Prevalence And Community-Based Interventions For HIV: A Global Review Essay.

Breastfeeding is one of the most natural and best forms of preventative medicine.
• Globally, only 38% of infants are exclusively breastfed in 4 months, and about 1.5 million deaths can be attributed to sub-optimal breastfeeding practices
• Exclusive breastfeeding in the first six months of life if universally practised could save an estimated 13% of all under 5 deaths, and that in India alone means the lives of 200,000 children saved each year.
• A global review of child undernutrition in 2012 revealed Nepal had the fourth highest prevalence of child underweight globally
• A recent meta-analysis of individual peer counselling for the promotion of exclusive breastfeeding found that the odds of exclusive breastfeeding in mothers receiving the counselling was “substantially increased in the neonatal period (15 studies; odds ratio [OR] 3·45, 95% Confidence Interval (CI):2·20–5·42, p<0·0001; random effects) and at 6 months of age (nine studies; OR 1·93, 95% CI:1·18–3·15, p<0·0001).
• Breastfed children are 6 times more likely to survive the first few months of life compared to non-breastfed children.
• Optimal Breastfeeding can prevent 13% of under-five mortality (U5M) in developing countries (including Nepal).
• Breastfeeding reduces under –five mortality from ARI & diarrhoea – common causes of under –five mortality in Nepal.
• Evidence from the 2016 Nepal Demographic and Health Survey (NDHS) revealed that 66% of infants <6 months were exclusively breastfed. 6% of these young infants consume plain water, 6% consume non-milk liquids, 10% consume other milk, and 12% consume complementary foods.

Although there are many research studies on breastfeeding in Nepal, there are hardly any systematic reviews and hence, the necessity of this review would contribute to the better understanding of breastfeeding practices in Nepal and would also enable policy makers to target subpopulation for future interventions.

2.2 Global HIV Epidemiology

The Human Immunodeficiency virus (HIV) is among the communicable diseases that have been in existence for long despite the increased focus on it by both scientists and stakeholders on how to prevent and manage its overwhelming prevalence. It is clear that up to date there is no specific cure for HIV infection, meaning that the only effective intervention is preventive and control of the transmission. Current global statistics on HIV indicate that the disease burden of HIV exists both in developed and developing countries but at different levels (World Health Organization, 2013).

Global statistics show a shift in HIV epidemic over the last three decades, with approximately 3.7 million new infections in the nineties to the decrease in the death rate associated with HIV infection in 2000 (UNAIDS, 2013). This decrease can be attributed to the advancement in treatment approaches such as the introduction of antiretroviral drugs (ART). It is estimated that 9.7 million people from developing countries were receiving ART in 2012 (UNAIDS, 2013). Whereas, the use of ARTs is plausible it has also significantly increased the number of people living with HIV (PLHIV) to 35.3 million by 2012 (Ambrosioni, Calmy, & Hirschel, 2011).

Additionally, improved access to ART has reduced the mortality rate related to HIV/AIDS in developing countries by 5.2 million in 2010 (World Health Organization, 2013). The incidences of new HIV infections has been reported to decrease at a slow pace with the most significant decline of 52%  being reported in children within ten years (UNAIDS, 2013). This unsteady decline can be attributed to the increased number of PLHIV, increased awareness of HIV infection and transmission among others.

HIV infection does not only affect the victim but the family and society as well. Studies have indicated that HIV infection leads to stigmatisation, reduced productivity and increased poverty due to its economic burden on both the individual, family and the country. This, therefore, calls for the necessity of a community-based intervention for the prevention and management of HIV.  This proposal seeks to explore the prevalence of HIV worldwide and recommend the most appropriate community-based intervention approach for the same.  

2.2  Global HIV Epidemiology

The incidence of HIV has been studied region wise due to the varying HIV risk factors. In sub-Sahara Africa the rate of new infections and mortality rates linked to HIV/AIDS is low according to the UNAIDS (2013) report. Additionally, the report shows that HIV prevalence had declined by 50% in 2012, but cases of PLthe HIV has also increased by 6 million in 2012 due to the increased accessibility to  ART. Subsequently, the death rate due to AIDs-related sickness has also declined by 1.2 million by 2012. According to the UNAIDS (2013), the leading cause of HIV infection and transmission is high cases of unprotected heterosexual conduct.

