Factors influencing access of HIV and sexual and reproductive health services among adolescent key populations in Kenya

Understanding school-going adolescent's preferences for accessing HIV and contraceptive care: findings from a discrete choice experiment among learners in Gauteng, South Africa

BACKGROUND

Many Adolescents in Sub-Saharan Africa do not access HIV and reproductive health services optimally. To improve uptake of these services, it is important to understand the Learners' preferences for how services are delivered so that implementation strategies can reflect this.

METHODS

A discrete choice experiment (DCE) was used to elicit preferences. The DCE was completed between 07/2018 and 09/2019 and conducted in 10 high schools situated in neighbourhoods of varying socio-economic status (SES) in Gauteng (South Africa). Learners aged ≥ 15 years (Grades 9-12) were consented and enrolled in the DCE. Parental consent and assent were required if < 18 years old. Conditional logistic regression was used to determine preferred attributes for HIV and contraceptive service delivery. Results were stratified by gender and neighbourhood SES quintile (1 = Lowest SES; 5 = Highest SES).

RESULTS

805 Learners were enrolled (67% female; 66% 15-17 years; 51% in grades 9-10). 54% of Learners in quintile 1 schools had no monthly income (family support, grants, part-time jobs etc.); 38% in quintile 5 schools had access to R100 ($7.55) per month. Preferences for accessing HIV and contraceptive services were similar for male and female Learners. Learners strongly preferred services provided by friendly, non-judgmental staff (Odds ratio 1.63; 95% Confidence Interval: 1.55-1.72) where confidentiality was ensured (1.33; 1.26-1.40). They preferred services offered after school (1.14; 1.04-1.25) with value-added services like free Wi-Fi (1.19; 1.07-1.32), food (1.23; 1.11-1.37) and youth-only waiting areas (1.18; 1.07-1.32). Learners did not have a specific location preference, but preferred not to receive services within the community (0.82; 0.74-0.91) or school (0.88; 0.80-0.96). Costs to access services were a deterrent for most Learners irrespective of school neighbourhood; female Learners were deterred by costs ≥$3.85 (0.79; 0.70-0.91); males by costs ≥ R100 ($7.55) (0.86; 0.74-1.00).

CONCLUSIONS

Preferences that encourage utilisation of services do not significantly differ by gender or school neighbourhood SES. Staff attitude and confidentiality are key issues affecting Learners' decisions to access HIV and contraceptive services. Addressing how healthcare providers respond to young people seeking sexual and reproductive health services is critical for improving adolescents' uptake of these services.

Which Intervention Synergies Maximize AGYW's HIV Outcomes? A Classification and Regression Tree Analysis of Layered HIV Prevention Programming

INTRODUCTION

Intersecting behavioral, social, and structural factors increase adolescent girls' (AG) and young women's (YW) HIV vulnerability. Yet, understanding of optimal intervention synergies remains limited. We identified intervention combinations that statistically maximized reductions in AGYW's HIV-related risk.

METHODS

Using data collected in 2018 with Zambian AG (n = 487, aged 15-19 years) and YW (n = 505, aged 20-25 years) after 12-14 months exposure to Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe (multisectoral HIV program), we used classification and regression trees to explore relationships between interventions (safe space/social asset building [SAB] and provision of/linkage to youth-friendly health services [YFHS], education social protection [Educ], economic social protection [Econ]) and HIV-related outcomes (HIV testing, consistent condom use, transactional sex, and sexual violence experience from partners and nonpartners).

RESULTS

Overall, 59.9% completed SAB and 81.5%, 35.4%, and 29.6% received YHFS, Educ, and Econ, respectively. For AG, HIV testing improved (from 73% to 83%) with exposure to all interventions, condom use improved with Econ (from 33% to 46%), transactional sex reduced with SAB + Educ, and sexual violence from partners and nonpartners reduced with Educ and SAB, respectively. For YW, HIV testing increased with Educ (from 77% to 91%), condom use increased with SAB + YFHS (from 36% to 52%), transactional sex reduced with combinations of all interventions, and sexual violence from partners reduced with YFHS and from nonpartners with SAB + Econ.

