HIV infections may be prevented—why some individuals act to guard themselves, and others do not

The variety of new HIV infections has fallen through the years—it declined by 39% from 2010 to 2023. However HIV’s devastating influence on international well being persists. In 2023, 1.3 million individuals acquired HIV—3 times greater than the 370,000 goal set by UNAids. In sub-Saharan Africa, HIV incidence amongst younger ladies aged 15–24 is reducing—however they accounted for 27% of all new infections in 2023, and have been 3 times extra prone to purchase HIV than male counterparts.

There are a number of efficient, user-centered HIV prevention choices. They embody oral pre-exposure prophylaxis (PrEp, a every day tablet that incorporates antiretroviral medication), condoms, vaginal rings (which may be inserted and launch medication), and long-acting injectables.

These are important within the struggle towards HIV, however an individual must determine to make use of them. It’s this consumer choice course of which is key in understanding the right way to forestall new HIV infections.

My colleagues in public well being analysis and I suggest a brand new, structured means of understanding individuals’s thought processes when deciding whether or not to make use of condoms, drugs, or different HIV prevention strategies. We name this framework the “choice cascade.” It is based mostly on behavioral science—the examine of how individuals assume, really feel and act.

To maintain and speed up the struggle towards HIV, we should do not forget that individuals are on the coronary heart of the HIV pandemic. Folks’s decisions will likely be influenced by their private judgment of whether or not they really want and may entry the strategies and instruments accessible, based mostly on their particular person circumstances and priorities.

We hope that the choice cascade will present researchers, public well being interventionists and coverage makers with a information to understanding individuals’s decisions. We additionally counsel approaches that might work.

The choice cascade

Constructing on earlier work, the cascade identifies varied kinds of decision-makers who want HIV prevention merchandise however do not use them. In contrast to many frameworks, it consists of those that do not think about using the providers, do not see a necessity for them, or face boundaries for private, social, or structural causes.

The choice cascade focuses on the particular person and the elements that affect their selections to behave. Folks undergo steps when making selections. The thought behind the cascade is to assist them full every step with the intention to act.

The steps are:

Step 1: triggers and cues

People are cued, or triggered, to contemplate an motion, reminiscent of utilizing a vaginal ring. Triggers may be exterior (like getting a flyer about HIV providers) or inner (nervousness about having had unprotected intercourse).

Present interventions typically depend on health-focused cues. They deal with rational explanations about well being advantages (for instance, “utilizing condoms reduces your threat of HIV”). They assume that if individuals are given logical, clear details about the right way to defend themselves, they may act accordingly.

The issue is that individuals might not course of info. They could be overwhelmed with different considerations (like monetary stress or relationships), or really feel that HIV shouldn’t be a priority for them. They may not deal with HIV prevention, even when the knowledge is offered.

One other drawback is that individuals are inclined to deal with what feels pressing, related or necessary to them in the meanwhile. If somebody does not see HIV as a right away risk or precedence, they might ignore prevention messages, no matter how logical or useful these messages appear.

Step 2: response

As soon as cued or triggered, individuals typically react instantly. Their reactions are sometimes unconscious and formed by what they already affiliate with HIV. If they’ve unfavorable emotions or discomfort in regards to the subject, they may ignore the message or react poorly to it.

The mind will make selections shortly based mostly on biases, like: “I do not know anybody with HIV, so it is not a threat for me,” “HIV solely impacts promiscuous individuals” or “I am wholesome, so I do not want prevention.”

These computerized processes could make it more durable for individuals to have interaction with selections about prevention efforts, even whether it is related to them.

Step 3: analysis of motion

People weigh the prices and advantages of performing. This analysis is advanced, subjective, and influenced by biases, private beliefs, and the trustworthiness of knowledge sources.

As an illustration, if an individual perceives utilizing PrEP as a threat to necessary relationships, she or he might want different actions that keep these relationships.

Step 4: means evaluation

After deciding that motion is worth it, people assess their means to behave on it. This includes sensible issues like understanding how and the place to entry providers or having the mandatory sources.

Some boundaries embody entry points, useful resource constraints, and a insecurity of their means to make use of the product.

Step 5: timing of motion

Timing is an often-overlooked component in HIV prevention. Even when a person decides that utilizing prevention providers is necessary and possible, they need to nonetheless determine when to behave. They could delay if taking motion does not appear pressing.

If an individual takes all these steps, they may doubtless act to forestall HIV an infection.

Designing profitable interventions

The choice cascade framework highlights the necessity for interventions that assist people all through your complete decision-making course of. Primarily based on this, we have now some suggestions to assist design profitable interventions:

• Set off engagement: Interventions ought to use various and interesting triggers to seize consideration and have interaction a large consumer base.
• Handle reactions: Concentrate on constructive messaging.
• Assist evaluations: Present clear, reliable info and spotlight the worth of performing. Assist individuals weigh the private prices towards the advantages to make knowledgeable, sensible selections.
• Improve means: Assist people to take sensible steps in the direction of HIV prevention. Examples embody prolonged clinic hours, adolescent pleasant providers, improved selection of merchandise, digital well being approaches, neighborhood based mostly providers and cash-incentive applications.
• Encourage well timed motion: Interventions ought to discover methods to scale back delays and assist constant use of prevention providers. It could possibly be by making commitments to going for check-ups, for instance, or motivating individuals by linking prevention providers with different targets.

Interventions which can be designed for the way in which individuals really make selections are prone to be more practical.

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