A Systematic Review of HIV Interventions for Young Women in Sub-Saharan Africa

Condom use increased after a peer group intervention implemented by community volunteers in Malawi

BACKGROUND

HIV prevention remains a global priority, especially in sub-Saharan Africa. Our research team previously developed an evidence-based peer group program for HIV prevention called Mzake ndi Mzake (Friend to Friend). A community-engaged collaboration adapted the program for community ownership and implementation. Here we report whether this HIV prevention program, implemented by community volunteers, increased condom use among sexually active individuals in rural Malawi.

METHODS

Three communities sequentially rolled out the program. Effectiveness was evaluated using a stepped wedge design. Repeated surveys 11-13 months apart were conducted between 2016 and 2019. At Time 1, no community had offered the intervention. At Time 2, the first community had offered the intervention and two had not (control group). At Time 3, two communities had offered the intervention and one had not (control group). We used two condom use indicators; condom use frequency in the last 2 months (N = 771) and condom use at last sex (N = 880). The analytical sample included all sexually active persons answering that question at one or more time points. Mixed-effects cumulative logit and Generalized Estimating Equation (GEE) models were used to model the two condom indicators over time, controlling for demographic factors, UNAIDS HIV knowledge, safer sex self-efficacy and partner communication.

RESULTS

This peer group intervention implemented by trained community volunteers increased both condom use indicators at Times 2 and 3. In the final adjusted models with non-significant factors removed, condom use in the last two months increased for the intervention group vs. control group [Time 2: Adjusted Odds Ratio (AOR) = 1.59 (1.15, 2.21); Time 3: AOR 2.01 (1.23, 3.30)]. Similarly, condom use at last sex increased for the intervention group vs. control group [Time 2: AOR = 1.48 (1.08, 2.03); Time 3: AOR 1.81 (1.13, 2.90)]. Other significant predictors of greater condom use were also described. Although the intervention increased UNAIDS HIV knowledge, knowledge did not predict condom use.

CONCLUSIONS

In this community-engaged implementation study, an evidence-based peer group program for HIV prevention increased condom use when delivered by trained community volunteers. Community ownership and program delivery by trained volunteers offer an innovative and cost-effective strategy to address ongoing HIV prevention needs without overburdening healthcare systems in sub-Saharan Africa.

TRIAL REGISTRATION

Clinical Trials.gov NCT02765659 Registered May 6, 2016.

Protective factors for adolescent sexual risk behaviours and experiences linked to HIV infection in South Africa: a three-wave longitudinal analysis of caregiving, education, food security, and social protection

BACKGROUND

Structural interventions are endorsed to enhance biomedical and behavioural HIV prevention programmes for adolescents. Aiming to inform future interventions, we evaluated longitudinal associations between six protective factors that link closely to existing structural HIV prevention interventions, and five sexual risk behaviours for HIV transmission in a cohort of adolescents in South Africa.

METHODS

We used three rounds of data between 2014-2018 on 1046 adolescents living with HIV and 473 age-matched community peers in South Africa's Eastern Cape (Observations = 4402). We estimated sex-specific associations between six time-varying protective factors - number of social grants, education enrolment, days with enough food, caregiver supervision, positive caregiving, and adolescent-caregiver communication; and five HIV risk behaviours - multiple sexual partners, transactional sex, age-disparate sex, condomless sex, and sex on substances. HIV risk behaviours were analysed separately in multivariable random effects within-between logistic regression models that accounted for correlation of repeated observations on the same individual. We calculated prevalence ratios (PR), contrasting adjusted probabilities of HIV risk behaviours at 'No' and 'Yes' for education enrolment, and average and maximum values for the other five protective factors.

