Reaching youth with out-of-facility HIV and reproductive health services: a systematic review

The impact of an innovative community-based peer-led intervention on uptake and coverage of sexual and reproductive health services among adolescents and young people 15-24 years old: results from the Yathu Yathu cluster randomised trial

BACKGROUND

The Yathu Yathu ("For Us, By Us") cluster-randomized trial (CRT) evaluated a peer-led community-based sexual and reproductive health(SRH) intervention implemented to address persistent barriers to SRH service use among adolescents and young people (AYP). We report the impact of the intervention on coverage of key SRH services among AYP.

METHODS

The trial was conducted from Jul 2019-Oct 2021 in two urban communities in Lusaka, Zambia, divided into 20 zones (~ 2350 AYP/zone). Zones were randomly allocated to intervention (N = 10) or control (N = 10) arm. In all zones, a census was conducted and all AYP aged 15-24-years offered participation. The intervention consisted of peer-led community-based hubs providing SRH services; a prevention points card (PPC) system to incentivize and track SRH service use and community engagement. This paper reports on the outcome of coverage (accessing at least one key SRH service), comparing intervention and control arms using PPC data and standard methods of analysis for CRTs.

RESULTS

Among enumerated AYP, 93.6% (14,872/15,894) consented to participate from intervention zones and 95.1% (14,500/15,255) from control zones. Among those who accepted a PPC, 63.8% (9,493/14,872) accessed at least one key SRH service during the study period in the intervention arm, compared to 5.4% (776/14,500) in the control arm (adjPR 12.3 95%CI 9.3-16.2, p < 0.001).

CONCLUSIONS

The Yathu Yathu intervention increased coverage of key SRH services among AYP and reached two-thirds of AYP. These findings demonstrate the potential of providing peer-led community-based SRH services.

TRIAL REGISTRATION

ISRCTN75609016 (11/10/2021), clinicaltrials.gov number NCT04060420 (19/08/2019); retrospectively registered.

Improving the Quality of Adolescent and Youth-Friendly Health Services Through Integrated Supportive Supervision in Four Nigerian States

BACKGROUND

Although the unique sexual and reproductive health needs of adolescents and youth (AY) are widely recognized, the challenge remains how to integrate adolescent- and youth-friendly health services (AYFHS) effectively within a systems-based approach that is both feasible and scalable. This article provides preliminary evidence from 4 Nigerian states that sought to overcome this challenge by implementing capacity-strengthening approaches centered around a shortened quality assurance (QA) tool that has become part of the state health system's routine supportive supervision process and follow-up quality improvement (QI) activities.

METHODS

A shortened QA tool was administered to assess and track the performance of 130 high-volume health facilities across 5 domains to serve its AY population with quality contraceptive services. Facility-based providers (N=198) received training on adolescent and youth sexual and reproductive health, AYFHS, and long-acting reversible contraceptive methods. To corroborate checklist findings, we conducted exit interviews with 754 clients (aged 15-24 years) who accessed contraceptive services from the facilities that met the World Health Organization's minimum standards for quality AYFHS.

RESULTS

In the 4 states, the QA tool was applied at baseline and 2 rounds, accompanied by QI capacity strengthening after each round. At baseline, only 12% of the 130 facilities in the 4 states scored met the minimum quality standards for AYFHS. After 2 rounds, 88% of the facilities met the minimum standards. AY client volume increased over this same period. All 4 states showed great improvements; however, the achievements varied by state. The exit interview feedback supported client satisfaction with the services provided to AY.

CONCLUSION

Integrating QA followed by QI within Nigeria's family planning supportive supervision system is not only feasible but also impacts the quality of AYFHS and contraceptive uptake by clients aged 15-24 years.

Study protocol for a type-II hybrid effectiveness-implementation trial to reach teenagers using mobile money shops to reduce unintended pregnancies in Uganda

INTRODUCTION

Unintended teenage pregnancies have become a global public health challenge, particularly in sub-Saharan Africa. There is a notably high prevalence of unintended pregnancies among unmarried teenagers in Uganda. This study will develop an intervention programme using mobile money shops (vendors) as a platform to deliver sexual and reproductive health and rights (SRHR) services to teenagers and assess its effectiveness and scalability in Uganda.

METHODS AND ANALYSES

This hybrid study comprises two integral components: an intervention study to assess the effectiveness of vendor-mediated intervention and implementation research to evaluate the implementation process. 30 vendors will be recruited for both intervention and control arms in 2 municipalities in Eastern Uganda, which have a high unintended pregnancy prevalence rate among unmarried teens aged 15-19 years. A preintervention and postintervention repeated survey involving 600 participants for each arm will be conducted over 4 months. The primary outcome is the rate of condom users among teenage vendor users. The secondary outcomes include the rate of preference for receiving SRHR services at vendors and knowledge regarding SRHR. A difference-in-differences analysis will be used to determine the effectiveness of the intervention. The Bowen model will be employed to evaluate the implementation design.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the Ethics Review Committee of Uganda Christen University and JICA Ogata Sadako Research Institute for Peace and Development in Japan. The findings will be widely disseminated. This study was registered with the University Hospital Medical Information Network in Japan (UMIN000053332) on 12 January 2024.

TRIAL REGISTRATION NUMBER

UMIN000053332.

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

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.

