text:
The impact of Community Mobilisation on HIV Prevention in Middle and Low Income Countries: A Systematic Review and Critique
- First Online:
DOI: 10.1007/s10461-014-0748-5
- Cite this article as:
- Cornish, F., Priego-Hernandez, J., Campbell, C. et al. AIDS Behav (2014) 18: 2110. doi:10.1007/s10461-014-0748-5
While community mobilisation (CM) is increasingly advocated for HIV prevention, its impact on measurable outcomes has not been established. We performed a systematic review of the impact of CM within HIV prevention interventions (N = 20), on biomedical, behavioural and social outcomes. Among most at risk groups (particularly sex workers), the evidence is somewhat consistent, indicating a tendency for positive impact, with stronger results for behavioural and social outcomes than for biomedical ones. Among youth and general communities, the evidence remains inconclusive. Success appears to be enhanced by engaging groups with a strong collective identity and by simultaneously addressing the socio-political context. We suggest that the inconclusiveness of the findings reflects problems with the evidence, rather than indicating that CM is ineffective. We discuss weaknesses in the operationalization of CM, neglect of social context, and incompatibility between context-specific CM processes and the aspiration of review methodologies to provide simple, context-transcending answers.
KeywordsCommunity mobilisation Community participation HIV prevention HIV/AIDS Systematic review
Mientras que la movilización de la comunidad (MC) es cada vez más recomendada para la prevención del VIH, su impacto en resultados mensurables no se ha establecido. Realizamos una revisión sistemática del impacto de la MC en intervenciones para la prevención del VIH (N = 20), en resultados biomédicos, conductuales y sociales. En grupos de riesgo (particularmente trabajadoras sexuales) la evidencia es más bien consistente, indicando una tendencia general de impacto positivo, siendo los resultados conductuales y sociales más robustos que los biomédicos. En los jóvenes y comunidades en general la evidencia no es concluyente. Resultados favorables parecen ser mejorados al involucrar grupos con una fuerte identidad colectiva y, simultáneamente, atender al contexto socio-político. Proponemos que la naturaleza poco concluyente de los hallazgos refleja problemas con la evidencia, en lugar de sugerir que la MC es inefectiva. Discutimos las debilidades en la operacionalización de la MC, la desatención al contexto social y la incompatibilidad entre procesos contextualmente específicos en la MC y la pretensión de las metodologías de revisión de proveer respuestas simples y que trasciendan el contexto.
Many HIV intervention programmes have disappointing outcomes, often ascribed to a lack of community 'buy-in'. It is often the case that outsiders such as academics, multilateral agencies, or international organisations implement interventions without assessing their relevance to their particular target community. Social research has documented failures of HIV interventions to resonate with local norms, cultures and needs [1, 2]. Behaviours advocated by external health professionals may not be feasible in contexts of poverty, political conflict and gender inequalities [2, 3]. As a result, there is a growing emphasis on the need for community involvement in the planning, implementation and ownership of interventions. Indeed, community mobilisation (CM) is now widely considered a "critical enabler" of an effective HIV/AIDS response [4]. Despite this increasing interest in CM, there has been little systematic attention to its impacts.
One reason for the lack of systematic attention to CM is that it is used across categories of HIV intervention usually considered separately, namely, biomedical, behavioural and structural interventions. CM has been argued to be valuable in recruiting men to take up circumcision in biomedical interventions [5, 6]. Similarly, in behavioural interventions, CM may be used to recruit participants through outreach, or to inform culturally-appropriate materials [7, 8]. CM is often termed a 'structural intervention' when it is considered as a means of empowering marginalised communities and thus changing power relations [9, 10, 11, 12]. For a smaller number of studies, CM is considered their main mechanism of intervention [13, 14, 15, 16]. Although the impacts of CM have not yet been subject to a systematic review, such a review stands to contribute to research and practice across the range of HIV prevention approaches, wherever CM might be considered a 'critical enabler'. The term 'community mobilisation' is not consistently defined, theorised, operationalized or systematically appraised [17]. In its fullest operationalization, CM seeks "to create and harness the agency of the marginalised groups most vulnerable to HIV/AIDS, enabling them to build a collective, community response, through their full participation in the design, implementation and leadership of health programmes and by forging supportive partnerships with significant groups both inside and outside of the community" [18]. This definition sets a high bar, and many operationalizations of CM are far less ambitious [19]. Although our definition preserves the conceptual distinctiveness of CM, we aimed to be relatively inclusive in this review, for very few published evaluations implement the 'maximalist' version of CM as defined above.
For the purposes of this review, we take the term 'community' to refer to collective resources that exist among a community, rather than at the individual level. We take the term 'mobilisation' to mean capitalising on those community connections and strengths to generate new possibilities of action. In keeping with the 'minimalist' definition of CM, in this paper we consider CM as a component of externally-triggered HIV interventions, rather than including indigenous CM initiated by grassroots actors with broader interests than HIV. This latter topic is addressed in the literature on social capital and HIV/AIDS [20, 21, 22].
Research on CM to date has tended to be qualitative, grounded in ethnographic methods, and to focus on processes rather than on outcome evaluation [13, 23, 24, 25]. A growing body of social research has underscored the role of CM in building HIV competent communities, ensuring interventions are relevant and accessible to local people, and enabling people to work collectively to create health-enabling environments [18, 26, 27]. This work has also emphasised the significance of partnerships between communities and outside agencies as a key supportive condition for effective CM [18, 28, 29]. Furthermore, the pertinence of Western conceptualisations of CM and its constituting elements needs to be validated in specific intervention contexts [17]. Such information is crucial to the appropriate design and evaluation of CM programmes. In the context of the ascendant 'evidence-based policy and practice' movements, however, quantitative evaluations, and systematic reviews of these, are valued as sources for informing policy or funding decisions.
The first aim of the current article, therefore, is to present a systematic review of studies of the impacts of CM as a component of complex HIV prevention interventions. The scope of this review is comprehensive in that we do not restrict it to any target group, and we consider the impact on biomedical, behavioural, and social outcome variables. The review draws conclusions about whether CM 'works' or not, and delineates more nuanced lessons about the conditions under which CM is more likely to succeed.
A systematic appraisal of the CM intervention literature is challenging. Mobilisation efforts are referred to by many terms (e.g. community solidarity, social mobilisation, community participation, community engagement), which defy simple search strategies. In addition, CM almost invariably constitutes 'complex interventions' [30], entailing multiple, indirect pathways between intervention and outcomes. A wide and unresolved debate surrounds the best way to deploy and evaluate CM interventions (CMI) [31, 32], with many arguing that the complex and improvisational nature of good CM defies summary in the linear 'input–output' models of change that characterise the 'gold standard' approach of randomised controlled trials (RCT). The second aim of the article is to reflect on the methodological challenges of operationalizing, evaluating and reviewing CMI.
The definition of CM cited above sets a high standard. However, many studies which use the term 'CM' do so in a very limited way, for instance using 'CM' to simply mean reaching out the community for service or research recruitment. Heeding this concession, our key criterion was that CMI should seek to foster new capacities in a community by facilitating meaningful contact among community members. The reviewed studies aimed to engage communities in one or more of the following: enhancing supportive interpersonal relationships, building within-community support and solidarity (bonding social capital), and building bridges between communities and outside support partners (bridging social capital). In order to do so, interventions employed activities such as setting-up peer support groups and clubs, fostering of community-based organisations, performing dramas, rallies and awareness camps, creating community centres as 'safe spaces' for debate and conscientisation, as well as holding multi stake-holder meetings and advocacy. On the methodological front, we included reports on the impact of CM as a component of more complex interventions, and excluded articles where the impact of a singled-out mobilisation activity (e.g. peer group membership) was measured.
To what extent does CM impact on measurable HIV-related prevention outcomes?
Is there a significant relationship between the implementation of programmes with a CM component and biomedical, behavioural and social outcomes? If so, what is the direction of this relationship for each outcome?
Under what programmatic conditions (target population and intervention components) is CM most successful?
What are the methodological challenges of evaluating and synthesising evidence on CM?
Reported community-based initiatives (as opposed to health facility-based medical interventions) that engaged one or more community groups in concrete participatory activities. Studies should have reported modes of CM that foster meaningful community connections.
Evaluated the intervention in terms of at least one quantifiable biomedical (incidence and/or prevalence of HIV-1, HSV-2 and bacterial STI) or behavioural (reported condom use, reported health-service use, and HIV test-taking) outcome.
Evaluated outcomes with reference to a comparator or control, irrespective of research design.
The second inclusion criterion is based on the rationale that CM, and derived social outcomes, shapes sexual behaviours, which in turn impact on biomedical indicators. Thus, we targeted the proximal outcomes of this logic model. Although reported condom use has been found to be poorly associated with biomedical markers [36, 37, 38], we included condom use as a behavioural outcome because it is a proxy measure of actual sexual risk historically applied in the prevention literature, affording some degree of comparability across studies. Behavioural outcomes were expanded ad-hoc to engagement in extramarital sex for one study [39], on the assumption that this might increase a person's HIV risk [40]. This study was selected given its careful consideration of community involvement.
To enable the implementation of the selection criteria, and given the diversity of terminology employed, two steps were taken in the selection process. First, during abstract screening, records reporting the same study were clustered together, so as to gather as much information about a study as possible. Second, during full-text vetting, "reference list checking" [41] was performed to aid final selection. Eleven articles were selected from this search and assessed for inclusion.
Data Extraction and Synthesis
Analytical table
Intervention name (if any) and setting
Study designa and length
Target group, sample size at baseline
Intervention components
Doyle et al. [50]
MEMA kwa Vijana
10 rural communities in Mwanza, rural Tanzania
Average exposure 5.4 years prior survey
Adolescents aged 14 years or more at programme onset.
N = 13814 (males: nI = 3807, nC = 3493; females: nI = 3276, nC = 3238)c
10 randomised comparison communities with no intervention
Participatory school programme.
Training and provision of health workers for youth-friendly SRH services.
Community-based condom social marketing by youth.
Initial community mobilisation.
No difference between intervention and control groups in HIV prevalence (males aPR 0.91, 95 % CI 0.50–1.65; females aPR 1.07, 95 % CI 0.68–1.67) or in HSV-2 (males aPR 0.94, 95 % CI 0.77–1.15; females aPR 0.96, 95 % CI 0.87–1.06).