RESULTS

The sample mean age was 15.29 (SD: 3.23) years and 58% were girls. Among girls, within-individuals, increases from mean to maximum scores in positive caregiving were associated with lower probability of transactional sex (PR = 0.79; 95%CI = 0.67-0.91); in caregiver supervision were associated with lower probability of transactional sex (PR = 0.75; 95%CI = 0.66-0.84), and age-disparate sex (PR = 0.84; 95%CI = 0.73-0.95); in adolescent-caregiver communication were associated with higher probability of transactional sex (PR = 1.70; 95%CI = 1.08-2.32); and in days with enough food at home were associated with lower probability of multiple sexual partners (PR = 0.89; 95%CI = 0.81-0.97), and transactional sex (PR = 0.82; 95%CI = 0.72-0.92). Change from non-enrolment in education to enrolment was associated with lower probability of age-disparate sex (PR = 0.49; 95%CI = 0.26-0.73). Between-individuals, relative to mean caregiver supervision scores, maximum scores were associated with lower probability of multiple sexual partners (PR = 0.59; 95%CI = 0.46-0.72), condomless sex (PR = 0.80; 95%CI = 0.69-0.91), and sex on substances (PR = 0.42; 95%CI = 0.26-0.59); and relative to non-enrolment, education enrolment was associated with lower probability of condomless sex (PR = 0.59; 95%CI = 0.39-0.78). Among boys, within-individuals, increases from mean to maximum scores in positive caregiving were associated with lower probability of transactional sex (PR = 0.77; 95%CI = 0.59-0.96), and higher probability of condomless sex (PR = 1.26; 95%CI = 1.08-1.43); in caregiver supervision were associated with lower probability of multiple sexual partners (PR = 0.73; 95%CI = 0.64-0.82), transactional sex (PR = 0.63; 95%CI = 0.50-0.76), age-disparate sex (PR = 0.67; 95%CI = 0.49-0.85), and sex on substances (PR = 0.61; 95%CI = 0.45-0.78), and in days with enough food at home were associated with lower probability of transactional sex (PR = 0.91; 95%CI = 0.84-0.98).

CONCLUSION

Effective structural interventions to improve food security and education enrolment among adolescent girls, and positive and supervisory caregiving among adolescent girls and boys are likely to translate into crucial reductions in sexual risk behaviours linked to HIV transmission in this population.

Condom use increased after a peer group intervention implemented by community volunteers in Malawi

Background

HIV prevention remains a global priority, especially in sub-Saharan Africa. Our research team previously developed an evidence-based peer group program for HIV prevention called Mzake ndi Mzake (Friend to Friend). A community-engaged collaboration adapted the program for community ownership and implementation. Here we report whether this HIV prevention program, implemented by community volunteers, increased condom use among sexually active individuals in rural Malawi.

Methods

Three communities sequentially rolled out the program. Effectiveness was evaluated using repeated surveys. At Time 1, no community had offered the intervention. At Time 2, the first community had offered the intervention and two had not (control group). At Time 3, two communities had offered the intervention and one had not (control group). We used two condom use indicators; condom use frequency in the last 2 months (N = 776) and condom use at last sex (N = 880). For each indicator, the sample included all sexually active persons answering that question at one or more time points. Regression analyses were used to model the two condom indicators over time, controlling for demographic factors, UNAIDS HIV knowledge, safer sex self-efficacy and partner communication.

Results

This peer group intervention implemented by trained community volunteers increased both condom use indicators at Times 2 and 3. In the final regression models. Other predictors of greater condom use for at least one condom use indicator included younger age group (13-19), male gender, not married/cohabiting, high involvement in religiously affiliated activities, higher safer sex self-efficacy, and greater partner communication. Although the intervention increased UNAIDS HIV knowledge, knowledge did not predict condom use.

Conclusions

This community engaged implementation study found that an evidence-based peer group program for HIV prevention increased condom use when delivered by trained community volunteers. Leveraging community strengths and human capital resources facilitated implementation of this effective HIV prevention program in rural Malawi. Community ownership and program delivery by trained local volunteers offers an innovative and cost-effective strategy to address ongoing HIV prevention needs without overburdening heathcare systems in sub.

Trial registration

Clinical Trials.gov NCT02765659 Registered May 6, 2016.

