Botswana has the 2nd highest HIV prevalence in the world, peaking at 40.2% in 30-34 year olds. Botswana also has been the world's leader in providing universal free access to AZT, prevention of mother to child transmission, an extensive network of VCT centers, and a nationwide male circumcision program. However, this emphasis on biomedical strategies for case finding, care, and treatment has not been paralleled by primary prevention programs. The new national strategic plan to be issued in 2010 now places importation and adaptation of evidence-based behavioral prevention as the highest strategic priority for the immediate future. It is in response to the new strategic plan that this collaborative R34 proposal to adapt and pilot an evidence-based program, the Becoming a Responsible Teen (BART) intervention, for Batswana youth is submitted. Guided by a teen advisory committee and a community advisory board, we will conduct focus groups with youth and in-depth interviews with key informants in the first year to inform adaptation of the measurement protocol and intervention for youths 14-19 in Gabarone secondary schools. In the 2nd year, measures will be pilot tested to establish their psychometric properties and to compare responses by gender. Role play vignettes will be drafted, their social and ecological validity assessed, and the BART intervention will be adapted for Batswana adolescents. New culturally appropriate modules addressing alcohol as a risk factor, conflict resolution to reduce intimate partner violence, and stigma reduction will be added. In addition, a new 3-session intervention for parents and a separate 3-session program for household caretakers will be added, addressing HIV/AIDS information, communicating with youth on sensitive topics, and monitoring, In the 3rd year, a pilot feasibility study will assess recruitment, retention, interventionists'fidelity, and youth and parents/caretakers'response to their respective interventions, and whether the results suggest that the Botswana version of BART provides value added when compared against the existing Life Skills curriculum in the secondary schools. This developmental application is the first step in a programmatic sequence developed in collaboration between the University of Botswana, governmental agencies and NGOs in Gaborone, and Mississippi State University. If the feasibility trial documents positive changes in behavior, it will inform a R01 application for a larger randomized controlled trial with cognitive, behavioral and biological endpoints. If the RCT provides strong evidence of effectiveness, we will work with the Ministries of Education, Health, and Youth and Culture to disseminate the intervention throughout Botswana's secondary schools and train staff in each community to deliver the program with fidelity.
Botswana is one of the two countries hardest hit by AIDS anywhere in the world with adult prevalence that peaks at 40.2% in 30-34 year olds. As a result, life expectancy is reduced from 70 to 33 years. An estimated 37-39% of Botswana's adults between the ages of 15-49 are HIV-infected in contrast to the sub-Saharan average of 5.0%. Despite extensive efforts by Botswana governmental and non- governmental organization s (NGOs) to combat the pandemic through testing, universal treatment, and male circumcision, these biomedical strategies have not been paralleled by attention to effective behavioral interventions. A new national strategic plan to be released in 2010 identifies behavioral primary prevention for youth based on evidence-based programs as the highest priority for the next three years. This proposal to adapt BART, an evidence-based HIV prevention program of proven effectiveness, for Botswana youth is timely, responding to the new national priorities that refocus attention to primary prevention in order to reduce the incidence of new infections, especially among youth.