The impact of community-based, peer-led sexual and reproductive health services on knowledge of HIV status among adolescents and young people aged 15 to 24 in Lusaka, Zambia: The Yathu Yathu cluster-randomised trial – ScienceOpen
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      The impact of community-based, peer-led sexual and reproductive health services on knowledge of HIV status among adolescents and young people aged 15 to 24 in Lusaka, Zambia: The Yathu Yathu cluster-randomised trial

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          Abstract

          Background

          The growing population of adolescents and young people (AYP) aged 15 to 24 in sub-Saharan Africa face a high burden of HIV in many settings. Unintended pregnancies among adolescent girls in the region remain high. Nonetheless, the sexual and reproductive health (SRH) service needs of AYP have remained underserved. We conducted a cluster-randomised trial (CRT) to estimate the impact of community-based, peer-led SRH service provision on knowledge of HIV status and other SRH outcomes, including met need for contraceptives.

          Methods and findings

          Yathu Yathu was a cluster-randomised trial (CRT) conducted from 2019 to 2021 in 2 urban communities in Lusaka, Zambia. The communities were divided into 20 zones (approximately 2,350 AYP/zone) that were randomly allocated to the Yathu Yathu intervention or control arm. In each intervention zone, a community-based hub, staffed by peer support workers, was established to provide SRH services. In 2019, a census was conducted in all zones; all consenting AYP aged 15 to 24 were given a Yathu Yathu card, which allowed them to accrue points for accessing SRH services at the hub and health facility (intervention arm) or the health facility only (control arm). Points could be exchanged for rewards, thus acting as an incentive to use SRH services in both arms. We conducted a cross-sectional survey in 2021 to estimate the impact of Yathu Yathu on the primary outcome: knowledge of HIV status (self-reporting living with HIV or HIV testing in the last 12 months) and secondary outcomes, including use of pre-exposure prophylaxis (PrEP) in the last 12 months, current use of antiretroviral therapy (ART), and met need for contraceptive services. The sampling was stratified on sex and age group, and we analysed data at cluster-level using a two-stage process recommended for CRTs with <15 clusters/arm. A total of 1,989 AYP consented to participate in the survey (50% male); consent was similar across arms (63% consent/arm). Across zones, knowledge of HIV status ranged from 63.6% to 81.2% in intervention zones and 35.4% to 63.0% in control zones. Adjusting for age, sex, and community, knowledge of HIV status was higher in the intervention arm compared to control (73.3% versus 48.4%, respectively, adjusted prevalence ratio (PR) 1.53 95% CI 1.36, 1.72; p < 0.001). By age and sex, results were similar. There was no evidence for impact on any secondary outcomes, including current use of ART and met need for contraceptives. There were no adverse events reported in either arm. A key limitation of our trial is that approximately 35% of the AYP randomly selected for participation in the endline survey could not be reached.

          Conclusions

          Delivering community-based, peer-led SRH services increased knowledge of HIV status among AYP, both males and females, compared with the control arm. Scaling up the highly effective Yathu Yathu strategy has the potential to make a substantial contribution to increasing access to HIV prevention and care services for young people. However, additional implementation research is needed to understand how to improve uptake of broader SRH services, beyond uptake of HIV testing.

          Trial registration

          ISRCTN75609016, clinicaltrials.gov number NCT04060420

          Abstract

          Bernadette Hensen and colleagues investigate whether community-based delivery of sexual and reproductive health services by peers increased knowledge of HIV status among adolescents and young people in Zambia.

          Author summary

          Why was this study done?
          • Adolescents and young people (AYP) have limited access to sexual and reproductive health (SRH) services; rigorous evidence of strategies, co-developed with young people, that improve access to these services is needed.

          • This trial was done to investigate whether community-based delivery of SRH services by peers would increase knowledge of HIV status among AYP aged 15 to 24 in Lusaka, Zambia.

