Project ACCLAIM: Intervention Effect on Community Knowledge, Attitudes and Beliefs of Maternal and Child Health and HIV/AIDS in Eswatini, Uganda and Zimbabwe

"...a package of community interventions may be most effective in increasing community HIV knowledge and improving gender equitable norms."

There are significant barriers to eliminating mother-to-child transmission (MTCT) of HIV in high-burden (priority) countries are not specific to HIV, including inequitable gender norms, HIV-related stigma, and inadequate mother and child health (MCH) knowledge. Convinced that interventions that target both community and individual levels may be more effective than interventions focused on one level, the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) created the Advancing Community-Level Action for Improving MCH/PMTCT (ACCLAIM) study, which aimed to assess the effect of a package of community interventions on the demand for, uptake of, and retention of HIV-positive pregnant/postpartum women in MCH and prevention of mother-to-child HIV transmission (PMTCT) services. The study occurred from 2013 to 2015 in Eswatini, Uganda, and Zimbabwe.

ACCLAIM was a multi-country, multi-component, three-arm randomised trial. In brief, in each of the three countries, three subunits (regions or districts) were identified, each consisting of 15 clusters (facilities). The regions or districts were then randomly allocated, one to each study arm:

• Arm 1 included a community leader engagement intervention that involved identifying and training formal and informal community leaders to have dialogues with their community about MCH, HIV care, and PMTCT.
• Arm 2 included the community leader engagement intervention plus a community days intervention (i.e., community health fairs that combined service provision such as HIV testing, blood pressure screening, etc., with community dialogues about HIV issues, PMTCT, and HIV testing).
• Arm 3 included the community leader engagement intervention, the community days intervention, plus men's and women's peer discussion groups, where peer-led discussions provided information and education on MCH and PMTCT. The women's peer groups were held with women attending antenatal care (ANC); the men's groups included, but were not limited to, partners of the women attending ANC.

There was no control group, as there was already a high level of background community programming in the form of national PMTCT programmes in study countries.

Household cross-sectional surveys on community members' MCH and PMTCT knowledge, attitudes, and beliefs (KAB) were analysed pre- and post-intervention, using MCH, HIV stigma, and gender-equitable men (GEM) indicators. The surveys garnered 3,337 pre-intervention and 3,162 post-intervention responses. The researchers used t-tests to measure the significance of mean pre- vs. post-intervention score changes stratified by gender within each intervention arm and generalised linear models to compare mean score changes of the cumulative intervention arms with the community leaders-only intervention.

Except for the gender equity score (GEM) in arm 1 for men (p = 0.31), all the interventions led to improvements in scores for both men and women (p < 0.01). Specifically, the study found that combined package of three interventions (Arm 3) demonstrated a significantly greater increase in MCH scores for both women (diff = 1.34, p ≤ 0.001) and men (diff = 2.03, p < 0.001). The arms that included interventions for both community leader engagement and community days (Arms 1 and 2) led to a greater increase in mean GEM scores compared to the community leader engagement intervention alone (Arm 1) for both women (diff = 1.32, p = 0.002) and men (diff = 1.37, p = 0.004). On the whole, these findings suggest that "individuals may be more likely to address their health behaviors regarding HIV prevention and PMTCT when given the chance to discuss these issues in small groups."

Thus, in this rural population, the results show that for both women and men, arm 2 (community leader engagement plus community days), and arm 3 (community leader engagement, community days, and peer groups) led to greater mean score changes than that of arm 1 (community leader engagement only), for at least two of the three outcome scores. These interventions led to the intended changes in MCH beliefs, HIV stigma, and gender-equitable norms among women in the countries studied. However, because both men and women were intentionally included in all three interventions, mean score improvements were seen among the men as well: an increase in MCH beliefs, reduction in HIV stigma, and increased gender-equitable norms. These changes could lead to more male involvement in MCH and PMTCT issues.

"Overall, the educational interventions seemed to be effective for all study arms, with greater improvements in outcomes for the cumulative interventions. These educational interventions could potentially reduce the MTCT rate by increasing MCH beliefs, reducing HIV-related stigma, and encouraging gender equitable norms."