Microenterprise and Behavioral Economics Intervention for Sexual and Biomedical HIV Prevention in Vulnerable U.S. Young Adults

项目摘要/摘要 经济脆弱性和种族差距导致非裔美国年轻人 不成比例地感染了艾滋病毒。非洲裔美国人占美国艾滋病毒诊断病例的近一半， 在美国所有年龄段中，年轻人的艾滋病毒感染率最高，这一比例在 城市贫民。经济不稳定，如无家可归和失业，与艾滋病毒的升高有关 流行率。经历经济不稳定可以创造参与生存战略的必要性， 增加艾滋病毒风险和减少避免艾滋病毒的动机，导致性行为冒险和对 预防性药物。微型企业干预(即，非常小的企业)改善了性行为 低收入国家艾滋病预防与商业相结合的行为与用药依从性 培训、指导和赠款--主要针对妇女。微型企业通过增加 通过就业和可就业的创收技能实现经济稳定。这反过来又减少了财务困境。 与危险行为相关，同时增加获得艾滋病毒服务的资源并改善非认知性 与健康行为相关的技能(即毅力、毅力)。然而，微型企业的研究在很大程度上 在纵向评估有限的男性和非裔美国人中被忽略。以前的研究也没有 利用移动医疗或行为经济学(BE)塑造年轻人对预防成本和 奖励。从我们完成的K01中获得了有希望的初步数据，证明了可行性和 微型企业试点的可接受性，建议的R01建立在K01的基础上，建立在两个 重要的HIV行为和生物医学主要结果：无避孕套的性行为和沿前 暴露预防(PrEP)连续体(即沉思、临床预约、启动)和中间阶段 以及调解与经济稳定有关的变量。我们将实施同行驱动的微型企业模式， 适应服务不足的美国社区。我们的跨学科团队在预防科学方面拥有专业知识， 性健康、小额信贷、流行病学、生物统计学、定性科学和行为经济学。我们会 将参与者随机分配到将接受创业、金融知识和艾滋病毒培训的试验组 预防教育(即避孕套使用、PrEP)、小额补助金、导师、BE通知的短信和工作 通知或将收到日常护理工作通知的控制组。我们将使用答辩人- 推动抽样以招募高风险、经济脆弱、未感染艾滋病毒的种子及其同龄人，年龄为18岁- 24.为了利用同伴的支持，我们将按集群随机进行，相当于一个种子和他们的新兵。具体的 目的是：(1)评价干预措施对经济稳定性、无套管性行为和PrEP的效果 开始干预后长达24个月；(2)评估干预效果的异质性；(3)检查 运用统计和定性的方法研究变化的机制。如果被发现是有效的，干预已经 有可能成为美国城市环境中降低艾滋病毒风险和经济赋权的典范。

Project Summary / Abstract Economic vulnerability and racial disparities contribute to African-American young adults being disproportionately infected by HIV. African-Americans account for nearly half of all HIV diagnoses in the U.S., and young adults have the highest HIV rates of all U.S. age groups, comprising an increasing proportion of the urban poor. Economic instability, such as homelessness and unemployment, is associated with higher HIV prevalence. Experiencing economic instability can create imperatives to engage in survival strategies that increase HIV risk and diminish motivations to avoid HIV, resulting in sexual risk-taking and low uptake of preventive medications. Microenterprise interventions (i.e., very small businesses) have improved sexual behaviors and medication adherence in low-income countries by combining HIV prevention and business training, mentoring, and grants – primarily in women. Microenterprise reduces HIV risk through increased economic stability via jobs and employable income-generating skills. This, in turn, decreases financial distress associated with risk behaviors, while increasing resources to access HIV services and improving non-cognitive skills (i.e., persistence, grit) associated with healthy behaviors. However, microenterprise studies have largely been omitted in men and African-Americans with limited longitudinal assessment. Prior studies have also not leveraged mobile health or behavioral economics (BE) to shape how youth perceive prevention costs and rewards. Having obtained promising preliminary data from our completed K01 that demonstrated feasibility and acceptability of a microenterprise pilot, the proposed R01 builds on the K01 by establishing efficacy on two important HIV behavioral and biomedical primary outcomes: condomless sex and movement along the pre- exposure prophylaxis (PrEP) continuum (i.e., contemplation, clinic appointment, initiation), and on intermediate and mediating variables related to economic stability. We will implement a peer-driven microenterprise model, adapted for underserved U.S. communities. Our interdisciplinary team has expertise in prevention science, sexual health, microfinance, epidemiology, biostatistics, qualitative science, and behavioral economics. We will randomize participants to experimental group that will receive entrepreneurial, financial literacy, and HIV prevention education (i.e., condom use, PrEP), microgrants, mentors, text messages informed by BE, and job announcements or to control group that will receive usual care job announcements. We will use respondent- driven sampling to recruit high-risk, economically-vulnerable, HIV-uninfected seeds and their peers, aged 18- 24. To leverage peer support, we will randomize by cluster, equal to a seed and their recruits. The specific aims are to: (1) Evaluate the efficacy of the intervention on economic stability, condomless sex, and PrEP initiation up to 24-months post-intervention; (2) Assess heterogeneity of intervention effects; and (3) Examine mechanisms of change using statistical and qualitative methods. If found to be effective, the intervention has the potential to be a model of HIV risk reduction and economic empowerment in U.S. urban settings.