Multi-Level Behavioral Economics and Community Psychology Approaches to Strengthen HIV Prevention Cascades in Adolescent Girls and Young Women in East Zimbabwe

南部非洲的少女和年轻妇女(AGYW)感染艾滋病毒的风险在全世界任何地方都是最高的。 整个世界。如果不减少这一群体的发病率，就不可能有疫情控制和#年艾滋病毒流行的前景。 高负担的国家将代代相传。现在已经有了有效的预防方法 (包括暴露前预防[PrEP]、避孕套和男性伴侣自愿医疗男性包皮环切术[VMMC]) 但使用率很低。我们假设使用率低的原因与个人因素(偏好和偏见)有关， 社区(同龄人压力和社会规范)和后勤水平(提供服务的性质)； 消除这些障碍将有助于释放现有方法的潜在预防影响。但这些因素如何相互作用，以及 最好的解决办法是干预，但人们对此知之甚少。这项研究将解决这一需要，以了解多层次 对AGYW和男性伴侣使用艾滋病毒预防的影响，并将通过以下方式制定新的预防措施 结合了行为经济学、社区心理学和数学建模的有前途的方法。这个 具体目标是：1)使用艾滋病毒预防级联的新框架来确定风险的驱动因素和瓶颈 为AGYW预防艾滋病毒；2)使用小规模随机试验来预先测试影响、可行性、可接受性和 加强艾滋病毒预防的行为经济学和社区心理干预的成本；以及3)估计 如果扩大干预措施，人口层面的影响和成本效益。 将在津巴布韦东部的8个地点进行家庭调查，覆盖所有AGYW(15-24岁)及其潜在男性 伴侣(15-29岁)和一组老年人。问题将包括社会人口统计特征，性行为， 艾滋病毒风险认知，以及对艾滋病毒预防方法的态度和感知的可获得性、接受性和坚守；以及 将进行艾滋病毒和HSV-2感染测试。风险、时间和社会偏好；风险感知；以及认知偏差 使用实验方法和实际回报进行衡量，超越自我报告的数据，并使用以下数据进行验证 随访12个月后收集HSV-2和HIV发病率。在每个地点，村庄将被随机分为干预和 控制村庄。在干预村，艾滋病毒阴性的AGYW将参加以反馈为基础的互动咨询 通过纠正对艾滋病毒风险以及PrEP的可获得性、可用性和有效性的误解，提高PrEP的使用率。 未接受割礼的艾滋病毒阴性的年轻男子将在VMMC上接受由接受割礼的年轻男性健康中心提供的咨询课程 并进一步随机分成不同的组，接受不同的经济/物质奖励，以使用VMMC。干预 而对照组参与者将在6个月后进行随访，以测量PrEP(使用ARV诊断)和VMMC的摄取情况。 对PrEP的干预和对照AGYW将随机分为PrEP依从性干预和个性化短期干预 短信。所有AGYW和年轻男子将在6个月后(总共12个月)再次接受随访，以检测艾滋病毒和 AGYW患者HSV-2感染与PrEP依从性的关系所有数据将用于艾滋病毒传播和艾滋病毒的数学模型 预防级联，以确定艾滋病毒预防方面的瓶颈，并评估人口层面的影响和成本效益 预先测试过的干预措施。这项研究还将有助于对津巴布韦的DREAMS计划进行评估。

Adolescent girls and young women (AGYW) in southern Africa suffer some of the highest risks of HIV infection anywhere in the world. Without reduced incidence in this group, there can be no prospect of epidemic control and the HIV epidemic in high-burden countries will be perpetuated into successive generations. Efficacious prevention methods are now available (including pre-exposure prophylaxis [PrEP], condoms and voluntary medical male circumcision [VMMC] for male partners) but use is low. We hypothesize that the reason why use is low is related to factors acting at individual (preferences and biases), community (peer pressure and social norms) and logistical levels (nature of availability of services); and that interventions that address these barriers will help unlock the potential prevention impact of existing methods. But how these factors interact, and are best addressed with interventions, is poorly understood. This research will address this need to understand the multi-level influences on use of HIV prevention in AGYW and male partners, and will develop new prevention interventions by combining promising approaches from behavioral economics, community psychology, and mathematical modelling. The specific aims are to: 1) use the novel framework of HIV prevention cascades to identify drivers of risks and bottlenecks in HIV prevention for AGYW; 2) use small-scale randomized experiments to pre-test the impact, feasibility, acceptability and cost of behavioral economics and community psychology interventions to strengthen HIV prevention; and 3) estimate the population-level impact and cost-effectiveness if interventions were scaled-up. A household survey will be conducted in 8 sites in east Zimbabwe, covering all AGYW (15-24) and their potential male partners (15-29) and a sub-sample of older people. Questions will cover socio-demographic characteristics, sexual behavior, HIV risk perception, and attitudes towards and perceived availability, uptake and adherence to HIV prevention methods; and tests for HIV and HSV-2 infections will be done. Risk, time and social preferences; risk perception; and cognitive biases will be measured using experimental methods and real rewards, to move beyond self-reported data, and validated using data on HSV-2 and HIV incidence collected after 12 months follow-up. In each site, villages will be randomized into intervention and control villages. In intervention villages, HIV-negative AGYW will participate in feedback-based interactive counselling sessions to increase PrEP uptake by correcting misperceptions of HIV risks and availability, usability and efficacy of PrEP. Uncircumcised HIV-negative young men will receive a counselling session on VMMC by a circumcised young male health worker and further randomized into groups receiving different financial/material rewards for taking up VMMC. Intervention and control participants will be followed-up after 6 months to measure uptake of PrEP (using ARV diagnostics) and VMMC. Both intervention and control AGYW on PrEP will be randomized to a PrEP adherence intervention with personalized short text messages. All AGYW and young men will be followed-up again after 6 months (12 months in total) to measure HIV and HSV-2 incidence and PrEP adherence in AGYW. All data will be used in mathematical models of HIV transmission and HIV prevention cascades to identify bottlenecks in HIV prevention, and assess the population-level impact and cost-effectiveness of the pre-tested interventions. This research will also contribute to the evaluation of the DREAMS program in Zimbabwe.