Evidence and gap map report: Social and Behavior Change Communication (SBCC) interventions for strengthening HIV prevention and research among adolescent girls and young women (AGYW) in low- and middle-income countries (LMICs)

BACKGROUND

Adolescent girls and young women (AGYW), aged 15-24 years, are disproportionately affected by HIV and other sexual and reproductive health (SRH) risks due to varying social, cultural, and economic factors that affect their choices and shape their knowledge, understanding, and practices with regard to their health. Socio-Behavioral Change Communication (SBCC) interventions targeted at strengthening the capabilities of individuals and their networks have supported the demand and uptake of prevention services and participation in biomedical research. However, despite growing global recognition of the domain, high-quality evidence on the effectiveness of SBCC remains scattered. This evidence and gap map (EGM) report characterizes the evidence base on SBCC interventions for strengthening HIV Prevention and Research among AGYW in low- and middle-income countries (LMICs), identifying evidence gaps and outlining the scope of future research and program design.

OBJECTIVES

The objectives of the proposed EGM are to: (a) identify and map existing EGMs in the use of diverse SBCC strategies to strengthen the adoption of HIV prevention measures and participation in research among AGYW in LMICs and (b) identify areas where more interventions and evidence are needed to inform the design of future SBCC strategies and programs for AGYW engagement in HIV prevention and research.

METHODS

This EGM is based on a comprehensive search of systematic reviews and impact evaluations corresponding to a range of interventions and outcomes-aimed at engaging AGYW in HIV prevention and research - that were published in LMICs from January 2000 to April 2021. Based on guidance for producing a Campbell Collaboration EGM, the intervention and outcome framework was designed in consultation with a group of experts. These interventions were categorized across four broad intervention themes: mass-media, community-based, interpersonal, and Information Communication and Technology (ICT)/Digital Media-based interventions. They were further sub-categorized into 15 intervention categories. Included studies looked at 23 unique behavioral and health outcomes such as knowledge attitude and skills, relationship dynamics, household dynamics, health care services, and health outcomes and research engagement. The EGM is presented as a matrix in which the rows are intervention categories/sub-categories, and the columns are outcome domains/subdomains. Each cell is mapped to an intervention targeted at outcomes. Additional filters like region, country, study design, age group, funding agency, influencers, population group, publication status, study confidence, setting, and year of publication have been added.

SELECTION CRITERIA

To be eligible, studies must have tested the effectiveness of SBCC interventions at engaging AGYW in LMICs in HIV prevention and research. The study sample must have consisted of AGYW between the ages of 15-24, as defined by UNAIDS. Both experimental (random assignment) and quasi-experimental studies that included a comparison group were eligible. Relevant outcomes included those at the individual, influencer, and institutional levels, along with those targeting research engagement and prevention-related outcomes.

RESULTS

This EGM comprises 415 impact evaluations and 43 systematic reviews. Interventions like peer-led interactions, counseling, and community dialogues were the most dominant intervention sub-types. Despite increased digital penetration use of media and technology-driven interventions are relatively less studied. Most of the interventions were delivered by peers, health care providers, and educators, largely in school-based settings, and in many cases are part of sex-education curricula. Evidence across geographies was mostly concentrated in Sub-Saharan Africa (70%). Most measured outcomes focused on disease-related knowledge dissemination and enhancing awareness of available prevention options/strategies. These included messaging around consistent condom use, limiting sexual partners, routine testing, and awareness. Very few studies were able to include psychographic, social, and contextual factors influencing AGYW health behaviors and decisions, especially those measuring the impact of social and gender norms, relationship dynamics, and household dynamics-related outcomes. Outcomes related to engagement in the research were least studied.

CONCLUSION

This EGM highlights that evidence is heavily concentrated within the awareness-intent spectrum of behavior change and gets lean for outcomes situated within the intent-action and the action-habit formation spectrum of the behavior change continuum. Most of the evidence was concentrated on increasing awareness, knowledge, and building risk perception around SRH domains, however, fewer studies focused on strengthening the agency and self-efficacy of individuals. Similarly, evidence on extrinsic factors-such as strengthening social and community norms, relationships, and household dynamics-that determine individual thought and action such as negotiation and life skills were also found to be less populated. Few studies explore the effectiveness of these interventions across diverse AGYW identities, like pregnant women and new mothers, sex workers, and people living with HIV, leading to limited understanding of the use of these interventions across multiple user segments including key influencers such as young men, partners, families, religious leaders, and community elders was relatively low. There is a need for better quality evidence that accounts for the diversity of experiences within these populations to understand what interventions work, for whom, and toward what outcome. Further, the evidence for use of digital and mass-media tools remains poorly populated. Given the increasing penetration of these tools and growing media literacy on one end, with widening gender-based gaps on the other, it is imperative to gather more high-quality evidence on their effectiveness. Timely evidence generation can help leverage these platforms appropriately and enable intervention designs that are responsive to changing communication ecologies of AGYW. SBCC can play a critical role in helping researchers meaningfully engage and collaborate with communities as equal stakeholders, however, this remains poorly evidenced and calls for investigation and investment. A full list of abbreviations and acronyms are available in Supporting Information: Appendix F.