CONCLUSIONS

Tailored interventions might be more effective than uniform combination intervention packages in reducing AGYW's HIV risk. AG benefitted most from SAB and/or Educ while YFHS, Educ, and/or SAB reduced YW's HIV-related risk. Educational and asset-building interventions could have the greatest impact on AGYW's HIV risk.

Factors influencing the transition from paediatric to adult HIV care in the Western Cape, South Africa: perspectives of health care providers

Transitioning to adult care for HIV-infected adolescents is a critical process in determining long-term health outcomes. Poor transitioning to adult care can lead to several adverse HIV-related outcomes for adolescents living with HIV, including disruption of care, non-adherence to ART and virological failure. In this qualitative study, we explore the barriers to and facilitators of the transition to adult care among HIV-infected youth from the perspectives of health care workers and allied staff. We enrolled 24 health care workers and allied staff from two infectious diseases clinics in the Western Cape of South Africa. Participants took part in a once-off, semi-structured interview that was conducted face-to-face at the respective clinics. Interviews were audio-recorded and transcribed verbatim for thematic analysis using ATLAS.ti. Two superordinate themes and seven subthemes emerged from the data. We found that barriers to the transition process were related to a lack of preparedness and readiness to transition at both an institutional level and at the level of the caregiver and adolescent. At the institutional level, a lack of a transition policy and limited time and resources available for the transition process were salient barriers. At the caregiver-adolescent level, adolescents' desire for normality and caregivers' reluctance to devolve responsibility of care to their children were important barriers to the transition process. Facilitators prepare adolescents and caregivers for transition from an early age. Our findings highlight the importance of considering both adolescent, caregiver and institutional factors when preparing for the transition process. Our findings also show that pressure on the health care system precludes the time required for this process. However, counselling for transition from an early age might be an important way to negate these issues.

Neglected gaps in improving the health, wellbeing, and care for sexual and gender minority young people living in low- and lower-middle- income countries: a scoping review

BACKGROUND

There is a lack of reliable data on the size, characteristics, and experiences of sexual and gender minority (SGM) young people (ages 10-24) in low- and lower-middle- income countries (LMICs). This review examines the research conducted in the last thirteen years with and about SGM young people living in low-income settings and seeks to answer the question: What is known about the mental and physical health needs, safety, and wellbeing of SGM young people living in LMICs?

METHODS

We conducted a scoping review informed by the methodological frameworks put forth by Arksey and O'Malley and the Joanna Briggs Institute. We systematically searched two general social science databases and one topic-specific database for peer-reviewed papers, of any research design, that included SGM young people or explored attitudes toward SGM young people in LMICs. We included papers that reported on factors influencing the health and wellbeing of SGM populations, including physical and mental health, healthcare-seeking behaviors, substance use, experiences of discrimination and/or stigma, experiences of violence and abuse (emotional, physical, and/or sexual), economically motivated paid sex practices, housing or economic security, and attitudes of others toward SGM populations.

RESULTS

Of the 5,409 unique records identified, 79 papers drawing from data collected from 74 unique studies met the inclusion criteria. Only 50 of the 79 papers included SGM young people as participants, with just 13 focusing exclusively on SGM young people ages 10-24. The included papers were classified into three thematic groupings: attitudes toward SGM populations (n = 26), risks to health (n = 40), and experiences of stigma and discrimination (n = 13).

CONCLUSION

The findings indicate that the health and wellbeing of SGM young people in LMICs has been historically under-researched. While SGM young people have received more attention from researchers in recent years, the body of literature as a whole is disjointed and sparse, and often studies are about SGM young people, rather than with and for them. Our review highlights the need for more and better research, more accurate and disaggregated demographic data, and leadership and participation of SGM-led community-based organizations in the co-design of studies that focus on SGM young people.

A modelling framework for translating discrete choice experiment results into cost-effectiveness estimates: an application to designing tailored and scalable HIV and contraceptive services for adolescents in Gauteng, South Africa

INTRODUCTION

South African youth and adolescents face a high burden of (Sexually Transmitted Infections) STIs, HIV and unintended pregnancies, but uptake of services remains low. To address this, tailored and scalable interventions are urgently needed. We developed a framework to fill the gap and translate the impact of facility-level attributes into a cost-effectiveness analysis for increasing HIV/contraceptive service uptake in adolescents using a discrete choice experiment (DCE).

