Social Theory Guided Strategies Inform Combination Prevention in the Iringa , Tanzania Trial

1. Social Theory Guided Strategies Inform Combination Prevention in the Iringa, Tanzania Trial David D Celentano Johns Hopkins University on behalf of the Iringa Trial Investigators

2. What is Combination HIV Prevention? • Individual prevention strategies have proven efficacious • Belief that combining individually effective strategies, at scale, will yield synergistic effects • Ultimate goal: decrease in HIV incidence at the population or community level • This would then change the HIV epidemic course

3. Why Iringa? • Highest HIV prevalence in Tanzania: 15.7% (increased from 13.4%) • National HIV prevalence: 5.7%

4. Iringa Region 0 ------------------------ 200 km Iringa Town Population density

5. Why Such High HIV Prevalence? • Vibrant emerging economy – Tanzam Highway • MARPs (truckers, sex workers, tea plantations, timber farms) • Migration/mobility to and from Dar es Salaam, other regions • Low male circumcision rates • 29% in Iringa vs. 67% in Tanzania • High burden of untested and untreated HIV • 22% ART coverage of eligible PLHIV (CD4 ≤ 200) in Tanzania • Disproportionate burden among young women • 8.2% HIV prevalence among young women vs. 4.8% among young men

6. Intervention Package Focus • Intensity (scale and coverage) • Focus (targeting proven interventions to key populations) • Synergy • Facilitation (reducing barriers, encourage participation, adherence, support) • Reduces structural vulnerability which drives risk behavior and reduces biological vulnerability

7. Biomedical Behavioral Structural Men Women Social and Behavioral Change Communication Medical Male Circumcision (MMC)Including outreach to older men HIV Testing and Counseling (HTC) Including outreach to MARPS Cash Transfer (CT)Including vulnerable women HIV Care and Treatment & ART Using point of care CD4 technology Reduced biological susceptibility Reduced behavioral risk Reduced HIV acquisition and transmission

8. Theory Underlying HTC • Social Capital Theory: networks, norms and trust enable participants to promote inclusion and strengthen the community (akin to collective efficacy) at the collective level • Utilizes institutional infrastructure • AIDS Risk Reduction Model at the individual level

9. Ecological Systems Theory • Beyond changing individual behavior, utilizes advocacy, organization change, policy development, economic supports, environmental change require multi-method programs • Intrapersonal factors • Interpersonal processes • Institutional factors • Community factors • Public policy • Interventions that intervene at more levels of influence will be more successful than those that affect only one.

10. Behavioral Economics for HIV Prevention • Behavioral economics combines economics and psychology to identify ways to influence behaviors • Message framing • Financial incentives • Prospect theory

11. Theory of Gender and Power • Addresses the wider social and environmental issues related to power • Focus on gender-based power imbalances • Economic factors, violence, socialization of women to be passive or ignorant • Incorporates the structure of gender relations, societal definitions of masculinity and femininity, and economic power

12. Interventions

13. Combination Prevention Framework

14. Iringa Trial Partners

15. Iringa Initiative Partners

16. The USAID | Project SEARCH, Task Order No.2, is funded by the U.S. Agency for International Development under Contract No. GHH-I-00-07-00032-00, beginning September 30, 2008, and supported by the President’s Emergency Plan for AIDS Relief. The Research to Prevention (R2P) Project is led by the Johns Hopkins Center for Global Health and managed by the Johns Hopkins Bloomberg School of Public Health Center for Communication Programs (CCP).