Shifting social norms to prevent age-disparate transactional sex in Tanzania: what we can learn from intervention development research

This paper reflects on the development process (2015-2020) of the Learning Initiative for Norms, Exploitation, and Abuse (LINEA) Intervention. The LINEA Intervention is a multi-component social norms intervention to prevent age-disparate transactional sex in Tanzania. This paper aims to: (1) critically reflect on the LINEA Intervention development process by retrospectively comparing it with a pragmatic, phased framework for intervention development in public health, the Six Essential Steps for Quality Intervention Development (6SQuID); and (2) discuss the usefulness and applicability of this framework to guide intervention development for gender-based violence prevention. This paper contributes to a growing field of intervention development research to improve the designs of interventions to prevent gender-based violence. Findings showed that the LINEA Intervention development approach mostly aligned with the steps in 6SQuID framework. However, the LINEA Intervention development process placed particular emphasis on two phases of the 6SQuID framework. First, the LINEA Intervention development process included significant investment in formative research, feasibility testing, and refinement; and second, the LINEA Intervention was informed by a clearly articulated behavior change theory-social norms theory. Beyond the 6SQuID framework the LINEA Intervention development process: (i) followed a non-linear, iterative process; (ii) applied ongoing feasibility testing to refine the intervention, and (iii) relied on co-development with local implementers and participants. This paper suggests future components for a robust intervention development process, highlighting beneficial additions to the 6SQuID approach, a well-recognized intervention development sequence. Particularly useful additions include incorporating sufficient time, flexibility, and resources to foster meaningful collaborations and iteration on the intervention design.

A mixed-methods, exploratory, quasi-experimental evaluation of a radio drama intervention to prevent age-disparate transactional sex in Tanzania

INTRODUCTION

Age-disparate transactional sex (ADTS) is associated with HIV, unintended pregnancy, school dropout and violence, yet few interventions have successfully prevented it, and none have set ADTS prevention as their primary outcome. This exploratory evaluation aimed to assess indications of change after exposure to the Learning Initiative on Norms, Exploitation and Abuse (LINEA) intervention, a mass-media, gender-transformative social norms intervention aimed at preventing ADTS in Tanzania.

METHODS

In a condensed implementation 331 participants were instructed to listen to the LINEA radio drama over seven weeks, and 60 were randomly allocated to household discussion sessions about content. In-depth interviews (n = 81) from girls aged 12-16 years, and women and men caregivers were collected at baseline (September 2021), midline (November) and endline (December 2021). Surveys were conducted (n = 120) at baseline and endline using the Norms and Attitudes on ADTS Scale (NAATSS) and the Gender Roles and Male Provision Expectations (GRMPE) scale. Interviews were thematically analyzed using a framework approach. Age-stratified linear regression models adjusted for baseline scores were used to measure association between the intervention and endline scale scores.

RESULTS

Longitudinal data were available from 59 qualitative (73%) and 95 quantitative participants (79%). Qualitative evidence revealed the drama facilitated family conversations about adolescent challenges, allowing caregivers to advise daughters. Some girls gained confidence to refuse men's gifts, learning that accepting them could necessitate sexual reciprocation. Some caregivers felt increased responsibility for supporting girls in the community to avoid ADTS. Blame for ADTS shifted for some from girls to men, suggesting increased understanding of inequitable power dynamics and reductions in victim blaming. Marginal quantitative evidence revealed that highly exposed girls had improved gender equitable beliefs on the GRMPE (β = -6.26; 95% CI: -12.94, 0.42). Moderately exposed men had increased gender inequitable norms on the NAATSS subscale (β = 0.42 95% CI: 0.05, 0.79), but there was no effect in highly exposed men.