METHODS

We used a DCE (n = 805) conducted in Gauteng, South Africa, which found that staff attitude, confidentiality, Wi-Fi, subsidized food, afternoon hours and youth-only services were preferred attributes of health services. Based on this, we simulated the uptake of services adapted for these preferences. We divided preferences into modifiable attributes that could readily be adapted (e.g. Wi-Fi), and challenging to modify (more nuanced attributes that are more challenging to cost and evaluate): staff attitude and estimated the incremental change in the uptake of services using adapted services. Costs for modifiable preferences were estimated using data from two clinics in South Africa (2019 US$). We determined the incremental cost-effectiveness ratio (ICER) for additional adolescents using services of 15 intervention combinations, and report the results of interventions on the cost-effectiveness frontier.

RESULTS

Greatest projected impact on uptake was from friendly and confidential services, both of which were considered challenging to modify (18.5% 95% CI: 13.0%-24.0%; 8.4% 95% CI: 3.0%-14.0%, respectively). Modifiable factors on their own resulted in only small increases in expected uptake. (Food: 2.3% 95% CI: 4.0%-9.00%; Wi-Fi: 3.0% 95% CI: -4.0% to 10.0%; Youth-only services: 0.3% 95% CI: -6.0% to 7.0%; Afternoon services: 0.8% 95% CI: -6.0% to 7.0%). The order of interventions on the cost-effectiveness frontier are Wi-Fi and youth-only services (ICER US$7.01-US$9.78 per additional adolescent utilizing HIV and contraceptive services), Wi-Fi, youth-only services and food (ICER US$9.32-US$10.45), followed by Wi-Fi, youth-only services and extended afternoon hours (ICER US$14.46-US$43.63).

CONCLUSIONS

Combining DCE results and costing analyses within a modelling framework provides an innovative way to inform decisions on effective resource utilization. Modifiable preferences, such as Wi-Fi provision, youth-only services and subsidized food, have the potential to cost-effectively increase the proportion of adolescents accessing HIV and contraceptive services.

Knowledge and utilization of sexual and reproductive health services among young males in a slum area in Nigeria: A cross-sectional study

Background

Globally, young people are faced with sexual and reproductive health challenges such as unintended pregnancies, sexually transmitted infections and unsafe abortions which result from limited knowledge of sexual and reproductive health and poor utilization of the available services. The purpose of this study was to assess the sexual and reproductive health knowledge, pattern of service utilization, and the associated factors among young males in slum communities of Mushin Local Government Area (L.G.A), Lagos State, Nigeria.

Methods

The study was conducted among young males, 15-24 years in Mushin Local Government Area, Lagos State, Nigeria. Data was collected using a pre-tested structured questionnaire that consisted of three domains with 57 questions, and was interviewer-administered. Multi-stage sampling technique was used to select 422 participants. Descriptive statistics, bivariate analysis, and binary logistic regression were carried out using SPSS version 20.

Results

The mean age of the respondents was 21.01 years ± 2.00, and 73.06% of the respondents had good knowledge of sexual and reproductive health. 52.85% of the respondents had poor knowledge regarding the likely occurrence of pregnancy at mid-menstrual cycle. Nearly two-third (64%) of the respondents have ever visited a health facility for sexual and reproductive health service. Ethnicity(AOR = 2.73), access to the internet(AOR = 1.77) and having ever had sex(AOR = 1.96) were significantly associated with the utilization of the services.

Conclusion

Good knowledge of sexual and reproductive health was observed among the respondents, although misconceptions still exist. Service utilization, however, remains low due to some individual and socio-cultural factors. It is therefore important to increase awareness of Sexual and Reproductive Health, and make the services available and affordable to young people for increased uptake.

