Protecting Women from Economic shocks to fight HIV in Africa (POWER)

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HIV/AIDS is one of the leading cause of mortality globally and the leading cause among women aged 15-44 years. African women aged 15-24 are twice more likely to be infected with HIV than their male counterparts. In Cameroon, one of the countries with the highest gender disparity in HIV globally, adolescent girls are five times more likely to be infected with HIV than boys of the same age. There is a growing number of studies showing that risks taken during transactional sex and commercial sex -in addition to biological susceptibility- are responsible for gender inequalities in HIV/AIDS. However, there is superficial understanding of the main causes driving risky sexual behaviours of women who engage in those practises in Africa. Recent studies have shown that women mainly adopt risky sexual behaviours in order to cope with negative income shocks (e.g. agricultural and climatic shocks, illness or death of family members) and suggest that economic shocks are a substantial piece of the HIV puzzle in Africa. If women adopt risky sexual behaviours to cope with negative income shocks, hence providing women formal risk-coping strategies could be a very promising approach to prevent HIV. However, there are still important gaps in knowledge, mainly because no previous study has been designed to specifically answer this research question. The goal of this research is to fill these gaps in knowledge in order to inform the design of novel public health interventions to tackle sexually transmitted infections (STIs) and HIV. Specifically, the study aims (1) to estimate the effect of economic shocks affecting households on sexual behaviours and STI and HIV acquisition of young women, (2) to identify the channels through which economic shocks affect STIs and HIV, (3) to estimate the effectiveness of health insurance as a strategy to protect women from economic shocks in order to prevent STI and HIV and (4) to measure the cost-effectiveness of an intervention that protects women from economic shocks to prevent HIV in the general population. The proposed study will follow a new cohort of women in Cameroon. The study will recruit 1,500 unmarried adolescent girls and young women engaging in transactional sex or commercial sex. Over a 1-year period, the study will collect three biobehavioural and socioeconomic surveys as well as weekly sexual diaries (n=78,000). A randomised controlled trial will be embedded to the cohort study and will provide women allocated to the treatment group with a formal risk-coping strategy (a family health insurance). This research is of immediate necessity to address a vital public health challenge of our time and has the strong potential to have a long lasting impact on shaping the research agenda on HIV/AIDS.