CONCLUSIONS

Given the small sample results should be interpreted cautiously. Our initial findings indicate high engagement with the LINEA intervention shows promise in shifting knowledge, behaviors, and attitudes, beliefs and social norms driving ADTS in Shinyanga, Tanzania, supporting a robust impact evaluation.

Barriers and facilitators to HIV prevention interventions for reducing risky sexual behavior among youth worldwide: a systematic review

BACKGROUND

Interventions aimed at reducing risky sexual behavior are considered an important strategy for averting Human Immunodeficiency Virus (HIV) infection among youth (15-24 years) who continue to be at risk of the disease. Enhancing intervention success requires a comprehensive understanding of the barriers and facilitators to interventions targeting youth. However, there is lack of a systematic review of both quantitative and qualitative studies to comprehensively identify and synthesize barriers and facilitators to HIV prevention interventions for reducing risky sexual behavior among youth worldwide. This review aimed to identify and synthesize barriers and facilitators to HIV prevention interventions for reducing risky sexual behavior among youth globally based on original peer-reviewed studies published in the last decade.

METHODS

The Joanna Briggs Institute approach for mixed methods systematic reviews and Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines were used to guide this review. Nine electronic databases, Joint United Nations Programme on HIV/AIDS and World Health Organization websites, and reference lists of included studies and systematic reviews on barriers and facilitators to HIV prevention interventions for reducing risky sexual behavior among youth were searched for eligible articles. Studies that met the inclusion criteria underwent quality appraisal and data extraction. Findings were analyzed using thematic synthesis and underpinned by Nilsen, 2015's Determinant Framework.

RESULTS

Overall 13 studies comprising of eight qualitative studies, four quantitative studies and one mixed methods study were included in the review. Several barriers and facilitators across the five Determinant Framework domains were identified. Most of the barriers fell under the characteristics of the context domain (e.g., gender-biased norms). The next important group of barriers emerged within the characteristics of the end users domain (e.g., fear of relationship breakdown). In terms of facilitators, the majority fell under the characteristics of the strategy of facilitating implementation domain (e.g., implementation of intervention with fidelity) and characteristics of the end users domain (e.g., fear of pregnancy or sexually transmitted infections). The next common set of facilitators appeared within the characteristics of the context domain (e.g., family support).

CONCLUSION

This review identified several multi-level barriers and facilitators to HIV prevention interventions for reducing risky sexual behavior among youth. Multi-level and combination approaches are needed to address these factors and enhance intervention success.

Personal beliefs and social norms regarding the sexual exploitation of girls in age-disparate transactional sexual relationships in Brazil: a mixed-methods study

Background

In the global debate around transactional sex little attention has concentrated on Brazil, despite ranking fourth globally in absolute number of girls married or co-habiting by the age of 15 years, and evidence showing that these unions often begin as age-disparate transactional sex (ADTS). This article contributes to filling this gap by exploring the personal beliefs and social norms related to ADTS in urban (favela) communities of Rio de Janeiro, Brazil between adult men (> 18 years) and girls and adolescents (G/A) (< 18 years) with a minimum 5-year age disparity. The primary objective of this study was to identify the social norms that promote and prevent ADTS, and the dynamics between individual beliefs and social norms, to provide contextualized recommendations to prevent ADTS in this setting.

Methods

An exploratory, sequential, mixed-methods design was used, starting with a qualitative phase that included semi-structured, in-depth interviews and focus groups, and a subsequent quantitative phase comprising of a community survey. The items for the quantitative questionnaires were developed based on the qualitative results.

Results

Mixed methods results indicate that in these communities ADTS is normalised and not considered exploitative. We identified three themes related to the reasons ADTS occurs: girls’ responsibility, male desires and benefits of ADTS. Men’s role in ADTS was largely minimised because of a general acceptance of a notion of masculinity characterised by hypersexuality and lack of impulse control. Individual beliefs, however, did not tend to align with these social norms.

Conclusions

In this study, personal beliefs and social norms often did not align, suggesting that initiatives working to change personal or attitudes regarding ADTS may not lead to meaningful change in ADTS behaviours, and social norms interventions may be more effective. Our findings reinforce the need to develop programs tailored to local understandings of ADTS, targeting not only girls but also a wide range of actors. Interventions could also consider the structural factors acting in local and global contexts that promote or prevent ADTS.

