“We went back to the community and told them it didn’t work” – lessons learned from a trial of youth-friendly health services

A large cluster randomised trial which offered community-based health services to young people in Zimbabwe failed to demonstrate improvements in the HIV care cascade but did showcase the positive impact of integrated health services. Results were presented at the 12th International AIDS Society Conference on HIV Science (IAS 2023) in Brisbane last month.

Dr Rashida Ferrand of the London School of Hygiene and Tropical Medicine said that the high attendance and uptake of services demonstrates the need for accessible, youth-friendly sources of sexual and reproductive health (SRH) information, including menstrual health management, contraception, and HIV testing in Zimbabwe. However, the outcomes, which were aligned to UNAIDS 90-90-90 targets, failed to meet the metrics of success. 

Limited engagement with health services contributes to the poorer HIV outcomes observed in young people in Zimbabwe, who are at high-risk of infection.  Trial coordinator Ethel Dauya of Biomedical Research and Training Institute, Zimbabwe, explained that “youth are infrequent facility users, because existing services are largely facility-based and do not cater to their needs.”

The study

Weekly integrated HIV and SRH services were delivered from community centres across three urban and peri-urban provinces in Zimbabwe. They were available to residents aged 16-24 years, over a period of 30 months, including a short pause for the COVID-19 lockdown in spring 2020.

The CHIEDZA study randomised communities, rather than individuals. There were 24 community clusters, with 12 in both arms. The control arm received standard of care, which included existing HIV testing and care services and sexual and reproductive health services. Those in the intervention arm received HIV testing and counselling (including both self-testing and provider-delivered testing), HIV treatment and monitoring, HIV treatment adherence support, sexual and reproductive health services (including testing and treatment for STIs, pregnancy tests, contraception and condoms), referrals for voluntary male circumcision, and general health information and counselling. All services were optional. The community centres also hosted social activities and provision of free or subsidised commodities, such as menstrual health products. Young people engaged in the design, delivery and evaluation of the intervention and their feedback fed into iterative changes.

Outcomes were measured by population-based surveys, at the end of the intervention. The surveys covered: knowledge of HIV status, history of HIV testing and care, sexual behaviour, contraceptive use, menstrual management, and circumcision. The surveys were used to measure how many of those living with HIV had a viral load under 1000 copies, which was set as the study’s primary outcome. Secondary outcomes assessed the impact of the intervention on the 90-90-90 targets.

Results

CHIEDZA resulted in high engagement of young people. In total 36,991 participants attended, with a total of 78,810 visits. In terms of age, 19,588 were aged between 16 and 19 and the other 17,402 were between 20 and 24. Most of them were female (75%). An average of 55 young people accessed the sites each day, with 41% of them returning for more than one visit, with one young person saying:

“I liked it very much and I somehow felt important.”

There was a high uptake of HIV testing, which was available to those who did not know their status and had not recently taken a test. In total, 84% of those eligible were tested, including 17% doing so on more than one occasion. Among those who were not eligible to test initially, 28% of them later returned and were tested. In total, HIV prevalence was 1%, with 377 people testing positive and 75% of them linking to care. Services were also used by 1162 young people who had previously been diagnosed. The HIV incidence rate of those who repeatedly accessed the service was less than 1%.

The most popular services for women were menstrual hygiene products (97%), HIV testing (84%) and period pain management (60%). For men the most popular were condoms (94%), HIV testing (86%) and text messages on sexual and reproductive health (67%). The average number of services accessed during a first visit was two. Most people took up multiple services, which researchers felt indicates that programmes focused on single issues should not be the norm.

 The results showed similar outcomes for those in either arm. In the control arm, 55% of people living with HIV knew their status vs 57% of people accessing CHIEDZA. Of those, 99% in the control arm were on treatment, compared with 95% of people accessing CHIEDZA. Finally, viral suppression rates were at 71% in the control arm and 76% for those accessing CHIEDZA.

The intervention was highly acceptable, with ratings of four out of five by 40% of participants and five out of five by 50%. One of the most highly valued aspects of CHIEDZA was its free services. One participant shared:

“I started panicking thinking that I have to source out some money for treatment at the hospital but then my friend said there is CHIEDZA which offers free STI services.”

Another success was the ease of access and friendly service providers. CHIEDZA hosted youth-only spaces, where being young was celebrated and safe. Youth workers were the first point of contact at CHIEDZA, and there were youth champions who were able to mobilise the communities and be sensitive to their needs. These were young people from the local communities who were trained to be able to engage and support other young people who used the service. There was a specific focus on understanding young people’s lives and needs, seeing participants as a whole person and being able to facilitate conversations about broader life needs and challenges.

Discussion

At face value, the trial was unable to demonstrate that those who engaged with CHIEDZA were more likely to achieve viral suppression, so it is considered to have failed. At a satellite session, the team explored whether a trial is the most effective way to test whether interventions work and whether success should be defined by communities, instead of researchers.

Dr Rashida Ferrand stated that integrated care models should be adopted into guidelines, but that “when a trial fails to show effect around a primary outcome, it becomes very difficult to get it pushed towards policy.”

Dr Meg Doherty from the World Health Organization shared that the global health body considers a range of evidence to inform policy, not just successful trials. Her key takeaway was that the trial didn’t fail, as it “satisfied what was requested and required by the community.” In future, a randomised trial design might not be the best approach, instead providing the services and evaluating them might be more effective.

Dr Sarah Bernays of the University of Sydney interrogated the trial framework used to assess community interventions. “Why is it that trials often tell us that good things are bad?” she asked. She made the case that what success looks like is too often based on “outcomes decided on at a distance from the community.” Even in trials where community knowledge is embedded in the design, the structure of research means if this clashes with trial evidence, it is not expertise that is treated equally.

The results from CHIEDZA affirm the importance of health care that is rooted in communities, adaptable and accessible, and able to offer a range of services. However, the challenge of measuring the tangible impact of such interventions on targets like the 90-90-90 goals frustrates the opportunity to deliver these models and access the funding to do so. Which ultimately means that even if a community wants what models like CHIEDZA can offer, it is likely only possible in a framework that demonstrates the service’s ability to deliver on key metrics.