No difference in prevalence of active syphilis (males aPR 1.1, 95 % CI 0.72–1.72; females aPR 0.91, 95 % CI 0.65–1.28), chlamydia (males aPR 1.24, 95 % CI 0.66–2.33; females aPR 1.27, 95 % CI 0.87–1.86), and gonorrhoea (males aPR 0.71, 95 % CI 0.21–2.41; females aPR 0.73, 95 % CI 0.20–2.63).
Reported condom use at last sex with non-regular partner increased among females (aPR 1.34, 95 % CI 1.07–1.69) with no difference among males (aPR 1.15, 95 % CI 0.97–1.36).
No significant differences in reported condom use at last sex (males aPR 1.19, 95 % CI 0.91–1.54; females aPR1.27, 95 % CI 0.97–1.67).
Kamali et al. [54]
Masaka district, Uganda
12 communities (groups A and B)
Median follow-up of 3.6 years.
All adults (13 years or older).
nA = 4931
nB = 4787,
nC = 4836
6 communities received routine government health facilities with general community development activities (group C, control)
Group A. IEC intervention: knowledge acquisition, skill development, motivational support and attitudes development. Community-level: group meetings, one-to-one discussions, information leaflets, local drama, videos.
Group B. A + STI intervention: trained health workers in STI syndromic management. Consistent supply of drugs and supervision, coupled with community-based STI health education.
Group C (control). Community development and general health-related issues: self-support groups and clubs, home-based care, and general health promotion seminars.
No difference between intervention (A/B) and control (C) groups in HIV-1 incidence (A vs C, aIRR 0.94, 95 % CI 0.60–1.45, p = 0.72; B vs C, aIRR 1.00, 95 % CI 0.63–1.58, p = 0.98).
Lower HSV2 incidence in group A than in group C (aIRR 0.65, 95 % CI 0.53–0.80, p = 0.003); no difference between group B and C (aIRR 1.00, 95 % CI 0.54–1.85, p = 0.99).
No difference between group A and group C in active syphilis (aIRR 1.02, 95 % CI 0.66–1.57, p = 0.92) and high titre active syphilis (aIRR 1.03, 95 % CI 0.59–1.79, p = 0.90). Lower incidence in group B than in group C of active syphilis (aIRR 0.77, 95 % CI 0.61–0.96, p = 0.029) and high titre active syphilis (aIRR 0.52, 95 % CI 0.27–0.98, p = 0.044).
Lower gonorrhoea prevalence in group B than in group C (aPR 0.25, 0.10–0.64, p = 0.013), but no difference between group A and group C (aPR 0.64, 95 % CI 0.25–1.59, p = 0.26).
No difference between intervention and control groups for chlamydia prevalence.
No differences in condom use with last partner in group A compared with C (aPR = 1.12, 95 % CI 0.99-1.25, p = 0.57). Increase in condom use with last casual partner in group B compared with C (aPR = 1.27, 95 % CI 1.02–1.56, p = 0.036).
No difference in reported ever condom use (A vs C, aPR = 0.92, 95 % CI 0.68–1.26, p = 0.54; B vs C, aPR = 1.10, 95 % CI 0.95–1.26, p = 0.16).
Cowan et al. [49]
Regai Dzive Shiri
15 communities in rural Zimbabwe
4 years
18–22 year-olds
Intervention = 3381
Control = 3410
15 randomised control villages with delayed intervention. Matched controls for each cohort
Participatory youth programme via peer educators.
Programme for parents and community stakeholders aimed at enhancing knowledge, communication and community support towards adolescents.
Training for nurses and other clinic staff.
No difference between intervention and control groups in HIV or HSV-2 prevalence in men (aOR 1.20, 95 % CI 0.66–2.18; aOR 1.23, 95 % CI 0.69–2.18) and women (aOR 1.15, 95 % CI 0.81–1.54; aOR 1.24, 95 % CI 0.93–1.65).
No difference between intervention and control groups in reported condom use at last sex in men (aOR 1.03, 95 % CI 0.83–1.29) and women (aOR 0.93, 95 % CI 0.72–1.20).
No difference in clinic attendance in men (aOR 0.99, 95 % CI 0.76–1.29) and women (aOR 0.98, 95 % CI 0.76–1.28).
Gregson et al. [52]
6 communities in Manicaland, Zimbabwe
3 years
Males (17–54 years) and females (15–44 years)
Intervention = 4792
Control = 4662
6 matched control communities with standard government services
Peer education and condom distribution: sex workers, male clients and general community.
Income-generating projects (withdrawn).
Strengthened syndromic management of STI.
Open days with HIV/AIDS IEC activities.
No difference between intervention communities and control communities in HIV incidence (aIRR 1.27, 95 % CI 0.92–1.75, p = 0.12).
Reported unprotected sex with casual partners higher in intervention than in control communities (males aPOR 1.46, CI 1.02–2.09, p = 0.039; females aPOR 6.51, CI 2.14–19.82, p = 0.001).
No group differences in consistent condom use with regular partners (males aPOR 1.01, CI 0.72–1.40, p = 0.975; females aPOR 1.09, CI 0.72–1.65, p = 0.686) or treatment-seeking within 3 days of STI symptoms (males aPOR 1.13, CI 0.59–2.16, p = 0.709; females aPOR 1.14, CI 0.74–1.77, p = 0.544).
Jewkes et al. [51]
Stepping stones
6 to 8 weeks
Young men (nI = 694, nC = 666) and women (nI = 715, nC = 701) aged 15 to 26 years
Control intervention: single three-hour session on HIV, safer sex and condoms.
Baseline and follow-up 12 and 24 months later
Preliminary community consultation.
Participatory learning approaches: critical reflection, role play and drama.
13 three-hour long sessions.
3 peer group meetings.
1 final community meeting.
No difference in HIV incidence among men and women (aIRR 0.95, 95 % CI 0.67–1.35, p = 0.78)
HSV2 incidence lower in the intervention than the control group (aIRR 0.67, 95 % CI 0.46–0.97, p = 0.036)
No difference between intervention and control groups in correct condom use at last sex at 12 and 24 months in men (aOR 1.26, 95 % CI 0.92–1.74, p = 0.16; aOR 0.88, 95 % CI 0.64–1.21, p = 0.43) and women (aOR 0.95, 95 % CI 0.72–1.28 p = 0.79; aOR 0.90, 95 % CI 0.70–1.17 p = 0.45).
Men reported perpetration of intimate partner violence less frequently than controls at 12 months and 24 months (aOR 0.73, 95 % CI 0.50–1.06 p = 0.099; aOR 0.62, 95 % CI 0.38–1.01, p = 0.054), with no difference among women (aOR 0.87, 95 % CI = 0.64–1.18, p = 0.36; aOR 1.14, 95 % CI = 0.77–1.68, p = 0.51)
Pronyk et al. [53]
4 villages in Limpopo, South Africa
18 months
Three cohorts:
1. Women who applied for loan (nI = 426, nC = 417;
2. 14–35 years old household co-residents (nI = 725, nC = 730);
3.Randomly selected community members (nI = 746; nC = 736)
4 matched villages with delayed intervention. Matched controls for each cohort
Poverty-focused microfinance.
Gender and HIV participatory curriculum (structured training and community mobilisation).
Community mobilisation as HIV and intimate partner violence awareness, village workshops and multi stake-holder meetings, marches, partnerships and committees.
No difference between cohort 3 and control group in HIV incidence (aRR 1.06, 95 % CI 0.66–1.69).
No difference in unprotected sexual intercourse with a non-spousal partner in cohort 2 (aRR 1.02, 95 % CI 0.85–1.23) and cohort 3 (aRR 0.89, 95 % CI 0.66–1.19) relative to controls.
No difference in having had an HIV test in cohort 2 (aRR 1.18, 95 % CI 0.73–1.91) and cohort 3 (aRR 1.09, 95 % CI 0.81–1.47) relative to controls.
Intimate partner violence reported less frequently in cohort 1 than in control group (aRR 0.45, 95 % CI 0.23–0.91).
Cohort 1 reported higher levels of participation in social groups (aRR 1.85, 95 % CI 0·95–3·61) and collective action (aRR 2·06, 95 % CI 0.92–4.49) than control group.
No difference in sense of community solidarity in times of crisis(aRR 1.65, 95 % CI 0.81–3.37) and belief of community work on common goals (aRR 1.11, 95 % CI 0.38–3.24).
Sweat et al. [15]
Accept, HPTN 043
Communities of Tanzania (10), Zimbabwe (8) and Thailand (14)
3 years
16–32 year-olds
Tanz (nI = 6250; nC = 6733);
Zimb (nI = 10,700; nC = 12,150);
Thai (nI = 11,290; nC = 10,033)
Equal number of matching communities received standard clinic-based voluntary counselling and testing (SVCT) for HIV
Preliminary participatory mapping.
Community mobilisation: community working groups, outreach workers activities, community-based outreach workers.
Community based voluntary counselling and testing (CBVCT): accessible mobile VCT for and community based-support services after testing.
Percentage of "clients" testing for HIV for the first time higher in CBVCT communities than in SVCT communities. Crude mean difference: 40.2 % (95 % CI 15.8–64.7, p = 0.019) across one pair of matched communities per country.
Coates et al. [48]
Accept, HPTN 043
No difference HIV incidence in CBVCT than in SVCT (RRi 0.86, 95 % CI 0.73–1.02, p = 0.08).
Kerrigan et al.
Santo Domingo and Puerto Plata in Dominican Republic
Cohort analytic
1 year
68 FSW establishments in 2 cities
Baseline and follow-up. Components 1–4 (CM) in both cities, component 5 (policy) only in Puerto Plata.
Exposure to intervention vs low-exposure
1. Solidarity and collective commitment.
2. Environmental cues.
3. Clinical services.
4. Monitoring and encouraging adherence.
5. Policy and regulation.
Prevalence of 1 or more STIs (gonorrhoea, trichomoniasis, or chlamydia) decreased in Puerto Plata (aOR 0.50, 95 % CI 0.32–0.78, p < 0.01) but had no significant changes in Santo Domingo (aOR 0.60, 95 % CI 0.35–1.03).