This article explores the personal beliefs and social norms related to the exchange of sexual favours or relationships for material favours, gifts and/or support in some form, between adult men (> 18 years) and girls and adolescents (< 18 years) with a minimum 5-year age difference. We used interviews, focus groups and questionnaires to understand the factors that promote and prevent these sexual relationships between men and girls. Motivators for these relationships were often related to girls’ responsibilities, male desires and the benefits of these relationships. Men’s responsibility for their participation in these relationships with girls were often minimised due to a general acceptance of men as overly sexual and lacking impulse control. In this study, personal beliefs and social norms were often not aligned, suggesting that interventions focused on changing personal beliefs or attitudes about these sexual relationships may not be enough to change social norms. The findings highlight the need to develop solutions that consider a wider range of actors, instead of interventions focused only on girls. The study findings also support the need to further investigate how communities and shared expectations can influence sexual relationships in exchange for goods between adult men and girls and adolescents.

Systematic review protocol of the effectiveness of HIV prevention interventions for reducing risky sexual behaviour among youth globally

INTRODUCTION

Human immunodeficiency virus (HIV) prevention interventions focused at reducing risky sexual behaviours are an important strategy for preventing HIV infection among youth (15-24 years) who continue to be vulnerable to the disease. This systematic review aims to synthesise current global evidence on the effectiveness of HIV prevention interventions for reducing risky sexual behaviour among youth in the last decade.

METHODS AND ANALYSIS

MEDLINE/PubMed, EMBASE, PsychINFO, ProQuest Central, CINAHL and Web of Science databases, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform and reference lists of included studies and systematic reviews on effectiveness of HIV prevention interventions for reducing risky sexual behaviour among youth will be searched for articles published from August 2011 to August 2021. Eligible studies will be longitudinal studies including randomised controlled trials and quasi-experimental studies that examined the effectiveness of HIV prevention interventions among youth populations (15-24 years) with risky sexual behaviour as a primary or secondary outcome. Study selection and quality assessment will be undertaken independently by three reviewers and disagreements will be resolved through consensus. Data analysis will be undertaken using RevMan software V.5.3.3. A random effects meta-analysis will be conducted to report heterogeneous data where statistical pooling is achievable. We will use I² statistics to test for heterogeneity. Where appropriate, a funnel plot will be generated to assess publication bias. Where statistical pooling is unachievable, the findings will be reported in a narrative form, together with tables and figures to assist in data presentation if required. Reporting of the systematic review will be informed by Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

ETHICS AND DISSEMINATION

Ethical approval is not required. Findings of the systematic review will be published in a peer-reviewed journal. The findings will be of interest to researchers, healthcare practitioners and policymakers.

PROSPERO REGISTRATION NUMBER

CRD42021271774.

'I trap her with a CD, then tomorrow find her with a big old man who bought her a smart phone'. Constructions of masculinities and transactional sex: a qualitative study from North-Western Tanzania

Men's role in transactional sex is relatively unexplored, limiting initiatives to prevent exploitative transactional sex and its negative health implications for girls and women. We addressed this literature gap by conducting eight focus group discussions and twenty in-depth-interviews with boys and men aged 14 - 49 years in 2015 in Tanzania. We employed a novel combination of theoretical perspectives - gender and masculinities, and social norms - to understand how transactional sex participation contributes to perpetuating gendered hierarchies, and how reference groups influence men's behaviour. Findings signal two gender norms that men display within transactional sex: the expectation of men's provision in sexual relationships, and the expectation that men should exhibit heightened sexuality and sexual prowess. Adherence to these expectations in transactional sex relationships varied between older and younger men and created hierarchies among men and between men and women and girls. We found that approval of transactional sex was contested. Although young men were likely to object to transactional sex, they occupied a structurally weaker position than older men. Findings suggest that interventions should employ gender synchronised and gender transformative approaches and should prioritise the promotion of alternative positive norms over preventing the exchange of gifts or money in relationships.

