School Support as Structural HIV Prevention for Adolescent Orphans in Kenya

说明（由申请人提供）：艾滋病毒/艾滋病流行病导致数百万成年人生病和过早死亡，这反过来又在撒哈拉以南非洲留下了数百万孤儿。仅在肯尼亚，就有240多万孤儿面临着辍学、过早性行为和感染艾滋病毒的巨大风险。在艾滋病流行的第四个十年即将来临之际，该领域的许多人呼吁改变艾滋病毒预防的模式，以解决结构性和个人层面的因素。本研究考察了学校支持作为一种结构性干预的影响，在肯尼亚尼扬扎省的洛族青少年孤儿中进行了测试。在全国所有族裔群体中，洛族的艾滋病毒感染率最高，孤儿患病率最高。该研究采用严格的随机对照试验设计，以检验学校支持是否能使青少年孤儿在过渡到高中期间留在学校，推迟初次性行为，并降低感染艾滋病毒和单纯疱疹病毒2型（HSV-2）的可能性。本研究的具体目的是：1)通过实验检验为罗氏孤男孤女提供综合学校支持是否会减少失学、减少性危险行为和预防HIV/HSV-2感染；2)对方案实施情况进行过程评价；3)进行比较成本效益分析，明确干预的成本和投资回报，以单位成本改善入学率、延迟初次性行为、预防危险行为和艾滋病毒/HSV-2感染的主要结局，以及与健康相关的生活质量的改善为证据。设计将24所小学随机分为干预组和对照组。所有失去父母一方或双方的七年级和八年级学生，无论死因如何，都将被邀请参加；被招募参加研究的总人数约为840名学生，每种情况420名。干预学校的青少年将获得5年的学校支持，包括学费、杂费、校服和一名校本成人“帮助者”。数据将包括年度ACASI调查、学校数据（出勤率、成绩）和HIV/HSV-2生物标本。分析将测试假设的中介和性别调节在因果途径和程序效应。成本效益分析将增加非常需要的与政策相关的信息。

DESCRIPTION (provided by applicant): The HIV/AIDS pandemic has led to illness and early death for millions of adults, and this, in turn, has left many millions of orphans in sub-Saharan Africa. In Kenya, alone, there are more than 2.4 million orphans who are at great risk for school dropout, early sexual debut, and HIV infection. Approaching the fourth decade of the AIDS epidemic, many in the field have called for a paradigm shift in HIV prevention, to address structural, as well as individual-level, factors. This study examines the impact of school support as a structural intervention, tested among adolescent Luo orphans in Nyanza Province, Kenya. The Luos have the highest HIV prevalence and largest orphan prevalence of all ethnic groups in the country. The study uses a rigorous randomized controlled trial design to test whether school support can retain adolescent orphans in school through the transition to high school, delay sexual debut, and reduce the likelihood of HIV and herpes simplex virus type 2 (HSV-2) infections. Specific aims for the proposed study are: 1) To experimentally test whether providing comprehensive school support to Luo orphaned boys and girls will reduce school dropout, reduce sexual risk behaviors, and prevent HIV/HSV-2 infection; 2) To conduct a process evaluation of the implementation of the program; and 3) To conduct comparative cost effectiveness analyses, specifying the intervention's cost and return on investment as evidenced by cost per unit improvement in the primary outcomes of school enrollment, delay of sexual debut and prevention of risk behaviors and HIV/HSV-2 infection, as well as by gains in health- related quality of life. The design randomizes 24 primary schools to intervention or control condition. All youth in grades 7 and 8 who have lost one or both parents, regardless of cause of death, will be invited to participate; the total number of participants to be recruited into the study is approximately 840 students, 420 in each condition. Youth in intervention schools will receive five years of school support, including tuition, fees, uniforms, and a school-based adult "helper." Data will comprise annual ACASI surveys, school data (attendance, grades), and HIV/HSV-2 bio-specimens. Analyses will test posited mediators and gender moderation in causal pathways and program effects. Cost effectiveness analyses will add much needed policy-relevant information.