Consistent condom use with new clients increased in Santo Domingo, (aOR 4.21, 95 % CI 1.55–11.43, p < 0.01) but not in Puerto Plata (aOR 2.27, 95 % CI 0.47–10.84).
Consistent condom use with regular partners and FSW's observed verbal rejection of unsafe commercial sex increased in Puerto Plata (aOR 2.97, 95 % CI 1.33–6.66, p < 0.01; aOR 3.86, 95 % CI 1.96–7.58, p < 0.001) but not in Santo Domingo (aOR 1.29, 95 % CI 0.62–2.70; aOR 1.49, 95 % CI 0.81–2.73).
Gao and Wang [72]
Chengdu, Southern China
Cohort analytic
5 months
Intervention n = 80;
Control n = 80
Baseline and follow-up. Control received no exposure to intervention
Gay bar-based participatory entertainment-education.
Outdoor edutainment activities to expand networks.
Fostering of a caring environment.
Increase in condom use among intervention group with casual partners: vaginal sex (6.1–73.5 %, p < 0.001), anal sex (4.3–76.8 %, p < 0.001) and oral sex (1.4–15.9 %, p < 0.01); with regular partners: vaginal sex (7.4–40.7 %, p < 0.001), anal sex (3.1–46.2 %, p < 0.001) and oral sex (1.5–10.3 %, p < 0.05).
No differences in condom use among comparison groups.
Swendeman et al. [65]
West Bengal, India
Cohort analytic
16 months
FSW, 1 replication community
Baseline and 3 follow-ups within 16 months. Control community receiving standard care: STD clinic free of charge, condom promotion and peer education
Enhanced intervention including standard care plus:
Rapid appraisal.
STD/HIV Intervention Project.
FSW community organisation.
USHA multi-purpose micro-finance cooperative.
Advocacy with stake-holders and power-brokers.
Social support through organising and solidarity increased among intervention group (p < 0.001 across items), while it decreased among controls (p < 0.001 across items). Political participation remained stable among intervention group (p > 0.05) and increased among controls (p < 0.001)
Basu et al. [66]
Intervention n = 110; control n = 106
Condom use increased more among FSW in intervention community than among controls (B = 0.3447, p = 0.002).
Erausquin et al. [56]
Rajahmundry, Andhra Pradesh, India
Cohort analytic
6 years: Project onset in 2004, 3 surveys: 2006, 2007, 2009/10.
3 time points. Comparison between no programme exposure, receptive exposure and active utilisation
Identification of social change agents among FSW.
Peer education and community organisation.
Traditional intervention (condom distribution, condom use promotion, etc.).
Advocacy and organisation of FSW-led CBOs.
Greater programme exposure related to increased probability of consistent condom use with clients (no exposure vs receptive exposure aOR 1.57, 95 % CI 1.22–2.02, p < 0.001; no exposure vs active utilisation aOR 2.03, 95 % CI 1.60–2.57, p < 0.001). Association maintained over time.
Blankenship et al. [55]
Case control
2 years (NA - see comparison)
Comparison between no programme exposure, receptive exposure and active utilisation
Greater programme exposure related to increased probability of consistent condom use (no exposure vs active utilisation aOR 2.09, 95 % CI 1.48–2.94, p < 0.005).
Greater programme exposure associated with increased collective identity, collective efficacy and collective agency (no exposure vs active utilisation p < 0.001 in bivariate analysis for all items).
Lippman et al. [67]
Corumba, Brazil
Cohort Analytic
Baseline and follow-up at 3, 6, 9 and 12 months later.
Sex workers: female, male and transvestite.
Baseline and 4 follow-ups. Ever exposed vs unexposed
Individual and interpersonal level: increased health services provision, counselling, free condoms provision, peer education and outreach.
Community level: forging of community partnerships, collective activities (e.g. workshops), mobilisation for dialogue, formation of a sex workers association, distribution of destigmatising materials.
No differences in probability of incident STI for exposed participants compared with unexposed (aOR 0.46, 95 % CI 0.2–1.3).
Exposure related to higher likelihood of reporting consistent condom use with regular clients (aOR 1.9, 95 % CI 1.1–3.3, p < 0.05), with no differences with new clients (aOR 1.6, 95 % CI 0.9–2.8) and non-paying partners (aOR 1.5, 95 % CI 0.9–1.5).
Active participants increased participation in networks (SD 0.3, 95 % CI 0.1–0.5) and did not change perceived cohesion (SD 0.1, 95 % CI −0.1 to 0.24).
Gutierrez et al. [63]
Frontiers Prevention Project
Andhra Pradesh, India
Cohort analytic
Baseline and follow-up 4 years later.
FSW & MSM in 12 geographically distinct sites
N = 2786MSM (1680 FPP, 1106 non-FPP); 3442 FSW (1692 FPP, 1750 non-FPP).
Baseline and follow-up. Non-FPP (12 sites) receiving Avahan intervention
STI services, behaviour change communication, condom programmes, community mobilisation, and enabling and structural interventions.
Emphasis on social capital building, network and support formation, empowerment, violence reduction, referrals for HIV testing and basic AIDS care services.
Intervention correlated with lower probability of sero-positivity to HSV-2 and syphilis among both MSM (p < 0.001, p < 0.05) and FSW (p < 0.05, p < 0.001).
MSM: intervention related to increase in condom use with last female sexual partner (p < 0.05) but no difference with last male sexual partner.
FSW: intervention associated with increase in condom use with regular partners (p < 0.05) but no difference with last sexual client.
Gutierrez et al. [69]
Frontiers Prevention Project
Cohort analytic
Baseline and follow-up 4 years later.
FSW & MSM in 6 cities
N = 1727 MSM (1248 FPP, 479 non-FPP); 1526 FSW (752 FPP, 774 non-FPP)
Baseline and follow-up.
3 intervention cities vs 3 comparison cities with standard national HIV initiatives
Individually focused health promotion. Ensuring access, scaling-up targeting and improving service and commodity delivery. Mobilisation of key populations' communities (participatory assessment, leadership workshops, human rights promotion, establishing of solid networks, safe meeting spaces provision). Advocacy, policy change and community awareness. Capacity building of NGOs and CBOs to effectively implement quality prevention interventions.
MSM: No difference in seroprevalence of HIV (aOR 0.84, 95 % CI 0.31 − 2.31) and HSV-2 (aOR 0.40, 95 % CI 0.11–1.5). Reduced odds of syphilis seroprevalence (aOR 0.32, 95 % CI 0.14–0.72).
FSW: No difference in seroprevalence of HIV (aRR 0.75, 95 % CI 0.42–1.3) and syphilis (aRR 1.08, 95 % CI 0.70–1.67). Lower risk of HSV2 seroprevalence (aRR 0.93, 95 % CI 0.85–0.99).
MSM: Higher odds of condom use with a male partner associated with intervention (aOR 2.89, 95 % CI 1.34–6.28). No difference in condom use with female partners (aOR 1.91, 95 % CI 0.47–7.8).
FSW: No difference in condom use with clients (aRR 0.98, 95 % CI 0.93–1.00) and regular partners (aRR 1.29, 95 % CI 0.85–1.90) associated with intervention.
Kerrigan et al. [70]
3 sites in Rio de Janeiro, Brazil
18 months
FSW older than 18 years
Pre-post intervention
Current FSW peer educator as agents of social change, trained to bring about and discuss issues of common concern.
FSW organisation.
Drop-in centre as safe space to discuss and hold project workshops and activities.
Community identified priority action areas that received funding and technical assistance.
No difference in consistent condom use with all clients in the last 4 months (87.2–88.6 %, p = 0.287) and consistent condom use with all (paying and non-paying) partners in last week (80.40–79.0 %, p = 0.808).
Social participation increased from 0.74 to 1.23 (p < 0.0001).
No differences in sense of community as social cohesion and mutual aid (values not reported).
Williams et al. [71]
Carletonville project.
Mothusimpilo intervention.
Carletonville, South Africa.
2 years.
Miners and sex workers, general population.
Miners = 899
Sex workers = 121
Men = 443
Women = 691
Baseline and follow-up
Community-based peer education, condom distribution, syndromic management of STIs and presumptive STI treatment for sex workers.
Increases in prevalence of:
Syphilis: among miners (5.5–8.3 %, aOR 1.57, p = 0.02) and women (9.8–18.7 %, aOR 2.06, p < 0.01). Gonorrhoea: miners (3.0–7.4 %, aOR 2.61, p = 0.01).
Chlamydial infection: miners (3.8–13.9 %, aOR 4.23, p < 0.01), men (3.6–12.4 %, aOR 3.54, p < 0.01) and women (7.9–13.8 %, aOR 1.88, p < 0.01).
No differences in STI were computed for sex workers in syphilis (25.0– 34.4 %, aOR 1.56, p = 0.15)., gonorrhoea (15.7–16.1 %, aOR 1.01, p = 0.96) and chlamydial infection (9.1–12.9 %, aOR 1.45, p = 0.40).
"Ever used a condom" report increased among miners (39.5–51.3 %, aOR 1.66, p < 0.01) and women (33.1–42.3 %, aOR 1.58, p < 0.01), but not among men (48.1–54.8 %, aOR 1.23, p = 0.17).
"Always use condoms with casual partner" report increased among miners (13.2–27.2 %, aOR 2.45, p < 0.01) men (14.7–35.6 %, aOR 3.19, p < 0.01) and women (17.8–24.9 %, aOR 1.56, p = 0.03).
No significant differences were reported among sex workers for "ever used a condom" (69.7–77.2 %, aOR 1.39, p = 0.34) and "always use condoms with casual partner" (54.3–41.9 %, aOR 0.57, p = 0.07).
Schensul et al. [39]
3 communities of Mumbai, India
3 years
Married men aged 21–40 yrs.
Pre-post intervention. Longitudinal panel sample (n = 403)
Formative community mapping.
Community education: street dramas, community meetings, poster sessions, banner presentations, videos/movies, printed materials, interpersonal communication.
Change in extramarital sex related to change in alcohol use (p < 0.01). Men who were drinkers in BL but non-drinkers in EL and non-drinkers more likely to report reduction in extramarital sex compared to their drinkers counterparts.