The uptake of key elements of sexual and reproductive health services and its predictors among rural adolescents in Southern Ethiopia, 2020: application of a Poisson regression analysis

BACKGROUND

Although 25% of the Ethiopian population is young, Sexual and Reproductive Health (SRH) Services have not been adequately researched and intervened, leaving adolescents with many reproductive health challenges. Assessment of the uptake of each element of SRH service and its determinants among those age groups is essential to improving service uptake and reducing the burden of illness and disability in adolescents. Thus, this study aimed at assessing the uptake of key elements of SRH services and its determinants among adolescents residing in rural districts of Guraghe zone, Southern Ethiopia.

METHODS

A community-based cross-sectional study was carried out from May 1 to 30, 2020, and a multi-stage sampling technique was employed to randomly select 1028 adolescents. The data were collected by using a pre-tested interviewer-administered questionnaire. The data were coded and entered into Epi-Data version 3.1 and exported into SPSS version 23 for analysis. Independent t-tests and analysis of variance (ANOVA) were run to determine whether there were statistically significant differences in the mean number of SRH services used across each categorical variable. A multivariable generalized linear regression (GLM) model with a Poisson link was used to determine the effect of each variable on the mean number of SRH services used. Adjusted odds ratios with their corresponding 95% confidence interval were used to declare the statistical significance of the independent variables.

RESULTS

The study included 1,009 adolescents, yielding a response rate of 98.1%. The use of the SRH service was assessed using eight elements, and the mean (± SD) score of service uptake was 4.05 (± 1.94), with only 6.8% of adolescents receiving all key elements. Comprehensive sexuality education (55.1%) and voluntary HIV/AIDS counseling and testing (51.0%) were the commonest service items used by adolescents, while the provision of contraceptives was the lowest service item received (25.9%). Educational level (AOR: 1.28, 95% CI: 1.03-1.56), having a parental discussion (AOR: 1.31, 95% CI: 1.13-1.51), lack of youth clubs (AOR: 0.71, 95% CI: 0.66-0.87), and knowledge on SRH issues (AOR: 0.79, 95% CI: 0.73-0.85) were identified as significant predictors of the uptake of key elements of SRH services.

CONCLUSION

The overall uptake of SRH services was found to be low in the study area. Schools should be an excellent means of educating adolescents to increase their knowledge of key elements of SRH services. Furthermore, stakeholders must work together to improve the culture of parental discussion with adolescents and establish and strengthen youth clubs, as measures for encouraging the use of SRH services.

Adapting community-based sexual and reproductive health services for adolescents and young people aged 15-24 years in response to COVID-19 in Lusaka, Zambia: the implications on the uptake of HIV testing services

BACKGROUND

Across Sub-Saharan Africa, adolescents and young people (AYP) aged 15-24 have limited access to sexual and reproductive health (SRH) services, including HIV testing services (HTS). In response, the Yathu Yathu study was implemented in two high-density communities in Lusaka, Zambia. Yathu Yathu provides comprehensive, community-based, peer-led SRH services, including differentiated HTS (finger-prick and HIV self-testing) and comprehensive sexuality education (CSE). We describe adaptations to the Yathu Yathu intervention in response to the COVID-19 epidemic, and implications on uptake of HTS among AYP.

METHODS

Yathu Yathu provides SRH services through community-based peer-led spaces. AYP in study communities were offered prevention points cards (PPC), which incentivizes and tracks service use. Social media (WhatsApp©/Facebook©) is used to engage and inform AYP about SRH. Due to COVID-19, hubs closed from April-June 2020. We describe adaptations in response to COVID-19 and, using routinely collected PPC data, describe uptake of HTS before (September 2019-March 2020) and after (July-December 2020) adaptations in response to COVID-19. We describe reach of the Yathu Yathu Facebook page and use qualitative data to describe AYP experiences of SRH service access.

RESULTS

During hub closures, CSE was delivered via video on social media, resulting in an increase in Facebook page followers from 539(April) to 891(June). WhatsApp groups evolved as a platform to deliver CSE and COVID-19 information, with higher participation among young people aged 20-24. Key service delivery adaptations included: reducing the number of participants in hubs, mandatory handwashing before entry, use of personal protective equipment by staff and provision of facemasks to AYP. HTS were provided as normal. Adaptations led to fewer AYP attending hubs. Uptake of HTS among AYP visiting hubs for the first time after COVID-19-related closures was higher (73.2%) compared to uptake before adaptations (65.9%; adjOR=1.24 95%CI 0.99, 1.56, p=0.06). Despite disappointments with some aspects of service delivery, AYP expressed happiness that hubs had reopened.

CONCLUSIONS

Social media can be a useful additional platform to reach AYP with HIV prevention information during COVID-19. With proper infection control in place, HTS can safely be provided to, accessed and accepted by AYP in community-based settings during COVID-19.

TRIAL REGISTRATION

National Clinical Trials NCT04060420,19th August 2019. Current Controlled Trials ISRCTN75609016 , 14th September 2021, retrospectively registered.

Temporal shifts in HIV-related risk factors among cohorts of adolescent girls and young women enrolled in DREAMS programming: evidence from Kenya, Malawi and Zambia

OBJECTIVES

To assess temporal shifts in HIV risk factors among adolescent girls (AG, aged 15-19 years) and young women (YW, aged 20-24 years) in Kenya, Malawi and Zambia.

DESIGN

Prospective cohorts with two time points (Kenya: 2016/2017, 2018; Malawi: 2017, 2018; Zambia: 2016/2017, 2018) SETTING: Community-based programming.