Intersectional Stigma and Implementation of HIV Prevention and Treatment Services for Adolescents Living with and at Risk for HIV: Opportunities for Improvement in the HIV Continuum in Sub-Saharan Africa

Adolescents in sub-Saharan Africa, specifically adolescent girls and young women, young men who have sex with men, transgender persons, persons who use substances, and adolescents experiencing homelessness experience intersectional stigma, have a high incidence of HIV and are less likely to be engaged in HIV prevention and care. We conducted a thematic analysis informed by the Health and Discrimination Framework using a multiple case study design with five case studies in 3 sub-Saharan African countries. Our analysis found commonalities in adolescents' intersectional stigma experiences across cases, despite different contexts. We characterize how intersectional stigma impacts the uptake and implementation of HIV prevention and treatment services along the continuum for adolescents. Findings reveal how intersectional stigma operates across social-ecological levels and worsens HIV-related outcomes for adolescents. We identify opportunities for implementation science research to address stigma-related barriers to the uptake and delivery of HIV services for adolescents in sub-Saharan Africa.

A scoping review of how exposure to urban violence impacts youth access to sexual, reproductive and trauma health care in LMICs

Violence in the community can impact access to health care. This scoping review examines the impact of urban violence upon youth (aged 15-24) access to sexual and reproductive health and trauma care in Low and Middle Income Countries (LMICs). We searched key electronic health and other databases for primary peer-reviewed studies from 2010 through June 2020. Thirty five of 6712 studies extracted met criteria for inclusion. They were diverse in terms of study objective and design but clear themes emerged. First, youth experience the environment and interpersonal relationships to be violent which impacts their access to health care. Second, sexual assault care is often inadequate, and stigma and abuse are sometimes reported in treatment settings. Third is the low rate of health seeking among youth living in a violent environment. Fourth is the paucity of literature focusing on interventions to address these issues. The scoping review suggests urban violence is a structural and systemic issue that, particularly in low-income areas in LMICs, contributes to framing the conditions for accessing health care. There is a gap in evidence about interventions that will support youth to access good quality health care in complex scenarios where violence is endemic.

Sexual and reproductive health service utilization among adolescent girls in Kenya: A cross-sectional analysis

We examined the association between adolescents' sexual and reproductive health (SRH) service utilization in the past 12 months and structural, health facility, community, interpersonal, and individual level factors in Kenya. This cross-sectional analysis used baseline data collected in Homa Bay and Narok counties as part of the In Their Hands intervention evaluation from September to October 2018. In total, 1840 adolescent girls aged 15 to 19 years were recruited to complete a baseline survey. We used unadjusted and adjusted logistic regression to model factors associated with SRH utilization across the social-ecological framework levels. Overall, 36% of participants reported visiting a health facility for SRH services in the past 12 months. At the structural level being out-of-school (AOR: 2.12 95% CI: 1.60-2.82) and not needing to get permission to go (AOR: 1.37 95%CI: 1.04-1.82) were associated with SRH service utilization. At the interpersonal level, participants who reported being able to ask adults for help when they needed it were more likely to report using SRH services in the past 12 months (AOR: 1.98, 95% CI: 1.09-3.78). At the individual level, having knowledge about where to obtain family planning (AOR = 2.48 95% CI: 1.74-3.57) and receiving information on SRH services in the past year (AOR: 1.44 95% CI:1.15-1.80) were associated with SRH service utilization. Our findings demonstrate the need for interventions, policies, and practices to be implemented across structural, health facility, community, interpersonal, and individual levels to comprehensively support adolescent girls to access and use SRH services.

Spatial analysis of the AIDS mortality rate among young people in a province of the Brazilian Amazon: An ecological study

Worldwide, policies to combat human immunodeficiency virus (HIV) have led to a small decrease in the acquired immunodeficiency syndrome (AIDS) mortality rate among young people. For greater policy efficacy, it is necessary to determine the influence of social determinants of health (SDHs) in each territory. The objective of this study was to spatially analyse the AIDS mortality rate among young people in a province of the Brazilian Amazon and the spatial variability of the rate promoted by SDHs. All reports of AIDS deaths between 2007 and 2018 among young people living in the state of Pará were included in the study. The mortality rate was analysed using spatial distribution and autocorrelation, spatial scanning, and geographically weighted regression (GWR). During the study period, there were 1,372 deaths from AIDS among young people with a territorial expansion. The spatial autocorrelation showed two high-high clusters in the period from 2007 to 2010, one formed by municipalities in south-eastern Pará and one in the metropolitan region of Belém, with only the latter remaining between 2011 and 2018. This region showed a higher spatial risk for AIDS mortality and was the only cluster with spatiotemporal risk in the 2013-2018 period. Spatial variability was promoted by the i) the youth homicide rate, ii) the elementary school dropout rate and iii) the number of families registered in the Unified Registry for Social Programs (CadÚnico). This study provides support for the implementation of effective focal policies to combat HIV and reduce the mortality rate among young people in Pará.