Alcohol-Antiretroviral Therapy Interactive Toxicity Beliefs and Intentional Medication Nonadherence: Review of Research with Implications for Interventions

The successful treatment of HIV infection relies on adherence to antiretroviral therapy (ART). Alcohol use remains a threat to ART adherence, including the beliefs held by people who drink alcohol that it is harmful to take ART when consuming alcohol (i.e., alcohol-ART interactive toxicity beliefs, AA-ITB). We reviewed the current research that has investigated AA-ITB and their relationship to intentional ART nonadherence. The review of 17 published studies found that AA-ITB are prevalent among people receiving ART and that AA-ITB are directly associated with ART nonadherence and incomplete HIV suppression. Family, friends and healthcare providers are common sources and reinforcers of AA-ITB. Studies suggest that AA-ITB may best be explained by the Medication Necessity and Concerns Beliefs Model, treating AA-ITB as a specific circumstance of medication concerns. Interventions are needed to communicate the realities of potential medication interactions and dispel myths that it is harmful to mix alcohol with ART, while not inadvertently suggesting that it is safe to drink with all medications, which could undermine adherence to ART by increasing alcohol use.

Psychosocial interventions for improving engagement in care and health and behavioural outcomes for adolescents and young people living with HIV: a systematic review and meta-analysis

INTRODUCTION

Adolescents and young people comprise a growing proportion of new HIV infections globally, yet current approaches do not effectively engage this group, and adolescent HIV-related outcomes are the poorest among all age groups. Providing psychosocial interventions incorporating psychological, social, and/or behavioural approaches offer a potential pathway to improve engagement in care and health and behavioural outcomes among adolescents and young people living with HIV (AYPLHIV).

METHODS

A systematic search of all peer-reviewed papers published between January 2000 and July 2020 was conducted through four electronic databases (Cochrane Library, PsycINFO, PubMed and Scopus). We included randomized controlled trials evaluating psychosocial interventions aimed at improving engagement in care and health and behavioural outcomes of AYPLHIV aged 10 to 24 years.

RESULTS AND DISCUSSION

Thirty relevant studies were identified. Studies took place in the United States (n = 18, 60%), sub-Saharan Africa (Nigeria, South Africa, Uganda, Zambia, Zimbabwe) and Southeast Asia (Thailand). Outcomes of interest included adherence to antiretroviral therapy (ART), ART knowledge, viral load data, sexual risk behaviours, sexual risk knowledge, retention in care and linkage to care. Overall, psychosocial interventions for AYPLHIV showed important, small-to-moderate effects on adherence to ART (SMD = 0.3907, 95% CI: 0.1059 to 0.6754, 21 studies, n = 2647) and viral load (SMD = -0.2607, 95% CI -04518 to -0.0696, 12 studies, n = 1566). The psychosocial interventions reviewed did not demonstrate significant impacts on retention in care (n = 8), sexual risk behaviours and knowledge (n = 13), viral suppression (n = 4), undetectable viral load (n = 5) or linkage to care (n = 1) among AYPLHIV. No studies measured transition to adult services. Effective interventions employed various approaches, including digital and lay health worker delivery, which hold promise for scaling interventions in the context of COVID-19.

CONCLUSIONS

This review highlights the potential of psychosocial interventions in improving health outcomes in AYPLHIV. However, more research needs to be conducted on interventions that can effectively reduce sexual risk behaviours of AYPLHIV, as well as those that can strengthen engagement in care. Further investment is needed to ensure that these interventions are cost-effective, sustainable and resilient in the face of resource constraints and global challenges such as the COVID-19 pandemic.

Facilitators and barriers to HIV pre-exposure prophylaxis (PrEP) uptake through a community-based intervention strategy among adolescent girls and young women in Seme Sub-County, Kisumu, Kenya

BACKGROUND

While the introduction of HIV Pre-Exposure Prophylaxis (PrEP) as an HIV prevention strategy has allowed women to exercise more control over the reduction of HIV transmission rates, adolescent girls and young women in Sub-Saharan Africa continue to experience higher rates of HIV infections and bear the greatest disease burden. Understanding progress in PrEP uptake among adolescent girls and young women would enhance risk reduction in this vulnerable population. The Determined, Resilient, AIDS-Free, Mentored and Safe women (DREAMS) Initiative plays a key role in this risk reduction strategy.