PARTICIPANTS

1247 AG (Kenya: 389, Malawi: 371, Zambia: 487) and 1628 YW (Kenya: 347, Malawi: 883, Zambia: 398) INTERVENTION: Determined, Resilient, Empowered, AIDS-free, Mentored and Safe (DREAMS), a multisectoral approach to reduce AGYW's HIV vulnerability by delivering a package of tailored, multilayered activities and services.Primary and secondary outcome measures: HIV testing, sexually transmitted infection (STI) symptom experience, number of sexual partners, condom use (consistently, at last sex), transactional sex, experience of physical violence (from intimate partners) and sexual violence (from intimate partners and strangers/non-partners).

RESULTS

Changes in HIV-related risk behaviours among DREAMS participants varied by age group and country. Among AG, HIV testing increased (Kenya and Zambia) and sexual violence from partners (in Kenya and Malawi) and non-partners (in Malawi) decreased. Among YW, HIV testing increased and STI experience decreased in Malawi; consistent condom use decreased in Kenya; transactional sex increased in Kenya and Zambia; and physical violence (in Malawi) and sexual violence from partners (in Kenya and Malawi) and non-partners (all three countries) decreased over time.

CONCLUSIONS

Improvements in HIV testing and reductions in experiences of sexual violence were coupled with variable shifts in HIV-related risk behaviours among DREAMS participants in Kenya, Malawi and Zambia. Additional consideration of AGYW's risk circumstances during key life transitions may be needed to address the risk heterogeneity among AG and YW across different contexts.

Disparities in sexual and reproductive health services utilization among urban and rural adolescents in southern Ethiopia, 2020: a comparative cross-sectional study

BACKGROUND

Although studies on the uptake of Adolescent sexual and reproductive health (ASRH) services in Ethiopia have been conducted they have failed to show the disparity in service uptake among rural and urban settings. Once the extent and determinants of ASRH service uptake in urban and rural contexts are known, it will be crucial to provide evidence-based information and recommendations for potential interventions to reduce the burden of disease and disability among adolescents. This study aimed at determining the level of SRH service utilization among urban and rural adolescents in the Guraghe zone, Southern Ethiopia.

METHODS

A community-based comparative cross-sectional study was undertaken from November 1 -30, 2020. A multi-stage sampling technique was employed and a total of 1083 adolescents (361 from the urban and 722 from the rural areas) were selected randomly to take part in the study. Pre-tested, interviewer-administered, structured questionnaires were used to collect the data. The data were encoded and entered into Epi-Data version 3.1 and then exported to SPSS version 23 for analysis. χ2 test was computed to see a significant difference in SRH service utilization among urban and rural adolescents. In a bivariable logistic regression analysis, a variable with a p-value less than 0.25 has been selected for a multivariable logistic regression model. Variables with p-values less than 0.05 were declared statistically significant in multivariate logistic regression.

RESULTS

A total of 1,075 adolescents (358 from urban and 717 from rural) took part in the study, yielding a response rate of 99.3%. The overall SRH service utilization among the whole adolescents was 39.5% (95%CI: 36.5, 42.4). There was a significant difference in SRH service utilization between urban 56.9% (95%CI: 51.8, 62.1) and rural 30.8% (95%CI: 27.4, 34.2) adolescents (χ2 = 68.3, p < 0.001). Residence[AOR = 2.62; 95%CI:1.63,3.41], availability of youth clubs [AOR = 4.73; 95%CI:3.43,6.53], taking part in peer education [AOR = 2.06; 95%CI:1.48,3.88], having parental discussion [AOR = 3.29; 95%CI:1.73,3.33], and being knowledgeable on SRH issues [AOR = 2.01; 95%CI: 1.45,3.03] were identified as a significant determinants of SRH service uptake. Having parental discussion, geographical accessibility, and knowledge on SRH were significant predictors of SRH service uptake among rural adolescents.

CONCLUSION

Overall, ASRH service utilization in the study area was low, despite urban adolescent service uptake becoming higher than rural adolescents. Since the majority of adolescents were enrolled in schools, schools should be an area of intervention to improve adolescents' knowledge of SRH services through mass media, community networks, and interpersonal/group communication. Furthermore, promoting parent-adolescent discussions, as well as peer-to-peer discussions at the family and school level, should be emphasized. Stakeholders in the education and health sectors need to strengthen their efforts to establish youth clubs in places where they do not yet exist, especially in rural schools.

Implementation Strategies to Enhance Youth-Friendly Sexual and Reproductive Health Services in Sub-Saharan Africa: A Systematic Review

Introduction: Youth-friendly health service (YFHS) interventions are a promising, cost-effective approaches to delivering sexual and reproductive services that cater to the developmental needs of young people. Despite a growing evidence-base, implementation of such interventions into practice have proven to be challenging in sub-Saharan Africa (SSA). Thus, the purpose of this review is to synthesize existing evidence on YFHS implementation in SSA and understand which implementation strategies were used, in what context, how they were used, and leading to which implementation outcomes.

Methods: A comprehensive literature search in PubMed, Embase, Scopus, and CINAHL, was conducted to identify peer-reviewed research articles published from database inception up until August 2020. Eligible studies were required to include young people (ages 10–24 years) in sub-Saharan Africa. Studies that described implementation strategies, as conceptualized by the Expert Recommendations for Implementing Change (ERIC) project, used to enhance the implementation of YFHS were included. Implementation outcomes were extracted using Proctor and colleagues' 8 taxonomy of implementation outcomes.

