This paper reports the findings of a cluster randomised trial of the Regai Dzive Shiri Project, a community-based human immunodeficiency virus (HIV) and reproduction health intervention that aimed to change social norms for adolescents in rural Zimbabwe. The intervention contained three integrated components: a youth programme, a programme for parents and community stakeholders and a training programme for nurses and other staff members working in rural clinics. For this study, 30 communities in seven districts in south-eastern Zimbabwe were randomised to either early intervention implementation (2003) or delayed implementation (2007), which served as the control group. A community comprised a rural clinic, its catchment population and its secondary schools. Overall, 4,684 18 to 22-year-old individuals participated in the final survey.
Two primary outcomes were measured: the prevalence of HIV and of herpes simplex virus type 2 (HSV-2), which were compared between clusters in early and deferred intervention arms. Secondary outcomes included pregnancy prevalence and reported knowledge, behaviour and attitudes. To assess the impact of the intervention on primary and secondary outcomes, univariate and multivariate unadjusted generalised estimating equations analysis that compared the outcomes between study arms was performed. Cox regression analysis was used to explore the association between intervention status and age of sexual debut. Results are presented via crude as well as adjusted odds ratios (AORs). Statistical analysis was by intention to treat, adjusted for clustering and stratified by sex. Subgroup analysis was conducted to assess whether impact varied with intensity of intervention exposure.
The authors found no impact of the intervention on the prevalence of HIV or HSV-2. Nor were impacts seen for self-reported sexual behaviour, current pregnancy or reporting of symptoms of sexually transmitted diseases (STDs) in either men or women. However, improvements in knowledge and attitudes amongst young men and women in intervention communities were seen. In men, there was an increase in knowledge related to STD acquisition (AOR = 1.32) and pregnancy prevention (AOR = 1.59) in the intervention arm. In women, there was an increase in knowledge related to STD acquisition (AOR = 1.45) and pregnancy prevention (AOR = 1.32) as well as a reduction in reported current or past pregnancies amongst all women (AOR = 0.64) in the intervention arm. A modest impact on reported self-efficacy was seen. The intervention also had an impact on women's attitudes to both relationship control (AOR = 1.34) and to gender empowerment (AOR = 1.32). For participants who attended a Regai Dzive Shiri trial school and lived in the trial community throughout the duration of the intervention, effects of the intervention on knowledge and attitudinal outcomes tended to be somewhat larger than in the full study population, but there was no evidence of an increased impact on the primary outcomes of HIV or HSV-2 in either men or women.
The authors discuss how the lack of impact of this intervention on HIV and HSV-2 prevalence adds to the evidence that behavioural interventions alone are unlikely to be sufficient to reverse the HIV epidemic. They point to the need for combination approaches, which integrate behavioural, biomedical and structural components to more effectively prevent HIV infection amongst young people at a population level.