Multi-component, Targeted HIV Prevention for sub-Saharan Africa: PreventionRx

描述（由申请人提供）： 摘要：撒哈拉以南非洲艾滋病毒普遍流行的特点是人口流行率高，对艾滋病毒血清状况的了解少，大多数艾滋病毒传播发生在稳定的异性伴侣关系中。任何单一的艾滋病毒预防战略都无法控制非洲的艾滋病毒流行病;因此，需要多层次和多组成部分的预防。我们建议制定一个协调的、多组成部分的艾滋病毒预防一揽子计划，包括循证生物医学和行为干预措施，这些措施将根据个人情况量身定制，并有针对性地最大限度地扩大覆盖面，并对非洲人口的艾滋病毒发病率产生影响。将通过以社区为基础的家庭自愿咨询和检测（HBCT）平台提供这套服务，以提高人口一级的覆盖率和对血清状况的了解，同时在社区一级提供关键的预防信息。HBCT在东非已被证明是可行的、可接受的和具有成本效益的，并提供了一种独特的适当机制，以确定不知道自己感染艾滋病毒的人、艾滋病毒不一致的夫妇和高风险的未感染艾滋病毒的人-针对艾滋病毒预防的高度优先人群。我们假设，使用HBCT平台，它是可行的和可接受的，提供个性化的“艾滋病毒预防处方”，以高水平的覆盖率的关键亚群，结合适当的生物医学和行为干预，有可能协同减少人口水平的艾滋病毒传播在广义的非洲异性恋流行。我们的具体目标是：1。进行流行病学分析，系统评价和数学建模，以确定撒哈拉以南非洲地区人口比例最高的异性恋艾滋病毒传播的可变决定因素，估计针对这些决定因素的有针对性的预防战略的影响，并根据这些分析选择预防一揽子计划的组成部分。2.试点数据收集，以确定最高风险的个人（艾滋病毒不一致的夫妇，艾滋病毒感染者，艾滋病毒阴性的人与高风险行为）的整合和有针对性的行为和生物医学预防干预措施，以人口为基础的HBCT计划。3.在HBCT的背景下，为东非和南部非洲设计一项全面、有针对性、生物医学和行为艾滋病毒预防一揽子计划的社区随机有效性试验。我们的多学科团队包括流行病学家，数学建模师，生物统计学家和研究人员，他们在非洲进行多中心生物医学和行为干预试验方面具有广泛的专业知识。我们建议HBCT作为一个平台，提供社区范围内的艾滋病毒风险行为评估，并提供个性化的，多成分的生物医学（例如，男性包皮环切术（ART）和艾滋病毒行为预防包的风险个人。这一有针对性的“预防处方”将成为本申请产品的基础：为撒哈拉以南非洲普遍异性恋流行病的多组分艾滋病毒预防包的未来社区随机试验设计和方案。基于流行病学分析和数学建模的艾滋病毒传播的决定因素在非洲和潜在的干预措施，我们将设计一个循证艾滋病毒预防包和社区随机试验，这将是一个平台上实施的家庭为基础的自愿艾滋病毒咨询和检测，以针对高危人群，实现高水平的覆盖率。

DESCRIPTION (provided by applicant): Abstract: The generalized HIV epidemics in sub-Saharan Africa are characterized by high population prevalence, low knowledge of HIV serostatus, and the majority of HIV transmissions occurring within stable heterosexual partnerships. No single HIV prevention strategy will control the African HIV epidemic; thus, multi-layered and multi-component prevention will be needed. We propose to develop a coordinated, multi-component HIV prevention package of evidence-based biomedical and behavioral interventions that will be individually-tailored and targeted to maximize coverage and impact on HIV incidence in an African population. The package will be delivered through a community-based platform of household-based VCT (HBCT) to enhance population-level coverage and knowledge of serostatus, coupled to community-level delivery of key prevention messages. HBCT has been demonstrated to be feasible, acceptable and cost-effective in East Africa and provides a uniquely suitable mechanism to identify persons unaware of their HIV infection, HIV discordant couples, and high-risk HIV uninfected persons - high priority populations for targeting HIV prevention. We hypothesize that, using a HBCT platform, it is feasible and acceptable to deliver an individualized "HIV prevention prescription" to critical subpopulations with high levels of coverage, combining appropriate biomedical and behavioral interventions that are likely to synergistically reduce population-level HIV transmission in the generalized African heterosexual epidemic. Our Specific Aims are to: 1. Conduct epidemiologic analyses, systematic reviews, and mathematical modeling to identify modifiable determinants of heterosexual HIV transmission with the highest population-attributable fraction in sub-Saharan Africa, estimate the impact of targeted prevention strategies directed at these determinants, and select components of a prevention package based on these analyses. 2. Pilot data collection for identification of highest-risk individuals (HIV discordant couples, HIV-infected persons, and HIV-negative persons with high-risk behaviors) with integration and targeting of behavioral and biomedical prevention interventions into population-based HBCT programs. 3. Design a community-randomized effectiveness trial of a comprehensive, targeted, biomedical and behavioral HIV prevention package for East and southern Africa in the context of HBCT. Our multi-disciplinary team includes epidemiologists, mathematical modelers, biostatisticians, and investigators with extensive expertise in conducting multi-center biomedical and behavioral intervention trials in Africa. We propose HBCT as a platform to deliver community-wide behavioral assessment of HIV risk and to provide individualized, multi-component biomedical (e.g., male circumcision, ART) and behavioral HIV prevention packages to at-risk individuals. This targeted "prevention prescription" will be the foundation for the product of this application: a design and protocol for a future community-randomized trial of a multi-component HIV prevention package for the generalized heterosexual epidemics in sub-Saharan Africa. Based on epidemiologic analyses and mathematical modeling of HIV transmission determinants in generalized heterosexual epidemics in Africa and potential interventions, we will design an evidence-based HIV prevention package and a community-randomized trial of this prevention package which will be implemented on a platform of home-based voluntary HIV counseling and testing to target high-risk persons and achieve high levels of coverage.