Results: We identified 18 unique interventions (reported in 23 articles) from an initial search of 630 articles, including seven from East Africa, seven from South Africa, and four from West Africa. In most studies (n = 15), youth-friendly health services were delivered within the context of a health facility or clinic setting. The most frequently reported categories of implementation strategies were to train and educate stakeholders (n = 16) followed by infrastructure change (n = 10), to engage consumers (n = 9), the use of evaluative and iterative strategies (n = 8), support clinicians (n = 8), and providing interactive assistance (n = 6). The effectiveness of the strategies to enhance YFHS implementation was commonly measured using adoption (n = 15), fidelity (n = 7), acceptability (n = 5), and penetration (n = 5). Few studies reported on sustainability (n = 2), appropriateness (n = 1), implementation cost (n = 1) and feasibility (n = 0).

Conclusion: Results of the review emphasize the need for further research to evaluate and optimize implementation strategies for promoting the scale-up and sustainability of evidence-based, YFHS interventions in resource-constrained settings. This review also highlights the need to design robust studies to better understand which, in what combination, and in what context, can implementation strategies be used to effectively enhance the implementation of YFHS interventions.

Concerns and educational needs of Iranian parents regarding the sexual health of their male adolescents: a qualitative study

BACKGROUND

Parents play an important role in promoting the sexual health of their adolescents. However, many parents experience several challenges. The purpose of this study was to explore the concerns and educational needs of Iranian parents regarding the sexual health of their male adolescents.

METHODS

This qualitative study was designed based on the conventional content analysis approach. Semi-structured and in-depth interviews were conducted with 16 parents of male adolescents aged 12-18 years. All interviews were audio recorded and transcribed verbatim. The data were collected through purposeful sampling and continued until data saturation. Finally, the Graneheim and Landman strategies were used to analyze data.

RESULTS

According to the participants' comments, four main categories were extracted as follows: fear of emotional and sexual harms, quality of parent-child relationships, effect of media and cyberspace, and necessity of sexuality health education.

CONCLUSIONS

The findings highlighted the need for sexuality health education through cooperation with schools for offering appropriate education to the students, parents, and school staffs. The results showed that parents required training to enhance their knowledge and skills to improve their communication with their adolescents about sexuality issues. Therefore, it is necessary to design, implement, and evaluate culture-appropriate educational programs to address the parents' concerns regarding adolescents' sexual health.

Associations between national development indicators and the age profile of people who inject drugs: results from a global systematic review and meta-analysis

BACKGROUND

Globally, an estimated 15·6 million people inject drugs. We aimed to investigate global variation in the age profile of people who inject drugs (PWID), identify country-level factors associated with age of PWID, and assess the association between injecting drug use (IDU) in young people and rates of injecting and sexual risk behaviours at the country level.

METHODS

We derived data from a previously published global systematic review done in April, 2016 (and updated in June, 2017) on the percentage of young PWID, duration of IDU, average age of PWID, average age at IDU initiation, and the percentage of PWID reporting sexual and injecting risk behaviours. We also derived national development indicators from World Bank data. We estimated the percentage of young PWID for each country, using a random-effects meta-analysis (DerSimonian-Laird methodology) and generated pooled regional and global estimates for all indicators of IDU in young people. We used univariable and multivariable generalised linear models to test for associations between the age indicators and country urban population growth, youth unemployment percentage, the percentage of PWID who are female, the percentage of the general population aged 15-24 years, Gini coefficient, opioid substitution therapy coverage (per PWID per year), gross domestic product (GDP) per capita (US$1000), and sexual and injecting risk behaviours.

FINDINGS

In the original systematic review, data on age of PWID was reported in 741 studies across 93 countries. Globally, 25·3% (95% uncertainty interval [UI] 19·6-31·8) of PWID were aged 25 years or younger. The highest percentage of young PWID resided in eastern Europe (43·4%, 95% UI 39·4-47·4), and the lowest percentage resided in the Middle East and north Africa (6·9%, 5·1-8·8). At the country level, in multivariable analysis higher GDP was associated with longer median injecting duration (0·11 years per $1000 GDP increase, 95% CI 0·04-0·18; p=0·002), and older median age of PWID (0·13 years per $1000 increase, 0·06-0·20; p<0·0001). Urban population growth was associated with higher age at IDU initiation (1·40 years per annual percentage change, 0·41-2·40). No associations were identified between indicators of IDU in young people and youth unemployment, Gini coefficient, or opioid substitution therapy coverage provision at the country level. No associations were identified between injecting and sexual risk behaviours and age of PWID.

INTERPRETATION

Variation in the age profile of PWID was associated with GDP and urbanisation. Regions with the highest prevalence of young PWID (aged ≤25 years) had low coverage of interventions to prevent the spread of blood-borne viruses. Data quality highlights the need for improvements in monitoring of PWID populations.

FUNDING

Australian National Drug and Alcohol Research Centre, Australian National Health and Medical Research Council, Open Society Foundation, WHO, the Global Fund, UNAIDS, National Institute for Health Research Health Protection Research Unit for Evaluation of Interventions, Wellcome Trust.

The DREAMS core package of interventions: A comprehensive approach to preventing HIV among adolescent girls and young women

In sub-Saharan Africa, adolescent girls and young women (AGYW) are 5 to 14 times more likely to be infected with HIV than their male peers. Every day, more than 750 AGYW are infected with HIV. Many factors make girls and young women particularly vulnerable to HIV, including gender-based violence, exclusion from economic opportunities, and a lack of access to secondary school. The President's Emergency Plan for AIDS Relief (PEPFAR) is dedicating significant resources through the Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe (DREAMS) partnership to impact the lives of women and girls based on PEPFAR's mission to help countries achieve epidemic control of HIV/AIDS. The data show that new HIV infections must be reduced in AGYW, or the global community risks losing the extensive progress made towards reaching epidemic control. With support from PEPFAR and private sector partners-the Bill & Melinda Gates Foundation, Gilead Sciences, Girl Effect, Johnson & Johnson and ViiV Healthcare, DREAMS works together with partner governments to deliver a core package of interventions that combines evidence-based approaches that go beyond the health sector, addressing the structural drivers that directly and indirectly increase girls' HIV risk. Not only is DREAMS an effort to reduce new HIV infections, but it aims to reduce other critical vulnerabilities such as gender-based violence. When girls and young women thrive, the effects are felt throughout their families, communities and countries.

