Can HIV Hot-Spots be eradicated? An intervention to decrease HIV transmission to young women in rural KwaZulu-Natal South Africa

 描述（由申请人提供）：在最近发表在《科学》杂志上的两篇论文中，我们证明了南非农村公共部门扩大ART的规模导致（i） 成年人预期寿命和（ii）艾滋病毒感染风险显著下降，两者都是在人群水平上测量的（Bor et al. 2013; Tanser et al. 2013）。然而：在艾滋病毒流行的环境中，艾滋病毒发病率和死亡率仍然高得令人无法接受。特别是，年轻妇女（15-30岁）感染艾滋病毒的风险仍然极高，迫切需要为这一群体制定更有效的预防方案。此外，虽然南非公共部门设施大规模提供免费抗逆转录病毒疗法，大大降低了男女艾滋病毒相关死亡率，但感染艾滋病毒的男子受益程度远远低于妇女，因为男子与艾滋病毒护理联系在一起的可能性要小得多。如果要实现艾滋病规划署的90-90-90目标，就必须消除获得抗逆转录病毒疗法方面的性别差距。目前艾滋病毒方案的两个不足之处-妇女艾滋病毒感染率居高不下和男子获得抗逆转录病毒治疗的机会相对较低-是密不可分的。为了成功的治疗-作为预防，迫切需要大量艾滋病毒感染男子-他们目前没有从抗逆转录病毒疗法中获益，而且正在感染年轻妇女-开始接受抗逆转录病毒疗法。来自这一社区的现有证据和初步数据表明，通过家庭-对艾滋病毒检测和与护理的联系给予财政奖励。在本提案中，我们寻求通过一次性、分两个阶段的财政激励措施，鼓励在沿着真实的世界环境中进行艾滋病毒检测并将其与艾滋病毒治疗联系起来，从而降低年轻女性艾滋病毒感染率和男性艾滋病毒相关死亡率。我们将补充一些激励性咨询的内容，并制定对性别问题敏感的方法，这些方法借鉴现有的男女价值观和规范。在发展之后，我们将在非洲中心艾滋病毒监测地区所含42个社区中的三分之一实施干预措施。在实施科学框架内使用差异中的差异设计，我们将利用通过十年之久的艾滋病毒监测获得的统计能力，并将分别比较接受和未接受干预的社区居民干预前后男性病毒载量、男性死亡率和女性发病率（15-30岁）的变化。然后，将通过非洲中心持续三年的基于人口的艾滋病毒监测对参与者进行例行跟踪。这项工作的结果将直接为在普遍抗逆转录病毒疗法覆盖范围内开展预防工作和确定预防目标提供信息。

 DESCRIPTION (provided by applicant): In two recent papers published in Science, we have demonstrated that public sector scale-up of ART in rural South Africa led to (i) large increases in adult life expectancy and (ii) significant declines in HIV infection risk, both measured at the population level (Bor et al. 2013; Tanser et al. 2013). And yet: HIV incidence and mortality rates remain unacceptably high in this HIV-endemic setting. In particular, young women (aged 15-30) remain at extremely high risk of HIV acquisition and more effective prevention programming is urgently needed for this group. Moreover, while the mass provision of free ART in public sector facilities in South Africa has dramatically reduced HIV-related mortality for both men and women, HIV-infected men are benefitting to a far lesser extent than women, because men are far less likely to link to HIV care. If the UNAIDS 90-90-90 targets are to be realized the gender gap in ART access has got to be closed. The two deficiencies in current HIV programs - continued high HIV incidence in women and comparatively low ART access in men - are inextricably linked. For successful treatment-as prevention, it is urgent that those large numbers of HIV-infected men - who are currently not benefitting from ART and who are infecting young women - are started on ART. Existing evidence and preliminary data from this community suggest that increased HIV testing and linkage to care can be successfully achieved through a combination of home-based HIV testing and financial incentives for both HIV testing and linkage to care. In this proposal we seek to reduce young female HIV incidence and male HIV-related mortality through a once-off, two-stage financial incentive to encourage HIV testing and linkage to HIV treatment in a real- world setting along. We will supplement this with some elements of motivational counselling and develop gender-sensitive approaches which draw on existing values and norms for men and for women. Following development we will implement the intervention in one third of the 42 communities contained in the Africa Centre's HIV surveillance area. Using a difference-in-differences design within an implementation science framework we will leverage the statistical power gained through a decade's long HIV surveillance and will compare the change in male viral load, male mortality and female incidence (15-30 years of age) pre and post intervention for residents of communities who receive and who do not receive the intervention respectively. Participants will then be followed up routinely through the Africa Centre's ongoing population-based HIV surveillance for three years. The results of this work will directly inform the development and targeting of prevention efforts in the context of generalized ART coverage.