Regai Dzive Shiri Project: Results of a Randomised Trial of an HIV Prevention Intervention for Zimbabwean Youth

This journal article describes findings of a cluster randomised trial to asses a community-based, multi-component HIV and reproductive health intervention designed to change social norms for adolescents in rural Zimbabwe. The findings suggest that despite an impact on knowledge, on some attitudes, and on reported pregnancy, this intervention had no impact on HIV or genital HSV-2 infection prevalence, providing further evidence that behavioural interventions alone are unlikely to be sufficient to reverse the HIV epidemic. The article states that there remains a challenge to find effective HIV prevention approaches for young people in the face of continued and unacceptably high HIV incidence, particularly among young women.

The trial was conducted in 30 communities in seven districts of southeastern Zimbabwe. A youth programme for in- and out-of-school youth was delivered by carefully selected, trained, and supervised Zimbabwean school youth in the year between leaving school and starting university. A programme for parents and community stakeholders comprised a 22-session community-based programme to improve: knowledge about reproductive health; communication between parents and their children; and community support for adolescent reproductive health. As well, a training programme for nurses and other staff working in rural clinics was provided, intending to improve accessibility of clinics for young people.

Overall, 4,684 of 4,822 eligible individuals participated in the final survey. Around 54% of participants (61% of males and 46% of females) had attended a school trial. Overall, 30% of survey participants in the intervention arm reported attending an intervention in school when a peer educator was present and so are likely to have received the in-school intervention. One-third of males and 61% of females surveyed did not report receiving any intervention (i.e., had not attended a school trial or the out-of school intervention.)

The study notes the following findings:

• The study found that, in males, there was an increase in knowledge related to sexually transmitted disease (STD) acquisition and pregnancy prevention in the intervention arm but not for HIV acquisition. There was no effect on reported self-efficacy. In women, there was an increase in knowledge related to sexually transmitted disease (STD) acquisition and pregnancy prevention in the intervention arm but, again, not for HIV acquisition. There was a modest impact on reported self-efficacy.
• Among men, there was no impact on attitudes relating to relationship control overall, although there was an impact on certain items within the scale. There was also no overall impact of the intervention on gender empowerment among men, but, again, there was impact on certain items. The intervention did have an impact on women's attitudes about both relationship control and to gender empowerment.
• Females were more likely to report having had sex than males (53% vs. 42%). Median age of partner at first sex was 24 for females and 17 for males. Sexually active males reported more lifetime partners and more partners in the last 12 months than females. Males were more likely to report condom use at last sex (81% vs. 59%). There was no effect of the intervention on any of these behavioural outcomes in men or women.
• There was no effect of the intervention on any aspect of clinic attendance. Women in the intervention arm were more likely to report that they would go to a clinic if they needed to access contraception.

According to the article, the findings show that there was no effect of the intervention on HIV prevalence, HSV-2 prevalence, or current pregnancy as measured by pregnancy test. There was an effect on some secondary endpoints, including an increase in knowledge related to STD acquisition and pregnancy prevention in intervention communities and a positive effect on some attitudes relating to relationship control and to gender empowerment. Among young women, there was also an increase in reported self-efficacy. There was no effect of the intervention on reported sexual behaviour, reported clinic use, or reported use of pregnancy prevention in males or females in intervention communities.

The article states that improving knowledge and changing attitudes of young people are important endpoints in their own right. While the rates of comprehensive knowledge (participants responding to all items correctly) were low, when responses to individual items were examined separately, levels were somewhat better, at 50-60%. Changing attitudes relating to gender issues is thought to be a particularly important prerequisite to changing the HIV risk environment, and it is encouraging that the intervention was able to make modest gains in this regard, particularly among young women.

The article concludes that consensus seems to be emerging that behavioural interventions alone are unlikely to be sufficient to reverse the HIV epidemic and that it is likely that combination approaches which integrate behavioural, biomedical, and structural components will be more effective at a population level. Finding ways to implement those HIV prevention interventions that are known to be effective (such as male circumcision, HIV testing, and counselling, condom promotion), while looking for innovative ways to combine or layer them, in addition to searching for novel intervention approaches, is the challenge for the next generation of HIV prevention research.