Lay counsellor-based risk reduction intervention with HIV positive diagnosed patients at public HIV counselling and testing sites in Mpumalanga, South Africa
Introduction
Denison, O’Reilly, Schmid, Kennedy and Sweat (2008) conducted a meta-analysis that focuses solely on Voluntary HIV counselling and testing (VCT) efficacy data from different VCT settings (health facility, stand alone, community-based, home) in developing countries. Overall, the pooled data from seven studies identified showed a moderate effect of VCT on unprotected sex [OR 1.69; 95%CI 1.25–2.31] and inconclusive evidence, based only on three studies, regarding the effect of VCT on recipients’ number of sex partners. Effect size estimates showed the largest effects seen among HIV positive individuals or discordant couples. The significant effect on unprotected sex has been confirmed in previous studies conducted among HIV-infected persons or discordant couples (Higgins et al., 1991, Weinhardt et al., 1999, Wolitski et al., 1997). Cremin et al. (2009) studied the patterns of self-reported behaviour change associated with receiving VCT in a longitudinal study from Zimbabwe, and found among women who received VCT, both those positive and negative, reduced their reported number of new partners. Among those testing positive, this risk reduction was enhanced with time since testing. In a similar longitudinal study in Mozambique, Mola et al. (2006) found that reported use of condoms while having sex with a friends/prostitute increased over each time period in the VCT group and between baseline and first visit in the non-VCT group. Both men and women in the VCT group increased their condom use over time, but the women in the non-VCT group did not.
Despite the need for the development of HIV risk reduction interventions for South African persons living with HIV (PLHIV) and the efficiency of situating such interventions in clinical settings, little research has focused on developing effective HIV prevention interventions for PLHIV in HIV counselling and testing sites in South Africa or elsewhere (Cornman et al., 2008, Fisher et al., 2006). Kalichman et al. (2001) were among the first to demonstrate positive effects of a theory-based behavioural intervention designed to reduce HIV sexual-transmission risks among men and women living with HIV infection. The intervention model was grounded in Social Cognitive Theory aimed at (1) developing skills to effectively cope with HIV-related stressors and sexual risk-producing situations, (2) enhancing effective decision-making skills for self-disclosing HIV serostatus to sexual partners, and (3) facilitating the development and maintenance of safer sexual practices. The intervention was delivered in five group sessions (Kalichman et al., 2001). The US-based Options Project is a clinic-based HIV risk reduction intervention with demonstrated effectiveness in reducing sexual risk behaviour among PLHIV (Cornman et al., 2008, Fisher et al., 2006). This intervention is based on the information–motivation–behavioural (IMB) skills model of HIV preventive behaviour, and it uses motivational interviewing techniques to deliver HIV risk reduction information, motivation, and behavioural skills content to help PLHIV reduce their HIV transmission risk behaviour. The intervention consists of collaborative, patient-centered discussions between the health care provider and the patient during routine clinic visits in which the provider assesses the patient's risk behaviours, identifies barriers to consistently practicing safer sex, elicits strategies from the patient for overcoming those barriers, and negotiates an individually tailored HIV risk reduction (or safer sex maintenance) goal with the patient (Cornman et al., 2008, Fisher et al., 2006).
There is an estimated 5.5 million people living with HIV in South Africa (UNAIDS, 2008), with 18.8% of the adult population (aged 15–49) and about 12% of the general population infected. Women are disproportionately affected, accounting for approximately 55% of HIV-positive people in South Africa (Department of Health, 2007). Peltzer, Matseke, Mzolo and Majaja (2009) studied the determinants of knowledge of HIV status in South Africa from a population-based HIV survey, and found that from the total sample of 16,395 15 years and above, 27.6% (CI = 26.5–28.7) reported to have ever had an HIV test and had received their HIV test results (knowledge of HIV status). Of those who had been tested for HIV, 38.8% had been tested within the year preceding the survey, 33.1% 1–2 years previously, and 28.2% more than 2 years previously; 7.8% of the total sample had taken an HIV test in the past 12 months and knew their test result. High HIV transmission risk behaviours among HIV seropositive persons have been reported in Southern Africa. For example, among 218 HIV positive sexually transmitted infection clinic patients in Cape Town, South Africa, 34 (16%) had engaged in unprotected vaginal or anal intercourse with uninfected or unknown HIV status sex partners in the previous month (Kalichman, Simbayi & Cain, 2009) and Kalichman, Ntseane, et al. (2007) found that multiple sexual partnerships, many of which are probably concurrent, were not uncommon among sexually active people living with HIV in Botswana. Research conducted in southern Africa confirms an association between alcohol use and sexual risks for HIV (Kalichman, Simbayi, Kaufman, Cain, & Jooste, 2007). Kalichman et al. (2009) found in a study in Cape Town, South Africa, that alcohol use in sexual contexts was associated with greater numbers of sex partners, higher rates of unprotected intercourse and condom failures. Evidence exists that hazardous alcohol consumption is deleterious to the health of persons living with HIV (e.g., Braithwaite et al., 2007).