2.3 Risk Factors of HIV

The HIV prevalence in Asia is second globally after Africa (UNAIDS, 2013). The incidences of HIV have been on the decline in Asia, but the PLHIV were reported to have increased by 1 million in 2012. Similarly, in 2012 the death rate due to AIDs and associated diseases in children and adults decreased by 70,000.  The accessibility to HIV treatment services in Asian countries is adequate. However, less than 20% of pregnant mothers received ART. The NHFPC (2014) indicates that India and China have the highest HIV prevalence with 46.5% heterosexual intercourse being the common mode of transmission, then substance abuse (28.4%).

According to the World Health Organization (2011), the prevalence of HIV-related deaths and new infections in the Middle East and North Africa is on the rise. Incidences of PLHIV increased by 50% and death rate by 32%. Injection drug use (IDU) and unprotected sex were found to be common modes of infection and transmission (UNAIDS, 2013). The Caribbean and Latin America have low cases of HIV prevalence of and mortality but with over 1 million cases of PLHIV in 2012 due to better medical services and accessibility to ARTs. The females account for 60% of PLHIV both in Latin American and the Caribbean, and this accounts for the highest rate worldwide (UNAIDS, 2013).

.2.3 Risk Factors of HIV 

Multiple sexual behaviour patterns determine HIV risk infection. Some of these include

2.3.1 Sexual Behavior Patterns

Violence in sexual relationships makes women more susceptible to sexual abuse. A study conducted by Bromfield (2014) indicated that forced sexual intercourse resulted in the rise of CD4+ cells in the cervical epithelium which directly exposed the vagina cells to sperms, thus increasing chances of HIV infection if the semen has HIV. A systematic review was conducted by Campbell, Lucea, Stockman, and Draughon (2013) on the association between forced sex and the risk of HIV. The findings indicated that women were more vulnerable to HIV infection because of their vulnerability to forced sex. Incidences of rape or forced sex have also been reported to be on the rise thus increasing the likelihood of HIV infection among the most vulnerable group. The WHO (2017) indicate that 1 out of 3 women have experienced sexual violence.

2.3.2 Knowledge and Belief about HIV/AIDS

Multiple studies have demonstrated that awareness on the fundamental information on the infection and transmission of HIV/AIDS has been achieved (Singh & Jain, 2009). However, there still exists erroneous views on HIV infection. The study by Thanavanh, Harun?Or?Rashid, Kasuya, and Sakamoto (2013) on the knowledge regarding HIV/AIDS among secondary students found out that as much as there was sufficient knowledge on the how HIV is transmitted, still there were 59.3% misconceptions on the routes of transmission. Such erroneous beliefs give people a wrong understanding of the actual risk infection of HIV. Studies have found out that inadequate knowledge on the basics of HIV increased its prevalence in assigned areas (Kharsany et al., 2012).

2.3.1 Sexual Behavior Patterns

2.3.3 Community Based Interventions

Community-based intervention (CBI) is defined as the primary care which comprises of preventive care, e.g. health screening, health awareness against HIV/AIDS in addition to AIDS treatment at the community level (Minkler & Wallerstein, 2011). Community-based interventions have been applause as the most effective approach towards the prevention and control of HIV due to its holistic approach, and the fact that HIV/AIDS has no specific cure. Through the critical review of the relevant literature on CBI, the following types of CBI were ascertained.

2.3.3.1 Workshops and Training

The outcomes of the literature review showed that education on HIV prevention offered through workshop training was the one used in most cases. Stangl, Lloyd, Brady, Holland, and Baral (2013) conducted a systematic review on the effectiveness of vocational skills training in addition to income generation interventions on the prevention of HIV and found out that the provision of microfinance aid did not have any significant effect on HIV prevention except when integrated with health education. Fonner, Armstrong, Kennedy, O'Reilly, and Sweat (2014) carried out a meta-analysis on sex education that is school-based and the prevention of HIV in developing countries. The authors found out that sex education that is school-based was the most appropriate in minimising HIV risk among students.

Barroso et al. (2014) conducted an RCT on the women of the Deep South to ascertain the effect of stigma on the prevention of HIV. The participants were supplied with educational video clips on stigma. The authors found out that the training on stigma was effecting in minimising the effects of stigma and prevention of HIV. While demonstrating similar positive outcomes, Harper et al. (2014) conducted a study on youths and adolescents infected with HIV using group-based interventions comprising of training sessions. The authors reported a significant reduction in HIV-related stigma.

