“The difference that makes a difference”: highlighting the role of variable contexts within an HIV Prevention Community Randomised Trial (HPTN 071/PopART) in 21 study communities in Zambia and South Africa

Figures & data

Table 2. Key features of 12 Zambian study communities within the four meta-indicator framework, open/closed typology.

Meta-indicators	12 Zambian study communities
Physical features	Type of terrain (boundaries, topography), infrastructure, population mix and economic options found in the community
Terrain and physical boundaries	All communities are urban, two on an international border. Some more porous than others (many/few entry/exit points). 5/12 better road networks. All situated on low-lying land, prone to seasonal flooding. Limited access to water, toilets and waste disposal
Infrastructure and population	Common to all: government clinic/s, churches, transport depots, market areas, education facilities, communal facilities, police posts, football pitches, recreational facilities (including drinking places). Private clinics present in seven communities. Few secondary schools. Population growing with a core group of long-term residents. Transient populations often newcomers, poorer and non-national
Population diversity, ethnicity, age and class	Population size estimates range from 22,500 to 100,391. Most residents in lower socio-economic status bracket. Small but growing presence of a middle-class. Mix of age groups, dominated by a younger age group. Mix of ethnic and language groups and small representation from other African countries
Employment, work, economic options	No welfare state. Limited formal employment options. Unemployment, particularly amongst youth. Providing sex in exchange for cash or goods is a livelihood option for some women. A few have industrial presence within or on the boundary
Social organisation	The relationship between people and place, including between local residents and housing, work, transport, local services, mobility and local HIV stakeholders
Distribution housing options across residents	Housing type mirrors social classes, with most urban working class residents residing in smaller housing and more likely to rent accommodation. Transient populations rent accommodation and are more likely to move out of as well as within a community
Distribution of categories of population across work options	Residents 18–45 dominate informal trading economy. Older residents more likely to be landlords. Entrepreneurial spirit of young people evident. Youth (i.e., younger than 30) mostly rely on casual work. Young men engaged in street vending, casual work (construction, physical labour), transport jobs or security work. Young women mainly involved in food and clothes trading in markets or domestic work (including childcare). Some young women earn a living from sex work or boost income through transactional sex
Access: transport/local services	Government clinic in walking distance for majority of residents. At least one taxi and bus stations in each community
Population movement in and out	Population movement embedded in livelihood patterns. Some traders coming into communities to sell goods spend nights under stalls or in communal spaces and some residents spend nights outside the community. Charcoal, fish and cross-border trading involve leaving the communities for longer periods
Presence/absence of HIV stakeholders	Since the 1980s, HIV is remembered as falling into distinct phases defined by absence/presence of HIV initiatives. In all study communities, the government health facility is perceived as the main HIV-related service provider/stakeholder. Average of 14 stakeholders delivering HIV-related services, including voluntary medical male circumcision and HIV testing (couples; home-based; mobile) identified. In three study communities, more than one health facility provided ART. Seeking faith healing and traditional medicine was reported in all
Networks	Relationships between people through patterns of connection, spread and boundaries, social capital and networks of particular significance to HIV (alcohol, drug use and transactional sex networks)
Patterns of connection relationship	Residence, kin, religion and occupation are often as strong as ethnic connections
Network spread and boundaries	Networks emanate from kin, peer groups, gender groups, class, livelihood options, schools, church affiliations, length of residence in the community, leisure activities and/or recreational spaces, transport depots, geographical zones, party political and civil society affiliations and community-based initiatives (including health). Many relatively local and intensive but trading, kin, church and political/civil society networks extend beyond the community. Some networks (e.g., class) more closed than others
Social capital	Social links exist between long-term residents, within livelihood and recreational activity groups. Tension between younger and older age groups common, with younger groups blamed by older people for social ills. Community action highly valued and aspired to by most established residents in communities, and is engendered by hardships
Networks of particular significance to HIV	Alcohol use, drug use and transactional sex networks identified as linked to HIV risk. Alcohol use is evident at any time of the day but more especially in evening and at weekends. Men most frequent drinkers, but younger women increasingly perceived as drinking. Participants regarded alcohol use as a barrier to HIV testing and treatment and related how it could lead to risky sexual behaviour. Alcohol use is also linked to arguments and violence – both bodily harm and rape. Alcohol considered a coping mechanism against harsh social circumstances. Drinking places targeted in HIV outreach activities and condoms often for sale Recreational drug use a growing problem. Marijuana use amongst younger men said to be widespread. Few reports of ART being “smoked” or “sniffed” as a recreational drug – for this purpose, ART could be stolen or sold Openly practised sex work evident. Female sex workers sometimes attached to recreational facilities in community or in town centre where they can rent rooms. Less overtly, women traders sometimes exchange access to wares for sex – sometimes a business arrangement but sometimes more opportunistic and/or forced. Some women who drink alcohol are said to exchange alcohol for sex
Narratives	The defining characteristic of a particular community
General	Most communities initially listed negative attributes about “their place”. These included: unemployment, limited recreation and educational opportunities, alcohol abuse, marijuana use, overcrowding, transactional sex and sex work, early marriage, teenage pregnancy, rainy season diseases (malaria and cholera), flooding, poor water and sanitation, poverty and hunger and street kids
Poverty	Most adult residents dependent on own endeavours in the informal economy. They struggle to manage periods of sickness, “hunger” linked to TB and HIV medication and other health needs, despite the presence of government health and education services
Crime	In six communities, lack of safety, particularly at night and weekends. Other communities took pride in safety of their communities
Community solidarity	Positive attributes which emerged include: safety, high birth rate, small-scale trading, socialising, cohesiveness, being quick to take up new initiatives, good communication channels and friendliness. Long-term residents had a strong commitment to the place they lived in

Table 1. Definition of selected process indicators, HPTN071/PopART.

