PROJECT SUMMARY/ABSTRACT Youth (ages 15-24) in sub-Saharan Africa (SSA) are disproportionately affected by HIV and are the most likely group to have poor outcomes along the HIV care cascade. The developmental changes of youth influence risk-taking behavior and increase their likelihood of alcohol use, which may be a key contributor to poor HIV outcomes. However, there are substantial knowledge gaps on the scope, context, and impact of alco- hol use on HIV outcomes among youth living with HIV (YLWH) in SSA and a need for youth-specific interven- tions to address risk factors that contribute to poor viral suppression outcomes and high rates of mortality. The proposed training and research plan for this K23 application will allow Sarah Puryear, MD, MPH, to acquire the necessary skills to achieve her career goal of becoming an independent clinical investigator with expertise in quantitative HIV/alcohol research and behavioral intervention design and implementation, to re- duce the negative impact of alcohol use on HIV outcomes, transmission, and co-morbidities among youth in low-resource settings. Under the guidance of a dedicated mentoring team, Dr. Puryear will test the central hy- pothesis that alcohol use among YLWH negatively impacts viral suppression in a life-stage and sex-dependent fashion. She will utilize her findings to develop a preliminary alcohol intervention for youth at high-risk of alco- hol-associated viral non-suppression. The rationale for this project is that high quality epidemiologic data can be used to establish a causal link between alcohol use and viral non-suppression among youth and leveraged to develop much-needed youth-specific solutions that can reduce alcohol use, improve viral suppression, and contribute to decreasing transmission. The central hypothesis will be tested by pursuing two specific aims: 1) Characterize the prevalence, patterns and trajectories of alcohol use among YLWH and examine predictors by life-stage and sex and 2) Determine how alcohol use contributes to viral non-suppression among YLWH. This will be applied in a third aim to (3) Develop a preliminary alcohol intervention that is youth-specific and cultur- ally appropriate. These scientific aims will support training in 1) youth behavior change theory, 2) advanced biostatistics, including causal inference and longitudinal data analysis, and 3) qualitative research for the pur- pose of intervention development. The proposed research will lay the epidemiologic foundation for further work on alcohol use among YLWH in East Africa, closing a critical knowledge gap. It will guide the identification of who (YLWH at highest risk for alcohol-associated viral non-suppression) and when (point in the life course, shifts in drinking pattern) to target interventions and it will incorporate these findings to develop a preliminary youth-specific, culturally appropriate alcohol intervention that will be refined and piloted in a subsequent R34, and subsequent R01 randomized-controlled-trial.

PROJECT NARRATIVE The proposed research is relevant to public health because among youth (ages 15-24) living with HIV (YLWH) in sub-Saharan Africa—who comprise 80% of the 3.5 million YWLH worldwide--AIDS remains the number one cause of death. This study will close the knowledge gaps on how alcohol use contributes to poor viral suppression among YLWH in sub-Saharan Africa and will develop a preliminary intervention to reduce alcohol use and improve viral suppression. This project is relevant to NIAAA's research priorities to track the prevalence, patterns, and trends of alcohol misuse across the lifespan and to develop effective strategies for preventing alcohol misuse at all life stages.