A Multisectoral Strategy to Address Persistent Drivers of the HIV Epidemic in East Africa

项目摘要 消除艾滋病毒的进展将停滞不前，除非我们克服新艾滋病毒感染的顽固驱动因素 共同优化艾滋病毒治疗，有效提供艾滋病毒预防模式。我们的目标是确定如何 使用创新的艾滋病毒预防和治疗战略，将艾滋病毒发病率同时降低到0.1% 通过分两个阶段对可扩展的干预措施进行优化和评估，触及“持之以恒的驱动力”人群。 ·在A阶段(1-2年)，我们将进行个别随机对照试验(RCT)，以优化 以下预防和治疗方案：1)动态选择艾滋病毒预防和灵活的预 将暴露/暴露后预防(PrEP/PEP)纳入计划生育、产前护理和 艾滋病毒诊所和社区青年中心，通过提供生活技能来产生需求， 小额信贷和职业培训。2)动态选择个人和系统护理的艾滋病毒治疗方案 专为年轻人、男性、流动人口和酗酒者量身定做的选项和服务。 ·在B阶段(3-5年)，我们将检验这样一种假设，即提供动态选择的多部门干预 对长期驾驶人群的艾滋病毒生物医学预防和治疗将加强病毒抑制 和预防覆盖面，并导致艾滋病毒发病率的下降超过护理标准。 目标1：优化动态预防和治疗干预措施：我们将进行PrEP/PEP随机对照试验 多地点高危人群动态预防和动态治疗干预 病毒载量未受抑制的多个种群。初步疗效结果(艾滋病毒预防覆盖率和 病毒抑制)将与实施成果、成本计算、建模预测和利益相关者一起使用 投入以优化B阶段的动态预防和治疗干预方案。 目的2)比较动态选择预防和动态选择治疗的效果 干预措施与标准护理在预防覆盖率、病毒抑制、艾滋病毒发病率和 3年后的社区健康结果。我们将使用社区随机2x2析因设计来确定 每个干预方案及其组合对预防覆盖率、病毒抑制和其他方面的影响 健康结果。B)通过评估执行情况，阐明干预影响的途径 社区、诊所和个人层面的过程结果和社会行为路径。 目标3：确定可持续性并为政策提供信息。我们会在多个地点计算每项工程的成本。 可避免的艾滋病毒感染的多成分干预和成本估算以及对多种疾病的影响 伤残调整寿命年(DALY)。将使用包含研究数据的建模来通知利益相关者 关于预期的长期健康影响和替代预防和治疗战略的成本。 意义：这项研究将解决有关如何克服助长艾滋病毒的关键因素的主要知识差距 为利益攸关方提供信息并指导政策，以加快消除艾滋病毒的道路。

Project Summary Progress towards HIV elimination will stall unless we overcome persistent drivers of new HIV infections by jointly optimizing HIV treatment and effectively delivering HIV prevention modalities. We aim to determine how to reduce HIV incidence to <0.1% using innovative strategies for HIV prevention and treatment to concurrently reach “persistent driver” populations with scalable interventions optimized and evaluated in two phases. • In Phase A (years 1-2), we will conduct individually randomized controlled trials (RCTs) to optimize the following prevention and treatment packages: 1) Dynamic Choice HIV Prevention with flexible Pre- exposure/post-exposure prophylaxis (PrEP/PEP) access integrated at family planning, antenatal care and HIV clinics and at community Youth Hubs that generate demand by also offering provision of life-skills, micro-finance and vocational training. 2) Dynamic Choice HIV Treatment with individual and system care options and services tailored for youth, men, mobile populations, and heavy drinkers. • In Phase B (years 3-5), we will test the hypothesis that a multi-sector intervention, offering dynamic choice of biomedical HIV prevention and treatment for persistent driver populations will increase viral suppression and prevention coverage and lead to a reduction in HIV incidence greater than standard of care. Aim 1: Optimize dynamic prevention and treatment interventions: We will conduct RCTs of PrEP/PEP dynamic prevention at multiple venues with high risk populations, and dynamic treatment interventions for multiple populations with unsuppressed viral load. Primary efficacy outcomes (HIV prevention coverage and viral suppression) will be used with implementation outcomes, costing, modelling projections, and stakeholder input to optimize dynamic prevention and treatment intervention packages for Phase B. Aim 2: a) Compare the effect of Dynamic Choice Prevention and Dynamic Choice Treatment interventions vs. standard-of-care on prevention coverage, viral suppression, HIV incidence and community health outcomes at 3 years. We will use a community randomized 2x2 factorial design to identify effect of each intervention package and their combination on prevention coverage, viral suppression, and other health outcomes. b) Elucidate pathways of intervention impact via evaluation of implementation and process outcomes and of socio-behavioral pathways of action at the community, clinic, and individual levels. Aim 3: Determine sustainability and inform policy. We will conduct multi-site costing of each aspect of the multi-component intervention and estimate costs per HIV infection averted and impacts on multi-disease disability-adjusted life-years (DALYs). Modelling incorporating study data will be used to inform stakeholders on anticipated long-term health impact and costs of alternative prevention and treatment strategies. Significance: This study will address major knowledge gaps on how to overcome key factors fueling the HIV epidemic that inform stakeholders and guide policies towards accelerating the path to HIV elimination.