Shaping the Health of Adolescents in Zimbabwe (SHAZ!)

描述(由申请人提供)：津巴布韦正面临普遍的艾滋病毒流行和经济迅速衰退的协同作用。两者都是造成2007年估计有150万孤儿和弱势儿童的原因。青春期女性OVC获得教育和经济机会有限，感染艾滋病毒的可能性是男性的两倍，而且比非OVC更有可能从事高风险的性行为。在感染艾滋病毒的人中，经济脆弱性以及贫穷和艾滋病毒阳性的心理后果增加了二次传播的风险和难以获得护理的机会。在这一弱势群体中，显然需要解决二级预防(艾滋病毒传播和艾滋病毒相关心理疾病)问题；然而，现有的行为干预措施可能影响有限，因为它们没有解决制约行为的基本经济因素。制定和评估针对这些因素的结构性干预措施至关重要。通过这一延续提议，我们提议扩大Shaz！(塑造津巴布韦青少年的健康)--艾滋病毒预防干预措施，通过改善经济机会并将她们与以生活技能为基础的艾滋病毒教育和临床护理联系起来，使青少年女性OVC能够避免性危险行为-艾滋病毒阳性参与者。在融入Shaz的20名艾滋病毒阳性参与者的试点工作基础上！在这项研究中，我们建议在另外650名HIV阳性参与者中进行一项全面的研究，所有这些参与者都将被联系到临床护理，然后随机分配到经济(职业培训、指导咨询和小额赠款)和生活技能干预相结合的组，与单独的生活技能干预相比。在主要研究进行期间启动这一扩展工作(计划于2009年初完成)将使我们能够在现有基础设施的基础上再接再厉，从而实现大量成本节约，并隐瞒研究参与者的艾滋病毒状况，促进我们确保保密的道德任务。通过我们提议的设计--将RTI国际妇女全球健康当务之急、津巴布韦大学-加州大学旧金山分校研究项目、泛古全球艾滋病基金会和Chitungwiza医院的艾滋病毒/艾滋病诊所--结合在一起，我们将评估Shaz的效果！关于以下方面的积极因素：(1)经济生计和社会资源指标；(2)坚持护理和治疗以及随后的健康结果；(3)心理社会发病率、披露和应对技能；(4)与艾滋病毒二次传播有关的行为；以及(4.A)二次传播风险行为是否由治疗结果或心理社会因素介导。如果这个创新的沙兹！对于积极的模型被证明是有效的，这些发现将在该地区和更远的地方具有深远的计划和政策含义。公共卫生相关性：该项目(Shaz！-Plus)旨在促进在高度脆弱的人群中进行二级预防(艾滋病毒传播和与艾滋病毒有关的心理疾病)：生活在津巴布韦的艾滋病毒阳性的青春期女孤儿。通过解决这一人群潜在的经济和社会脆弱性，Shaz！-Plus有可能促进二级预防，超越行为干预可能仅有的有限影响。如果这一创新模式被证明是有效的，这些发现将对该地区乃至更远地区的计划规划和政策产生深远的影响。

DESCRIPTION (provided by applicant): Zimbabwe is confronting the synergistic plagues of a generalized HIV epidemic and rapid economic decline. Both have contributed to the large number of orphans and vulnerable children (OVC) estimated at 1.5 million in 2007. Adolescent female OVC have limited access to educational and economic opportunities, are twice as likely to be HIV infected than their male counterparts, and are more likely than non-OVC to engage in high-risk sexual behavior. Among those that are HIV infected, economic vulnerability and the psychological consequences of being poor and HIV positive, increase the risk of secondary transmission and poor access to care. There is a clear need to address secondary prevention (of HIV transmission and of HIV- related psychological morbidity) in this vulnerable population; however, existing behavioral interventions are likely to have limited impact in that they do not address the fundamental economic factors conditioning behavior. It is critical that structural interventions that do address such factors be developed and evaluated. Through this continuation proposal, we propose to expand SHAZ! (Shaping the Health of Adolescents in Zimbabwe)-an HIV prevention intervention that empowers adolescent female OVC to avoid sexual risk behaviors by improving economic opportunities and linking them to life skills-based HIV education and clinical care-to HIV-positive participants. Building on pilot work among 20 HIV-positive participants integrated into the SHAZ! study, here we propose to conduct a full study of "SHAZ! for Positives" among 650 additional HIV-positive participants, all of whom will be linked to clinical care and then randomly assigned to the combined economic (vocational training, guidance counseling, and a micro-grant) and life skills intervention compared to the life skills intervention alone. Initiating this expansion while the main study is ongoing (targeted for completion in early 2009) will enable us to build on our existing infrastructure and, thus, effect substantial cost savings, as well as conceal the HIV status of study participants, facilitating our ethical mandate to ensure confidentiality. Through our proposed design-that brings together the Women's Global Health Imperative at RTI International, the University of Zimbabwe-UCSF Research Programme, the Pangaea Global AIDS Foundation and the HIV/AIDS clinic at the Chitungwiza Hosptial-we will evaluate the effect of SHAZ! for Positives on: (1) indicators of economic livelihoods and social resources; (2) adherence to care and treatment, and subsequent health outcomes; (3) psychosocial morbidity, disclosure, and coping skills; (4) behaviors associated with the secondary transmission of HIV, and (4.a) whether secondary transmission risk behavior is mediated by treatment outcomes or psychosocial factors. If this innovative SHAZ! for Positives model is proven effective, these findings will have far-reaching program and policy implications in the region and beyond. PUBLIC HEALTH RELEVANCE: This project (SHAZ!-Plus) aims to promote secondary prevention (of HIV transmission and of HIV-related psychological morbidity) among a highly vulnerable population: HIV-positive adolescent female orphans living in Zimbabwe. By addressing the underlying economic and social vulnerability of this population, SHAZ!-Plus has the potential to promote secondary prevention beyond the limited impact behavioral interventions are likely to have alone. If this innovative model is proven effective, these findings will have far-reaching implications for program planning and policy in the region and beyond.