Middelkoop, Keren MBChB*; Myer, Landon PhD†‡; Smit, Joalida MA*; Wood, Robin MBChB, FCP*; Bekker, Linda-Gail MBChB, FCP, PhD*
From the *Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine and the †Infectious Diseases Epidemiology Unit, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa; and the ‡Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
The authors thank S. Mthimunye, T. Pepeteka, T. Maqweqana, I. Matinise, P. Mdlulwa, N. Nashwa, and L. Vellem for their roles in the design and implementation of the intervention.
The educational programme and its evaluation were funded by the South African AIDS Vaccine Initiative (SAAVI).
Correspondence: Linda-Gail Bekker, PhD, Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Anzio Road Observatory, 7925, Cape Town, South Africa. E-mail: email@example.com
Received for publication September 28, 2005, and accepted November 29, 2005.
Background: Voluntary counseling and testing (VCT) services are a major component of HIV prevention and treatment efforts. We developed a drama-based intervention to promote VCT services in a peri-urban community in South Africa.
Methods: Young adults from the community received training in HIV/AIDS and drama, and developed sketches to address perceived barriers to VCT. Over 12 months, 80 performances were held in busy community settings. The intervention was evaluated through changes in VCT uptake at the local clinic compared with comparable communities nearby.
Results: After the start of the intervention in August 2003, a 172% increase in the uptake of VCT services was observed in the intervention community. This was significantly greater than demand for VCT in either of the control communities during the same period (P <0.0001).
Conclusion: A structured, community-based education program based on drama can lead to substantial increases in the demand for VCT services in resource-limited settings.
VOLUNTARY COUNSELING AND TESTING (VCT) services play an integral role in the response to the HIV/AIDS epidemic in South Africa and other countries heavily affected by the epidemic. VCT programs serve as an entry point to HIV care and treatment services1 and are an important tool for HIV prevention because individuals who know their HIV status may be less likely to practice high-risk sexual behaviors compared with individuals who have not been tested.2–4
Despite the importance of VCT services, and a substantial body of research into the predictors of seeking HIV counseling and testing among at-risk individuals, there have been few evaluations of interventions to promote VCT uptake at a community level. One program to promote VCT among adolescents in the United States suggested that a targeted media campaign raised awareness of VCT.5 Although these results are encouraging, the effectiveness of campaigns that rely on expensive electronic or written media may not be generalizable to resource-poor settings. Drama and related interventions may provide an important mechanism to promote VCT services in resource-poor settings.6 In one of the few evaluations of VCT promotion from sub-Saharan Africa, the use of community drama to promote VCT has been shown to increase levels of knowledge regarding HIV and VCT services in Malawi.7 However, it remains unclear how increased knowledge of VCT translates into demand for services, and there is a need for further research into how best to promote VCT services in the countries where HIV is most prevalent.
We developed a low-cost drama intervention to promote VCT services in a periurban community in South Africa. We report the design and implementation of that intervention and its impact on uptake of VCT services.
The intervention was conducted in a predominantly Xhosa-speaking township located 40 km outside of Cape Town. The community is poor, with unemployment estimated at over 50%, and is served by a single primary health care clinic that has offered VCT services since 2001. Despite the availability of these services, the uptake of VCT has been poor, and attempts to promote VCT have been prioritized by the local health department.
The central aim of the program was to increase the uptake of VCT at the local clinic by improving the community's understanding of HIV/AIDS and promoting the benefits of VCT. In conjunction with clinic staff and the local community advisory board, we developed an intervention based on the Xhosa tradition of intsomi, in which storytelling is used as an educational tool. Historically, stories in the tradition of intsomi have been used to help instruct young people on the traditions and customs of Xhosa-speaking peoples as well as to teach moral values and impart knowledge. Traditionally, intsomi stories often include a mixture of historical and mythical characters, and focus on topics including personal relationships, rites of passage, and marriage. The stories are driven by a narrator (the storyteller) who introduces the characters initially and periodically interrupts the actors to ensure that the audience follows key plot developments and related lessons.8
Five young adults with an interest in community drama (age range = 21–28 years; 2 male and 3 female) were selected from the intervention community to fill the roles of community educators. Over the period of 1 month, they received training in HIV/AIDS from health professionals. A simple manual on HIV/AIDS formed the basis of the training and covered topics such as HIV testing, the VCT process, HIV life cycle, HIV treatment, and HIV prevention methods.
In parallel with these training sessions, the team received instruction from a professional actor who taught skills related to improvisation and street theatre, including practice in performing dramatic sketches in informal settings. A selection of 10 different sketches was developed to address key HIV knowledge issues, correct myths and misconceptions, and to promote VCT (see Table 1), and could be adapted to ensure appropriateness for particular audiences. Specific topics for these sketches were identified through local community consultations. A diverse team, including the educators, medical personnel, and the dramatist, compiled the sketches together to ensure local appropriateness and accuracy of the content. The community drama intervention was launched in August 2003. Local sites for performances included areas where members of the community congregate, including taxi ranks, bus stops, taverns, churches, shops, the local clinic, and busy street corners. A structured program was developed to ensure regular performances in key locations, thus providing complete coverage of different parts of the community. Performances were held 3 to 4 times a week for a 12-month period. Each of the sketches were regularly evaluated to assess the interpretation and understanding of the audience as well as to ascertain the ongoing relevance of HIV messages.