Benzaken et al. [68]
Princesinha Project in Manacapuru, Amazonas State, Brazil
2 years
Baseline and follow-up
Sex workers peer-education and referrals to services. Activities on a daily and weekly basis.
Activities to increase project visibility and to foster sex workers' social inclusion.
Peer educators conducted mapping of condom retail locations and data collection about the town's sex work networks and dynamics.
Increases in reported condom use for oral sex with clients (37.2– 56.1 %, p < 0.001), in all situations (0.0–77.7 %, p < 0.001) and during last week (41.9–78.0 %, p < 0.001). Non-significant increases in reported condom use in anal sex with clients (37.2–48.2 %, p = 0.050) and in vaginal sex with clients 68.9–77.7 %, p = 0.090).
Guha et al. [59]
States of Tamil Nadu and Maharashtra, India
Case control
18 months
Comparison between (Avahan and non-Avahan) intervention exposure: either active or passive.
Distinction between metropolitan and 'rest of state' areas.
Propensity score matching including matched controls unexposed to intervention
Trainings and meetings of FSWs, formation of self-help groups. Facilitating formation of CBOs. Fostering of capacity building and power negotiation.
Increases in consistent condom use with all clients associated with level of participation:
Attending a training session: Rest of Tamil Nadu (p < 0.001) and rest of Maharashtra (p = 0.008).
Belonging to a self-help group: Rest of Tamil Nadu (p < 0.001) and Mumbai (p < 0.001).
Belonging to a FSW collective: Mumbai (p = 0.013).
No significant effects for Chennai.
Except in Mumbai, joining meeting or training associated with collective efficacy and community support.
Belonging to a self-help group associated with collective efficacy in the rest of Tamil Nadu and Mumbai.
Belonging to a self-help group associated with community support in the rest of Tamil Nadu and rest of Maharashtra
Ng et al. [60]
Six Indian states: Nagaland, Manipur, Tamil Nadu, Maharashtra, Karnataka and Andhra Pradesh.
Case control
High-risk groups (FSW, their clients and partners, MSM, IDU, and truck drivers).
Comparison between intensity of Avahan by district (amount of grant per HIV population) using National Family Health Survey
Peer outreach for safe –sex counselling.
Clinical services.
Distribution of free condoms.
Needle and syringe exchange.
Community mobilisation and advocacy activities.
Greater programme intensity associated with lower likelihood of HIV prevalence in Andhra Pradesh (effect size −0.0026, 95 % CI −0.0044 to −0.0009, p = 0.004), Karnataka (effect size −0.0026, 95 % CI −0.0042 to −0.0008, p = 0.004) and Maharashtra (effect size −0.0022, 95 % CI −0.0039 to −0.0005, p = 0.008).
Non-significant association in the other 3 states.
Ramesh et al. [61]
Five districts within Karnataka state: Mysore, Belgaum, Shimoga, Bellary and Bangalore Urban
Baseline: 7–19 months after project initiation;
follow-up: 28–37 months later.
Baseline and follow-up
Participatory mapping and enumeration exercises.
Peer-mediated outreach and behaviour change communication.
Dedicated sexual health services with STI syndromic management.
Advocacy with stakeholders.
Creation of drop-in centres (safe spaces for dialogue and services).
Community mobilisation and capacity building.
Reductions prevalence of HIV (aOR 0.81, 95 % CI 0.67–0.99, p = 0.04), high-titre syphilis (aOR 0.53, 95 % CI 0.37–0.77, p = 0.001) and chlamydia and/or gonorrhoea (aOR 0.72, 95 % CI 0.54–0.94, p = 0.02).
No differences in syphilis (aOR 0.77, 95 % CI 0.57–1.04, p = 0.09).
Increases in condom use at last sex with repeat clients (aOR 1.98, 95 % CI 1.58–2.48, p < 0.001).
No differences in condom use at last sex with occasional clients (aOR 1.22, 95 % CI 0.89–1.66, p = 0.2) and regular partners (aOR 1.07, 95 % CI 0.76–1.51, p = 0.7).
Reza-Paul et al. [62]
Mysore district only
Baseline: 6 months after project initiation, follow-up 2.5 years later
Baseline and follow-up
Participatory mapping and enumeration exercise.
Community mobilisation and peer-mediated outreach.
Increased access to sexual health services, expansion of condom availability in non-traditional outlets.
Creating an enabling environment to support the programme.
No difference in HIV prevalence (aOR 0.91, 95 % CI 0.66–1.23)
Increases in HSV-2 prevalence (64.4–79.0 %, aOR 2.15, 95 % CI 1.46–3.18, p < 0.001)
Decreases in STI prevalence: syphilis (aOR 0.38, 95 % CI 0.25–0.59, p < 0.001); trichomonas (aOR 0.28, 95 % CI 0.18–0.41, p < 0.001); chlamydial infection (aOR 0.52, 95 % CI 0.27–0.96, p = 0.04) and gonorrhoea (aOR 0.42, 95 % CI 0.17–1.01, p = 0.03).
Increases in condom use: at last sex with occasional clients (aOR 4.30, 95 % CI 2.80–6.62, p < 0.001); with repeat clients (aOR 1.76, 95 % CI 1.22–2.55, p = 0.003); with regular partners (aOR 5.49, 95 % CI 2.91–10.37, p < 0.001). "Zero unprotected sex acts in past months" increased (aOR 5.45, 95 % CI 3.82–7.79, p < 0.001)
Saggurti et al. [57]
Andhra Pradesh, India
Case control
FSW and men who have sex with men and transgenders (HR-MSM)
Comparison between low and high degree of 4 CM indicators: collective efficacy (both groups), collective agency (only FSW), collective action (only FSW), and participation in public events (only HR-MSM)
"[T]he implementation of community mobilization varied, with the differences mainly in group structures and focus on the local priorities and needs of communities".
FSW: High collective efficacy associated with greater likelihood of consistent condom use (CCU) with occasional (aOR 1.3, 95 % CI 1.1–1.7) and regular (aOR 1.4, 95 % CI 1.1–1.9) clients, and with STI treatment at government health facilities in past year (aOR 3.3, 95 % CI 2.1–5.1)
High collective agency associated with greater likelihood of STI treatment only (aOR 1.6, 95 % CI 1.1–2.2)
Collective action associated with greater likelihood of CCU with occasional (aOR 1.3, 95 % CI 1.1–1.8) and regular (aOR 1.5, 95 % CI 1.1–2.0) clients, and with a lower likelihood of STI treatment (aOR 0.5, 95 % CI 0.3–0.8).
HR-MSM: participation in public event associated with greater likelihood of CCU with paid (aOR 3.3, 95 % CI 2.1–5.2) and paying (aOR 2.7, 95 % CI 2.0–3.6) partners.
Higher collective efficacy associated with greater likelihood of CCU with paying partners. (aOR 1.9, 95 % CI 1.5–2.3) only.
Blanchard et al. [58]
Districts in Karnataka (Belgaum, Gulbarga, Gadag, Dharwad) and Maharashtra (Solapur), India
Case control
Comparison between high intensity intervention (Belgaum, Gulbarga and Gadag) and low intensity intervention (Dharwad and Solapur) districts. Analysis by dimensions of empowerment (within, with and over)
Only power with (collective identity and solidarity) included here
CM through an "integrated empowerment framework": sex work organisation, program and structural interventions, sociodemographic characteristics impacting upon empowerment dimensions, which in turn result into the power to address a disempowering social context (power imbalances, social exclusion and vulnerability).
Sensitisation of stakeholders in and beyond the community.
In both high and low intensity districts, power with was associated with likelihood of condom use at last sex with regular client (aOR 2.56, p < 0.001; aOR 1.65, p < 0.01) and frequency of condom use with regular clients (aOR 2.27, p < 0.001; aOR 1.80, p < 0.001), with no significant differences in condom use at last sex with regular partner, frequency of condom use with regular partner and number of visits to health clinic for health problems.
Power with was associated with lower odds of violence or abuse by more powerful groups in high intensity districts (aOR 1.34, p < 0.05), but not in low intensity ones.
Parimi et al. [64]
India HIV/AIDS Alliance programme
Andhra Pradesh, India
Case control
FSW in 5 districts of Andhra Pradesh
n = 1116 from project areas where STI services were in partnership with government
870 FSW (43.8 % of sample) from project areas where STI services were delivered by other (agency-implemented or in partnership with private providers) STI service delivery models
Promotion of governmental STI services utilisation.
Syndromic management of STIs among government facilities.
Sensitisation meetings with outreach staff and community members.
Community-based group promotion of health care facilities use among FSW.
Awareness camps focused on risk perception: games, street plays, puppet shows and magnet theatre shows.
Regardless of project area, FSW who reported high collectivisation (collective-efficacy, -agency and -action) were more likely to access STI treatment from government health facilities in the previous year than their low collectivisation counterparts (78.1 vs 63.2 %, aOR 2.1, 95 % CI 1.6–2.8)
Outcomes related to knowledge, attitudes, individual level perceptions (e.g. attitude towards condoms, self-efficacy or individual-level 'power-within') were not included, given that knowledge, individual skills and attitudes are not a sound reflection of behaviour [42, 43, 44]. Similarly, reported STI were omitted on the basis that an actual measure (incidence/prevalence), rather than a proxy, was more valid. We included results for different types of outcomes if reported in more than one article belonging to the same study. When similar outcomes for the same study were reported by more than one article, we included the results using a larger sample, given that this frequently aggregated the smaller samples reported elsewhere.
Quality assessment
Assigned designa
Selection bias
Study design
Data collection method
Withdrawals and dropouts
Global rating
Doyle et al. [50]
Kamali et al. [54]
Cowan et al. [49]
Gregson et al. [52]
Jewkes et al. [51]
Pronyk et al. [53]
Sweat et al. [15]
Kerrigan et al. [14]
Cohort analytic
Gao and Wang [72]
Cohort analytic
Swendeman et al. [65]
Cohort analytic
Erausquin et al. [56]
Cohort analytic
Lippman et al. [67]
Cohort analytic
Gutierrez et al. [63]
Cohort analytic
Gutiérrez et al. [69]
Cohort analytic
Kerrigan et al. [70]
Williams et al. [71]
Schensul et al. [39]
Benzaken et al. [68]
Ng et al.b [60]
Case control
Parimi et al. [64]
Case control
The Studies
Of the corpus of twenty studies, seven were RCT: project Accept [15, 48], the Regai Dzive Shiri intervention [49], the MEMA kwa Vijana trial [50], the Stepping Stones intervention [51], the Manicaland Project [52], the IMAGE project [53], and a trial in the Masaka district, Uganda [54]. Project Accept was carried out simultaneously in Sub-Saharan Africa and South and South East Asia, while the other six trials were implemented in Sub-Saharan Africa.