          What did the researchers do and find?
          • Through spaces in the community (called hubs), peer support workers, a nurse and supervisor, delivered a range of SRH services, including HIV testing, comprehensive sexuality education, and contraceptives, daily to AYP aged 15 to 24.

          • Service delivery through hubs was complemented by incentives, namely the collection of points for services accessed and the ability to use these points to “buy” rewards, such as soap, toothbrush, and toothpaste.

          • After approximately 24 months, we compared knowledge of HIV status (defined as either self-reporting knowing ones HIV–positive status or having HIV tested in the previous 12 months) between random selections of AYP aged 15 to 24 ( N = 1,989) living in areas that received the Yathu Yathu intervention and in areas that did not receive the intervention.

          • We found that knowledge of status was considerably higher in the intervention areas (73.3%) as compared to the non-intervention areas (48.4%), but that there was no difference in uptake of other SRH services, such as linkage to PrEP for the prevention of HIV.

          What do these findings mean?
          • These findings show that community-based hubs that deliver a range of SRH services and are complemented by incentives can increase knowledge of HIV status.

          • Additional research is needed to improve delivery of other services, including linkage to prevention and care services, and access to contraceptive services.

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          Most cited references49

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          Contraception for adolescents in low and middle income countries: needs, barriers, and access

          Substantial numbers of adolescents experience the negative health consequences of early, unprotected sexual activity - unintended pregnancy, unsafe abortions, pregnancy-related mortality and morbidity and Sexually Transmitted Infections including Human Immunodeficiency Virus; as well as its social and economic costs. Improving access to and use of contraceptives – including condoms - needs to be a key component of an overall strategy to preventing these problems. This paper contains a review of research evidence and programmatic experiences on needs, barriers, and approaches to access and use of contraception by adolescents in low and middle income countries (LMIC). Although the sexual activity of adolescents (ages 10–19) varies markedly for boys versus girls and by region, a significant number of adolescents are sexually active; and this increases steadily from mid-to-late adolescence. Sexually active adolescents – both married and unmarried - need contraception. All adolescents in LMIC - especially unmarried ones - face a number of barriers in obtaining contraception and in using them correctly and consistently. Effective interventions to improve access and use of contraception include enacting and implementing laws and policies requiring the provision of sexuality education and contraceptive services for adolescents; building community support for the provision of contraception to adolescents, providing sexuality education within and outside school settings, and increasing the access to and use of contraception by making health services adolescent-friendly, integrating contraceptive services with other health services, and providing contraception through a variety of outlets. Emerging data suggest mobile phones and social media are promising means of increasing contraceptive use among adolescents.
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            Cabotegravir for HIV Prevention in Cisgender Men and Transgender Women

            Safe and effective long-acting injectable agents for preexposure prophylaxis (PrEP) for human immunodeficiency virus (HIV) infection are needed to increase the options for preventing HIV infection.
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              Is Open Access

              Impact of a universal testing and treatment intervention on HIV incidence in Zambia and South Africa: results of the HPTN 071 (PopART) community-randomized trial

              Background Universal testing and treatment (UTT) is a potential strategy to reduce HIV incidence, yet prior trial results are inconsistent. We report results from HPTN 071 (PopART), the largest HIV prevention trial to date. Methods In this community-randomized trial (2013-18), 21 communities in Zambia and South Africa were randomized to Arm A (PopART intervention, universal antiretroviral therapy [ART]), Arm B (PopART intervention, ART per local guidelines), and Arm C (standard-of-care). The PopART intervention included home-based HIV-testing delivered by community workers who supported linkage-to-care, ART adherence, and other services. The primary outcome, HIV incidence between months 12-36, was measured in a Population Cohort (PC) of ~2,000 randomly-sampled adults/community aged 18-44y. Viral suppression (VS, <400 copies HIV RNA/ml) was measured in all HIV-positive PC participants at 24m. Results The PC included 48,301 participants. Baseline HIV prevalence was similar across study arms (21%-22%). Between months 12-36, 553 incident HIV infections were observed over 39,702 person-years (py; 1.4/100py; women: 1.7/100py; men: 0.8/100py). Adjusted rate-ratios were A vs. C: 0.93 (95%CI: 0.74-1.18, p=0.51); B vs. C: 0.70 (95%CI: 0.55-0.88, p=0.006). At 24m, VS was 71.9% in Arm A; 67.5% in Arm B; and 60.2% in Arm C. ART coverage after 36m was 81% in Arm A and 80% in Arm B. Conclusions The PopART intervention with ART per local guidelines reduced HIV incidence by 30%. The lack of effect with universal ART was surprising and inconsistent with VS data. This study provides evidence that UTT can reduce HIV incidence at population level. Trial registration ClinicalTrials.gov NCT01900977
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                Author and article information

