Resubmission: Multilevel Strategies & Tailored HIV Prevention & Care for Young Couples who use Alcohol & Other Drugs Across Cape Town

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PROJECT SUMMARY/ABSTRACT The highest HIV incidence in South Africa is among young women, many of whom are in relationships with a primary partner in which alcohol and other drug (AOD) use is common between them, in addition to condomless sex, outside sex partners, and gender-based violence (GBV). Many young women and their partners are in young adulthood, a critical period characterized by sexual risk. The proposed revised comprehensive prevention and treatment approach is needed to address these intersectional epidemics. We propose to modify our evidence-based couples' intervention for young couples in Cape Town. The proposed Couples' Health CoOp Plus (CHC+) biobehavioral intervention will include information about and linkage to PrEP and ART. We also will refine a stigma-reduction training for clinics to address stigmatizing attitudes and behaviors toward young people who use AODs and seek HIV services. We propose a multilevel approach through a cluster randomized trial with a modified factorial design whereby 24 clinics are randomized to receive either stigma-reduction training or no training. From the clinic catchment areas in economically disadvantaged communities, we will use NIDA's Seek, Test, Treat and Retain paradigm to seek 480 couples (aged 18 to 30). Clinics in catchment areas will be randomized to receive HIV testing services (HTS) and/or the CHC+. An earlier study demonstrated the efficacy of the couples' intervention on AOD use, sex risk, gender roles and HIV incidence, but it did not incorporate ART and PrEP (treat); nor was it integrated into clinics to address stigma in service provision (treat and retain). The Specific Aims are: Aim 1. To modify the CHC intervention to include ART/PrEP in a formative phase and with review from our Community Collaborative Board and a Peer Advisory Board. Aim 2. To evaluate the impact of a stigma-reduction training on clinic staffs' attitudes and behaviors toward young women and their primary male partner seeking HIV services (testing/ART/PrEP) and other sexual and reproductive health services with clinic staff at 6 and 12 months. Aim 3. To test the efficacy of the CHC+ to increase both partners' PrEP/ART initiation and adherence (at 3, 6, 9, and 12 months), and reduce AOD use, sexual risk and GBV, and enhance positive gender norms and communication relative to HTS (at 6 and 12 months). Aim 4. To examine through mixed methods the interaction of the stigma-reduction training and the CHC+ on increased PrEP and ART initiation, retention, and adherence among young women and their primary partners. If this multilevel approach demonstrates efficacy in increasing PrEP and ART initiation, adherence and retention, it could help achieve the Undetectable=Untransmittable (U=U) goals. If successful, the project could help the governments of South Africa and the United States identify new approaches to expanding the HIV continuum of prevention and care among young couples at risk for HIV.