Can HIV Hot-Spots be eradicated? An intervention to decrease HIV transmission to young women in rural KwaZulu-Natal South Africa

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 DESCRIPTION (provided by applicant): In two recent papers published in Science, we have demonstrated that public sector scale-up of ART in rural South Africa led to (i) large increases in adult life expectancy and (ii) significant declines in HIV infection risk, both measured at the population level (Bor et al. 2013; Tanser et al. 2013). And yet: HIV incidence and mortality rates remain unacceptably high in this HIV-endemic setting. In particular, young women (aged 15-30) remain at extremely high risk of HIV acquisition and more effective prevention programming is urgently needed for this group. Moreover, while the mass provision of free ART in public sector facilities in South Africa has dramatically reduced HIV-related mortality for both men and women, HIV-infected men are benefitting to a far lesser extent than women, because men are far less likely to link to HIV care. If the UNAIDS 90-90-90 targets are to be realized the gender gap in ART access has got to be closed. The two deficiencies in current HIV programs - continued high HIV incidence in women and comparatively low ART access in men - are inextricably linked. For successful treatment-as prevention, it is urgent that those large numbers of HIV-infected men - who are currently not benefitting from ART and who are infecting young women - are started on ART. Existing evidence and preliminary data from this community suggest that increased HIV testing and linkage to care can be successfully achieved through a combination of home-based HIV testing and financial incentives for both HIV testing and linkage to care. In this proposal we seek to reduce young female HIV incidence and male HIV-related mortality through a once-off, two-stage financial incentive to encourage HIV testing and linkage to HIV treatment in a real- world setting along. We will supplement this with some elements of motivational counselling and develop gender-sensitive approaches which draw on existing values and norms for men and for women. Following development we will implement the intervention in one third of the 42 communities contained in the Africa Centre's HIV surveillance area. Using a difference-in-differences design within an implementation science framework we will leverage the statistical power gained through a decade's long HIV surveillance and will compare the change in male viral load, male mortality and female incidence (15-30 years of age) pre and post intervention for residents of communities who receive and who do not receive the intervention respectively. Participants will then be followed up routinely through the Africa Centre's ongoing population-based HIV surveillance for three years. The results of this work will directly inform the development and targeting of prevention efforts in the context of generalized ART coverage.