To determine the impact of a community empowerment model of combination HIV prevention (Project Shikamana) among female sex workers (FSW) in Iringa, Tanzania.
We conducted a 2-community randomized trial. Intervention elements included the following: (1) Community‐led drop‐in center and mobilization activities; (2) venue-based peer education, condom distribution, and HIV testing; (3) peer service navigation; (4) provider sensitivity trainings; and (5) SMS reminders. We used time-location sampling to enroll 496 FSW and conducted a survey and blood draws to screen for HIV and assess viral load at 0 and 18 months. We conducted an intent-to-treat analysis using logistic and Poisson regression and inverse probability weighting for primary outcomes.
The analysis included 171 HIV-positive and 216 HIV-negative FSW who completed baseline and 18-month study visits. Participants in the intervention were significantly less likely to become infected with HIV at 18-month follow-up (RR 0.38; P = 0.047), with an HIV incidence of 5.0% in the intervention vs. 10.4% control. Decreases in inconsistent condom use over time were significantly greater in the intervention (72.0%–43.6%) vs. control (68.8%–54.0%; RR 0.81, P = 0.042). At follow-up, we observed significant differences in behavioral HIV care continuum outcomes, and positive, but nonsignificant, increases in viral suppression (40.0%–50.6%) in the intervention vs. control (35.9%–47.4%). There was a strong association of between higher intervention exposure and HIV outcomes including viral suppression.
Project Shikamana is the first trial of community empowerment-based combination prevention among FSW in Africa to show a significant reduction in HIV incidence warranting its broader implementation and evaluation.
aDepartment of Sociology, Center on Health, Risk and Society, American University, Washington, DC;
bDepartment of Psychiatry, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania;
cDepartment of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD;
dDepartment of Medicine, University of California at San Francisco, San Francisco, CA;
eDepartment of Microbiology and Immunology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania;
fDepartment of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; and
gUniversity of Haifa, Haifa, Israel.
Correspondence to: Deanna Kerrigan, PhD, MPH, Department of Sociology, Center on Health, Risk and Society, American University, 4400 Massachusetts Avenue, Washington, DC NW 20016 (e-mail: firstname.lastname@example.org).
Supported by the US National Institute of Mental Health (R01MH104044).
Presented in part at the 22nd International AIDS Society Meeting; July 2018; Amsterdam, Netherlands.
The authors have no conflicts of interest to disclose.
Received December 31, 2018
Accepted May 29, 2019