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）是世界上感染艾滋病毒风险最高的地区之一 世界如果不减少这一群体的发病率，就不可能有控制艾滋病流行的前景， 高负担的国家将延续几代人。有效的预防方法已经出现 （包括暴露前预防、避孕套和男性伴侣自愿接受的医学包皮环切术） 但使用率很低。我们假设，使用率低的原因与作用于个人的因素（偏好和偏见）有关， 社区（同侪压力和社会规范）和后勤水平（服务提供的性质）; 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， 最好通过干预来解决，但人们对此知之甚少。这项研究将解决这一需要了解的多层次 影响青少年妇女和男性伴侣对艾滋病毒预防的使用，并将制定新的预防干预措施， 结合了行为经济学、社区心理学和数学建模等有前途的方法。的 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驱动因素和瓶颈， 2）使用小规模随机实验来预先测试AGYW的影响、可行性、可接受性和 行为经济学和社区心理干预措施的成本，以加强艾滋病毒预防;和3）估计 如果扩大干预措施，人口一级的影响和成本效益。 将在津巴布韦东部的8个地点进行一次家庭调查，涵盖所有年龄在15-24岁之间的青年妇女及其潜在的男性。 伴侣（15-29岁）和老年人的子样本。问题将涵盖社会人口特征，性行为， 对艾滋病毒风险的认识，以及对艾滋病毒预防方法的态度，以及对艾滋病毒预防方法的可用性、吸收和坚持的认识;以及 将进行HIV和HSV-2感染检测。风险、时间和社会偏好;风险感知;以及认知偏差将 使用实验方法和真实的奖励进行测量，超越自我报告的数据，并使用以下数据进行验证： 在12个月随访后收集HSV-2和HIV发病率。在每个研究中心，村庄将被随机分配到干预组， 控制村庄。在干预村，艾滋病毒抗体阴性的女青年将参加基于反馈的互动咨询 通过纠正对艾滋病毒风险的误解以及PrEP的可用性，可用性和有效性，增加PrEP的吸收。 未接受包皮环切术的艾滋病毒阴性年轻男子将接受一个由一名接受包皮环切术的年轻男子健康顾问提供的关于VMMC的咨询。 工人，并进一步随机分组接受不同的财政/物质奖励采取VMMC。干预 6个月后，将对对照组参与者进行随访，以测量PrEP（使用ARV诊断）和VMMC的摄取情况。 PrEP干预和对照AGYW将被随机分配到PrEP依从性干预， 短信所有AGYW和年轻男性将在6个月（共12个月）后再次接受随访，以测量艾滋病毒和 AGYW中HSV-2发病率和PrEP依从性。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的瓶颈，并评估人口一级的影响和成本效益 预测试的干预措施。这项研究还将有助于评估津巴布韦的DREAMS方案。

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.