Article Review: Mobilization of Community Members to Improve Uptake Rates for HIV Treatment
The study objective: A study by Leddy et al.  assessed HIV service uptake rates for a trial study of community mobilization initiative that focused on various social barriers in South Africa.
Background or context of the research: The authors cite the increase in recent efforts to improve the level of service uptake for HIV care in South Africa, but there remains a lack of timely research concerning which gender norms are most relevant in adversely affecting these rates.
Study design and method: This qualitative study used an inductive-deductive approach to analyze a series of 55 interviews of community members and intervention staff that were conducted during the closing months of a 3-year project in a rural South African province.
The principal conclusions and/or the results of the study: The results of this study determined that there are some specific strategies that clinicians can use to improve the uptake rate of HIV services by individuals in a rural South African community, including most especially directly addressing structural barriers and challenging gender norms that limit the accessibility of HIV services .
Keywords: HIV, South Africa, gender, service uptake, community mobilization
Statement of the Problem: Given that South Africa remains the largest epicenter of HIV globally, here is an urgent need to identify and implement custom-designed interventional strategies that take into account specific culture-based gender norms that currently limit the uptake of HIV services.
Purpose of the Study; The purpose of the Leddy et al. study was to evaluate the effectiveness of community mobilization initiative that was designed to improve the acceptance of HIV services by men and women in a rural South African community. The HIV-uptake improvement initiative, Tsima (or, loosely, Working together), included both women and men, and was implemented over the course of 3 years in a rural South African community in Mpumalanga province. In sum, this qualitative study sought to assess whether and how relevant gender norms were shifting, and to understand whether and how shifting norms were impacting HIV service uptake .
Research Questions or Hypotheses and Limitations (if any): Although not articulated as such, this study was guided by the general research question, How do gender norms in a South African community affect the uptake rates for HIV services? The authors also cite two main limitations: 1) the findings that emerged from this study are relevant for the South African community of interest and may not be generalizable to other jurisdictions; and 2) the purposive sample method used may also limit the generalizability of the results of the study to the community in a broader context .
Methods: The study site encompassed 31 villages of which 15 participated in the 3-year community mobilization intervention. These villages were randomly assigned to the intervention (n = 8) or a control group (n = 7). The authors implemented various strategies to improve engagement with men and women in the targeted intervention villages in an effort to identify opportunities to improve the delivery of efficacious treatments for HIV infections. A series of interviews with village residents in the intervention group and health care staff were used to determine the effectiveness of the intervention on individual gender-related attitudes about seeking health care and the effects it had on their personal relationships.
Participants: All told, the Leddy et al. study used a series of 55 interviews with 25 community members (60% of whom were HIV positive) and 30 key informants; these individuals were community mobilizers (n = 16), community action team members (n = 7), and community opinion leaders (n = 7).
Data Collection Procedures: The qualitative data for this study were collected using a series of semi-structured interviews to evaluate the effect of the intervention on gender norms, HIV testing, intimate partner violence, the disclosure of HIV status and treatment uptake rates.
Data Analysis Procedures: The transcripts of the recorded semi-structured interviews were entered into the ATLAS qualitative analysis application to generate relevant codes. Using an inductive-deductive strategy, the authors reviewed the transcripts and corresponding codes multiple times and new codes were added in an iterative fashion as they were identified. In addition, the authors also met on a regular basis during the conduct of the study to discuss newly identified themes and the full staff ultimately reached a consensus on which codes were most salient for the purposes of their analysis.
Quality of the Literature Review:
The authors clearly assumed that their audience would have a working knowledge of the importance of community mobilization efforts as well as the criticality of engaging individuals who are infected with HIV to promote their use of available health care resources because their literature review is very brief. Nevertheless, they successfully describe both the context of their study as well as its relevance for other communities that are faced with gender-related constraints to health care delivery. One surprising issue that was presented in the literature review concerned the fact that structural and institutional barriers frequently pose as much or an even greater barrier to engaging HIV-infected individuals in rural communities in sub-Saharan African nations including South Africa.
The results of the Leddy et al. study found three specific gender norms that were affected by the intervention that improved uptake rates for HIV services: 1) mens need to demonstrate toughness and avoidance of help-seeking, 2) mens expected control over women in the home, and 3) womens sole responsibility for the familys health . In addition, specific themes that emerged from the research included clinic-level barriers that adversely affected the accessibility of HIV services, most especially among the male participants.
Conclusions and Recommendations:
The authors conclude that the gender-related constraints to service uptake rates for HIV treatment in the South African rural communities investigated were likely also applicable to other similarly situated community in the country as well as elsewhere in highly masculine societies. Based on their findings, the authors recommend the use of comparable community-specific interventions in the future.
To their credit, the Leddy et al. study was a timely investigation of a critically important issue for South Africa today. For instance, the research to date confirms that there are multiple gender-related constraints to HIV services uptake by South African people in general and those living in rural communities in particular. In addition, these constraints adversely affect the willingness of infected individuals to receive the antiretroviral therapy that is available but which is currently underused due to these gender-related issues . These constraints to service uptake are perplexing to many Western observers who fail to take into account the centrality of gender norms in other societies.
Further, the authors employed a rigorous research method that was especially useful for the purposes of the study as well as the members of the targeted communities. In addition, the trustworthiness and soundness of the qualitative methods used by the authors was supported by the use of the ATLAS qualitative analysis application and the double-coding of the interview results. Finally, the studys research design was highly appropriate for the unique community settings that were involved, and the findings that emerged from the data analysis and interpretation were likely highly applicable for community health by identifying effective strategies to improve community mobilization.
Finall, HIV is certainly not a new public health threat for South Africa, and the prevalence of the disease continues to increase despite increasingly aggressive efforts by South African and international health organizations. The ongoing global Covid-19 pandemic has, of course, impeded progress in improving the delivery of health care services to treat HIV, but it makes little sense to save someones life from Covid only to have them die of another treatable disease. Therefore, studies of this nature are an important step in the right direction in identifying cost-effective ways to better engage people who are currently infected with HIV or face the threat on a daily basis.
 Leddy AM, Gottert A, Haberland N, et al. Shifting gender norms to improve HIV service uptake: Qualitative findings from a large-scale community mobilization intervention in rural South Africa. PLoS ONE. 2021;16(12):1-17.
 Kalichman S, Mathews C, El-Krab R, Banas E, Kalichman M. Forgoing antiretroviral therapy to evade stigma among people living with HIV, Cape Town, South Africa. Journal of Behavioral Medicine. 2021;44(5):653-661.
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