incidence.
Results: Two interdependent social factors were relevant to communities’ capability to manage HIV: stability/
instability and responsiveness/resistance. Key components of stability were social cohesion; limited social change; a
vibrant local economy; better health, education and recreational services; strong institutional presence; established
middle-class residents; predictable mobility; and less poverty and crime. Key components of responsiveness were
community leadership being open to change, stronger history of HIV initiatives, willingness to take up HIV services,
less HIV-related stigma and a supported and enterprising youth population. There was a clear pattern of social
factors across arms. Intervention arm A communities were notably more resistant and unstable. Intervention arm B
communities were overall more responsive and stable.
Conclusions: In the specific case of the dissonant primary outcome results from the HPTN 071 (PopART) trial, the
chance allocation of less stable, less responsive communities to arm A compared to arm B may explain some of the
apparently smaller impact of the intervention in arm A. Stability and responsiveness appear to be two key social
factors that may be relevant to secular trends in HIV incidence. We advocate for a systematic approach, using these
factors as a framework, to community context in CRTs and monitoring HIV prevention efforts.
Description
CITATION: Bond, V., et al. 2021. How place matters for addressing the HIV epidemic : evidence from the HPTN 071 (PopART) cluster-randomised controlled trial in Zambia and South Africa. Trials, 22:251, doi:10.1186/s13063-021-05198-5.
The original publication is available at https://trialsjournal.biomedcentral.com
The original publication is available at https://trialsjournal.biomedcentral.com
Keywords
Community randomised trials, HIV infections -- Prevention, Mass medical screening, Africa, Sub-Saharan
Citation
Bond, V., et al. 2021. How place matters for addressing the HIV epidemic : evidence from the HPTN 071 (PopART) cluster-randomised controlled trial in Zambia and South Africa. Trials, 22:251, doi:10.1186/s13063-021-05198-5