Ecological Barriers to HIV Service Access among Young Men who have Sex with Men and High-Risk Young Women from Low-resourced Urban Communities

Using an ecological perspective, we sought to elucidate the perceived barriers preventing HIV service access among two groups of U.S. youth (ages 12-24) disproportionately affected by HIV, men who have sex with men and high-risk women. We content analyzed interviews with 318 key informants to identify distinct service barriers. The 29 barriers informants named were organized into six categories (service-seeking demands, stigmas, knowledge and awareness, service quality, powerful opposition, and negative emotions). Findings suggest that barriers impacting access to HIV prevention, testing, and linkage-to-care services are remarkably similar and point to the need for comprehensive approaches to improving youth's access services that address both individual-level barriers and extra-individual barriers simultaneously. Findings can be used to guide future research, programming and interventions to reduce the disproportionate spread of HIV among US youth.

Features of successful sexual health promotion programs for young people: findings from a review of systematic reviews

ISSUE ADDRESSED

Young people have a high burden of sexual and reproductive health (SRH) problems, and it is important to reach this group through health promotion initiatives. We conducted a systematic review of reviews to identify successful elements of health promotion programs for improving SRH of young people.

METHODS

We identified and collated systematic reviews published in 2005-2015 which focused on young people (10-24 years), reported on SRH outcomes (pregnancy, sexually transmissible infections, condoms/contraceptive use, risky sexual behaviour, sexual healthcare access or intimate partner violence), and included primary studies predominantly conducted in high-income countries. This report focuses on features of successful SRH programs identified in the interpretation and discussion of included systematic reviews.

RESULTS

We identified 66 systematic reviews, of which 37 reported on program features which were anecdotally or statistically associated with improved program effectiveness and success. Common features of effective interventions were: longer term or repeated implementation; multi-setting and multi-component; parental involvement; culturally/gender/age appropriate; and inclusion of skills-building. SO WHAT?: There is marked consistency of features improving SRH program effectiveness for young people despite the wide variation in interventions reviewed. There is a need to better implement this knowledge in future programs, and our findings provide useful guidance for optimising the design of SRH interventions for young people.

Assessing the reach and effectiveness of mHealth: evidence from a reproductive health program for adolescent girls in Ghana

BACKGROUND

While mobile health (mHealth) programs are increasingly used to provide health information and deliver interventions, little is known regarding the relative reach and effectiveness of these programs across sociodemographic characteristics. We use data from a recent trial of a text-messaging intervention on adolescent sexual and reproductive health (SRH) to assess the degree to which mHealth programs reach target adolescent subpopulations who may be at higher risk of poor SRH outcomes.

METHODS

The study was conducted among girls aged 14-24 in 22 secondary schools in Accra, Ghana. The mHealth intervention was an interactive mobile phone quiz in which participants could win phone credit for texting correct answers to SRH questions. We use detailed data on individuals' level of engagement with the program, SRH knowledge scores, and self-reported pregnancy collected as part of the original trial to assess the extent to which engagement and program impact vary across parental education, sexual experience, SRH knowledge deficit, and parental support.

RESULTS

Eighty-one percent of participants engaged with the mHealth program, with no evidence that the program disproportionally reached better-off groups. The program was effective at increasing knowledge of SRH across all strata. Higher levels of engagement were associated with higher knowledge scores up to year later. There was no significant impact of the program on self-reported pregnancy within subgroups.

CONCLUSION

mHealth programs for adolescents have the potential to engage and increase SRH knowledge of adolescent girls across sociodemographic strata, including those who may be at higher risk of poor SRH outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02031575 . Registered 07 Jan 2014.

Delivery arrangements for health systems in low-income countries: an overview of systematic reviews

BACKGROUND

Delivery arrangements include changes in who receives care and when, who provides care, the working conditions of those who provide care, coordination of care amongst different providers, where care is provided, the use of information and communication technology to deliver care, and quality and safety systems. How services are delivered can have impacts on the effectiveness, efficiency and equity of health systems. This broad overview of the findings of systematic reviews can help policymakers and other stakeholders identify strategies for addressing problems and improve the delivery of services.

OBJECTIVES

To provide an overview of the available evidence from up-to-date systematic reviews about the effects of delivery arrangements for health systems in low-income countries. Secondary objectives include identifying needs and priorities for future evaluations and systematic reviews on delivery arrangements and informing refinements of the framework for delivery arrangements outlined in the review.

METHODS

We searched Health Systems Evidence in November 2010 and PDQ-Evidence up to 17 December 2016 for systematic reviews. We did not apply any date, language or publication status limitations in the searches. We included well-conducted systematic reviews of studies that assessed the effects of delivery arrangements on patient outcomes (health and health behaviours), the quality or utilisation of healthcare services, resource use, healthcare provider outcomes (such as sick leave), or social outcomes (such as poverty or employment) and that were published after April 2005. We excluded reviews with limitations important enough to compromise the reliability of the findings. Two overview authors independently screened reviews, extracted data, and assessed the certainty of evidence using GRADE. We prepared SUPPORT Summaries for eligible reviews, including key messages, 'Summary of findings' tables (using GRADE to assess the certainty of the evidence), and assessments of the relevance of findings to low-income countries.