The remaining twelve studies used various observational designs. In India, South and South East Asia, the RISHTA project [39], the Parivartan project [55, 56], the Avahan project [57, 58, 59, 60, 61, 62], the Frontiers Prevention Project (India) [63], a programme by the India HIV/AIDS Alliance [64], as well as a Sonagachi-replication [65, 66] were implemented; in Latin America and the Caribbean, the Encontros project [67], the Princesinha project [68], the Frontiers Prevention Project (Ecuador) [69], a Sonagachi-inspired intervention [70], and a comparison between CM and CM plus policy changes [14] were carried out. Finally, the Carletonville project [71] was undertaken in Sub-Saharan Africa and a participatory intervention was implemented in Chengdu, China [72].
The boundaries of 'community' were conceptualised in three main ways by the selected studies. First, in contexts of concentrated HIV epidemics, interventions targeted groups most at risk: ten studies focused on sex workers [14, 56, 59, 63, 64, 65, 67, 68, 69, 70], four on men who have sex with men (MSM) [57, 63, 69, 72], and one study [39] focused on local heterosexual men whose high levels of alcohol consumption were found to be putting their sexual health at risk [73]. These communities were thus assumed to share a social identity, location and concrete practices (e.g. work and leisure). Second, mainly in contexts of generalised epidemics, youth were targeted by four studies [15, 49, 50, 51], treating them also as communities in terms of identity and sexual risks, within geographically-bound communities. Four further studies [52, 53, 54, 71] conducted in the generalised epidemic of Sub-Saharan Africa were concerned with mobilising geographically-bound communities by targeting adults or a number of groups (e.g. women who applied for a loan; miners, sex workers and adults simultaneously) within the community. Outcomes were evaluated at the level of participant communities and their comparators, except for four projects (Accept, Avahan, IMAGE and Regai Dzive Shiri), which evaluated the effects of the intervention at the wider community- or population-level.
Do CM Interventions Work? It Depends on for Whom
Since the pattern of findings differs by population, we have divided our presentation of the findings into two sections, reporting first the findings for sex workers and other most at risk groups, and then findings for youth and general communities.
Sex Workers and Other Most at Risk Groups
The first group are mainly sex workers and, to a lesser extent, other most at risk groups such as men who have sex with men (MSM), who have been targeted in contexts of concentrated HIV epidemics. Inconsistent results were reported in the Avahan programme, in which for population effects at state level, "greater intensity" of the intervention was significantly associated with lower HIV prevalence in 3 Indian states, but with very small effect sizes (−0.0026 to −0.0022). The association between CMI and HIV prevalence was non-significant in 3 other states [60, 61, 62], although authors acknowledge that the prevalence in chronic diseases such as HIV could require long periods to be apparent. The Frontiers Prevention Project in Ecuador found no significant effects of the intervention on HIV seroprevalence among FSW and MSM [69].
With regards to other STI, a sub-study of the Avahan programme in Karnataka reported that chlamydia and/or gonorrhoea prevalence, and high-titre syphilis, were significantly reduced, while this reduction was non-significant in relation to syphilis among female sex workers (FSW) [61]. Encouragingly, the Frontiers Prevention Project in Andhra Pradesh was associated with lower likelihood of syphilis and HSV-2 among both FSW and MSM [63]. A similar project in Ecuador rendered a significant impact in the reduction of likelihood of syphilis seroprevalence among MSM, while having a borderline effect of lower HSV-2 seroprevalence among FSW in the programme [69]; non-significant programme effects were observed on HSV-2 among MSM and syphilis among FSW [69]. Active participation in the Encontros study was related to a non-significantly lower probability of incident chlamydia and/or gonorrhoea [67], while the Carletonville project rendered a non-significant increase of syphilis, gonorrhoea and chlamydia among participant sex workers [71]. Furthermore, the study in the Dominican Republic [14] found CMI to reduce prevalence of one or more STI (gonorrhoea, trichomoniasis, or chlamydia) among FSW. A further analysis shows that this effect was statistically significant when CM was combined with implementing and enforcing a government policy supporting consistent (100 %) condom use [14]. On the whole, the evidence points to CMI tending to impact on the reduction of STI among sex workers, with this effect being more likely to be significant when CMI is combined with policy interventions [14].
Regarding behavioural outcomes, among sex workers, condom use is the behaviour most addressed, and with the strongest evidence, with various degrees of effect depending on whether sexual encounters are with paying clients, casual or stable partners. Exposure to interventions was found to be significantly associated with increased likelihood of condom use [66], consistent condom use with clients [56], with new clients [14 in Santo Domingo], consistently or during last encounter with regular clients or partners, [14 in Puerto Plata, 61, 63, 67], and for oral sex with clients, in "all situations" and during last week [68]. Other studies have found non-significant or marginal increases related to the intervention, including ever using a condom [71], condom use with last client [63, 70], with all clients [70], with occasional or new clients [14 in Puerto Plata, 61, 67], with non-paying [67] and regular partners [14 in Santo Domingo, 61, 69], as well as for anal and vaginal sex with clients [68]. Marginal decreases in consistent condom use with all partners [70] and casual partners [71] were reported in Rio de Janeiro, Brazil and South Africa.
Of note are two behavioural outcomes reported in the interventions with FSW. In the Dominican Republic [14], authors recorded the observed FSW's verbal rejection of unsafe commercial sex, which increased from pre- to post-intervention in both sites, being significant only for the community where both CM and policy enforcement were implemented. Similarly, in Andhra Pradesh [64], FSW who reported high collectivisation were considerably more likely to procure STI treatment from government health facilities than those who reported low collectivisation, as were those who reported high collective efficacy and collective agency [57]. Collective action, in contrast, was associated with a lower likelihood of STI treatment-seeking [57].
CMI targeting MSM were found to be related to a significant increase in reported condom use with casual and regular sexual partners for vaginal sex, anal sex and oral sex [72] and to the likelihood of condom use with last female partner [63] and last male sexual partner [69]. An association in the same direction was non-significant for condom use with last female partner [69] and last male sexual partner [63]. In one subsample of MSM and transgender people in the Avahan project [57] it was found that participation in a public event was significantly associated with higher likelihood of consistent condom use among paying and non-paying partners, with the same positive trend for collective efficacy, although significant only with paying partners. In the RISHTA intervention [39], which engaged local heterosexual males whose high levels of alcohol consumption were found to put their sexual health at risk, it was reported that changes in extramarital sex were significantly associated to change in alcohol use, so that significant decreases in extramarital sex were observed among men who were drinkers at baseline but non-drinkers at endline.
Social outcomes tended to be positive mainly in terms of community participation and collective identity, with inconsistency in the way social outcomes were measured. Two Sonagachi-inspired programmes found significantly positive changes in social participation [67, 70], but not in perceived social cohesion [67, 70] after intervention in Corumbá [67] and Rio de Janeiro [70], Brazil. Similarly, another Sonagachi adaptation found significant increases in social support through organising and solidarity, but not in political participation in West Bengal, India [65]. An evaluation of the Avahan project, in turn, found that joining a meeting, belonging to a help group and being member of a sex worker collective were significantly associated with higher perceived collective efficacy and higher perceived collective support in non-metropolitan Tamil Nadu, with varying positive effects in the other three settings of Tamil Nadu and Maharashtra, in India [59]. A different evaluation report of Avahan also found that collective identity and solidarity were significantly associated with lower odds of violence or abuse by more powerful groups in high-intensity intervention districts, but not in low-intensity ones [58]. In Andhra Pradesh, the study on project Parivartan found a positive relationship between collective identity, collective efficacy and collective agency and programme exposure, which becomes stronger as the level of exposure rises [55].
In sum, there is reasonable evidence for the effectiveness of CMI in reducing STI and increasing condom use among sex workers. Among MSM, there is some evidence that CMI results in increased condom use. Findings regarding social outcomes remain uneven, depending on the social outcome measured. The evidence of CMI effects on HIV prevalence remains limited to projects Avahan and Frontiers Prevention (Ecuador), which provided inconclusive results. It is difficult to draw broad conclusions about which programmatic elements or conditions are most effective (e.g. targeting casual vs. regular partners; working in urban vs. rural areas) because each intervention employed a different design, measured different outcomes, and was conducted in a unique setting.
Youth and General Community
Studies targeting either youth or the general community reported mainly non-significant intervention effects in terms of HIV incidence [51, 52, 53, 54] or prevalence at the community level [49, 50]. Project Accept intervention reported lower HIV incidence in intervention than in control communities with borderline statistical significance (p = 0.08) [48]. Similarly, regarding other STI, mainly non-significant effects have been reported for HSV-2 prevalence [49, 50] and incidence [54 for one arm] as well as prevalence of chlamydia, syphilis and gonorrhoea [50, 54 for one arm], while the Carletonville study reported significant increases of chlamydia among miners, men and women, of syphilis among miners and women, and of gonorrhoea among miners [71]. The Masaka trial in Uganda, in turn, found dissimilar results depending on intervention arm: incidence of active syphilis and prevalence of gonorrhoea were significantly lower in one of the intervention arms than in the control group, while HSV-2 incidence was lower in the other intervention arm than in the control group [54]. Only the Stepping Stones programme was associated with a significantly lower HSV-2 incidence in comparison with controls [51]. Hence, there is little evidence that CMI succeed in reducing numbers of HIV and/or STI cases among youth and general communities, with some success limited to the Stepping Stones programme and project Accept.
