Background: Community HIV care providers (CHiPs) delivering a combination HIV prevention package directly to households is part of the intervention being tested in the HPTN071 (PopART) trial in Zambia and South Africa. Using qualitative research methods, we evaluated community responses over time
in 4 Zambian intervention communities.
Methods: Longitudinal qualitative data (2014-17) from 4 Zambian urban communities receiving the full intervention package included: eight Focus Group Discussions, eight household drop-in discussions, three in-depth interviews with traditional healers, 128 observations of door-to-door delivery, 20 community observations and over 400 researchers reflections on community responses. Group discussions and interviews were transcribed while observations and reflections were captured in structured report forms. Thematic and inductive analysis was conducted.
Results: The intervention initially met with some resistance emanating from fears of HIV disclosure within households and mistrust of staff, study motives and conduct. However, communities also hoped that the intervention might reduce HIV transmission and stigma and encourage HIV testing in men. Community concerns about men and traders missing out on the door-to-door delivery were confirmed by observations showing lower intervention uptake from men, which resulted in amending working hours. As the intervention progressed, community reported appreciation for: detailed HIV information, relatively private and confidential services, enabling less contact with the local clinic(s) (thereby reducing congestion), affording disabled people better access to services, linkage to other HIV services and a perceived reduction in mortality. However, stigma, acceptance of HIV-positive results and linkage to care remained challenging. Despite this, CHiPs, identified by uniforms and staff cards, became well known and rapport with and trust in them was evident. Indeed, cases of community members seeking out and requesting certain services from CHiPs increased over time. Familiarity and optimism nurtured during intervention years was accompanied by concerns about what would happen when the trial ended.
Conclusions: Community confidence in home delivery of HIV services took time to build. Once established, better community management of HIV played out into optimism and appreciation of home delivered services and increasing reliance on CHiPs. This represents a much supported novel direction for policy to achieve universal ART coverage.