Combination Prevention Begins In Village

DIGAWANA, Botswana –Digawana is a lot like the dozens of other villages dotting the desert landscape of southeast Botswana: It is small, quiet and unassuming with the familiar sight of donkeys and goats lining the road that runs through it.

The residents of Digawana, however, say their village is a place like no other. A Facebook page dedicated to the village calls it the “land of air & rhythm … the place with its own vibe.” A letter to a local newspaper describes it as “the talent hub of the nation” and boasts that Digawana (with an estimated 3,300 residents) has produced football stars, jazz maestros and even a former Auditor General.

Last year, Digawana took on another identity – it became a partner in one of the most important HIV prevention studies of this decade. The Botswana Combination Prevention Project, also known by its Setswana name Ya Tsie, aims to drastically reduce new HIV infections in communities like Digawana.

An estimated 300,000 people are living with HIV in Botswana, and insufficient scale-up and coordination of prevention interventions have limited southern Africa’s ability to curb the epidemic. This has led public health experts to call for a “combination prevention” strategy that involves combining and strengthening multiple HIV interventions, both known and new. If the strategy works and is cost-effective, Botswana’s program could be a model for other African nations.

“I was very proud that my village was chosen to be a part of this study,” says Kgosi Kgwakgwe, the village chief of Digawana, one of the first study villages in the four-year project.  “What they are doing is very important, and we have never had anything like this in Digawana before. We are proud to lead the way.”

Ya Tsie is a shortened form of a longer Setswana proverb, “Kgetsi ya tsie e kgonwa ke go tshwaraganelwa,” which means that teamwork bears more fruit than individual effort. It represents the way that combination prevention works, with many interventions working together towards the common goal of stopping new HIV infections. Ya Tsie also refers to the many partners involved, including the Botswana Ministry of Health, the U.S. Centers for Disease Control and Prevention (CDC) and Botswana Harvard Partnership. But perhaps the most important partners to the study are the communities.

Thirty communities from three regions in Botswana have been selected. In half of them, large numbers of community mobilizers will go house-to-house, promoting prevention services like HIV testing and counseling, antiretroviral therapy, male circumcision and Prevention of Mother-to-Child Transmission (PMTCT).  HIV care and treatment clinics in all 30 communities are receiving improvements in medical data systems and in management of supplies and equipment.

Although Kgosi Kgwakgwe has never heard Digawana described as the “land of air & rhythm,” he agrees that his village carries its own vibe. Historically, Digawana is a diverse mix of cultures and tribes that have converged in one place. “There are many different kinds of people who have come to live here, but they are good people and we get along very well.”

When the Ya Tsie team moved into Digawana late last year, Kgwakgwe was initially worried that hosting a study team in his small community would be a challenge. Water shortages and accommodation were on his mind, but he was mainly concerned that members of the study team might disturb the peaceful balance – a concern that was quickly put to rest after he met them.

“They did things in the right way. They came to me and explained what was going to happen, and allowed me to introduce them to my community,” he said. “That’s how our culture works; you must consult with us first.”

In February 2014, former U.S. Ambassador Michelle Gavin visited Digawana and met with Kgwakgwe and his staff to thank them for their involvement in Ya Tsie. The U.S. government, through the President’s Emergency Plan for AIDS Relief (PEPFAR), is supporting the study with $64 million and is expecting big things from the partnerships, she said.

 “It could very well be the most important thing any of us do over the next decade in response to HIV and AIDS,” Ambassador Gavin said.

For his part, Kgwakgwe told the Ambassador he was happy with how the study team had engaged with Digawana residents, and proud of his community’s enthusiastic participation.

The Ya Tsie team has departed Digawana for now with plans to return next year. But Kgwakgwe says the team left his community better off than when they found it – more people now know their HIV status and have been linked with life-saving services. Kgwakgwe says he would encourage other study communities to accept the team with open arms.

“Look, this is a good thing. Allow them to get into your village because this is very important study and people need this knowledge,” he says. “They can learn something from us.”

Frequently Asked Questions about Ya Tsie (also called the Botswana Combination Prevention Project)

What is the Ya Tsie study about?

Botswana has agreed to host an HIV prevention study to evaluate whether coordinated and strengthened community-based HIV prevention methods prevent the spread of HIV better than the standard methods that are offered individually today. The overall goal of the study is to reduce new HIV infections at the community level, and to determine whether this method is cost-effective.

Who is involved in this study?

The Botswana Ministry of Health, the Harvard School of Public Health through the Botswana-Harvard Partnership, and the U.S. government, through the U.S. Centers for Disease Control and Prevention are collaborating on this four-year project. The study is funded by the U.S. government through the President’s Emergency Plan for AIDS Relief (PEPFAR).

How were the study communities selected?

Thirty communities have been selected from three broad geographic regions in Botswana (Southern, Central, and North). The average population size of each community is 6,000 residents (ranging from 2,400-12,000). The eligible study participants are adults aged 16-64. Communities were selected to be large enough to meet sample size requirements yet not too large to avoid unfeasible targets.

How is this study designed?

The design of the Ya Tsie study is called a pair-matched community randomized trial. This means that communities within the study will be paired with one another based on their geographic location and population size. Villages in each pair will be randomly assigned as either Enhanced Care Communities (ECCs) or Combination Prevention Communities (CPCs).

What are the benefits to people living in the participating communities?

Enhanced Care Communities will receive additional testing and monitoring, and assurance that their regular health care services will be delivered optimally. Combination Prevention Communities will receive household visits by community mobilizers to promote combination prevention services, including HIV testing and counseling (HTC), antiretroviral therapy (ART), safe male circumcision (SMC) and Prevention of Mother-To-Child Transmission (PMTCT).

In addition, HIV treatment and care services will be expanded in the CPC villages to reach HIV-infected individuals with high viral loads (>10,000 copies/ml), and women who take ART for PMTCT will be targeted to receive lifelong treatment as a strategy for reducing HIV transmission risk.

Are there any drawbacks or risks for participating communities?

Communities may be inconvenienced by a larger presence of research personnel and activity in their communities than they would ordinarily have, but the benefits of having additional clinical personnel and improved services will outweigh this temporary inconvenience.

What measures have been taken to ensure the human rights of study participants are protected?

Institutional review boards (IRBs) at the Botswana Ministry of Health and in the U.S. have reviewed and approved the study protocols. In addition, regional community advisory boards will be formed to enable communication between the study team and the community. Study participants will be asked to voluntarily consent to all study specific procedures and may withdraw from the study at any time if they wish.

When is the study starting and ending?

Study initiation in the first communities started in late October 2013. The planned study duration in most communities is for approximately 4 years.