Peer Community-based Assistant in REtention: Effect of Peer Health Workers on People Living with HIV Not on Antiretroviral Therapy—A Randomized Operations Research Trial

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Human resource limitations, long travel times, and a weak health care infrastructure pose significant challenges to the delivery of anti-retroviral therapy (ART) in rural settings such as the Rakai District in southwestern Uganda. HIV increases demand for health services and also impacts the health workforce as health workers may resign, become ill, or die. According to the WHO report the health workforce is not only unevenly distributed, it is especially challenged because “too many people are leaving the health systems due to poor health, high pressure and poor working conditions, or through migration abroad or to urban areas, the private sector or nongovernmental organizations.” In 2007 the WHO published a report on task-shifting, emphasizing the need for distribution of responsibilities in the prevention, care and treatment of HIV/AIDS in resource limited settings (RLS) as one solution to the human resource crisis. The report suggests that one strategy for increasing the numbers of effective health workers is by assigning appropriate tasks to community-based health workers who require less intensive training than doctors and nurses. 

Given the workforce shortages and in conjunction with the great need for care and insights from research, Johns Hopkins and Rakai Health Sciences Program (RHSP) researchers initiated a community-based, operational research, cluster-randomized trial in 2006 (approved under IRBs at the Johns Hopkins Bloomberg School of Public Health and the Uganda Virus Research Institute) in an attempt to study ways to improve ART delivery and adherence using community-based peer educators (PE). The study was conducted at 15 community-based mobile clinics in the rural Rakai District of Uganda that each serve several surrounding villages, and consist of a mobile group of staff and supplies visiting each location at a defined community site on a bi-weekly basis. These community-based mobile clinics are more accessible to patients in need of primary and urgent care than the central clinic, but they are only available to patients once every fourteen days. Community-based PEs are one potential strategy to further improve care under this model by acting as frontline health workers, treatment supporters, and clinical monitors. Additionally, as part of the study, a subgroup of PEs were given mobile phones to assist with communication with centrally located clinical staff. The 15 communities were randomized into three arms: communities with PEs only (Arm A), communities with PEs and mobile phones (Arm B), and control communities without PEs (Arm C). The trial focused primarily on measuring hard clinical outcomes such as differences in virologic failure between the arms.


  1. To develop a deeper and more reasoned understanding about the daily perceptions and practices that inhibit or enable peer educators (PE) to provide AIDS care in the rural, resource limited setting of Rakai, Uganda. 
  2. To learn more about the perceptions and practices of using mobile telecommunications to support and improve AIDS care interventions in a rural, RLS in sub-Saharan Africa. 
  3. To improve the PE intervention using results from the interviews, focus group discussions and structured observation as the program is considered for scale up.

Rakai Health Sciences Program