In terms of behavioural markers, CMI were found to be significantly positively associated with the likelihood of condom use with casual partners [50 in females, 54 in one arm; 71 in miners, men and women] and ever using a condom [71 in miners and women]. However, for a number of interventions no significant changes in either direction were reported on condom use at last sex [49, 50, 51], reported ever condom use [54, 71 in men] and condom use with regular [52] and non-spousal [53] partners. For the Manicaland study [52], reported condom use with casual partners was significantly more common in control than in intervention communities. Behaviours other than condom use were also addressed. In the Accept study, the proportion of people taking their first HIV test was significantly larger in community based voluntary counselling and testing communities than in standard care areas [15]. However, the IMAGE project found non-significant differences in having had an HIV test in intervention groups relative to controls [53]. Similarly, in terms of health service use, the Regai Dzive Shiri project had no effect on clinic attendance [49] and the Manicaland project found no intervention-related differences in treatment-seeking within 3 days of STI symptoms [52]. In light of these results, CMI appears to have some effect among youth and targeted communities on condom use with casual partners and promising effects in the uptake of voluntary testing, although evidence for the latter is limited to one study.
Among programmes targeting youth and the general population, evidence of effects on social outcomes is limited to the IMAGE and the Stepping Stones projects. In the former, targeted women reported a significant reduction in intimate partner violence and were more likely to report higher levels of participation in social groups and collective action, than their comparison counterparts, with no significant differences regarding the perception of solidarity and that the community would work together to achieve common aims [53]. In the Stepping Stones programme the proportion of male participants who reported enactment of intimate partner violence was lower than among controls, with this trend maintained across the intervention's lifetime (p = 0.099, p = 0.054 at 12 and 24 months, respectively), although there was no evidence of this difference among women [51]. Therefore, while these results are promising, there still remain inconsistencies regarding their diffusion into biomedical and behavioural indicators.
In sum, for studies involving youth, targeted groups within communities and geographically-bound communities, no significant results were found for reductions of HIV incidence or prevalence, while marginal impact on the reduction of other STI was identified, mirroring the results of previous reviews [33]. The evidence suggests that while these programmes impact on reported condom use with casual partners, this improvement may not translate into significant changes in biomedical markers. The results obtained for social outcomes are fairly positive but limited to two studies, and hence their relationship with behavioural and biomedical indicators remains to be clarified.
The present review has gathered evidence of the effectiveness of interventions with a CM component on biomedical, behavioural and social outcomes. We present our discussion in two sections. The first assesses what can be learnt from our review to inform contemporary CM programming. Given that the findings are generally inconclusive, the second section critically reflects on the literature, to explore reasons for the inconclusiveness of the evidence.
The Systematic Review: What has been Found?
Overall, this systematic review has produced a somewhat inconclusive set of findings. Among sex workers and groups most at risk, the evidence bears some degree of consistency, indicating an overall tendency of positive impact, with more consistent and stronger results for behavioural and social outcomes than for biomedical ones. Among youth and general communities, the evidence of the effects of CMI remains inconclusive. Overall, it is not possible at this point in time to come to a general conclusion as to whether CMI are effective or not, though there is suggestive evidence for sex worker groups. Our review suggests, nonetheless, two more nuanced lessons that may be drawn.
The first is that CMI appear to be more successful with groups who have a meaningful collective identity rather than with more generalised populations. One of the main characteristics of interventions engaging sex workers and groups most at risk is that they capitalise on these groups' collective identity. CMI often work through their situation of vulnerability to foster mobilisation that is cohesive and fuelled by a need not only to attain HIV-related goals, but also to increase their material and symbolic power and status in the community. Indeed collective identity could arguably have been one of the reasons for success of organic forms of CM efforts such as Sonagachi [74].
One explanation for the different approach in these programmes is that young people and general communities do not evidently display the extreme and conspicuous disadvantages of sex workers and thus do not appear in need of tackling the social determinants of their problems. It is plausible that sex workers can mobilise against specific structural factors that marginalise them particularly (policies, structures and laws to deter sex work), which is not the case with general populations. Similarly, it is possible that mobilising a sub-set of a population is easier than mobilising entire communities. For the case of youth, hence, if they were discriminated against (as is the case of MSM in some contexts), this might foster a collective identity in the group, which would in turn facilitate tackling identifiable social determinants of health among this group.
Second, CMI seem more likely to generate favourable outcomes if accompanied by efforts for change at the structural level. For example, Kerrigan and colleagues' study in the Dominican Republic provided evidence that CMI alone renders some positive outcomes, but when implemented alongside structural changes such as brothel policy of 100 % condom use its results were more effective [14]. Similarly, researchers of the MEMA kwa Vijana trial identified the low status of young people in the community as a barrier to attaining better results as well as females' lower social status and financial reliance on males [75]. These factors, among other sociocultural issues identified by researchers, point to the need to work not only with the 'target group' but also with other community groups, in order to tackle structural barriers to CMI effectiveness.
Critique: Why are the Findings Inconclusive?
We suggest that the evidence is inconclusive not because CMI are ineffective, but instead due to problems with operationalization, evaluation and review methodologies. In other words, the full potential of CMI has rarely been evaluated. In what follows, we discuss problems in the literature, at the level of operationalization of CM, the attention to socio-political context, and the nature of review methodologies. While these problems afflict some parts of the literature, various authors have actively sought to address the problems appropriately. Thus, following each problem we also discuss ways of pre-empting or mitigating such problems.
First, inconclusive results may be related to the operationalization of CM. For complex interventions and trials in general there are a number of programme design issues that impinge on intervention impact, such as programme length, follow-up timespan, intervention exposure and adherence, as well as "underpowered" designs, as has been previously pointed out [33, 50, 60, 76]. In this review, we have identified three flaws in the operationalization which we discuss in turn: (i) understandings of CM remain underdeveloped, and often tokenistic; (ii) implementations of CMI are often characterised by inflexibility; and (iii) the evaluation of CMI tends to inadequately account for social impact.
The first point about operationalization concerns the degree to which CM interventions allow for genuine community ownership. In theory, the merit of CM lies in building sustainable community strengths and agency at the community level [77, 78]. In practice, however, the concept is often used to refer to static and tokenistic activities in which researchers gather "the community" and establish contact with relevant stakeholders. Despite our efforts to employ appropriate inclusion criteria, limited versions of CM were employed in several of our reviewed studies. This was particularly notable in interventions with youth and general communities. Articles describing the nature of CM in the reviewed studies included statements referring to CM as "community sensitisation…to inform the community about the study" and to obtain authorisation [79], activities "to reduce opposition" to the intervention programme [75], "the process of gaining community support for the study" [80], and undertakings to ascertain leaders' "views and seek their support in encouraging community participation" [81]. In these instances, interventions draw on local knowledge and input to execute programmes planned by outsiders [82]. In such cases, at best, communities are "mobilised" first, to gain access to their networks and thus enable research execution and second, to participate in programme delivery [82]. They may not in fact be building and capitalising on the community connections that comprise the main rationale for CM.
Examples of projects that managed to operationalize CM in a way that fostered supportive community relations come from those targeting sex workers and groups most at risk. Overall, these interventions included activities that triggered active community engagement through de-stigmatising public events, fostering of within-community cohesion and alliances with external stakeholders. The Princesinha project in Brazil [68], for example, engaged sex workers as leaders of project activities and data collectors. Public exposure was raised through celebrating the eldest sex worker, carnival participation through a "prejudice-free" samba group carrying prevention posters [68]. In a similar attempt in Brazil, the Encontros project [83] included activities that allowed within-community dialogue around sex work, discrimination, human rights and HIV/STI prevention. They also organised "hot-pink" parties, cultural performances by sex workers at the city's cultural centre, along with external partnerships with the community at large [83]. What these and other interventions [e.g. 72] have in common is the thoughtful implementation of activities that are inclusive of community members and build cohesive relationships among them, while fostering their self-presentation as an assertive 'community' in negotiations with stakeholders in the public sphere.
Stemming from this understanding of CM and in line with requirements of standardisation of intervention components in evaluation research, the second problem at the level of operationalization is inflexibility in the way the majority of the programmes included in our review responded to the needs of communities. A premise of CM is that interventions must be appropriate, and thus adapted to specific local contexts based on community ownership and leadership [2, 18]. However, when studies reported changes in the planned implementation and evaluation, this was presented as a remedial measure taken by researchers, which limits meaningful engagement of the target community and therefore ownership of the project's objectives. For instance, the Manicaland project did not implement the income-generating intervention component originally planned because of country-wide economic decline during the trial [52]. While Stepping Stones programmers acknowledged that "development of interventions is an iterative process, and interventions are generally strengthened by being more extensively tested and adapted" [51], adaptations to the original intervention occurred before this trial was implemented and to fulfil research needs rather than community demands [51].
Among the studies included in this review, two interventions made explicit adaptations while implementing CM. Project Accept [84] made an explicit programmatic point of allowing "site-specific adaptations" to accommodate "site-specific sociocultural differences" in its varying settings. Researchers developed a thoughtful way of balancing consistency and flexibility while maintaining a "minimum level of comparability" [85]. Strategies used to enable consistency of themes across adaptations included engaging field staff in producing the adaptations, ensuring community acceptance, and using steering committee, ethical review boards and intervention subcommittees to approve and implement adaptations [85]. The Avahan intervention also documented the changes applied according to community demands during its implementations [86]. The remaining challenge, of course, is that such complexity, changes, and relative lack of control are at odds with the requirements of rigorous and internally-valid designs such as RCT.
The third problematic point regarding the current operationalization of CM concerns methodological issues in the measurement of impact, particularly social impact. The choice of impacts to measure, and of measurement tools, is often weak, particularly for social outcomes. There might be benefits gained by CMI participants that are not necessarily part of the programmes' evaluated outcomes (e.g. health service use) or that are intangible (e.g. increased participation in groups outside the 'target' community). Among interventions with sex workers, some programmes [55, 59] limit the appraisal of social outcomes to one question per dimension (e.g. collective efficacy), restricting the power of such measurements. This indicates the need both to improve quantitative instruments, and to triangulate evidence from more open-ended data collection methods, to maximise learning from an intervention.
