The current paper underlined the assumption that real efforts in using community-based behavioural interventions as part of combination prevention in London should be increased, while carefully considering the dynamic network of dimensions located both at the individual and contextual levels. Given that in this paper individuals’ behavioural change was considered to be the primary means of achieving the goal of getting London to zero infections, a review was undertaken to explore the interventions that have previously been used to reduce HIV infections at community levels in similar contexts worldwide.
Evidence Supporting the Efficacy of Community-based Behavioural Interventions Focused on Combination HIV Prevention
The review highlights the overall effectiveness of behavioural strategies within community-based projects using counselling (individual and group levels), peer support mentoring intervention and couple-focused approach, either face-to-face or remotely (video or computer-based). Successful approaches mostly targeted at-risk population groups disproportionately affected by the epidemic and in need of effective preventative strategies. The use of behavioural modification training within local communities in enhancing safe sex was considered to be effective. Specifically, it improved HIV risk knowledge, limited the number of sexual partners, and increased both condom use and the negotiation of unprotected sex. Furthermore, the review highlighted an increase in both HIV testing and ART adherence. Moreover, it showed improvements in HIV viral suppression and reductions of both HIV and STIs. This demonstrates that community-based approaches are successful in achieving early diagnoses and access to ART, leading to the reduction of HIV transmission.
Other promising findings shown throughout the review referred to the enhancement of PrEP desire, adherence and knowledge as a result of behavioural interventions at community levels. These mirror the case studies’ outcomes referred to in the introduction, where effective London-based community-level interventions (??? PrEP Champions Project, 11; ???’s PrEP exploratory research, 12) were shown to increase knowledge and accessibility of PrEP in vulnerable groups. Specifically, the evidence resulting from both the review and the London-based interventions demonstrate how knowledge and accessibility are complementary in tackling the problem of stigma as the major barrier to accessing PrEP. In fact, it is because of the stigma attached to PrEP use that people fear being judged negatively by their community members. Other successful interventions designed to operate at community levels when targeting structural elements such as stigma included opinion leaders. These showed to be powerful in changing social norms, and subsequently, in influencing individual behaviours in relation to HIV prevention within a specific context. Here, counselling and peer support mentoring interventions have brought significant improvements in attitudes and skills in order to maintain safer sex.
This aspect thus reinforces the idea that individuals are able to gain autonomy over their sexual behaviours once becoming aware of risks and their own choices. We argue here that in the absence of behavioural interventions that prevent stigma from hampering knowledge and awareness at community levels, HIV prevention biomedical tools would have restricted impact. Therefore, for the widespread use of any HIV-related medication, it is important that individuals at risk feel emotionally safe to be well informed about its benefits in order to make informed choices (24). The review found that increasing knowledge about HIV transmission and its strategies for prevention helped the studies’ participants perceive their level of risk of infection. Here, HIV-related awareness enhanced the reduction of risky behaviour and strengthened the knowledge necessary to enable individuals to protect themselves from potential transmission. This is a very important aspect, since past research (9) has shown that lack of risk perception can limit acceptability of the concept of TasP. The idea that incorporating skills-building behavioural interventions and stigma-related structural interventions within any community-based HIV preventative programme is fundamental. As such, this paper agrees with Flowers and colleagues (13) when considering behavioural interventions to be supporters rather than competitors of biomedical technologies.
With regard to the importance of providing the combination of multi-level interventions, the review also illustrated the importance of both structural and community-based approaches in order to increase effectiveness within high-risk environments. This was particularly so in contexts where endangered structural factors (homelessness and unemployment) could easily magnify the likelihood of infections. The above demonstrates that interventions should always be contextually appropriate and specific to their audience’s values and needs when attempting to change behaviours. As a result, we argue that communities should function as primary agents in any local prevention efforts, where community-based actors are identified as intervention specialists (16). In this respect, they should be actively involved in the development, implementation, and oversight of programme-interventions intended to change individuals’ behaviours. One of the rationales behind this is to understand that increasing knowledge of HIV in the community, while also respecting the human rights of those targeted, is critical in reaching the marginalised groups with effective HIV prevention services. Community ownership would therefore enable open discussions on community knowledge and perspectives of HIV and facilitate the engagement of those at risk, while increasing the chances for successful interventions.