Primary and Triage Cervical Screening Diagnostic Value of Methods for the Detection of Cervical Dysplasia

Background. Cervical cancer is a leading cause of mortality among women globally. Approaches to reduce cervical cancer incidence and mortality are “screen-and-treat,” where positive primary test only is used in the treatment and “screen, triage and treat,” where treatment is based on positive primary and triage tests with/without histological analysis. Objectives. To determine cervical screening outcomes among HIV-infected and noninfected women using VIA, Pap smear, and HPV-PCR cervical screening methods and to determine the sensitivity, specificity, PPV and NPV of VIA, Pap smear, and HPV-PCR as primary test and sequential triage based on abnormal histopathology among HIV-infected and noninfected women. Methodology. This was a comparative cross-sectional study where women aged 18-46 years women underwent cervical screening and colposcopy-biopsy test as a positive-confirmatory test in the Referral Hospitals of Eastern Kenya. Results. A total of 317 (HIV negative: 156/317 (49.2%) and HIV positive: 161/317 (50.8%)) women were enrolled. Of these 81/317 (25.6%), 84/317 (26.5%), 96/317 (30.2%), and 78/122 (63.9%) participants had VIA, HPV DNA-PCR, Pap smear, and cervical histology positive results, respectively; average: 27.4% (HIV positive: 21.5%; HIV negative: 5.9%). Majority of women with LSIL [17/317 (5.4%)], HSIL [22/317 (6.9%)], invasive cancer [5/317 (1.6%)], cervicitis [45/317 (14.2%], and candidiasis 47/317 (14.8%) were HIV-infected ( $p<0.001$ ). 78/317 (24.6%) participants had positive histology test [ASCUS: 34/317 (10.7%) CIN1:17/317 (5.3%), CIN2: 16/317 (5.0%), CIN3:6/317 (1.9%), and ICC: 5/317 (1.6%)] ( $p>0.001$ ). A higher primary diagnostic accuracy was established by HPV DNA-PCR (sensitivity: 95.5%; specificity: 92.6%) than Pap smear and VIA test while in triage testing, high sensitivity was obtained by HPV DNA-PCR parallel testing with VIA test (92.6%) and Pap smear test (92.7%) and VIA cotesting with Pap smear (99.9%). HIV-infected women had increased specificity and reduced sensitivity and diagnostic accuracy by both primary and triage testing approaches. Discussion. Abnormal cervical screening outcome was high among HIV-infected than noninfected women. HIV-infected women had significantly high cases of cervical neoplastic changes. The diagnostic value of primary tests increased upon concurrent testing with other test methods hence reducing the number of women who would have been referred for biopsy. Conclusion. High sensitivity and specificity in detection of CIN+ were established among HIV-infected than HIV noninfected women by HPV DNA-PCR and Pap smear than VIA test. HPV DNA-PCR test and Pap smear are more accurate in primary and sequential triage cervical screening based on abnormal histopathology outcomes among HIV-infected than noninfected women.

Exploring and Monitoring Privacy, Confidentiality, and Provider Bias in Sexual and Reproductive Health Service Provision to Young People: A Narrative Review

Purpose: Poor privacy and confidentiality practices and provider bias are believed to compromise adolescent and young adult sexual and reproductive health service quality. The results of focus group discussions with global youth leaders and sexual and reproductive health implementing organizations indicated that poor privacy and confidentiality practices and provider bias serve as key barriers to care access for the youth. Methods: A narrative review was conducted to describe how poor privacy and confidentiality practices and provider bias impose barriers on young people seeking sexual and reproductive health services and to examine how point of service evaluations have assessed these factors. Results: 4544 peer-reviewed publications were screened, of which 95 met the inclusion criteria. To these articles, another 16 grey literature documents were included, resulting in a total of 111 documents included in the review. Conclusion: Poor privacy and confidentiality practices and provider bias represent significant barriers for young people seeking sexual and reproductive health services across diverse geographic and sociocultural contexts. The authors found that present evaluation methods do not appropriately account for the importance of these factors and that new performance improvement indicators are needed.

