Most countries will miss the UNAIDS target of reducing new HIV infections by 75% by 2020 compared to 2010. HIV prevention cascades have been proposed to assist in the advocacy for and planning, monitoring, and improved delivery of HIV prevention programmes and interventions by identifying gaps in effective use of prevention methods, similar to treatment cascades. The overarching aim of this thesis was to develop and pilot-test a generic HIV prevention cascade framework that can be used for different populations, prevention methods, and purposes. This proposed prevention cascade consists of three steps of motivation to use a prevention method, access to it, and effective use in a priority population. Characterising reasons underlying gaps across motivation, access, and effective use creates a comprehensive framework. To develop this framework, I conducted consultations and data analyses. In a study of data from eastern and southern Africa, I demonstrated increases in both non-regular partnerships and condom use, exemplifying complexities of population-level HIV risks and challenges in defining priority populations for prevention cascades. As it has previously been proposed as the first step in prevention cascades, I analysed HIV risk perception using longitudinal data from Manicaland, Zimbabwe. Results suggest that 1) risk perception can be accurate as there were associations between perceptions and actual HIV acquisition but there were considerable gaps in risk perception and 2) increasing risk perception was associated with condom use but fractions of condom use attributable to risk perception were small, highlighting that HIV prevention behaviour is influenced by a range of factors. The importance of structural factors for HIV prevention was underlined by analyses of cash transfers and HIV prevention in Manicaland. Finally, I operationalised the proposed HIV prevention cascade framework using newly collected data from Manicaland, demonstrating the utility of the concept for identifying gaps in prevention.Open Acces