Within the review, there was found to be a paucity in terms of community-based studies from the UK in the past ten years. This means that evidence-based community-based behavioural interventions have not been implemented, published or reported consistently. This should be perceived as a loss of opportunity for the advocacy of community-based behavioural interventions in the UK context, particularly when considering the limiting effects of the over-reliance on biomedical tools (13). As Collins and colleagues (17) have previously asserted, evidence-based behavioural strategies within community-level interventions have the power to bridge the gap between communities at risk and HIV prevention intervention research. This concern cannot be overestimated when aiming to end AIDS by 2030. Therefore, further efforts should be directed towards documenting and evaluating such interventions.
Finally, the majority of the studies used combination HIV prevention as part of their strategies of intervention. This means that the behavioural aspects were combined with biological and structural elements of prevention. The current paper considers this to be a positive sign, while agreeing with Noar (21) when highlighting the importance of behavioural approaches within community-based interventions in supporting recent advances of biomedical strategies. In order to achieve optimal public health impact in the real-world context, simultaneous implementation of both HIV treatment and prevention plays a vital role when used within the comprehensive behavioural, biomedical and structural combination of strategies adaptable to a specific setting. Unfortunately, from this point of view it seems that the combination HIV prevention model in the UK still has a long way to go.
We argue that in the absence of community-based culturally tailored behaviour change interventions, HIV prevention relying on a solely biomedical approach would have a restricted impact in helping London to get to zero new HIV infections. Consequently, after summarising the review and examining emerging issues, a number of recommendations are proposed at different levels, with the further need to expand a more robust collaboration between community-based interventions and empirical research. Through this, it is hoped that the effectiveness of these behavioural interventions will increase respect within the multidimensional combination of HIV prevention in London.
Recommendations at the Individual Level
Evidence from the UK context shows an increased practice of condomless anal sex in MSM and a scarcity of prevention interventions directed at women, requiring additional effort to be placed on counselling and peer mentoring. The review has illustrated the positive aspects of using both video and peer-based facilitators to promote safer sex and increase HIV knowledge in MSM. These strategies could be also replicated with MSM who are reluctant to test for HIV, particularly as small group-level interventions in targeted familiar environments (e.g., bars or other LGBT+ venues). Pre- and post- peer-based counselling will facilitate access to testing, while discussing with service users any potential barriers to the use of condoms. Peer mentoring becomes a valid alternative to help create an empathic approach as this presents the ability to understand the emotional burdens that similar individuals face in relation to protection, HIV testing, diagnosis and treatment.
Further recommendations should aim to reach out to women, particularly those from minority backgrounds. For example, evidence from the review has shown that culturally tailored HIV-related counselling and group support are effective interventions in seronegative women from ethnic minority background. Specifically, the review has demonstrated the effectiveness of adopting emotion-based writing workshops and computer-based counselling in combination with structural elements such as stigma. Consequently, it is strongly believed that a community coaching model using groups in targeting stigma-related issues could assist women at risk on how to best approach both self-sampling and self-testing without the risk of feeling discriminated. Community-level distribution of test kits together with contextually tailored behavioural interventions, particularly for women from the Black African community is strongly recommended. In this instance, community-based counselling through established support groups would help women to understand the importance of testing or safer sex and receive both health and psychological back up. This method of intervention will be community-based in the sense that specific settings will be targeted as spaces to facilitate the intervention: home-base networking, spiritual and religious sites, communal gathering venues such as hairdressers and other familiar publicly frequented spaces. The goal of promoting a supportive and enabling environment for women will provide the opportunity to address through community dialogue the underlying inequalities faced by this high-risk population group.