MAIN RESULTS

We identified 7272 systematic reviews and included 51 of them in this overview. We judged 6 of the 51 reviews to have important methodological limitations and the other 45 to have only minor limitations. We grouped delivery arrangements into eight categories. Some reviews provided more than one comparison and were in more than one category. Across these categories, the following intervention were effective; that is, they have desirable effects on at least one outcome with moderate- or high-certainty evidence and no moderate- or high-certainty evidence of undesirable effects. Who receives care and when: queuing strategies and antenatal care to groups of mothers. Who provides care: lay health workers for caring for people with hypertension, lay health workers to deliver care for mothers and children or infectious diseases, lay health workers to deliver community-based neonatal care packages, midlevel health professionals for abortion care, social support to pregnant women at risk, midwife-led care for childbearing women, non-specialist providers in mental health and neurology, and physician-nurse substitution. Coordination of care: hospital clinical pathways, case management for people living with HIV and AIDS, interactive communication between primary care doctors and specialists, hospital discharge planning, adding a service to an existing service and integrating delivery models, referral from primary to secondary care, physician-led versus nurse-led triage in emergency departments, and team midwifery. Where care is provided: high-volume institutions, home-based care (with or without multidisciplinary team) for people living with HIV and AIDS, home-based management of malaria, home care for children with acute physical conditions, community-based interventions for childhood diarrhoea and pneumonia, out-of-facility HIV and reproductive health services for youth, and decentralised HIV care. Information and communication technology: mobile phone messaging for patients with long-term illnesses, mobile phone messaging reminders for attendance at healthcare appointments, mobile phone messaging to promote adherence to antiretroviral therapy, women carrying their own case notes in pregnancy, interventions to improve childhood vaccination. Quality and safety systems: decision support with clinical information systems for people living with HIV/AIDS. Complex interventions (cutting across delivery categories and other health system arrangements): emergency obstetric referral interventions.

AUTHORS' CONCLUSIONS

A wide range of strategies have been evaluated for improving delivery arrangements in low-income countries, using sound systematic review methods in both Cochrane and non-Cochrane reviews. These reviews have assessed a range of outcomes. Most of the available evidence focuses on who provides care, where care is provided and coordination of care. For all the main categories of delivery arrangements, we identified gaps in primary research related to uncertainty about the applicability of the evidence to low-income countries, low- or very low-certainty evidence or a lack of studies.

Development of an Intervention to Increase Sexual Health Service Uptake by Young People

This study aimed to develop and implement an intervention, delivered via a website and Web app, to increase the uptake of sexual health services by young people. The intervention was co-designed with a group of 10 young people. Intervention mapping was used to guide development. To identify barriers and facilitators of access to sexual health services, three focus groups with 24 young people aged 13 to 19 years, and interviews with 12 professionals recruited from across a range of health and social services, were conducted. Data were analyzed using content analysis. Evidence was supplemented through a literature review. Barriers and facilitators were categorized as theoretical determinants and then suitable behavior change techniques (BCTs) for targeting them were selected. Targeted determinants were attitude, subjective norm, perceived behavioral control, and knowledge. Selected BCTs included "information about others' approval," "framing/reframing," and "credible source." The website/app enable users to search for services, access key information about them, watch videos about what to expect, and have key concerns removed/addressed. This is the first known digital evidence-based intervention to target this behavior described in the literature. A clear and full description of intervention development and content, including of theorized causal pathways, is provided to aid interpretation of future outcome evaluations.

Behavioral interventions for improving contraceptive use among women living with HIV

BACKGROUND

Contraception services can help meet the family planning goals of women living with HIV as well as prevent mother-to-child transmission. Due to antiretroviral therapy, survival has improved for people living with HIV, and more HIV-positive women may desire to have a child or another child. Behavioral interventions, involving counseling or education, can help women choose and use an appropriate contraceptive method.

OBJECTIVES

We systematically reviewed studies of behavioral interventions for HIV-positive women intended to inform contraceptive choice, encourage contraceptive use, or promote adherence to a contraceptive regimen.

SEARCH METHODS

Until 2 August 2016, we searched MEDLINE, CENTRAL, Web of Science, POPLINE, ClinicalTrials.gov and ICTRP. For the initial review, we examined reference lists and unpublished project reports, and we contacted investigators in the field.

SELECTION CRITERIA

Studies evaluated a behavioral intervention for improving contraceptive use for family planning (FP). The comparison could have been another behavioral intervention, usual care, or no intervention. We also considered studies that compared HIV-positive versus HIV-negative women. We included non-randomized studies as well as randomized controlled trials (RCTs).Primary outcomes were pregnancy and contraception use, e.g. uptake of a new method or improved use or continuation of current method. Secondary outcomes were knowledge of contraceptive effectiveness and attitude about contraception or a specific contraceptive method.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted the data. One entered the data into RevMan and a second verified accuracy. We evaluated RCTs according to recommended principles. For non-randomized studies, we examined the quality of evidence using the Newcastle-Ottawa Quality Assessment Scale. Given the need to control for confounding factors in non-randomized studies, we used adjusted estimates from the models when available. Where we did not have adjusted analyses, we calculated the odds ratio (OR) with 95% confidence interval (CI). Due to varied study designs and interventions, we did not conduct meta-analysis.