For example, some of the studies included in this review have used process evaluation to explain their quantitative effects [75, 87] to document the challenges of implementing RCT among deprived, rural groupings [81], and to report the most successful CM approaches to engage communities [88]. Process evaluation represents a viable option to gauge the social transformations triggered by CMI because it documents the context of the 'black box' that often seems to be present in 'input–output' models. In addition, it documents 'achievements' that are part of the intervention per se. This is the case because in many contexts the sheer implementation of the programme might be in fact contesting the status quo of its target population, which was the case of a number of studies in this review [67, 68], but that is often missed in quantitative evaluations such as those included here.
Second, many of the interventions failed to engage with the broader social and political context and power relations that structure health in very disadvantaged communities [2]. Contemporary understandings of CM emphasise that communities alone rarely have the power to make the social changes needed to sustain healthy behaviour, and hence, that alongside CM, efforts to engage powerful stakeholders and to move towards structural changes are also required [18, 27, 89]. In contrast to these understandings, in programmes involving youth and general communities, there was evidence of limited efforts to engage the broader community. Where efforts were made to engage groups beyond the target group, this often had the limited aim of enabling the diffusion of health-related knowledge, to parents or other groups [53, 79] rather than engaging them in transformative change.
Among our reviewed studies, it was notable that interventions with sex workers often took greater account of the socio-political context. In such studies, having a support network, altering community relationships and fostering collective action have the potential to bring much wider benefits and thus be valued in their own right, beyond their contribution specifically to HIV prevention. For instance, advocacy was conducted with the police, local government officials, community leaders, FSW's partners and clients, and other gatekeepers [62, 66]. In this way, the 'community' that brings about the project is more inclusive than the interventions' target community groups [23].
Third, reflecting on the very uneven nature of the findings, we suggest that the goal of providing an over-arching statement of 'the evidence' for CM may itself be misguided [90, 91]. Most obviously, we have noted that there is a different pattern of findings for sex workers and for youth and general communities. We have observed that in some studies, there appear to be impacts on condom use with some types of partners, but not others. The IMAGE study found impressive effects on intimate partner violence (and this is widely argued to be a likely contributor to HIV transmission), but no effects on HIV incidence, which by its nature is more difficult to assess. Based on earlier positive results from the Sonagachi Project [16, 92], replications were implemented in Brazil [67, 70] and India [65, 66] but to less positive effect. Furthermore, the Avahan intervention has disaggregated CM components and their impact on a host of measures of condom use in a variety of settings, finding some significant relationships at a fine-grained level, but not much consistency across results [57, 58, 59, 61, 62].
Such inconsistent findings make it appear unrealistic to expect a singular statement about whether CM 'works' or not. More nuanced statements, about the conditions under which CM is more likely to work might have greater potential (e.g. our review suggests that CM may be more likely to succeed if it is implemented in tandem with policy changes). However, it seems unlikely that a definitive set of decision rules to determine when CM should be attempted could be achieved. CM is, by its very nature, contextual and evolving. CM mobilises contextually-specific local networks, in locally-appropriate ways, and allows communities power to create and alter objectives. Thus, CM is not simply an intervention that is equivalent across sites, but takes different forms in different sites. Although the 'evidence-based policy and practice' paradigm prioritises controlled trials and systematic reviews of these, it may be that multi-faceted and context-specific CMI are more challenging to quantify, compare and appraise.
The above critical discussion has implications for future implementation and evaluation of CM. The first is the need for operationalization of CM informed by a committed understanding of social change. We are concerned that the evaluated CMI may not in fact be a good test of the effectiveness of CM, because the interventions do not always heed the transformative objectives behind CM, but treat it simply as an instrumental add-on to increase uptake, being inflexible to the contextual needs of the community participating in the intervention, and using simplistic measures of social outcomes. Part of the issue may be that the improvisational and responsive nature of genuine CM is not compatible with the methodological requirements of controlling variables and standardising intervention components. Another possibility is that the biomedical professionals who often lead such interventions are not equipped with the skills to facilitate an open-ended and complex social process of mobilisation [2, 93]. We propose that a clear understanding of CM, informed by a social scientific theory of change, and recognising the need for specific community development skills is needed. The more established our understanding of CM is, the less likely it will be that the concept is stripped-down and depoliticised when operationalized.
Second, our discussion of context and social groups points towards the need to work with communities to address the socio-political context and to build supportive partnerships with more powerful groups, rather than with community groups in isolation. An enabling policy environment (e.g. decriminalisation and de-stigmatisation of sex work and homosexuality, governmental policies for participatory community planning of interventions) is required for communities to address socio-political issues. The reviewed studies targeting sex workers illustrate that, when such an enabling environment is absent, advocacy may be needed as part of CMI in order to negotiate power relations.
Finally, our critique of the systematic review methodology suggests that judgements about the suitability of CM may need to be made on a more local basis, and informed by a wider set of evidence than that provided by systematic reviews and/or rigorous outcome evaluations. Contemporary work in the philosophy of science questions the desirability of conceptualising social interventions in terms of 'replication' across diverse contexts, arguing that "to draw causal inferences about a target population, which method is best depends case-by-case on what background knowledge we have" [94]. The implication here is that a systematic review of outcome evaluations is insufficient information on which to base the choice or design of a CM intervention. Such information needs to be combined with other sources, including a plausible theory of change and knowledge of the particular context into which the intervention is being introduced.
Taking the evidence at face value (irrespective of our critiques of the form of this evidence), it seems too early to decide whether CM works or not, especially considering the heterogeneity of interventions. At present, at least two RCT which explicitly include CM as a component are being conducted and awaiting biomedical results [95, 96]. They may offer further evidence of the contribution of these quantifying approaches to the planning, implementation and evaluation of CM as currently conceptualised. However, taking our critiques seriously, we suggest that the very aspiration to provide a single statement of 'the evidence' for diverse, evolving, and multifaceted CMI in complex settings may be misguided.
This research was supported by funding from the International HIV/AIDS Alliance.
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Justin Bieber rules pop chart as sales slump
By Keith Caulfield
LOS ANGELES (Billboard) - Canadian teen idol Justin Bieber returned to the top of the U.S. pop chart Wednesday with the second-lowest sales tally for a No. 1 album since tracking firm Nielsen SoundScan started keeping data in May 1991.
Bieber's "My World 2.0" sold 60,300 copies during the week ended May 16, jumping four places to mark a fourth non-consecutive week at the top. The album originally debuted at No. 1 on March 31. Sales to date stand at 1.04 million.
The record low at No. 1 came in January 2007, when the "Dreamgirls" soundtrack spent its second of two weeks at No. 1 with a shade more than 60,000 sold.
Overall album sales hit a record low in the Nielsen SoundScan era. Sales totaled 5.32 million units, down 12% compared to the previous week, and down 9% compared to the comparable sales week of 2009. Year-to-date album sales are off 10 percent.
Last week's No. 1 album, Godsmack's "The Oracle," slid to No. 9 with just under 43,000, taking its two-week total to 117,500.
The top 10 contained four new releases.
New York rock band the National arrived at No. 3 with its fifth full-length album "High Violet," selling 51,000 -- its best week ever. Its last set, "Boxer," debuted and peaked at No. 68 in 2007.
The Dead Weather debuted at No. 5 with "Sea of Cowards," selling 45,000. It's the second album in less than a year for the Jack White side project, whose "Horehound" debuted at No. 6 last July with 51,000 copies. Continued...


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The Wooden Dragon(2004)
A Picture Book by Joan Aiken
Joan Aiken tells the story of lame Window and her sailor brother, Handle, who live in a small house in a wooded hollow. Each autumn, when the leaves fall from the trees, Handle must sweep them all away. But one day, Handle breaks the news that he must go away on an extra long trip and leaves Window a little wooden dragon.
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Description: Peter Bagge is famous for his slacker character Buddy Bradley and, more recently, for his contributions to the libertarian magazine Reason. Margaret Sanger was a noted nineteenth-century birth- activist, as well as an educator, a nurse, a mother, and a founder of Planned Parenthood. The Woman Rebel by Peter Bagge would seem to be an improbable pairing in content and in form, but Sanger's life takes on a whole new vivacity as Bagge creates an adoring, fast-paced biography of this trailblazing woman whose legacy is still incredibly relevant and inspiring. Drawn in full color with an extensive bibliography and an introduction by the journalist Tom Spurgeon of the Comics Reporter, The Woman Rebel showcases Bagge's signature cartoony, rubbery style and potent sense of humor, as well as his respect for the precedent-setting political and social maverick. In a style jam-packed with fact and fun, Bagge charts Sanger's life, from her impoverished childhood in rural New York to her brief formal education, from her work in the Lower East Side tenements to her involvement with the burgeoning birth- movement. Bagge has created the most accessible Sanger biography ever; The Woman Rebel is perfect for introducing this vanguard of the women's rights movement to a whole new generation of readers.
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List price: $21.95Publisher: Drawn & Quarterly PublicationsPublication date: 10/15/2013Binding: HardcoverPages: 88Size: 6.75" wide x 9.00" long x 0.75" tall Weight: 0.946Language: English
Peter Bagge is the internationally acclaimed, award-winning creator of Buddy Does Seattle and Woman Rebel; he lives and teaches in Seattle, WA.
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Location: Bee Research Laboratory2011 Annual Report
1a. Objectives (from AD-416)
The objective of this program is to improve overall colony survival and availability for pollination by bringing together recent ARS research findings on mite-resistant bee stocks, improved diets, mite and disease control alternatives and general colony management techniques into a comprehensive bee management system. The overarching goal of this Areawide program is to increase colony survival and availability for pollination and thus increase the profitability of beekeeping in the U.S.
1b. Approach (from AD-416)
The research will focus on bringing together recent ARS research including: 1) two ARS bee stock improvements, Russian bees and the Varroa Sensitive Hygiene (VSH) trait (Baton Rouge); 2) improvements in nutrition, Mega Bee® (Tucson), HFCS research results (Weslaco); 3) parasitic mite management techniques including new chemical controls 2-heptanone (Tucson), Hivastan® (Weslaco) and non-chemical controls plastic drone comb (Beltsville) and screen bottom boards (Beltsville); 4) management practices including the use of antibiotics, Tylosin® (Beltsville) and Nosema controls (Weslaco and Beltsville). A year-round management scheme will be tested in large migratory and smaller non-migratory beekeeping operations with an emphasis on the larger migratory beekeepers that supply bees to almonds (almost half of all managed bees in the U.S.) The country will be divided into geographic regions as follows; East, Mid-West & West. It is imperative to test in many geographic regions as bees and bee pests and diseases grow at different rates in different parts of the country.
