HIV infection is preventable – why some people act to protect themselves and others don't

The number of new HIV infections has been decreasing in recent years. 39% However, the devastating impact of HIV on global health continues. In 2023, 1.3 million people The number of people infected with HIV is triple the target of 370,000 set by UNAIds. In sub-Saharan Africa, the prevalence of HIV among young women aged 15 to 24 is decrease – However, they accounted for 27% of all new infections in 2023 and were three times more likely to be infected with HIV than men.

There are many effective, user-centered HIV prevention options available. They include: Oral pre-exposure prophylaxis (PrEp) (daily tablets containing antiretrovirals), condoms, vaginal ring (capable of inserting and releasing drugs), and long-acting injectables.

While these are crucial in the fight against HIV, people should: decide to use them. This user decision process is fundamental to understanding how to prevent new HIV infections.

Public health research colleagues and me suggest A new structured method for understanding people's thought processes when deciding whether to use condoms, drugs, and other HIV prevention methods. We call this framework a “decision cascade.” It is based on behavioral science, which studies how people think, feel, and behave.

As we continue and accelerate the fight against HIV, we must remember that people are at the heart of the HIV pandemic. People's choices are influenced by personal judgments about whether they really need and can access the available methods and tools, based on their individual circumstances and priorities.

Decision cascades focus on individuals and the factors that influence their behavioral decisions. People go through stages when making decisions. The idea behind Cascade is to help you complete each step of taking action.

We hope that this decision cascade will provide researchers, public health interventionists, and policy makers with a guide to understanding people's choices. We also suggest approaches that may be effective.

decision cascade

lay the foundation previous workCascade identifies different types of decision makers who need HIV prevention products but are not using them. Unlike many frameworks, it also includes people who are not considering using services, do not see a need for services, or face barriers for personal, social and structural reasons.

Decision cascades focus on individuals and the factors that influence their behavioral decisions. People go through stages when making decisions. The idea behind Cascade is to help you complete each step of taking action.

Here are the steps:

Step 1: Triggers and cues

Individuals receive cues, or triggers, to consider behaviors such as using a vaginal ring. Triggers can be external (such as receiving a leaflet about HIV services) or internal (anxiety about having unprotected sex).

Current interventions often rely on health-focused cues. They focus on rational explanations of health benefits (e.g., “Using condoms reduces the risk of HIV”). They assume that if people are given logical and clear information about how to protect themselves, they will act accordingly.

The problem is that people may not be able to process the information. They may feel overwhelmed by other concerns (such as financial stress or relationships) or feel that HIV does not concern them. Even when information is available, they may not be focused on HIV prevention.

Another problem is that people tend to focus on what feels urgent, relevant, and important to them in the moment. People who do not see HIV as an immediate threat or priority are likely to ignore prevention messages, no matter how logical or helpful they may seem.

Step 2: Reaction

Once cued or triggered, people often respond quickly. Their reactions are often subconscious and shaped by what they already associate with HIV. If you have negative feelings or discomfort about the topic, you may ignore the message or respond poorly.

The brain makes decisions quickly based on biases such as: “I don't know anyone with HIV, so it's not a risk for me,” “HIV only affects people who don't have sexual relations,” or “I'm healthy, so I can't get it.” Prevention is required. ”

These automatic processes can make it difficult for people to be involved in decision-making about prevention efforts, even when they are relevant to them.

Step 3: Evaluate your actions

People weigh the costs and benefits of acting. This assessment is complex and subjective, and is influenced by bias, personal beliefs, and source credibility.

For example, if a person perceives PrEP use to be a risk to important relationships, he or she may prefer alternative behaviors to preserve those relationships.

Step 4: Competency assessment

After determining that a behavior is worthwhile, individuals evaluate their ability to act on that behavior. This includes practical considerations such as knowing how and where to access services and ensuring you have the resources you need.

Barriers include access issues, resource constraints, and lack of confidence in their ability to use the product.

Step 5: Timing of action

Timing is an often overlooked factor in HIV prevention. Even if an individual determines that access to preventive services is important and feasible, a decision still needs to be made. when To act. If you don't think it's urgent to take action, there may be a delay.

All of these steps can help prevent HIV infection.

Design successful interventions

The decision cascade framework emphasizes the need for interventions that support individuals throughout the decision-making process. Based on this, there are several recommendations to help design successful interventions.

Trigger engagement: Interventions should use diverse and engaging triggers to capture attention and attract a broad user base.

Dealing with reactions: Focus on positive messages.

Support rating: Provide clear, reliable information and emphasize the value of acting. We help people weigh personal costs and benefits and make informed, practical decisions.

Capability enhancement: Helping individuals take practical steps towards HIV prevention. example This includes extended clinic hours, youth-friendly services, improved product selection, digital health approaches, community-based services, cash incentive programs, and more.

Encourage timely action. Interventions should find ways to reduce delays and support consistent use of preventive services. For example, you might motivate people by making a promise to go for a health check or by tying preventive services to other goals.

Interventions designed to match the way people actually make decisions are likely to be more effective.