MAIN RESULTS

With three new reports, 10 studies from seven African countries met our eligibility criteria. Eight non-randomized studies included 8980 participants. Two cluster RCTs had 7136 participants across 36 sites. Three studies compared a special FP intervention versus usual care, three examined FP services integrated with HIV services, and four compared outcomes for HIV-positive and HIV-negative women.In four studies with high or moderate quality evidence, the special intervention was associated with contraceptive use or pregnancy. A study from Nigeria compared enhanced versus basic FP services. All sites had integrated FP and HIV services. Women with enhanced services were more likely to use a modern contraceptive method versus women with basic services (OR 2.48, 95% CI 1.31 to 4.72). A cluster RCT conducted in Kenya compared integrated FP and HIV services versus standard referral to a separate FP clinic. Women with integrated services were more likely to use more effective contraception (adjusted OR 1.81, 95% CI 1.24 to 2.63). Another cluster RCT compared an HIV prevention and FP intervention versus usual care in Kenya, Namibia, and Tanzania. Women at the special intervention sites in Tanzania were more likely to use highly effective contraception (adjusted OR 2.25, 95% CI 1.24 to 4.10). They were less likely to report unprotected sex (no condom use) at last intercourse (adjusted OR 0.23, 95% CI 0.14 to 0.40). Across the three countries, women at the special intervention sites were less likely to report any unprotected sex in the past two weeks (adjusted OR 0.56, 95% CI 0.32 to 0.99). A study in Côte d'Ivoire integrated HIV and FP services. HIV-positive women had a lower incidence of undesired pregnancy, but not overall pregnancy, compared with HIV-negative women (1.07 versus 2.38; reported P = 0.023).

AUTHORS' CONCLUSIONS

The studies since 2009 focused on using modern or more effective methods of contraception. In those later reports, training on FP methods and counseling was more common, which may strengthen the intervention and improve the ability to meet clients' needs. The quality of evidence was moderate from the more recent studies and low for those from the 1990s.Comparative research involving contraceptive counseling for HIV-positive women is limited. The FP field needs better ways to help women choose an appropriate contraceptive and continue using that method. Improved counseling methods are especially needed for limited resource settings, such as clinics focusing on people living with HIV.

Reaching the hard to reach: longitudinal investigation of adolescents' attendance at an after-school sexual and reproductive health programme in Western Cape, South Africa

BACKGROUND

Adolescents need access to effective sexual and reproductive health (SRH) interventions, but face barriers accessing them through traditional health systems. School-based approaches might provide accessible, complementary strategies. We investigated whether a 21-session after-school SRH education programme and school health service attracted adolescents most at risk for adverse SRH outcomes and explored motivators for and barriers to attendance.

METHODS

Grade 8 adolescents (average age 13 years) from 20 schools in the intervention arm of an HIV prevention cluster randomised controlled trial in the Western Cape Province of South Africa, were invited to participate in an after-school SRH program and to attend school health services. Using a longitudinal design, we surveyed participants at baseline, measured their attendance at weekly after-school sessions for 6 months and surveyed them post-intervention. We examined factors associated with attendance using bivariate and multiple logistic and Poisson regression analyses, and through thematic analysis of qualitative data.

RESULTS

The intervention was fully implemented in 18 schools with 1576 trial participants. The mean attendance of the 21-session SRH programme was 8.8 sessions (S.D. 7.5) among girls and 6.9 (S.D. 7.2) among boys. School health services were visited by 17.3 % (14.9 % of boys and 18.7 % of girls). Adolescents who had their sexual debut before baseline had a lower rate of session attendance compared with those who had not (6.3 vs 8.5, p < .001). Those who had been victims of sexual violence or intimate partner violence (IPV), and who had perpetrated IPV also had lower rates of attendance. Participants were motivated by a wish to receive new knowledge, life coaching and positive attitudes towards the intervention. The unavailability of safe transport and domestic responsibilities were the most common barriers to attendance. Only two participants cited negative attitudes about the intervention as the reason they did not attend.

CONCLUSIONS

Reducing structural barriers to attendance, after-school interventions are likely to reach adolescents with proven-effective SRH interventions. However, special attention is required to reach vulnerable adolescents, through offering different delivery modalities, improving the school climate, and providing support for adolescents with mental health problems and neurodevelopmental academic problems.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN56270821 ; Registered 13 February 2013.

HIV and Sexually Transmitted Infection Testing Among High-Risk Youths: Supporting Positive Opportunities With Teens (SPOT) Youth Center

OBJECTIVES

We investigated the development of and service utilization at Supporting Positive Opportunities with Teens (SPOT)-a community-based health and social service facility in St. Louis, Missouri, for youths that focuses on increasing HIV and sexually transmitted infection (STI) testing.

METHODS

We identified the US-based, co-located youth health and social service models that guided the establishment of the SPOT. We analyzed the first 5 years (2008-2013) of service delivery and utilization data.

RESULTS

During the study period, the SPOT provided services for 8233 youths in 37,480 visits. The 5 most utilized services included HIV and STI screening, food, transportation, contraception, and case management. A total of 9812 gonorrhea and chlamydia screenings revealed 1379 (14.1%) cases of chlamydia and 437 (4.5%) cases of gonorrhea, and 5703 HIV tests revealed 59 HIV infections (1.0%); 93.0% of patients found to have an STI were treated within a 5-day window.

CONCLUSIONS

Co-locating health and social services in informal community settings attracts high-risk youths to utilize services and can prove instrumental in reducing STI burden in this population.

Adolescent girls and young women: key populations for HIV epidemic control

INTRODUCTION

At the epicentre of the HIV epidemic in southern Africa, adolescent girls and young women aged 15-24 contribute a disproportionate ~30% of all new infections and seroconvert 5-7 years earlier than their male peers. This age-sex disparity in HIV acquisition continues to sustain unprecedentedly high incidence rates, and preventing HIV infection in this age group is a pre-requisite for achieving an AIDS-free generation and attaining epidemic control.

