The recent review by Michielsen et al.  of HIV prevention trials for youth in sub-Saharan Africa and the subsequent correspondence between them and Helen Epstein [2,3] offer much of value to ongoing HIV intervention research. In their comments, Michielsen et al.  described the 1998–2002 MEMA kwa Vijana trial [4,5] in northern Tanzania as one of the two ‘most well elaborated interventions and rigorous evaluations’. As principal investigators and other senior staff within that trial, we read the review and resultant correspondence with great interest.
We agree with Epstein, Michielsen et al., and others  that concurrency warrants greater attention within research and interventions in sub-Saharan Africa. The extent and complexity of different forms of concurrency are poorly understood today and were even less understood when the interventions reviewed by Michielsen et al. were developed and implemented. Qualitative data collected in many villages during the MEMA kwa Vijana trial suggest that many, if not most, young men and women had experienced concurrent partnerships by their late teens or early 20s. Three common types of sexual partnership for young people (i.e. one-time sexual encounters; occasional opportunistic encounters within an open-ended timeframe; and steady, sometimes semipublic partnerships) could each take place concurrently with other partnerships. Critically, both the second and third categories of relationship sometimes contributed to the long-term concurrency with the same partners that Epstein refers to in her letter. Our findings on these and other sexual relationship patterns will be analysed in a forthcoming book .
We also appreciate the comment by Michielsen et al. that published evaluations typically lack detailed information on the content of interventions. Until recently, this was largely due to journal article word limits, which often led authors to reduce content and process descriptions to only one to two sentences. However, today the Internet provides an unprecedented opportunity to share detailed curricula, training manuals, and process and impact evaluation reports with other researchers and programme developers. We strongly recommend that leaders of carefully designed and implemented sexual health projects in sub-Saharan Africa make such materials available online, ideally in all languages in which they are drafted in order to maximize their usefulness. This would enable researchers and intervention developers to review materials themselves and adapt and build upon prior work as appropriate. Since 2008, the English translation of the MEMA kwa Vijana teacher's curriculum and other resources used in the programme have been available online (http://www.memakwavijana.org/materials-and-resources/teachers-guides-english.html, accessed March 22, 2011). Recognizing that many programme managers lack the resources to do this (and in order to make the materials easier to locate), we recommend that an international body such as the WHO sponsor a central website repository for such materials.
In their correspondence, Michielsen et al. commented that they ‘could not detect a clear progression in the design of interventions, where subsequent interventions build upon the previous’. In fact, this process is well documented for the MEMA kwa Vijana intervention in journal articles other than the one used in the review [8,9]. Initially, the intervention incorporated exercises and drew upon the experiences of various programmes, including the WHO/UNESCO guides [10–12], the UK SHARE programme , and programmes in east and southern Africa [14,15]; it then was modified during the first 3 years of implementation based on process evaluation.
The review by Michielsen et al. correctly points out that the selected interventions were diverse both in their content and intensity. We were concerned, however, that Epstein overgeneralizes about the interventions, stating, for example, that ‘none of them explained how long-term concurrent or overlapping partnerships amplify the sexual transmission of HIV in this region’. She illustrates this with one example from South Africa in which ‘concurrent partnerships were never mentioned, nor was monogamy (even temporary monogamy) or the need for partner reduction or the complexity of using condoms consistently and correctly’. This might suggest that all of the reviewed interventions ignored critical areas of sexual risk and harm reduction. We feel this is an inaccurate portrayal, at least as it relates to the MEMA kwa Vijana intervention. The MEMA kwa Vijana teachers’ curriculum included a series of activities to convey the prevalences of HIV and other sexually transmitted infections, the nature of their transmission within networks, and the greater risk involved in multiple partnerships. These issues were addressed in increasing complexity within each upper primary school year, commensurate with participants’ education level and local policies. Thus, by the final year, a session on ‘being faithful’ addressed how monogamy must be both long term and mutual between two uninfected partners to be protective, but that given one cannot be certain of a partner's fidelity, it is safest to use condoms. Condom use was promoted throughout the in-school curriculum, with detailed discussion of consistent, correct condom use by the final year of school; permission for this was only achieved after lengthy negotiation with school authorities.
We are not suggesting that the MEMA kwa Vijana programme was perfect. It had a positive impact on knowledge and some reported attitudes and behaviour during the trial, but it did not have a positive impact on biological markers, so clearly it needs to be improved. We believe this is necessary in general and specifically as pertains to concurrency. Nonetheless, if a carefully designed and implemented intervention does not succeed as hoped, this does not mean that it should be rejected outright. There is a critical need to learn from and build upon what worked well within such an intervention, and to improve what did not. For example, at the end of the MEMA kwa Vijana trial, we identified a need for community programmes which support adolescent interventions by addressing broader norms , an issue that Michielsen et al. also highlighted in their recent correspondence. Since the MEMA kwa Vijana trial, this has led to the development of a community-based programme with parents . The intervention has also been further modified and evaluated as part of its scale-up from 62 to 649 primary schools .
For the 1998–2002 MEMA kwa Vijana trial, M.L.P. was the social science coordinator, D.W. was a principal investigator of the process evaluation, A.O. was the intervention coordinator, J.C. cosupervised laboratory testing, R.J.H. was a principal investigator, and D.A.R. was the project director. M.L.P. wrote the letter and D.W. edited it. All authors read and approved it. Financial support for the trial and process evaluation was provided by the European Commission, Ireland Aid, the UK Medical Research Council, UNAIDS, the UK Department for International Development, and the British Academy.
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