Activating Treatment as Prevention through Community Mobilization in South Africa

描述（由申请人提供）：通过减少未确诊感染的比例和扩大抗逆转录病毒治疗（ART）的早期和持续使用，可以大大减少艾滋病毒传播。事实上，治疗即预防（TasP）已被提议作为结束艾滋病毒流行的关键。为了在高流行率国家（如南非）启动TasP，必须激励社区了解自己的状况，参与护理并保持护理-需要社区动员（CM）。CM有可能通过解决参与艾滋病毒护理系统的主要社会障碍，大大增加接受检测、与护理的联系和保留，这对艾滋病毒感染人口水平下降至关重要。CM战略的联系和保留尚未得到严格的评价，尽管他们的承诺。为了解决这一差距，我们的目标是实施和评估一项基于理论的CM干预措施，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率，从而减少未确诊的感染（目标1），改善与护理的联系（目标2），并增加南非农村地区的护理保留率（目标3）。同时也探索CM通过其改善沿着护理级联的结果的机制（目标4）。将通过比较南非普马兰加省农村健康和人口监测点（HDSS）内16个未干预社区（8个干预社区和8个对照社区）在检测、联系和保留护理方面的收益，对CM干预进行评估。CM干预是基于四年的形成性社会科学研究和两年的实施经验，在该地区利用我们的团队开发的相同的概念模型。干预活动映射到CM的六个领域，必须解决CM成功发生：1）围绕TasP的共同关注的发展; 2）社区敏感或批判意识的建设; 3）与支持TasP的团体/网络联系的组织结构; 4）领导力; 5）集体活动/行动;和6）社区凝聚力。动员活动包括经过试点测试的战略，将由我们的执行伙伴Sonke性别公正组织执行。为了衡量检测率、联系率和保留率，我们将把HDSS中所有诊所使用的现有电子临床跟踪系统与纵向HDSS普查数据联系起来。这提供了一个独特的机会，建立一个开放的，以人口为基础的队列超过30,000 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，并描述高流行率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CM流程，以使用经验证的CM措施监测干预暴露和社区水平变化。该提案建立在我们团队在研究领域的CM经验和强大的合作伙伴团队的基础上-我们有能力进行严格设计和评估的试验，以确定CM对护理级联的影响，帮助满足迫切的需求。

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.