Multi-component, Targeted HIV Prevention for sub-Saharan Africa: PreventionRx

摘要： 撒哈拉以南非洲普遍的艾滋病毒流行的特点是人口流行率高，低 对艾滋病毒血清状态的了解，以及大多数艾滋病毒传播发生在稳定的异性恋中 合伙企业。任何单一的艾滋病毒预防战略都不会控制非洲的艾滋病毒流行；因此，多层次和 将需要多个组成部分的预防。我们建议开发一种协调的、多组分的艾滋病毒 基于证据的生物医学和行为干预的预防一揽子计划，将根据个人情况量身定做 目标是最大限度地扩大覆盖范围并最大限度地影响非洲人口的艾滋病毒发病率。套餐将会是 通过基于社区的家庭VCT(HBCT)平台提供，以提高人口水平 对血清状态的覆盖率和知识，再加上社区一级关键预防信息的传递。 HBCT在东非已被证明是可行的、可接受的和具有成本效益的，并提供了 独特适用的机制，以识别不知道自己感染艾滋病毒的人、艾滋病毒不和谐的夫妇，以及 未感染艾滋病毒的高危人群--以预防艾滋病毒为目标的高度优先人群。我们假设， 使用HBCT平台，提供个性化的“艾滋病毒预防处方”是可行和可接受的 到具有高覆盖率的关键亚群，结合适当的生物医学和行为 有可能协同作用减少人口层面艾滋病毒传播的干预措施 非洲异性恋流行病。我们的具体目标是：1.进行流行病学分析，系统化 综述和数学建模以确定异性艾滋病病毒的可改变决定因素 撒哈拉以南非洲人口可归因率最高的传播估计 针对这些决定因素的有针对性的预防战略的影响，以及 基于这些分析的预防一揽子计划。2.收集试点数据以确定最高风险 个人(艾滋病毒不和谐的夫妇、艾滋病毒感染者和艾滋病毒阴性的高危人群 行为)，并将行为和生物医学预防干预措施整合和定向到 以人口为基础的HBCT方案。3.设计一项社区随机有效性试验 为东部和南部地区提供全面、有针对性的生物医学和行为艾滋病毒预防一揽子计划 在HBCT框架内的非洲。我们的多学科团队包括流行病学家、数学建模专家、 生物统计学家和在进行多中心生物医学和行为学方面具有广泛专业知识的研究人员 在非洲进行的干预试验。我们建议将HBCT作为提供社区范围行为评估的平台 并提供个性化、多成分的生物医学(例如，男性包皮环切术、抗逆转录病毒治疗)和 向高危人群提供行为艾滋病毒预防套餐。这份有针对性的“预防药方”将成为 本提案产品的基础：未来社区的设计和方案-随机试验 针对撒哈拉以南非洲普遍的异性恋流行病的多成分艾滋病毒预防一揽子计划。

Abstract: The generalized HIV epidemics in sub-Saharan Africa are characterized by high population prevalences, low knowledge of HIV serostatus, and the majority of HIV transmissions occurring within stable heterosexual partnerships. No single HIV prevention strategy will control the African HIV epidemic; thus, multi-layered and multi-component prevention will be needed. We propose to develop a coordinated, multi-component HIV prevention package of evidence-based biomedical and behavioral interventions that will be individually-tailored and targeted to maximize coverage and impact on HIV incidence in an African population. The package will be delivered through a community-based platform of household-based VCT (HBCT) to enhance population-level coverage and knowledge of serostatus, coupled to community-level delivery of key prevention messages. HBCT has been demonstrated to be feasible, acceptable and cost-effective in East Africa and provides a uniquely suitable mechanism to identify persons unaware of their HIV infection, HIV discordant couples, and high-risk HIV uninfected persons - high priority populations for targeting HIV prevention. We hypothesize that, using a HBCT platform, it is feasible and acceptable to deliver an individualized "HIV prevention prescription" to critical subpopulations with high levels of coverage, combining appropriate biomedical and behavioral interventions that are likely to synergistically reduce population-level HIV transmission in the generalized African heterosexual epidemic. Our Specific Aims are to: 1. Conduct epidemiologic analyses, systematic reviews, and mathematical modeling to identify modifiable determinants of heterosexual HIV transmission with the highest population-attributable fraction in sub-Saharan Africa, estimate the impact of targeted prevention strategies directed at these determinants, and select components of a prevention package based on these analyses. 2. Pilot data collection for identification of highest-risk individuals (HIV discordant couples, HIV-infected persons, and HIV-negative persons with high-risk behaviors) with integration and targeting of behavioral and biomedical prevention interventions into population-based HBCT programs. 3. Design a community-randomized effectiveness trial of a comprehensive, targeted, biomedical and behavioral HIV prevention package for East and southern Africa in the context of HBCT. Our multi-disciplinary team includes epidemiologists, mathematical modelers, biostatisticians, and investigators with extensive expertise in conducting multi-center biomedical and behavioral intervention trials in Africa. We propose HBCT as a platform to deliver community-wide behavioral assessment of HIV risk and to provide individualized, multi-component biomedical (e.g., male circumcision, ART) and behavioral HIV prevention packages to at-risk individuals. This targeted "prevention prescription" will be the foundation for the product of this proposal: a design and protocol for a future community-randomized trial of a multi-component HIV prevention package for the generalized heterosexual epidemics in sub-Saharan Africa.