Activating Treatment as Prevention through Community Mobilization in South Africa

描述(由申请人提供)：通过减少未诊断感染的比例和扩大早期和持续使用抗逆转录病毒疗法(ART)，可以大幅减少艾滋病毒的传播。事实上，治疗即预防(TasP)已被认为是结束艾滋病毒流行的关键。要在南非等高发国家启动TasP，必须激励社区了解自己的状况，参与护理，并继续接受护理--需要社区动员(CM)。CM有可能通过解决与艾滋病毒护理系统接触的主要社会障碍，显著增加对艾滋病毒人口水平下降至关重要的摄取检测、与护理的联系和保留率。CM的联系和保留战略尽管前景看好，但尚未得到严格评估。为了解决这一差距，我们旨在实施和评估基于理论的CM干预措施，以解决参与护理的已知社会障碍，目的是增加艾滋病毒检测的接受，从而减少未诊断的感染(目标1)，改善与护理的联系(目标2)，并在南非农村增加护理的保留率(目标3)，同时还探索CM改善护理级联过程中的结果的机制(目标4)。CM干预措施将通过比较南非姆普马兰加省农村健康和人口监测点(HDSS)内16个干预社区(8个干预和8个对照)在检测、联系和保留护理方面的收益来评估。CM干预是基于四年的形成性社会科学研究和两年的该领域实施经验，使用我们团队开发的相同概念模型。干预活动映射到CM的六个领域，CM必须成功地解决这些领域：1)围绕TASP发展共同关注；2)社区敏感化或建立批评意识；3)与支持TASP的团体/网络链接的组织结构；4)领导力；5)集体活动/行动；以及6)社区凝聚力。动员活动包括经过试点测试的战略，并将由我们的执行伙伴--Sonke性别正义执行。为了衡量检测率、关联率和保留率，我们将把目前在人类健康统计系统中所有诊所使用的电子临床跟踪系统与人类健康统计系统的纵向人口普查数据联系起来。这提供了一个独特的机会，以建立一个开放的、以人口为基础的队列，其中有30,000多名18-49岁的居民。合并人口普查和临床数据使我们能够同时评估我们的干预措施的效果，并确定高发人群中艾滋病毒护理级联的特征。此外，我们将通过开展社区调查来评估社区管理过程，以监测干预暴露和社区水平的变化，使用经过验证的社区管理措施。这项建议建立在我们团队在研究领域对CM的经验和强大的合作伙伴团队的基础上-我们处于有利地位，可以进行严格设计和评估的试验，以确定CM对护理级联的影响，帮助满足迫切需要。

DESCRIPTION (provided by applicant): HIV transmission can be decreased substantially by reducing the proportion of undiagnosed infections and expanding early and consistent use of antiretroviral therapy (ART). In fact, Treatment as Prevention (TasP) has been proposed as key to ending the HIV epidemic. To activate TasP in high prevalence countries, like South Africa, communities must be motivated to know their status, engage in care, and remain in care - community mobilization (CM) is needed. CM has the potential to significantly increase uptake testing, linkage to and retention in care, essential to population level declines in HIV by addressing the primary social barriers to engagement with the HIV care system. CM strategies for linkage and retention have not yet been rigorously evaluated despite their promise. To address this gap, we aim to implement and evaluate a theory-based CM intervention addressing known social barriers to engagement in care with the aim of increasing HIV testing uptake, thereby decreasing undiagnosed infections (aims 1), improving linkage to care (aim 2), and increasing retention in care (aim 3) in rural South Africa, while also exploring the mechanisms through which CM improves outcomes along the care cascade (aim 4). The CM intervention will be evaluated by comparing gains in testing, linkage, and retention in care in 16 intervention na¿ve communities (8 intervention and 8 control) within a health and demographic surveillance site (HDSS) in rural Mpumalanga province, South Africa. The CM intervention is based on four years of formative social science research and two years of implementation experience in the area utilizing the same conceptual model developed by our team. The intervention activities map onto six domains of CM that must be addressed for CM to successfully occur: 1) development of a shared concern around TasP; 2) community sensitization or building of critical consciousness; 3) an organizational structure to links to groups/networks in supporting TasP; 4) leadership; 5) collective activities/actions; and 6) community cohesion. Mobilization activities include pilot-tested strategies and will be carried out by our implementing partner, Sonke Gender Justice. To measure rates of testing, linkage and retention, we will link an existing electronic clinical tracking system in use in all clinics in the HDSS to the longitudinal HDSS census data. This provides a unique opportunity to establish an open, population-based cohort with over 30,000 18-49 year old residents. Merging census and clinical data allows us to simultaneously evaluate the effects of our intervention and to characterize the HIV care cascade in a high prevalence population. In addition, we will evaluate CM processes by conducting community based surveys to monitor intervention exposure and community level change using validated measures of CM. This proposal builds on our teams experience with CM in the study area and a strong team of partners-we are well positioned to conduct a rigorously designed and evaluated trial to determine the impact of CM on the care cascade, helping to fill an urgent need.