                Contributors
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: Funding acquisitionRole: MethodologyRole: Project administrationRole: Writing – original draftRole: Writing – review & editing
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: MethodologyRole: Writing – review & editing
                Role: ConceptualizationRole: MethodologyRole: Project administrationRole: Writing – review & editing
                Role: Data curationRole: Formal analysisRole: MethodologyRole: Software
                Role: Data curationRole: Project administration
                Role: Methodology
                Role: Data curationRole: Methodology
                Role: MethodologyRole: Supervision
                Role: MethodologyRole: Supervision
                Role: ConceptualizationRole: Funding acquisitionRole: MethodologyRole: SupervisionRole: Writing – review & editing
                Role: ConceptualizationRole: Formal analysisRole: Funding acquisitionRole: InvestigationRole: MethodologyRole: VisualizationRole: Writing – review & editing
                Role: Funding acquisitionRole: MethodologyRole: Project administrationRole: Writing – review & editing
                Role: ConceptualizationRole: Funding acquisitionRole: InvestigationRole: MethodologyRole: Project administrationRole: SupervisionRole: Writing – review & editing
                Role: Academic Editor
                Journal
                PLoS Med
                PLoS Med
                plos
                PLOS Medicine
                Public Library of Science (San Francisco, CA USA )
                1549-1277
                1549-1676
                21 April 2023
                April 2023
                : 20
                : 4
                : e1004203
                Affiliations
                [1 ] Department of Public Health, the Institute of Tropical Medicine, Antwerp, Belgium
                [2 ] Department of Clinical Research, the London School of Hygiene and Tropical Medicine, London, United Kingdom
                [3 ] Department of Infectious Disease Epidemiology, the London School of Hygiene and Tropical Medicine, London, United Kingdom
                [4 ] Zambart, Lusaka, Zambia
                [5 ] Department of Infectious Disease, Imperial College London, United Kingdom
                University of Washington, UNITED STATES
                Author notes

                The authors have declared that no competing interests exist.

                Author information
                https://orcid.org/0000-0001-6719-6720
                https://orcid.org/0000-0002-8615-7601
                https://orcid.org/0000-0001-6029-9372
                https://orcid.org/0000-0002-5959-526X
                https://orcid.org/0000-0003-1676-7583
                https://orcid.org/0000-0002-1729-9892
                https://orcid.org/0000-0002-0684-6897
                https://orcid.org/0000-0003-4108-2842
                Article
                PMEDICINE-D-22-02482
                10.1371/journal.pmed.1004203
                10121029
                37083700
                90ebe902-3a3f-4cac-a660-fe57d7f4e84d
                © 2023 Hensen et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 19 July 2022
                : 20 February 2023
                Page count
                Figures: 3, Tables: 4, Pages: 21
                Funding
                Funded by: funder-id http://dx.doi.org/10.13039/501100000265, Medical Research Council;
                Award ID: MR/R022216/1
                Award Recipient :
                This work was supported by the Medical Research Council, Department for International Development, and National Institute for Health Research (grant number MR/R022216/1 to HA). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
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