Women Who Sell Sex in Eastern and Southern Africa: A Scoping Review of Non-Barrier Contraception, Pregnancy and Abortion

Objectives: There is a need to hone reproductive health (RH) services for women who sell sex (WSS). The aim of this review was to collate findings on non-barrier contraception, pregnancies, and abortion amongst WSS in Eastern and Southern African (ESA). Methods: A scoping review methodology was employed. Inclusion criteria were: 1) empirical papers from 2) ESA, 3) published since 2010, and 4) addressing WSS in relation to 5) the identified RH issues. Results: Reports of rates of non-barrier contraceptive usage varied from 15% to 76%, of unintended pregnancy from 24% to 91%, and of abortion from 11% to 48%. Cross-cutting factors were alcohol use, violence, health systems problems, and socio-economic issues. Pregnancy desire was associated with having a non-paying partner. Barriers to accessing, and delaying, antenatal care were reported as common. Targeted programmes were reported as promoting RH amongst WSS. Conclusion: Programmes should be contextually relevant, based on local patterns, individual, interpersonal and systemic barriers. Targeted approaches should be implemented in conjunction with improvement of public health services. Linked HIV and RH services, and community empowerment approaches are recommended.

Oral PrEP Consultations Among Adolescent Girls and Young Women in Kisumu County, Kenya: Insights from the DREAMS Program

Although Kenya nationally scaled up oral pre-exposure prophylaxis (PrEP) in May 2017, adolescent girls' (AG, aged 15-19 years) and young women's (YW, aged 20-24 years) PrEP use remains suboptimal. Thus, we analyzed PrEP consultations-interactions with a healthcare provider about PrEP-among Kenyan AGYW. In April-June 2018, AGYW enrolled in DREAMS in Kisumu County, Kenya self-reported their HIV-related knowledge, behaviors, and service use. Among HIV negative, sexually active AG (n = 154) and YW (n = 289), we examined associations between PrEP eligibility and PrEP consultations using prevalence ratios (PR, adjusted: aPR). Most AG (90.26%) and YW (94.12%) were PrEP-eligible due to inconsistent/no condom use, violence survivorship, or recent sexually transmitted infection symptoms. Between PrEP-eligible AG and YW, more YW were ever-orphaned (58.09%), ever-married (54.41%), ever-pregnant (80.88%), and out of school (78.31%); more PrEP-eligible YW reported PrEP consultations (41.18% vs. 24.46%, aPR = 1.51 [1.01-2.27]). AG who used PEP (post-exposure prophylaxis) reported more consultations (aPR = 5.63 [3.53-8.97]). Among YW, transactional sex engagers reported more consultations (58.62% vs. 39.09%, PR = 1.50 [1.06-2.12]), but only PEP use (aPR = 2.81 [2.30-3.43]) and multiple partnerships (aPR = 1.39 [1.06-1.82]) were independently associated with consultations. Consultations were lowest among those with 1 eligibility criterion (AG = 11.11%/YW = 27.18%). Comparatively, consultations were higher among AG and YW with 2 (aPR = 3.71 [1.64-8.39], PR = 1.60 [1.07-2.38], respectively) or ≥ 3 (aPR = 2.51 [1.09-5.78], PR = 2.05 [1.42-2.97], respectively) eligibility criteria. Though most AGYW were PrEP-eligible, PrEP consultations were rare and differed by age and vulnerability. In high-incidence settings, PrEP consultations should be conducted with all AGYW. PrEP provision guidelines must be re-assessed to accelerate AGYW's PrEP access.

Factors influencing HIV testing and counselling services among men who have sex with men in Western China: a cross-sectional study based on Andersen’s Behavioral Model

Background

Men who have sex with men (MSM), as a marginal population, has been largely ignored by health service projects. We assessed the utilization of HIV testing and counselling services and its influencing factors based on Andersen’s Behavioral Model, so as to provide a theoretical basis for future infectious disease prevention and control strategies and health services policy formulation for these population.

