HIV Infection Clinical Trial
Official title:
Enabling People Living With HIV/AIDS (PHA) to Serve as Change Agents for HIV Prevention
The Appreciative Inquiry Change Agents (CA) program (NAMWEZA) intends to address broad
societal issues by engaging HIV-positive leaders as 'change agents' in their communities. In
this study, the CAs will be recruited from an HIV Care and Treatment Centre in Dar es
Salaam. The Namweza program has the potential to address structural issues related to HIV
risk, such as access to limited resources, through an entrepreneurial component of the
program. A positive, or appreciative, focus promotes CAs to examine assets in themselves and
in their networks, encourages strengthening of relationships, and facilitates planning for a
positive future for themselves, their families, and their communities.
A stepped wedge randomized trial will be performed to evaluate the effectiveness of the
program for the following primary outcomes: uptake of HIV services among network members of
the CAs; rate of unprotected sex and frequency of concurrent relationships among CAs and
their social networks; and levels of self-esteem, general self efficacy, and risk of
intimate partner violence in the CAs. Secondary outcomes include: depressive symptoms,
hopefulness, and HIV-related stigma (among CAs); social support and quality of relationships
(among CAs); and HIV knowledge, attitudes and self-efficacy in preventing HIV transmission
or re-infection (CAs and their networks).
The following are primary hypotheses that will be tested through this stepped wedge
randomized trial evaluation:
1. Uptake of HIV services will increase among individuals in the network of the
HIV-positive Change Agents related to the intervention;
2. Levels of self-esteem and general self-efficacy will increase in trained Change Agents;
3. Rate of unprotected sex and number of concurrent partners will decrease (among network
of Change Agents as well as Change Agents themselves; i.e. the 'study population'); and
4. Prevalence of intimate partner violence (IPV) will decrease in Change Agents.
Secondary hypotheses are:
5. Prevalence of depressive symptoms and HIV-related stigma will decrease and level of
hopefulness will increase in trained Change Agents;
6. Levels of HIV knowledge, attitudes and self-efficacy in preventing HIV transmission and
re-infection among CA and their networks will increase; and
7. Degree of social support and quality of relationships will improve among CA.
If the proposed intervention is found to be effective, linkages with the Tanzanian Ministry
of Health and other stakeholders will enable scale-up of the program throughout the country.
Intervention approach: Appreciative Inquiry Change Agents (CA) program (NAMWEZA) (see
Appendix D for draft Facilitators' Guide). The intervention is based on an Appreciative
Inquiry approach that comprises a 10-session program based on learning by doing rather than
factual classroom type learning, although it includes discussion of relevant facts about
HIV, and other STIs. The intervention is based on the template of Stepping Stones (Jewkes et
al., 2008), which is internationally one of the most widely used participatory behavioral
interventions targeting sexual health. The Stepping Stones curriculum was shortened and
radically adapted from more than 20 sessions. However NAMWEZA borrows generously from many
of the exercises and games. It also employs the successful experience of stratification by
age and sex to engage 4 different working groups (younger and older, male and female). The
intervention is described in detail in Appendix D in the facilitators guide. A full draft
curriculum is available on request. It is currently being translated into Swahili for use in
Tanzania.
The intervention uses a number of psychological methods for creating change as effectively
and rapidly as possible. It focuses on showing affirmation and being appreciative by looking
for what is working in people's lives. Looking for resilience and coping strategies, and
naming these, aims to raise self-esteem and the sense of competence in
'someone-who-has-a-future'. In every session, participants dream or imagine whom they might
talk to about the things they have learned, or what they might do to prevent the spread of
HIV personally or in their community. Imagining or dreaming their personal scenarios creates
possibilities for different positive futures, for ways of behaving and being in relationship
with people. These exercises, that are repeated every session in different forms, are
designed to empower participants, giving them energy and hope. Participants learn and
practice these life skills and report on their practical utility as they interact with their
social networks each week.
Every exercise is discussed in small groups or role-played so that ideas and strategies can
be shared and different responses can be practiced. Participants rehearse and try different
ways of saying and doing things, until they find their own words and personal approaches
within the given format. Discussions about love and safe, enjoyable sex allow participants
to explore these personal subjects in the security of sex and age stratified groups. There
is a particular emphasis on assertiveness and communication skills to raise self-esteem and
decrease interpersonal violence.
Most sessions end with meditation or mindfulness so that people become aware of how their
bodies feel. This helps them to recognize their own and others' body language and non-verbal
communication, helping them to be more aware of other people's responses. Integration and
awareness of the body is developed in the process of mindfulness training. This is
particularly useful when thinking about disclosure and potential intimate partner violence
(IPV).
Closing circle is a daily session closing/winding up activity where all participants gather
into a circle and each has a chance to say one thing they have learned in that day which
they might share with someone in the community and one thing they are looking forward to
doing before the next meeting. As part of the intervention, facilitators will be required at
the end of each session to document their perception of how the session was conducted and
meet with other facilitators in a self evaluation and support session that will form the
basis for preparation for the next training session. They will be requested to provide
reports on level of participant's comfort with content of sessions, level of participation,
range of learning reported, and areas for improvement reported.
The last sessions engage participants in thinking about practical issues of encouraging
entrepreneurial skills. Participants explore ways that they might work in their local
communities as change agents to reduce the spread of the virus and improve the situation of
those living with HIV.
;
Allocation: Randomized, Endpoint Classification: Efficacy Study, Intervention Model: Crossover Assignment, Masking: Open Label, Primary Purpose: Prevention
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