Indicator	Numerator	Denominator
Proportion of adult (≥18 years) household members who know their HIV status, from a prior HIV-positive test result or acceptance of the offer of HIV testing by CHiP teams	Number of adult (≥18 years) household members tested for HIV by the CHiP team and/or self-report they are HIV-positive	Number of adult household members who consented to participate in the intervention, among enumerated households
Adults who refuse to participate in the intervention	Number of adult household members who refused (verbally) to participate in the intervention	Number of adults who were enumerated as a household member, among households that gave permission for household members to be enumerated
Adults not contacted by the intervention	Number of adult household members who could not be contacted by CHiPs during repeated household visits and could therefore not be invited to participate in the intervention	Number of adults who were enumerated as a household member, among households that gave permission for household members to be enumerated
Proportion of HIV-positive adult household members who started ART within three months of being referred to HIV care by a CHiP team	Number of HIV-positive adult household members who start ART within three months of being referred to HIV care by a CHiP team	Number of HIV-positive adult household members who were referred to HIV care by a CHiP team, among adults who either self-reported they were HIV-positive or accepted the offer of HIV testing from CHiP teams and the test result was HIV-positive, and were not taking ART at the time of the annual round visit

Note: Community Lay Workers working for HPTN071 to deliver the household-based intervention are called Community HIV care Providers (CHiPs).

Table 3. Four Zambian Arm A study communities process indicator results, cumulative for first year of the intervention (2014–2015), HPTN 071.

Process indicator	Study community: Z2			Study community: Z5			Study community: Z8			Study community: Z10
Adults who know their HIV status	Overall:	7382/12510	59.0%	Overall:	19327/23076	83.8%	Overall:	37174/49329	75.4%	Overall:	10678/16663	64.1%
	Men:	3006/5682	52.9%	Men:	8301/9941	83.5%	Men:	16987/22921	74.1%	Men:	4325/7066	61.2%
	Women:	4376/6828	64.1%	Women:	11026/13135	83.9%	Women:	20187/26408	76.4%	Women:	6353/9597	66.2%
Adults who refuse to participate in the intervention	Overall:	812/13975	5.8%	Overall:	1201/29748	4.0%	Overall:	4921/57672	8.5%	Overall:	1024/20303	5.0%
	Men:	430/6506	6.6%	Men:	682/14861	4.6%	Men:	3091/28601	10.8%	Men:	660/9590	6.9%
	Women:	382/7469	5.1%	Women:	519/14887	3.5%	Women:	1830/29071	6.3%	Women:	364/10713	3.4%
Adults not contacted by the intervention	Overall:	602/13975	4.3%	Overall:	4991/29748	16.8%	Overall:	2914/57672	5.1%	Overall:	2455/20303	12.1%
	Men:	372/6506	5.7%	Men:	3993/14861	26.9%	Men:	2339/28601	8.2%	Men:	1761/9590	18.4%
	Women	230/7469	3.1%	Women	998/14887	6.7%	Women	575/29071	2.0%	Women	694/10713	6.5%
Adults LWH starting ART within three months of community Lay worker referral	Overall:	111/362	30.7%	Overall:	461/1593	28.9%	Overall:	626/2746	22.8%	Overall:	193/977	19.8%
	Men:	26/88	29.5%	Men:	167/562	29.7%	Men:	221/945	23.4%	Men:	51/273	18.7%
	Women:	85/274	31.0%	Women:	294/1031	28.5%	Women:	405/1801	22.5%	Women:	142/704	20.2%
summary of intervention outcomes patterns	Almost 95% of adults contacted participated in the intervention with few differences between men and women across all indicators (with men slightly less likely to be contacted or know their HIV status). Knowledge of HIV status is notably lower in this site (compared to other Arm A communities) and ART uptake within three months of testing positive through the intervention is the highest, but still low			Highest uptake of intervention participation (96%), striking differences between men and women not contacted (with men much less likely to be contacted), the highest number of adults who already know their HIV status and the second highest uptake of ART, but again, still low (29%)			Compared to other communities, lower participation in intervention, but still high levels (91.5%). Men are less likely to participate and be contacted, but minimal difference between adult men and women who know their HIV status and uptake ART. Knowledge of HIV status amongst adults is high but not as high as Z5, and uptake of ART is lower than Z5 and Z2 with almost 23% starting ART within three months			High participation rates in intervention (95%) and sustained difference between men and women across indicators, with men less likely to participate, be contacted, to know their status, and uptake ART. Difference in men is particularly marked in adults not contacted (18% of men). Knowledge of HIV status is lower than Z8 and Z5, but higher than Z2. Uptake of ART within three months is lowest at just under 20%

Note: knowledge of HIV status is defined as adults sharing a prior HIV-positive test result or acceptance of the offer of HIV testing by community lay worker teams (see Table 1). LWH, living with HIV.

Table 4. The difference that makes a difference – meta-indicators, open/closed typology.

Meta-indicator	Significant features of difference
Physical features	How porous a community is, the proximity to a town centre and an international border, the presence of industry, population size, type of housing, proportion of middle-class, the informal economy
Social organisation	Distribution of population across housing options, young men’s work patterns, the link between informal livelihood and mobility, the presence/absence of HIV stakeholders over time
Networks	Social capital, community action, open/closed nature of networks
Narratives	The “hunch” and “feel” of a place

Figure 1. Four Arm A study communities placed on an open/closed typology qualitative scale.