METHODS

We performed a qualitative study to explore facilitators and barriers to PrEP implementation and assess factors effecting initiation and persistence on PrEP among adolescent girls and young women enrolled in the DREAMS Initiative at Pamoja Community Based Organization in Kisumu, Kenya. We conducted key informant interviews (n = 15) with Pamoja Community Based Organization staff, health care providers and community leaders. Additionally, we conducted focus group discussions with young women receiving PrEP and peer mentors (n = 40). We performed a directed content analysis using the Consolidated Framework for Implementation Research to organize the identified facilitators and barriers.

RESULTS

We found that the use of the safe space model, decentralization of PrEP support and delivery, peer mentors, effective linkage to local health care facilities, the sensitization of parents and male sexual partners, disclosure of PrEP use by beneficiaries, active stakeholder involvement and community engagement were among some of the facilitators to PrEP uptake. Barriers to PrEP implementation, initiation and persistence included stigma associated with the use of anti-retroviral drugs, drug side effects, frequent relocation of beneficiaries, limited resources for routine screening and medication monitoring, and a limited number of qualified health care workers for PrEP distribution and administration.

CONCLUSION

Overall, the community roll-out of PrEP within the DREAMS Initiative was successful due to a number of key facilitating factors, which ultimately led to successful PrEP implementation, increased PrEP initiation and enhanced persistence among adolescent girls and young women. The identified barriers should be addressed so that a larger scale-up of PrEP roll-out is possible in the future.

Capitalising on aspirations of adolescent girls and young women to reduce their sexual health risks: Implications for HIV prevention

This paper explores adolescent girls' and young women's (AGYW) aspirations, factors that influence aspirations, and how their aspirations inform their sexual decision-making and behaviour. This study employed a qualitative design involving six participatory focus group discussions and 17 in-depth interviews with AGYW in - and out-of-school. Fieldwork was undertaken in rural and urban Tanzania. Thematic analysis was conducted using NVIVO software. Aspirations of AGYW's were categorised as short and long-term. Short-term aspirations were associated with the social status derived from obtaining trendy items such as nice clothing, or smart phones. Long-term aspirations included completing secondary education, having a professional job, being respected, getting married and having children. Aspirations were influenced by aspects of the social context, such as peers and structural factors that dictated what was acceptable for respectable AGYW. AGYW lacked the independent capabilities to meet long-term aspirations such as completing education. In pursuit of their short - and long-term aspirations, AGYW engaged in higher risk sexual behaviours such as transactional sex, age-disparate sex and condomless sex. AGYW's aspirations were important in determining their sexual decision making. Interventions should capitalise on AGYW's aspirations when addressing their SRH risks by finding innovative ways of engaging them based on their circumstances and aspirations.

Factors associated with age-disparate sexual partnerships among males and females in South Africa: a multinomial analysis of the 2012 national population-based household survey data

BACKGROUND

In South Africa, age-disparate to sexual relationships where the age difference between partners is 5 years or greater is an important contributor to the spread of HIV. However, little is known about the predictors of age-disparate sexual relationships. This study investigates factors associated with age-disparate sexual relationships among males and females in South Africa.

METHODS

This analysis used the 2012 nationally representative population-based household survey conducted using multi-stage stratified cluster sampling design. Multivariate multinomial stepwise logistic regression models were used to determine factors associated with age-disparate sexual relationships.

RESULTS

Of 15,717 participants, who responded to the question on age-disparate sexual relationships, 62% males versus 58.5% females had partners within 5 years older or younger, 34.7% of males versus 2.7% of females had partners at least 5 years younger and 3.3% of males versus 38.8% of females had partners at least 5 years older. Among both males and females predictors of age-disparate sexual relationships were education, employment, socioeconomic status, locality type, age at sexual debut, condom use at last sexual act and HIV status while race was also an additional predictor for among females. Including unprotected sex and risk of HIV infection among adolescent girls and young women with sexual partners 5 years older their age.

CONCLUSIONS

This study suggest that there is a need for reprioritizing the combination of behavioural and structural interventions to address risky sexual behaviours, unprotected sex, poverty, limited education and gender inequitable norms related to age-disparate sexual relationships and HIV.