Little information exists on the use of an enhanced HIV risk reduction intervention in the context of VCT and in particular conducted by lay counsellors.
The present study consisted of a pre–post implementation evaluation with the Options Project intervention with PLHIV (Cornman, Christie, Amico, Cruess & Shepherd, 2007) in an HIV counselling and testing site setting in South Africa, the fidelity with which the intervention could be implemented, and the potential effectiveness of the intervention in reducing risky sexual behaviour over a 4 months period.
Section snippets
Sample and procedure
Patients (N = 488) receiving services at 13 public HIV counselling and testing (HCT) clinics in Albert Luthuli sub-district, Gert Sibande District, Mpumalanga, between December 2008 and April 2009 were referred after HIV post-test counselling by a lay counsellor in the clinic to an external trained field worker to participate in the study. The criterion for referral to the study was that the patient was 18 years and older and was diagnosed HIV positive. Patients who agreed to enroll in the study
Data analyses
For sexual behaviour outcomes, differences between baseline and 4 months following the intervention were examined using 3-month retrospective rates of behaviours. Analyses tested for differences between baseline and follow-up using Paired samples t-tests for continuous variables and McNemar Chi-square tests for categorical variables. Individual cell sizes vary as a result of missing values. To compare means between continuous variables and one, two or three counselling sessions exposures ANOVA
Sample characteristics and attrition analysis
The average age of study participants was almost 33 years and they had a mean of 8.6 years of formal education. At baseline, 70.2% of the participants were women and 29.8% men, the majority (71.2%) were unemployed, only 18.8% were married, and 71.5% had children. Of the 488 patients who completed the baseline assessment, 360 (73.8%) also completed the 4-months follow-up assessment. Reasons for loss to follow-up are not clear since patients were not contacted when failing to turn up to their
Fidelity and acceptability analysis
Assessment of intervention feasibility based on a review of patient monitoring forms indicated that the intervention was delivered in 360 of 366 (98.4%) HIV-infected referred patients, with a mean of 2.3 intervention sessions per patient (one session = 117, 32.5%; two sessions = 155, 43.1%; three sessions = 88, 24.4%) over a 2-months period.
Assessment of intervention fidelity via the patient monitoring forms found that the intervention was delivered with sufficient fidelity. In 65% of the
Sexual behaviour
Compared to baseline participants reported at follow-up significant reductions in multiple sexual partners, unprotected sexual intercourse, use of alcohol or drugs in the context of sex and transactional sex. There was also an increase of sexual abstinence and reduction of alcohol use and abuse following the intervention (see Table 3).
Discussion
The current study findings are among the first to demonstrate that a brief lay counsellor-delivered HIV risk reduction intervention for PLHIV immediately after diagnosis can be implemented into routine care, is acceptable to HIV-infected patients, and may be effective in reducing HIV risk behaviour (multiple sexual partners, unprotected sex, and alcohol or drug use in the context of sex) among HIV-infected patients. Similar results were found among PLHIV in the US (Kalichman et al., 2001),
Strength and limitations
The current study used 13 clinics, with 26 lay counsellors having been trained and a relatively large sample size. Limitations include reliance on self-reports on sexual behaviour and only one short follow-up period. There is a possibility of desirability bias in reporting unprotected sexual behaviour. In addition, in the routine brief (15–20-min for HIV positive) post-test counselling session patients receive their HIV status; discuss risk reduction strategies and disclosure of test results.
Acknowledgements
We thank the Bill and Melinda Gates Foundation for financial support of the study.
William Fisher is thanked for sharing the Options for Health intervention training manual.
Karl Peltzer is research director in the research programme Social Aspects of HIV/AIDS and Health, Human Sciences Research Council, South Africa. He is a prevention researcher and evaluator with over 20 years of experience in the study of health promotion, risk behaviour and disease prevention, and socio-behavioural interventions. He has published extensively on health behaviour and health interventions (13 books and 300 articles). He has worked extensively on public health subject areas of
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Karl Peltzer is research director in the research programme Social Aspects of HIV/AIDS and Health, Human Sciences Research Council, South Africa. He is a prevention researcher and evaluator with over 20 years of experience in the study of health promotion, risk behaviour and disease prevention, and socio-behavioural interventions. He has published extensively on health behaviour and health interventions (13 books and 300 articles). He has worked extensively on public health subject areas of substance use, cancer, tuberculosis and HIV control; nutrition, physical activity, hypertension, mental health, injury and violence prevention and health systems.