The highest HIV incidence in South Africa is among young women, many of whom are in relationships with
a primary partner in which alcohol and other drug (AOD) use is common between them, in addition to
condomless sex, outside sex partners, and gender-based violence (GBV). Many young women and their
partners are in young adulthood, a critical period characterized by sexual risk. The proposed revised
comprehensive prevention and treatment approach is needed to address these intersectional epidemics. We
propose to modify our evidence-based couples' intervention for young couples in Cape Town.
The proposed Couples' Health CoOp Plus (CHC+) biobehavioral intervention will include information about
and linkage to PrEP and ART. We also will refine a stigma-reduction training for clinics to address
stigmatizing attitudes and behaviors toward young people who use AODs and seek HIV services. We
propose a multilevel approach through a cluster randomized trial with a modified factorial design whereby 24
clinics are randomized to receive either stigma-reduction training or no training. From the clinic catchment
areas in economically disadvantaged communities, we will use NIDA's Seek, Test, Treat and Retain
paradigm to seek 480 couples (aged 18 to 30). Clinics in catchment areas will be randomized to receive HIV
testing services (HTS) and/or the CHC+. An earlier study demonstrated the efficacy of the couples'
intervention on AOD use, sex risk, gender roles and HIV incidence, but it did not incorporate ART and PrEP
(treat); nor was it integrated into clinics to address stigma in service provision (treat and retain).
The Specific Aims are: Aim 1. To modify the CHC intervention to include ART/PrEP in a formative phase
and with review from our Community Collaborative Board and a Peer Advisory Board. Aim 2. To evaluate
the impact of a stigma-reduction training on clinic staffs' attitudes and behaviors toward young women and
their primary male partner seeking HIV services (testing/ART/PrEP) and other sexual and reproductive
health services with clinic staff at 6 and 12 months. Aim 3. To test the efficacy of the CHC+ to increase both
partners' PrEP/ART initiation and adherence (at 3, 6, 9, and 12 months), and reduce AOD use, sexual risk
and GBV, and enhance positive gender norms and communication relative to HTS (at 6 and 12 months).
Aim 4. To examine through mixed methods the interaction of the stigma-reduction training and the CHC+ on
increased PrEP and ART initiation, retention, and adherence among young women and their primary
If this multilevel approach demonstrates efficacy in increasing PrEP and ART initiation, adherence and
retention, it could help achieve the Undetectable=Untransmittable (U=U) goals. If successful, the project
could help the governments of South Africa and the United States identify new approaches to expanding the
HIV continuum of prevention and care among young couples at risk for HIV.