3. Progress Report
Pesticide exposure is of concern for honey bee colonies and debate continues about the role of pesticides in pollinator health. Samples were collected from across the U.S. of bees, pollen and wax to determine the diversity and levels of pesticides present in honey bee colonies. A broad range of pesticides were documented in bee hives with 121 different pesticides detected. The pesticides found were from colonies classified as either healthy or suffering from Colony Collapse Disorder (CCD) and no correlations were obvious to CCD alone. The range of pesticides found is of concern for bee health. Honey bee colony losses continue and data are needed to document bee survival to insure pollination needs can be met. A fourth year of honey bee colony losses in the U.S. was surveyed in the fall and winter of 2010-2011. The overall losses, due to a variety of causes, were 34%. Beekeepers reporting CCD-like symptoms reported higher losses than those that did not report CCD-like symptoms. The overall rate of colony losses has remained steady for four years at approximately 33% and is unsustainable. A targeted survey of ten commercial beekeeping operations was conducted in advance of almond pollination in California. This survey is in its fourth year and is designed to give an overview of the strength of colonies used in almond pollination each year. Increasing colony strength for pollination was correlated with decreasing levels of pests and diseases but no single factor was consistently shown to negatively impact colony strength. ARS scientists at the Bee Research Laboratory in Beltsville, Maryland, are currently testing means to limit the negative effects of pests and pathogens on colony survival with the goal of providing solutions for beekeepers trying to meet the ever-expanding pollination demands of U.S. agriculture. Most honey bee losses due to CCD occur in the late fall and winter in advance of almond pollination and many of these colonies originate in the mid-west. A study was initiated in 2009 that placed commercial colonies in pollen rich and pollen poor areas to determine if resource availability was driving at least a portion of the colony losses. Additionally, the pollen at each site was analyzed for pesticide residue to determine if pesticide exposure was occurring. The survivorship of the colonies in the first and second year of study could not be tied to any specific factor but colonies at poor sites produced lighter weight worker bees with lower vitellogenin levels and feeding at these sites increased individual bee weights. Research findings must be transferred to the user; in this case beekeepers across the U.S. To meet this need an extension website (http://www.extension.org/beehealth) was launched in July 2008 to provide a platform for information exchange on honey bee issues. The website has been upgraded and improved by incorporating user feedback and the placement of recent research findings on the site for ready access by the public. The Web site provides an avenue to disperse up-to-date information and research findings to stakeholders.
4. Accomplishments
1. Publication of the pesticide levels in North America honey bee colonies. A survey was conducted that examined the pesticide levels in honey bee colonies in the U.S. The publication of the survey results documented high levels of a broad range of pesticides in both dying colonies and colonies identified as being apparently healthy. This survey lays the groundwork for more detailed studies on specific interactions between pesticides as it provides a tool to decide which pesticides are most abundant in bee colonies and thus warrant further study. Beekeepers can use this information to identify possible pesticide contamination from specific crops and avoid placing colonies in harmful places. ARS scientists at the Bee Research Laboratory in Beltsville, Maryland, in conjunction with university partners, are currently testing various pesticide combinations based on the findings from this published survey to determine their impact on individual bee and or colony health.
Review Publications
Mullin, C., Frazier, M., Frazier, J.L., Ashcraft, S., Simonds, R., Vanengelsdorp, D., Pettis, J.S. 2010. Pesticides and honey bee health: High levels of Acaricides and crop protection chemicals in U.S. apiaires. Proceedings of the National Academy of Sciences. 5(3):e9754.


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by A.O. Kime (re-edited April 2012)
First of all, it should be said beforehand that our use of the term 'matrix' is quite unlike anything one might expect after seeing the 'matrix movies' - the trilogy. The only commonality is that both the scriptwriters of the movie and I recognized the utility of the term 'matrix' about the same time... how ingeniously it could be applied. Once an innocuous word - as any in the dictionary are until empowered - the scriptwriters decided to breathe life into it, make it play the role as a powerful (but evil) entity... but I saw its usage differently.
If you don't already know, one definition of matrix means 'something within which something else originates or develops'. From this, I saw it fitting for my purposes just as the scriptwriters saw it fitting for theirs.
In the summer of 2002 - before the movie premiered and the resulting 'matrix craze' - I started a company called Matrix of Mnemosyne for the purpose of distributing books and articles. At that time, I had no idea movies were about to be released which would be utilizing the same term (matrix). In other words, I didn't choose that name to capitalize on the craze. In contrast to the movies, I saw it as the perfect term to describe the workings of a divine phenomenon.
However, since the workings of the spirit world can only be expressed allegorically - and since the ancient Greek characterizations can't seem to be improved upon - I chose the goddess Mnemosyne (of Greek mythology) as the 'something' and the 'something else' being divine intelligence.
While likely everyone knows that knowledge is power but likely few know divine intelligence emanates and can be made available. It is clear, this marvelous phenomenon was intended to benefit mankind, certainly not to enslave him. If anything, it could be said we're already enslaved and contact with divine intelligence will set us free. While access to divine intelligence isn't so easy - in fact difficult - enlightenment (knowledge), inspiration and creativity can be taken to new heights.
Mnemosyne was chosen because she is credited as being the mother of the muse and it is they who best represent (allegorically) the mysterious process of emanation. Since Mnemosyne set things in motion so to speak (being their mother), she is ultimately responsible.
Unlike scientific explanations, Greek mythology isn't about the mechanics - typically shallow - and has allegorically characterized this phenomenon better than any attempt since. Of no surprise - but not characterized as proficiently - the Bible utilizes allegories as well (due to the fogginess of the spirit world). It's often the only way to express spiritual realities.
So now you know. But if interested in some related matters... read on.
Curiously, the quest for metaphysical knowledge will eventually lead to the matter of supernaturalness. It's as if they cannot be disentangled.
While the matrix movies revolve around extraordinary powers, or that 'supernatural', so does Greek mythology... except the ancient Greek accounts have nothing to do with 'artificial intelligence' (like in the movie). The Greeks based their tales on what they felt actually existed (more or less) within the spirit world. While the movies were fiction, and the sequences dramatized for effect (to sell tickets), nonetheless the ability to gain supernatural powers appears true. And, as the ticket sales of the movies demonstrated, there's a lot of interest in the supernatural. Perhaps it could be better described as a 'yearning'.
However, physical superhuman abilities would pale in comparison to the miraculous power of the mind... such as our healing powers. After all, if deemed a threat someone with superhuman physical abilities can easily be neutralized... by a gun, for example. Then there is the 'power of the written word' currently available to anyone who wants to write. After all, there's a certain metaphysical aspect to the mastery of languages. Still, to be superhuman is tempting... until, that is, one learns it's problematic (see the 3-part series entitled Man, God and Supernatural Abilities).
Metaphysical powers could be unlimited but to the extent so far demonstrated, none are of a 'spectacular' nature. From all indications, they're subtle and unassuming, so much so that once acquired you can often doubt you even have them. They are difficult to recognize. In other words, it wouldn't be a case of throwing balls of fire or flipping in the air six times… but a way to 'achieve' without the dramatics. Sorry, but there's nothing exciting about metaphysical powers.
However, these 'non-dramatic' superhuman abilities must first be discovered before they can be cultivated... experimentation being the key to discovery. A lot depends on whether one's state of mind is 'healthy' however.
Although there are probably limitations and some things one can never do, these abilities are often masked in a variety of ways. Some may be hidden within the terms 'will power', 'talent' and 'genius'. The only really obvious power are healing powers. Others may have gone untapped for so long they're no longer recognized... although through emanation they can be re-discovered. There are reasons - better reasons than commonly accepted - as to why some people have propelled themselves upwards and others haven't.
Divine intelligence is sometimes referred to as 'the Divine Intellect' and the same phenomenon which Plotinus (205-270) revealed 1,800 years ago which he called the 'nous'.
For 2,500 years, the muse have been widely believed to be the source of inspiration for artists, musicians, writers and poets... and it's still the case today. Of course, such distinctions may not exist as we perceive them since there's nothing you can put your finger on in the world of etherealness. For that matter, distinctions may not exist at all. The spirit world is so bizarre, being metaphysics in effect, about all we humans can do is attempt to describe things as we believe them to exist. In a way, we're probably naming actions rather than entities. For example, when something miraculous happens to save us from disaster, we might often attribute it to our 'guardian angels'. Yet, most people probably consider the term 'guardian angel' a noun (in the physical sense), not a verb (action). In other words, terms can often paint the wrong picture.
|For a different view on instincts and the frame-of-mind see
Instincts and for a philosophical analysis
of light see
The Quest for the Nature of Light
Unfortunately, not much about the spirit world can be explained briefly to give it justice... there's just too much it entails. However, I've tried to break it down and addressed many of the aspects within my articles. Almost every one contain the metaphysical aspects… and that includes the sociopolitical, ancient history and agricultural articles. There's a metaphysical aspect to every reality which shouldn't be overlooked.
A.O. Kime
Matrix of Mnemosyne... the place of smoke signals from the spirit world
Last modified: 03/05/16


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The Voyer family has been producing cognac in the Grande Champagne region since 1870. Wines from the Ugni Blanc grape are distilled on the lees to create rich, fruity eaux de vies, which are then aged in Limousin oak barrels, firstly in new oak for the 'attack' of tannin, then a lengthier time in older barrels in damp cellars to allow them to evolve and complete their slow maturation.
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Northland Radiology provides sports medicine in Wyandotte, MI. A Sports Medicine Physician is able to prevent, diagnose, treat and manage sports-related injuries and conditions.
Please call Northland Radiology at (734) 281-6675 to schedule an appointment in Wyandotte, MI or to get more information.
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Northland Radiology can be found at Fort St 3363. The following is offered: Doctors & Clinics. The entry is present with us since Sep 9, 2010 and was last updated on Nov 14, 2013. In Wyandotte there are 36 other Doctors & Clinics. An overview can be found here.
Northland Radiology is located at 3363 Fort St, Wyandotte, MI. This business specializes in Radiology and Sports Medicine.