Quality improvement as a framework for behavior change interventions in HIV-predisposed communities: a case of adolescent girls and young women in northern Uganda

Esther Karamagi, Simon Sensalire, Juliana Nabwire, John Byabagambi, Alfred O. Awio, George Aluma, Mirwais Rahimzai, Jacqueline Calnan, Sheila Kyobutungi

Despite the conventional approaches to HIV prevention being the bedrock for early reductions in HIV infections in Uganda, innovations that demonstrate reduction in risk to infection in vulnerable populations need to be embraced urgently. In the past 2 years, a USAID-funded project tested a quality improvement for behavior change model (QBC) to address barriers to behavioral change among adolescent girls and young women (AGYW) at high risk of HIV infection. The model comprised skills building to improve ability of AGYW to stop risky behavior; setting up and empowering community quality improvement (QI) teams to mobilize community resources to support AGYW to stop risky behavior; and service delivery camps to provide HIV prevention services and commodities to AGYW and other community members. We recruited and followed a cohort of 409 AGYW at high risk of HIV infection over a 2-year period to examine the effect of the QBC model on risky behaviors. High-risk behavior was defined to include transactional sex, having multiple sexual partners, and non-use of condoms in high-risk sex. We documented unique experiences over the period to assess the effect of QBC model in reducing risky behavior. We analyzed for variances in risk factors over time using repeated measures ANOVA. There were statistically significant declines in high-risk behavior among AGYW over the QBC roll-out period (p < 0.05). Univariate analysis indicated reduction in AGYW reporting multiple sexual partners from 16.6% at baseline to 3.2% at follow up and transactional sex from 13.2 to 3.6%. The proportion of AGYW experiencing sexual and other forms of gender based violence reduced from 49% a baseline to 19.5% at follow up due to the complementary targeting of parents and partners by QI teams. The QBC model is appropriate for the context of northern Uganda because it provides a framework for the community to successfully drive HIV prevention efforts and therefore is recommended as a model for HIV prevention in high-risk groups.