2.3.3.2 Prevention and Awareness Campaigns

A meta-analysis on the efficacy of HIV prevention using mass media interventions was conducted by LaCroix, Snyder, Huedo-Medina, and Johnson (2014) and the outcomes of the authors indicated that the campaign awareness led to the increase in the use of condoms (25%), knowledge on transmission (30%) and prevention (39%). Thus, the findings were evidence of the efficacy of campaign awareness on reducing the global prevalence of HIV/AIDS. Bagali and Makhoahle (2013) examined the effect that awareness campaigns on the prevention of HIV on university students. All the participants showed that they were conscious of the correct transmission modes of HIV with 66% consenting to the fact that unprotected sex and breastfeeding (75%) were the major HIV transmission modes. 93% were aware that HIV, has no cure. The most common source of information was Television followed by magazines.

2.3.2 Knowledge and Belief about HIV/AIDS

This study will adopt a qualitative case study design to ascertain the effectiveness of community nursing based intervention on HIV prevention and reduction on people living with HIV/AIDS (PLHA) in Queensland Australia.

The target population will consist of 100 PLHA in Queensland Australia

3.3 Sampling Methods

The researcher will use purposive sampling to identify the study subjects based on the following inclusion criteria:

• The participants must be HIV positive for at least 24 weeks
• The participants must be 18 years and above
• The participants must be living in Queensland as at the time of the research
• It is mandatory for the participants to be fluent in English
• The participants have to be ready and willing to share their life experiences during the in-depth interview
• It is mandatory that the participants be willing to consent to the audio recording of the conversation
• 3.4 Sample Size and Power

The sample size for the study will be determined using Cronbach's formula as demonstrated below:

Where; n = the desired sample size

N = the target population and

e= acceptable margin of error estimated at 0.05 (95% C.I)

e2 = (0.05)2 = 0.0025

Therefore, sample size (n) = 100/(1+0.3)   = 120/(1.3)

= 76.92

N= 76 (sample population)

3.5 Intervention

A community-based intervention on HIV prevention and reduction will be implemented to a defined group of residents living with HIV alongside their partners in Queensland Australia. The intervention will include workshop seminars that will last for four days and emphasize on the following matters:

• Increasing awareness on HIV prevention and management
• Equipping the PLHA and their associates with required leadership skills to lead their communities towards the prevention and reduction of HIV
• The community based intervention will comprise of a four day workshop with the first two days involving trainings and later on the participants will be encouraged to initiate a project with other cohorts within the community for a period two years. The remaining two days will be used to assess the effectiveness of the project they will have implemented and a follow-up made continuously for three years. Six participants will be trained per session until all of the 76 participants undergo training. It is estimated that the entire  project will last for three years.
• The workshop training will be structured in a way that it includes processes and activities aimed at developing knowledge and comprehension of the HIV prevention and reduction and how to manage it, foster interactive understanding and trust through contact and sharing.  The CBI will employ a participatory method aimed at promoting participant involvement, association and teamwork. This will be achieved by utilising multiple participatory activities and objective inputs by the project facilitators. The facilitators will initially undergo training prior to the commencement of the project.
• 3.5.1 In-depth Interviews

Assessment will be carried out at the conclusion of each day of workshop training using in-depth interviews. All the participants will be granted the opportunity to take part in the reflection of the day’s activities, and the outcomes gathered as case record. The facilitators will then under the guidance of an interview schedule with two major open-ended questions inquire of the experiences of the participants regarding the day’s workshop training. An example of question will look like

“What was your experience of day one of the workshop?” Why?

“What do you think are the risk factors of HIV?”

The interviews will then be audio recorded. The audio recording machine will be placed at an ideal place to avoid any distraction of the novice researcher and making the participant uneasy. For effectiveness in data collection, the researcher will employ various communication methods such as listening, contemplation, analytical, minimal verbal interposes, inspiring, recognising and clarifying (Botma, Greeff, Mulaudzi, & Wright, 2010).

3.5.2 Field notes

Both the co-facilitator and facilitator will take field notes while the workshops are in session and at the conclusion of the day’s workshop. The field notes will be structured in such a way that they cover all the primary elements of the training. Therefore the field notes will contain sections on observational notes, methodology notes and individual notes. Yin (2017) indicates that the preparation and use of field notes should focus on the primary tasks in data collection such as:

• Acquiring access to the significant organisations or interviewsEnsuring that there is adequate resource while in the field. This comprises of a personal computer, writing materials, paper clips, and serene writing environment.
• Designing a protocol for calling for aid and directions, when necessary, from other facilitators in other case studies
• Outlining the unambiguous procedure for gathering data tasks that should be completed within a pre-determined time
• Making provisions for unexpected happenings such as the absence of the required number of interviewees, in addition to the variations in the mood and impulses of the researcher Yin, 2017)

2.3.3 Community Based Interventions

The case record will consist of an in-depth account of the intervention on HIV prevention and reduction, presentations and the interventions guide, and the views of the respondents after the conclusion of each day’s intervention. Additionally, the case record will include the field notes of the investigator while the intervention was in force, an in-depth account of the project of the study group and the assessment report.