DISCUSSION

Adolescent girls and young women in southern Africa are uniquely vulnerable to HIV and have up to eight times more infection than their male peers. While the cause of this vulnerability has not been fully elucidated, it is compounded by structural, social and biological factors. These factors include but are not limited to: engagement in age-disparate and/or transactional relationships, few years of schooling, experience of food insecurity, experience of gender-based violence, increased genital inflammation, and amplification of effects of transmission co-factors. Despite the large and immediate HIV prevention need of adolescent girls and young women, there is a dearth of evidence-based interventions to reduce their risk. The exclusion of adolescents in biomedical research is a huge barrier. School and community-based education programmes are commonplace in many settings, yet few have been evaluated and none have demonstrated efficacy in preventing HIV infection. Promising data are emerging on prophylactic use of anti-retrovirals and conditional cash transfers for HIV prevention in these populations.

CONCLUSIONS

There is an urgent need to meet the HIV prevention needs of adolescent girls and young women, particularly those who are unable to negotiate monogamy, condom use and/or male circumcision. Concerted efforts to expand the prevention options available to these young women in terms of the development of novel HIV-specific biomedical, structural and behavioural interventions are urgently needed for epidemic control. In the interim, a pragmatic approach of integrating existing HIV prevention efforts into broader sexual reproductive health services is a public health imperative.

Effective strategies to provide adolescent sexual and reproductive health services and to increase demand and community support

Access to youth friendly health services is vital for ensuring sexual and reproductive health (SRH) and well-being of adolescents. This study is a descriptive review of the effectiveness of initiatives to improve adolescent access to and utilization of sexual and reproductive health services (SRHS) in low- and middle-income countries. We examined four SRHS intervention types: (1) facility based, (2) out-of-facility based, (3) interventions to reach marginalized or vulnerable populations, (4) interventions to generate demand and/or community acceptance. Outcomes assessed across the four questions included uptake of SRHS or sexual and reproductive health commodities and sexual and reproductive health biologic outcomes. There is limited evidence to support the effectiveness of initiatives that simply provide adolescent friendliness training for health workers. Data are most ample (10 initiatives demonstrating weak but positive effects and one randomized controlled trial demonstrating strong positive results on some outcome measures) for approaches that use a combination of health worker training, adolescent-friendly facility improvements, and broad information dissemination via the community, schools, and mass media. We found a paucity of evidence on out-of-facility-based strategies, except for those delivered through mixed-use youth centers that demonstrated that SRHS in these centers are neither well used nor effective at improving SRH outcomes. There was an absence of studies or evaluations examining outcomes among vulnerable or marginalized adolescents. Findings from 17 of 21 initiatives assessing demand-generation activities demonstrated at least some association with adolescent SRHS use. Of 15 studies on parental and other community gatekeepers' approval of SRHS for adolescents, which assessed SRHS/commodity uptake and/or biologic outcomes, 11 showed positive results. Packages of interventions that train health workers, improve facility adolescent friendliness, and endeavor to generate demand through multiple channels are ready for large-scale implementation. However, further evaluation of these initiatives is needed to clarify mechanisms and impact, especially of specific program components. Quality research is needed to determine effective means to deliver services outside the facilities, to reach marginalized or vulnerable adolescents, and to determine effective approaches to increase community acceptance of adolescent SRHS.

Effective approaches for programming to reduce adolescent vulnerability to HIV infection, HIV risk, and HIV-related morbidity and mortality: a systematic review of systematic reviews

BACKGROUND

In 2012, an estimated 2.1 million adolescents were living with HIV. Though there are effective interventions to prevent and treat HIV infection, adolescents face specific barriers in accessing them. As a result, new infections and poor outcomes among HIV-infected adolescents are common. HIV programming for adolescents should focus on interventions of proven effectiveness and address underlying factors driving incidence and lack of effective treatment and care in this age group.

METHODS

We conducted a systematic review of systematic reviews to summarize the global data on effectiveness of 20 intervention types, to identify characteristics of effective interventions, and to explore evidence of how adolescents can access interventions with proven effectiveness. Interventions were in 2 broad categories: those designed primarily for adults and those designed specifically for adolescents. Where available, we evaluated the evidence of impact on the key outcomes: HIV risk, HIV transmission, and HIV morbidity and mortality.

RESULTS

Among the interventions designed for adolescents, there was high-quality evidence that in-school interventions and some interventions in geographically defined communities can positively impact important HIV-related outcomes, such as self-reported sexual risk behaviors. Interventions designed primarily for adults that had high-quality, consistent biological evidence of efficacy included voluntary medical male circumcision (VMMC), antiretrovirals for the prevention of mother-to-child transmission, HIV testing and counseling, HIV treatment, condom use, and provision of sterile injecting equipment to people who inject drugs. There was also an evidence of potential efficacy for oral preexposure prophylaxis and behavior change interventions among certain populations. There was a dearth of systematic review data on how best to enable adolescents to access the intervention types identified as having proven effectiveness among adults.

CONCLUSIONS

This series of reviews allowed us to rigorously and systematically review a large number of intervention types at once using a standard, transparent methodology. Eight key interventions showed clear evidence of effectiveness, with evidence of potential efficacy for some additional interventions among certain populations.

DISCUSSION

These priority interventions with proven effectiveness should be included in all HIV prevention programming for adolescents. There is a pressing need for more rigorous research on how best to enable adolescents to access these effective interventions.

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.