title: The importance of choice disability and structural intervention in the HIV epidemic in Sub-Saharan Africa.
abstract: BACKGROUND
  Despite massive investment in HIV control programs, HIV incidence rates in countries with generalized epidemics have not fallen for most of the last decade. It appears that those at risk are not adopting effective prevention strategies. Those who are unable to implement their prevention preferences are referred to as choice disabled. We examined how and to what extent structural intervention measures that support choice-disabled individuals can reduce HIV transmission and prevalence.
  
  
  METHODS
  A mathematical model was developed to describe HIV transmission among and between choice-disabled and choice-enabled individuals. Data were available from field trials identifying factors and effects of choice disability. The model was used to estimate the potential impact of an intervention strategy in which choice-disabled individuals are enabled to make prevention choices. Several scenarios were considered and compared: supporting only one or both genders; supporting only HIV- individuals or also HIV+ choice-disabled individuals.
  
  
  RESULTS
  Substantial declines in HIV incidence and prevalence are observed when supportive interventions are included in the model. The magnitude of these declines depends on the scope of the intervention program. The largest positive effect occurs when the support program is offered regardless of HIV status.
  
  
  CONCLUSIONS
  Addressing the effects of choice disability in any HIV intervention program could be crucial to the program's success. Structural intervention programs to support choice-disabled individuals in implementing prevention strategies greatly reduce HIV incidence and prevalence in mathematical models.
authors.affiliation: Department of Mathematics and Statistics, University of Ottawa, Ottawa, Ontario, Canada.
authors.forename: Rebecca
authors.initials: R
authors.lastname: de Boer
authors.affiliation: Department of Mathematics and Statistics, University of Ottawa, Ottawa, Ontario, Canada.
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Musgrave
authors.affiliation: Department of Family Medicine, McGill University, Montreal, Quebec, Canada.
authors.forename: Neil
authors.initials: N
authors.lastname: Andersson
authors.affiliation: Department of Mathematics and Statistics, University of Ottawa, Ottawa, Ontario, Canada.|Department of Biology, University of Ottawa, Ottawa, Ontario, Canada.
authors.forename: Frithjof
authors.identifier: http://orcid.org/0000-0001-7380-7647
authors.initials: F
authors.lastname: Lutscher
mesh_terms: D017954:Africa South of the Sahara / Q000453:epidemiology; D002755:Choice Behavior; D005260:Female; D015658:HIV Infections / Q000453:epidemiology* / Q000523:psychology; D006801:Humans; D008297:Male