3.6 Data Collection Procedure

Community access will be gained by using the local administration alongside Non-Governmental Organizations (NGOs) who have also gained trust in the community. Moreover, field workers will be utilised in linking the investigators to the potential respondents. Based on the nature of the CBI, the venue should be free of distractions and private. Thus the Queensland community social hall will be used. However, private rooms at the homes of the participants will also be used in cases where the participants would prefer so.

The researcher assistant will at the first encounter with the potential participants explain the aim of the study and ensure that they are aware of their role in the research and the nature of data to be gathered. Free transportation to and from the venue will be provided to the participants in addition to meals and refreshments in the course of the intervention. The researchers will give the autonomy to pull out from the study at any time (Botma et al., 2010). The audio recording will be used to collect data during interviews.                                     

3.7 Data Collection Methods

3.7.1 Secondary Data: Literature Review    

The scope of the literature review section of this study focused on the studies conducted in the prevention and management of HIV using community-based nursing interventions. The research articles included in the analysis had first to be based on community-based interventions the prevention and control of HIV/AIDS, and secondly, the researches must have been published within ten years. The articles included in the study were based on both CBI in developing and developed countries in order to obtain comprehensive insight into the study topic.

 The key terms used in the search included community based intervention, HIV, AIDS, HIV risk factors. A total of 1000 published articles were searched using search engines and databases such as Google Scholar, PubMed, BMC, and NCBI. The researcher then screened the topics and abstracts and 200 full texts were found. A further qualitative check led to the inclusion of 19varticles for critical review. The findings from the literature view were presented under different themes as shown in the literature section in this paper.

In-depth interviews will be conducted on the possible risk factors of HIV and the effectiveness of the workshop training. The workshop facilitators will also be used as interviewers after undergoing short-term training on how to conduct in-depth training. Seidman (2013) asserts that in-depth interviews provides detailed information because the interviewee can probe for more information from the interviewee. Audio recording will be used to collect data during the interviews. The researcher chose audio recording because it ensures that quality data is recorded since the actual responses of the feedback are used for analysis (Evans & Jones, 2011).

3.7.2.2 Field notes

Field notes are a written reflection of the events that the researcher observes, ears, perceives and thinks when the interview is underway (Botma et al., 2010). Field notes will be noted down while the workshop training is ongoing and immediately after the interview.

.8 Ethical Statement

Institutional ethical approval is to be obtained before the commencement of the study. Informed consent will be obtained from the prospective participants before the study (Felt, Bister, Strassnig, & Wagner, 2009). All the participants will be provided with the details of the research such as the objectives of the study, the nature of data to be collected and the purpose of the data to be collected. The researcher will also endeavour to assure the participant that the received data will only be used for the disclosed purposes. The participants will be given specific identification codes that will be used throughout the study. This will ensure that their specific identifies such as names are hidden.  

3.9 Data Analysis

The researcher will analyse each case independently and then compiled. Different elements of the case record will be ascertained. Document analysis and pattern matching will be used to investigate the case record. Bowen (2009) observes that document analysis reduces researcher biases due to the stability of the documents which are unreactive and can be assessed severally without making any changes by the researcher.  

The data obtained through tape recording will be transcribed and analysed using the guidelines recommended by Creswell and Creswell (2017). These include

• The researcher will first obtain a view of the entire thing by meticulously going through the transcriptions and noting down some thoughts that cross  the mind
• Then one interview transcript will be picked and then perused with a view of understanding the meaning without going through the content. Similarly, important points are noted down
• The researcher will then go through multiple transcripts of data while incorporating the details in the second step. All the topics that come up are noted down in columns  
• Using the generated list of topics, the researcher will again go back to the data and abridge the topics as codes and near to the correct parts of the text. Then the emergence of new categories and codes will be observed
• The researcher will then look for the best descriptive wording for the topics and change them into groups. then the categories that are similar will be grouped and any inter-associations noted
• A final verdict on the acronym is made for each class, and then the codes are given alphabet names
• Then the data in each category will be gathered together, and a preliminary assessment carried out
• If need be the current data can be recorded (Botma et al., 2010)

The data will be analysed by an independent researcher not involved in the study. The independent researcher for coding will be informed of the objective of the research in addition to the recommended procedures for data analysis. The coding of categories and the emergent themes will be discussed, and an agreement arrived

 There are expected low cases of HIV/AIDS prevalence in the selected towns because the training will address on the prevention and management of HIV under topics such as condom use, voluntary counselling, HIV infection and transmission modes. Studies have shown that the implementation of interventions aimed at preventing and managing HIV/AIDS when implemented in the community settings led to the reduction in the spread of HIV.