Recommendations at the Community Level
Behavioural interventions also aim at building active connected communities through constructed dialogue. Giving voice to members of high-risk groups create conditions for them to play a more active role in community life. The review has shown that interventions implementing group counselling and awareness raising have been successful in empowering individuals from diverse cultural backgrounds, while enhancing sex risk reduction. However, these interventions also have the ability to inform and educate, while providing communities with the relevant information tailored to the needs of their local contexts. This includes information regarding the benefits of testing, how to access HIV testing services, the importance of testing as a communal responsible act, and the benefits of knowing their own status. In cities with a richness of cultures and languages, such as London, particular attention must be given to any non-English speaking subgroups. Here, culturally sensitive information needs to be translated appropriately while considering the meaning, nuances and cultural specificity of the messaging. The aim is to tackle the physical, social and legal realities within which unsafe attitudes take place, wherein group counselling and peer mentoring activities are included in culturally appropriate interventions.
Recommendations at the Structural Level
HIV authorities in England should attempt to alter social norms by including policy interventions that produce behavioural change. Here, structural elements such as inequality and stigma should always be considered. It is recommended that interventions should include a combination of policy actions and other programmatic initiatives that would target gender, economic and social inequality. These should also include antidiscrimination laws that support human rights. Further national strategies should see HIV prevention as a continuum. Here, the funding of comprehensive programmes should include a coordinated system of technical support in developing an inclusive HIV-related national plan. Its objective is to increase awareness of STI and HIV prevention strategies and treatment options, while also aiming at reducing levels of stigma within affected communities.
Recommendations for Improved Evaluation of Community-based Interventions
Finally, from the review it was evident that inconsistent implementation of evidence-informed interventions caused limitations in some of the studies when transferred to a different context. It is strongly believed that community-based behavioural interventions are well suited to improve health, including HIV prevention. However, the evidence of its effectiveness cannot be objectively evaluated without reliable outcome documentation. At present, most community-based service-delivery in London has been documented through grey literature, with very little evaluation made through robust studies. Therefore, conducting more robust evaluations in order to identify community-level best practices for health improvement is highly recommended.
A valid alternative would be to establish a framework for conceptualising community-academic partnerships around capacity building (53). This advocates for community-based organisations to improve their evaluation-based capacity, fundamental in the collection, analysis and interpretation of own data in order to make sense of their actions and improve results. This means that in order to maximise the accuracy of information about a specific intervention, service-providers should receive training on how the data should be collected and evaluated. Quality of information through the provision of robust evaluation and monitoring will be fundamental in assessing the effectiveness (including evaluation of costs) of a specific intervention. Through this, it could be possible to identify key behaviours, context-related values and optimal delivery strategies, while giving greater emphasis to understanding the key trends of local epidemics. This strengthened monitoring and evaluation capacity will allow for the impact and value of any HIV preventative programmes to be effectively assessed, while also informing decisions on further allocation of funding. The final goal would be a system that comprises use of intervention protocols, technical assistance, training, and fidelity assessment.
At present, the system appears to operate in a vicious cycle of budgetary constraints that national HIV prevention programmes have faced in these past years (54). By not funding the provision of evidence, it is impossible for community-based behavioural interventions to show reliable empirical conclusions. At the same time, the inability to establish the interventions’ effectiveness (including cost-effectiveness) limits the reliability of these approaches and therefore their subsequent funding. This means that lack of community embedded evidence becomes a self-fulfilling prophecy. Increasing emphasis on evidence-based community behavioural interventions will contribute to the efforts in understanding the key trends of local epidemics, and assess the overall feasibility of successful behavioural programmes into the London context.
Various limitations should be also considered when analysing this paper. Only studies from USA where found to be undertaken after the year 2010, wondering whether these could be easily transferred to the UK context. Consequently, in order to have studies based in high-income contexts outside the USA, these were further included by expanding the scope of publication back to 2000. The reviewed studies’ interventions follow-up effects were limited to a maximum of 12 months, despite previous research specifically showing that long-term (> 1 year) changes are difficult to sustain (55). This is an issue requiring further investigation. The reviewed studies over-relied mostly on self-reported or less robust assessment, rather than complementing with more objectively measured behavioural interventions (e.g., randomised controlled trials). Finally, the lack of detailed interventions’ descriptions within the studies’ reports restricted the objectivity in assessing the effectiveness of their interventions. A weakness that further community-based behavioural interventions research should consider when reporting their outcomes in the future.