Microenterprise and Behavioral Economics Intervention for Sexual and Biomedical HIV Prevention in Vulnerable U.S. Young Adults - Project Summary / Abstract Economic vulnerability and racial disparities contribute to African-American young adults being disproportionately infected by HIV. African-Americans account for nearly half of all HIV diagnoses in the U.S., and young adults have the highest HIV rates of all U.S. age groups, comprising an increasing proportion of the urban poor. Economic instability, such as homelessness and unemployment, is associated with higher HIV prevalence. Experiencing economic instability can create imperatives to engage in survival strategies that increase HIV risk and diminish motivations to avoid HIV, resulting in sexual risk-taking and low uptake of preventive medications. Microenterprise interventions (i.e., very small businesses) have improved sexual behaviors and medication adherence in low-income countries by combining HIV prevention and business training, mentoring, and grants – primarily in women. Microenterprise reduces HIV risk through increased economic stability via jobs and employable income-generating skills. This, in turn, decreases financial distress associated with risk behaviors, while increasing resources to access HIV services and improving non-cognitive skills (i.e., persistence, grit) associated with healthy behaviors. However, microenterprise studies have largely been omitted in men and African-Americans with limited longitudinal assessment. Prior studies have also not leveraged mobile health or behavioral economics (BE) to shape how youth perceive prevention costs and rewards. Having obtained promising preliminary data from our completed K01 that demonstrated feasibility and acceptability of a microenterprise pilot, the proposed R01 builds on the K01 by establishing efficacy on two important HIV behavioral and biomedical primary outcomes: condomless sex and movement along the pre- exposure prophylaxis (PrEP) continuum (i.e., contemplation, clinic appointment, initiation), and on intermediate and mediating variables related to economic stability. We will implement a peer-driven microenterprise model, adapted for underserved U.S. communities. Our interdisciplinary team has expertise in prevention science, sexual health, microfinance, epidemiology, biostatistics, qualitative science, and behavioral economics. We will randomize participants to experimental group that will receive entrepreneurial, financial literacy, and HIV prevention education (i.e., condom use, PrEP), microgrants, mentors, text messages informed by BE, and job announcements or to control group that will receive usual care job announcements. We will use respondent- driven sampling to recruit high-risk, economically-vulnerable, HIV-uninfected seeds and their peers, aged 18- 24. To leverage peer support, we will randomize by cluster, equal to a seed and their recruits. The specific aims are to: (1) Evaluate the efficacy of the intervention on economic stability, condomless sex, and PrEP initiation up to 24-months post-intervention; (2) Assess heterogeneity of intervention effects; and (3) Examine mechanisms of change using statistical and qualitative methods. If found to be effective, the intervention has the potential to be a model of HIV risk reduction and economic empowerment in U.S. urban settings.