The program was evaluated by monitoring the VCT service utilization at the local community clinic, the only site at which VCT was available in the community, from January 2002 (18 months before the intervention began) until May 2004 (10 months after the intervention was initiated). Individuals attending VCT services in the intervention community were classified as either medical referrals (i.e., attending VCT after referral from another medical service) or as self-referred (i.e., seeking VCT independent of any other medical care). To gauge secular trends in VCT demand in this region, the VCT rates at 2 other communities around Cape Town with similar demographic makeup, socioeconomic characteristics, and HIV epidemiology were monitored over the same period. Because the control communities were larger than the intervention community (and thus monthly demand for VCT services was greater in absolute numbers), we used the first 6 months of 2002 as a reference period from which to calculate percent change in monthly VCT demand within each community. Data were analyzed using the statistical program SAS Version 9.1 (Cary, NC); a second-order autoregression model was used to compare monthly demand for VCT services in the intervention and control communities around the time of the drama intervention (August 2003).9
From August 2003 to July 2004, approximately 80 performances of the drama intervention were conducted in the intervention community. Estimated audience sizes varied from 20 to over 300 people, and most audiences were between 30 and 50 people. Overall, VCT service utilization (including medical referrals and self-referrals) monitored at the local clinic in the period before the intervention (January 2002 to July 2003) showed an average uptake of 39 individuals attending the clinic per month during this period, including an average of 18 individuals self-referred for VCT each month (see Table 2).
After the implementation of the community education program, the overall VCT demand at the local clinic increased to an average of 82 individuals per month, including 49 individuals self-referred to VCT per month. This represents a 172% increase in the utilization of VCT by self-referred clients, an increase of 110% among all clients, and an increase of more than 400% from the average number of patients during the reference period January to June 2002 (Fig. 1). Each of these increases in VCT uptake was highly significant (P <0.0001).
The 2 control communities showed similar trends to the intervention community in demand for VCT services before August 2003, with a slight increase in the numbers of individuals seeking HIV testing each month. This slight trend continued after August 2003, leading to more modest increases in VCT uptake during the intervention period; in control community A, VCT rates increased by 17% after August 2003 (P = 0.122) and in control community B, VCT rates increased by 37% during the same period (P = 0.023).
These results demonstrate a marked increase in demand for VCT services in a periurban community after the implementation of a drama intervention. The design and content of this type of intervention requires close understanding of the levels of knowledge regarding HIV in the local community, because simple, unambiguous messages may be the most appropriate way to address prevalent misconceptions regarding the disease. Although these results may not be universally generalizable, this approach can be easily adapted to a variety of settings. The total cost of implementing this program for a 12-month period is approximately US $10,000, with the salaries of the community educators forming the bulk of this amount. Although there have been few reports on the cost-effectiveness of interventions that promote VCT uptake in resource-limited settings, we feel that our roughly estimated cost of $27 per additional self-referred VCT client per month (calculated as the program cost of $833 per month divided by the additional increase of 30 self-referred VCT clients per month) is moderate compared with other options for VCT promotion such as media campaigns or mobile VCT services.
We did not collect data on the reasons for attending VCT during this period, and thus we are not certain that the increase in VCT in the intervention community during this period can be directly attributed to the intervention. However, the timing of the rapid increase in VCT demand at the start of the drama intervention (August 2003), coupled with the lack of a comparable increase in the nearby control communities during the same period, suggests that the increased demand is attributable to the drama intervention. Related to this, we do not know of any other programs to promote VCT in the intervention community introduced during this time, but we cannot exclude the possibility that other reasons to seek VCT were operating concurrently with the drama-based intervention described here.
Sustaining this type of drama intervention presents a challenge in the long term. The educator's role is a physically and emotionally demanding one, particularly because they have to quickly develop the capacity to deal with a variety of unpredictable community responses. We found that a strong support structure for educators was required, particularly during the first 6 months. This included regular, detailed feedback sessions for the team, which provided an opportunity for discussion and problem-solving. To date, a “train the replacement” model to deal with turnover in community educators has been useful for conveying drama skills; however, more formal training of new team members is required around HIV-related factual information.
In conclusion, VCT is a critical entry point for all aspect of HIV management whether it be care or preventive measures, yet it is an underused service in many of the settings where HIV is most common. Our experience suggests that a locally appropriate, structured education program based on drama performed in informal settings can help lead to substantial increases in the demand for VCT services in resource-poor settings.
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