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.

Public Health Relevance

The scale-up of antiretroviral therapy has transformed the health of HIV-endemic populations in South Africa, with unprecedented gains in life expectancy (Bor et al. 2013) and significant reductions in risk of new infection (Tanser et al. 2013). Nevertheless HIV-related mortality and HIV incidence rates remain high in many communities in sub-Saharan Africa (SSA). 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. Utilizing the statistical power of a decade-long population-based HIV cohort in KwaZulu-Natal, South Africa, we will establish for the first time - through a rigorous impact evaluation - whether an intervention targeting men for motivation of HIV testing and ART program linkage can reduce HIV-related mortality in men and HIV incidence in young women. The results of this work will directly inform the development and targeting of prevention efforts in the context of generalized ART coverage.

National Institute of Health (NIH)
National Institute of Allergy and Infectious Diseases (NIAID)
Research Project (R01)
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Special Emphasis Panel (ZRG1)
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Miller, Judith A
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Kwazulu-Natal Research Institute Tb-HIV
South Africa
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Yapa, H Manisha; Bärnighausen, Till (2018) Implementation science in resource-poor countries and communities. Implement Sci 13:154
Ortblad, Katrina F; Musoke, Daniel K; Ngabirano, Thomson et al. (2018) Female Sex Workers Often Incorrectly Interpret HIV Self-Test Results in Uganda. J Acquir Immune Defic Syndr 79:e42-e45
Brennan, Alana T; Bor, Jacob; Davies, Mary-Ann et al. (2018) Medication Side Effects and Retention in HIV Treatment: A Regression Discontinuity Study of Tenofovir Implementation in South Africa and Zambia. Am J Epidemiol 187:1990-2001
Geldsetzer, Pascal; Fink, Günther; Vaikath, Maria et al. (2018) Sampling for Patient Exit Interviews: Assessment of Methods Using Mathematical Derivation and Computer Simulations. Health Serv Res 53:256-272
Haber, Noah; Harling, Guy; Cohen, Jessica et al. (2018) List randomization for eliciting HIV status and sexual behaviors in rural KwaZulu-Natal, South Africa: a randomized experiment using known true values for validation. BMC Med Res Methodol 18:46
Ortblad, Katrina F; Chanda, Michael M; Musoke, Daniel Kibuuka et al. (2018) Acceptability of HIV self-testing to support pre-exposure prophylaxis among female sex workers in Uganda and Zambia: results from two randomized controlled trials. BMC Infect Dis 18:503
Hontelez, Jan A C; Bor, Jacob; Tanser, Frank C et al. (2018) HIV Treatment Substantially Decreases Hospitalization Rates: Evidence From Rural South Africa. Health Aff (Millwood) 37:997-1004
Oldenburg, Catherine E; Seage, George R; Tanser, Frank et al. (2018) Antiretroviral Therapy and Mortality in Rural South Africa: A Comparison of Causal Modeling Approaches. Am J Epidemiol :
Ortblad, Katrina F; Kibuuka Musoke, Daniel; Ngabirano, Thomson et al. (2018) HIV self-test performance among female sex workers in Kampala, Uganda: a cross-sectional study. BMJ Open 8:e022652
Ginsburg, Carren; Bocquier, Philippe; Béguy, Donatien et al. (2018) Association between internal migration and epidemic dynamics: an analysis of cause-specific mortality in Kenya and South Africa using health and demographic surveillance data. BMC Public Health 18:918

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