Reaching Uganda’s fishing communities with HIV prevention
Evaluating the population-level impact of HIV combination prevention for fishing communities in Uganda is hindered by poor participation and loss to follow-up.
Highly mobile fishing communities can benefit from the provision of HIV combination prevention along Lake Victoria, Uganda – but improving recruitment and retention in clinical trials to understand the best intervention delivery methods remains a significant challenge.
Fishing communities are a high-risk group for HIV in Uganda and a bridging population for HIV – meaning they also transmit HIV to other population groups. But they present a major challenge to reach with HIV services because they are also a highly mobile community. Few studies have looked at the feasibility and impact of combination prevention on highly mobile groups in hyperendemic, low-resource settings.
This study was a pilot cluster-randomised trial with four research communities, two of which were rural, while the other two were urban. All were geographically distant from one another to avoid any cross-contamination. They consisted of fishing communities situated along Lake Victoria in Uganda. Within each rural or urban pair, one cluster was randomly assigned to receive the combination prevention package, while the other cluster served as the control.
The control arm received the standard of care provided by public health facilities, which included the intermittent provision of condoms, HIV testing and counselling, behaviour change communication, voluntary medical male circumcision (VMMC) and referral for antiretroviral treatment.
The combination prevention package included five services, which were implemented using a combination of innovative methods, at the facility and in the community, to maximise continuous community engagement. The components were: community hub-based voluntary HIV testing and counselling (HCT) offered to all residents throughout the study period; VMMC; condom promotion during community meetings, household visits and counselling for behaviour risk reduction; and screening for symptoms suggestive of sexually transmitted infections.
The main differences between the two arms were that, at the public facilities, VMMC and condom promotion were not routinely promoted, and behaviour change communications were delivered on an ad-hoc basis.
Using household census data, residents were randomly selected and those who consented completed a baseline sero-survey and two repeat surveys. 862 participants were enrolled and followed for 15 months.
Loss to follow-up (LTFU) was high across all communities and similar by arms – at an average of 21.6%. LTFU was associated with having lived in the community for less than a year, being HIV-positive, being young (compared to being over 35), living in an urban area, and having to live elsewhere for over a month over the course of the year.
Reported condom use throughout the study period was 36% in the intervention arm versus 28% in the control arm. The number of males who reported VMMC increased in both arms, but the jump was greater in the intervention arm – from 58% to 79% in the intervention arm, compared with 39% to 46% in the control. Self-reported abstinence and faithfulness increased in both arms, but was more pronounced in the control arm – from 53% to 73%, compared with 55% to 67% in the intervention.
As LTFU was above 20%, the validity of any findings in this study may be less impressive. The authors note in their discussion: “The high rates of LTFU and low participation in this mobile population confirms the need to examine approaches to community engagement and to trial modes of delivery of HIV prevention before implementing HIV combination prevention packages. This could improve uptake of methods and potentially study retention.”
In their conclusion, they note that recruitment and retention of study participants remains a challenge for any longitudinal trials among highly mobile populations. “Improving recruitment and retention and investigating modes for delivering and supporting delivery of HIV combination prevention should be a primary focus of future trials.”