Rhodes, Malow, and Jolly (2010) carried out a study on the efficacy of community-based participatory research on the prevention and management of HIV/AIDS. The findings of the authors indicated that the incidences of HIV/AIDS reduced once a CBI was successfully implemented because this approach ensures that the affected community is involved in decision making and in ascertaining priorities leading to the development of interventions that are aimed at meeting the needs of the community.

Sweat et al. (2011) also carried out a randomised CBI in three developing countries to ascertain the impact of increasing HIV testing on the prevention of HIV/AIDS.  The authors found out that a greater percentage of participants were tested in the CBI than in the control group.  Salam, Haroon, Ahmed, Das, and  Bhutta (2014) reviewed the impact of CBI on HIV awareness, perceptions and transmission and indicated that CBI was more efficacious in the prevention and control of HIV.

4.2 Improved Impact on Behavioural Change

It is likely that the proposed CBI will positively influence positive behaviour change among community residents because it will increase awareness on the modes of transmission and techniques. Coates et al. (2014) ascertained that voluntary involvement in CBI led to changes in social behaviours which are directly linked to the infection and transmission of HIV.

4.3 HIV Risk Factors addressed much better

The intervention will only focus on PLHA and thus the relevant HIV risk factors in Queensland will be determined and the prospective control measures recommended. Studies have pointed out that the control of HIV risk factors will lead to the prevention and spread of HIV.  Miller, Hellard, Bowden, Bharadwaj, and Aitken (2009) undertook a study on the HIV, HCV risk factors in Melbourne and showed that addressing the risk factors was the most effective approach in reducing the prevalence of the diseases.

4.4 Strategies to Evaluate Outcomes

The strategies to evaluate the outcomes of the CBI to be implemented in Queensland on the management and prevention of HIV will be based on the expected results. The following strategies will be used:

• Reduction in HIV prevalence in Queensland. The number of HIV cases after and before evaluation will be assessed to ascertain the impact and outcomes of the CBI.
• Improvement in behavioural change. Since the objective of the CBI is to prevent and manage HIV through workshop trainings, the outcomes will be evaluated based on the behaviours that promote HIV. For instance, the level of prostitution, drug abuse through injection will be assessed to ascertain the outcomes of implementing the CBI.
• The awareness level of HIV risk factors among the participants can be used as an evaluation strategy to determine the outcomes at the end of the training period

The overall total budget for the study has been estimated to cost $ 470 for all the three years with year one a more substantial amount ($200), second year ($150), and final year ($120). The expenses for the years decrease due to the decline in the study activities as will be justified herein. The study will require the services of two project facilitators to aid in delivering training services to the 76 potential participants. Since these will be novice facilitators they will be paid 50 dollars in the first year and 40 dollars in the second year.

Their services will only be required in the first two years only since the third year will comprise of follow-ups on the study and shall be conducted by the researcher and research assistant. Similarly, the transportation of all the personnel namely, the lead investigator, research assistant, and two facilitators will cost approximately ten dollars per year. Designing and printing of interview schedule are estimated to cost fifty dollars because an expert will be hired to assess the schedule designed by the lead researcher. The community social hall shall not be paid for since it had been confirmed that the community would not charge us since the project is to benefit the community.

An independent coding expert shall be hired at the cost of 20 dollars during data analysis to avoid researcher bias and increase the credibility and reliability of the study. A government bus shall be used to transport the potential participants at the cost of 120 dollars during the entire period of study, after prior arrangements with the Local area government of Queensland. This move will ensure that the expenses are subsidised.  

	Year 1	Year 2	Year 3
	Amount ($)
Personnel
Project Facilitators 2- ($10/hr)	50	40
Research Assistant 1 ($14/hr)	30
Cording expert			20
Sub-total	80	40	20
Project Support
Transportation expenses for all personnel	10	10	10
Transportation expenses for all participants	30	40	40
Data collection equipment and materials:
Designing and printing of interview schedule			50
Hiring audio recording equipment	10
Meals and refreshments for all participants	40	60
Sub-total	90	110	100
Project Activities
Access fees for literature review	30
Hiring of community social hall
Sub-total	30	0	0
Total/Year	200	150	120
Overall Total	$470

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