Method

This was a cross-sectional study. A sample survey was conducted in Western China, and an anonymous self-administered questionnaire survey was conducted among MSM. Based on Andersen’s Behavioral Model, the questionnaire divided the influencing factors into predisposing factor, enabling factor and need factor. Multivariate logistic regression analysis was used to explore the factors influencing the utilization of HIV testing and counselling.

Results

There were 3184 valid questionnaires. In the survey of HIV health services, 82.85% MSM had HIV testing and 64.98% MSM had HIV counselling, respectively. Among the predisposing factor, age 25 years old and over was a facilitator of HIV testing and counselling, and ethnicity was a factor associated with HIV testing. Among the enabling factor, MSM living in urban were more likely to have access to testing and counselling services, and income was also linked to HIV testing. Among the need factor, a high level of HIV knowledge could promote testing and counselling, and a history of sexually transmitted diseases (STD) was a facilitator of testing.

Conclusions

HIV testing is widespread in Western China and higher than counselling service. MSM with high-risk characteristics should be identified as a priority in the future public health services.

Peer- and community-led responses to HIV: A scoping review

INTRODUCTION

In June 2021, United Nations (UN) Member States committed to ambitious targets for scaling up community-led responses by 2025 toward meeting the goals of ending the AIDS epidemic by 2030. These targets build on UN Member States 2016 commitments to ensure that 30% of HIV testing and treatment programmes are community-led by 2030. At its current pace, the world is not likely to meet these nor other global HIV targets, as evidenced by current epidemiologic trends. The COVID-19 pandemic threatens to further slow momentum made to date. The purpose of this paper is to review available evidence on the comparative advantages of community-led HIV responses that can better inform policy making towards getting the world back on track.

METHODS

We conducted a scoping review to gather available evidence on peer- and community-led HIV responses. Using UNAIDS' definition of 'community-led' and following PRISMA guidelines, we searched peer-reviewed literature published from January 1982 through September 2020. We limited our search to articles reporting findings from randomized controlled trials as well as from quasi-experimental, prospective, pre/post-test evaluation, and cross-sectional study designs. The overall goals of this scoping review were to gather available evidence on community-led responses and their impact on HIV outcomes, and to identify key concepts that can be used to quickly inform policy, practice, and research.

FINDINGS

Our initial search yielded 279 records. After screening for relevance and conducting cross-validation, 48 articles were selected. Most studies took place in the global south (n = 27) and a third (n = 17) involved youth. Sixty-five percent of articles (n = 31) described the comparative advantage of peer- and community-led direct services, e.g., prevention and education (n = 23) testing, care, and treatment programs (n = 8). We identified more than 40 beneficial outcomes linked to a range of peer- and community-led HIV activities. They include improved HIV-related knowledge, attitudes, intentions, self-efficacy, risk behaviours, risk appraisals, health literacy, adherence, and viral suppression. Ten studies reported improvements in HIV service access, quality, linkage, utilization, and retention resulting from peer- or community-led programs or initiatives. Three studies reported structural level changes, including positive influences on clinic wait times, treatment stockouts, service coverage, and exclusionary practices.

CONCLUSIONS AND RECOMMENDATIONS

Findings from our scoping review underscore the comparative advantage of peer- and community-led HIV responses. Specifically, the evidence from the published literature leads us to recommend, where possible, that prevention programs, especially those intended for people living with and disproportionately affected by HIV, be peer- and community-led. In addition, treatment services should strive to integrate specific peer- and community-led components informed by differentiated care models. Future research is needed and should focus on generating additional quantitative evidence on cost effectiveness and on the synergistic effects of bundling two or more peer- and community-led interventions.

An Exploratory Study of Current Sources of Adolescent Sexual and Reproductive Health Information in Kenya and Their Limitations: Are Mobile Phone Technologies the Answer?

Purpose The prevalence of pregnancy and sexually transmitted infections among adolescents in low and middle-income countries leads us to believe that sexual and reproductive health (SRH) information needs are still unmet. This paper investigates current sources and their limitations and then explores the role technology could play. Methods: In an exploratory qualitative study themes identified; (1) preferred sources of SRH information; (2) their limitations; (3) the role of technology in meeting their needs. Results: Mobile phone-based apps could improve awareness and provide information in a confidential way. Conclusions: Adolescents have an unmet need that vary by age and gender. Mobile phones could offer accessible, user-friendly platform.