Effective strategies are needed to increase engagement in HIV services in HIV hyperendemic settings. We conducted a cluster-randomized trial in a fishing community on Lake Victoria (HIV prevalence ~41%) in Rakai, Uganda to assess the impact of a community health worker intervention called “Health Scouts” which used motivational interviewing strategies, a situated Information, Motivation, and Behavioral Skills framework, and mobile health (mHealth) counseling support tools to promote engagement in HIV treatment and prevention services.
From September 2015 to December 2018, the Health Scout intervention was deployed in the community which had been divided into 40 contiguous, similarly populated clusters (20 intervention; 20 control). Community-wide surveys of consenting 15-49 year-old residents with HIV viral load testing of HIV-positive participants were conducted at mid-study (~15 months) and end-of-study (~39 months) to assess self-reported antiretroviral therapy (ART) and male circumcision coverage and HIV viral load suppression (defined as <400 copies/mL). The primary analytic method was an as-treated analysis using generalized estimating equations models including participants from both surveys in a pragmatic analysis due to high participant mobility and contamination by study arm.
2522 and 1891 community residents completed the mid-study and end-of-study surveys respectively. By end-of-study, 95.7% (1789/1891) of residents reported awareness of the Health Scouts; 31% (580/1891) of residents reported having been visited and counseled by a Health Scout (i.e. exposed); 2.2% (41/1311) reported being approached but refusing to be seen. Health Scout exposure was higher in intervention (38%) compared to control clusters (23%), among those living with HIV (39%) compared to those who were not (23%), and among women (32%) compared to men (26%). As shown in Table 1, residents who reported having received the intervention (exposed) were more likely to report being on ART and to be virologically suppressed compared to residents who reported not having received the intervention (unexposed); however, there were no differences in male circumcision coverage.
A novel community health worker intervention using motivational interviewing techniques and mHealth tools was associated with improved ART coverage and HIV virologic suppression. However, intervention uptake varied by subgroups and cluster contamination was substantial. This intervention may be a useful community-based component of a comprehensive HIV response.