https://orcid.org/0000-0002-2502-8718
ABSTRACT
The uptake of HIV prevention services is lower among youth than adults in sub-Saharan Africa. Existing youth livelihood trainings offer a potential entry point to HIV prevention services. We determined feasibility and preliminary effectiveness of integrating HIV prevention into youth clubs implementing an empowerment and livelihood for adolescents (ELA) intervention in rural Uganda. Staff conducted community mobilization for youth (15–24 years) over one month. Clubs met (3×/week) over six months, with local peer mentors trained to teach life-skills and sexual/reproductive health education. We integrated mentor-led education on HIV prevention, including pre- and post-exposure prophylaxis (PrEP/PEP). Clubs offered on-site HIV testing, a field trip to a local clinic and PrEP referrals after one month and six months. Surveys were conducted at baseline and six months. Forty-two participants (24 adolescent girls/young women (AGYW) and 18 adolescent boys/young men (ABYM)) joined the clubs. At baseline, no participants accepted referral for PrEP, whereas 5/18 (28%) sexually active, HIV-negative AGYW requested PrEP referral at follow-up. One ABYM requested PEP referral. Integration of HIV prevention services into an established ELA curriculum at mentor-led youth clubs in rural Uganda was feasible. PrEP uptake increased among sexually active AGYW. Evaluation of this approach for HIV prevention among youth merits further study.
Introduction
Adolescent girls and young women (AGYW) make up a disproportionate number of new HIV infections in sub-Saharan Africa, and represent a priority group for HIV prevention interventions (Dellar et al., Citation2015; Ministry of Health, February, Citation2020; UNAIDS, Citation2019). However, uptake of biomedical HIV prevention services, including pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) has been lower among youth (adolescents and young adults) than adults in sub-Saharan Africa (Ford et al., Citation2014; Sidebottom et al., Citation2018). Mechanisms leading to relatively lower PrEP/PEP uptake among youth include insufficient knowledge of prevention options, lack of access, and other barriers such as stigma (Ajayi et al., Citation2018; Maseko et al., Citation2020). Although PrEP is recommended for those at high HIV risk, including AGYW, by WHO and the Ugandan Ministry of Health (Ministry of Health, February, Citation2020; World Health Organization, Citation2015), uptake has remained suboptimal in Uganda: as of September 2020 there were approximately 31,000 Ugandans taking PrEP (PrEPWatch Uganda, Citation2020). In Uganda in 2021, the estimated population of youth aged 15–24 was 10.1 million, and the prevalence of HIV among AGYW was 2.6% and among ABYM was 1.1% (The World Bank, Citation2021; United Nations, Citation2022).
Structural factors, including poverty, low educational attainment, and lack of income-generating opportunities, have been associated with increased HIV risk among youth (Bajunirwe et al., Citation2019; Kennedy et al., Citation2014; Stoner et al., Citation2017). However, interventions that promote income-generating activities, such as vocational training and microfinance, have had variable effects on HIV risk behaviors (Brody et al., Citation2019; Kennedy et al., Citation2014), and though implemented in many settings, their effects on HIV prevention uptake remain unclear. BRAC, an international non-governmental organization (NGO), operates over 1200 clubs that deliver an Empowerment and Livelihood for Adolescents (ELA) curriculum to youth across Uganda. The ELA curriculum offers life-skills and vocational training, and education on sexual and reproductive health. A prior evaluation of BRAC’s ELA curriculum demonstrated a 34% reduction in youth pregnancy over four years (Bandiera et al., Citation2020). This ELA curriculum has been implemented in South Sudan (Buehren et al., Citation2017) and Sierra Leone (Bandiera et al., Citation2018) and has shown positive impacts on economic outcomes among young women in the program. However, to date, the ELA clubs have not integrated biomedical HIV prevention services, and the feasibility of integrating HIV prevention education and services into ELA clubs is unknown.
The objective of this pilot study was to determine the feasibility and preliminary effectiveness of integrating HIV education and access to HIV prevention services into youth clubs providing the ELA curriculum in rural Uganda.
Methods
Study participants and setting
We conducted a pilot study in a rural village, Kabura, Ibanda District, in Southwestern Uganda. We selected this village based on proximity to a government-run health center (Rukoho Health Centre IV) offering free biomedical prevention services, including PrEP and PEP. BRAC staff conducted community mobilization by meeting with key community stakeholders and holding informational meetings about the ELA clubs with adult community members in the month prior to the start of the pilot. Local, peer mentors (aged 22–32) were hired to lead the clubs and were trained on the ELA curriculum over five days.
Eligible participants included youth (15–24 years) living in Kabura village who were interested in and willing to participate in the clubs. One club for adolescent boys and young men (ABYM) and one for AGYW were established in separate nearby buildings (<0.5 km). Separate clubs were established to enable the curriculum to be tailored to AGYW and ABYM and to allow for sensitive questions and topics to be discussed freely.
Study design and procedures
We conducted club activities over six months (September 2019 through March 2020). Club members met three times per week, apart from national holidays. The BRAC-ELA Curriculum is designed to cover one topic per club meeting, with each lesson lasting 1–3 h, as previously described (Bandiera et al., Citation2020). Life-skills curriculum topics include values and goals, communication, and growth and development. Health topics include education on puberty, pregnancy, family planning, and sexually transmitted infections. Apart from life-skills education, other activities include vocational training, indoor and outdoor sports, and mobilizing community support. Clubs offered vocational training, including liquid soap making and reusable menstrual pad making. To mobilize community support and to integrate the adolescents with their social network, the clubs also organized a meeting between BRAC staff and parents of potential club members to answer questions regarding the intervention and address any potential concerns over the content of the curriculum covered in the clubs.
We integrated one-week of HIV prevention education on HIV testing, PrEP, PEP, voluntary medical male circumcision (VMMC), and general HIV knowledge into the ELA curriculum one month after club initiation. The first session was taught alongside a local clinician to address questions and to ensure medical information was accurate and complete. Thereafter, peer mentors provided a monthly HIV education “booster” session to review HIV prevention topics.
Study staff offered HIV and pregnancy testing one month and six months following club initiation. Staff disclosed all test results privately, with referral to the local clinic for care, if necessary. Peer mentors and study staff offered PrEP referrals to any youth who were interested and provided referral cards that allowed club members to “skip the line” at the local health center. Three months after club initiation, club members went on a field trip to the local health center, accompanied by peer mentors where a clinician showed club participants where to go to access HIV testing, PrEP and PEP.
Measures
At baseline and six months post-enrollment, Independent Evaluation & Research Cell (IERC) of BRAC conducted surveys on HIV knowledge and self-reported risky sexual behavior with participants. A trained field supervisor collected baseline data using a mobile data collection technique. The same enumerator conducted the endline survey.
Outcomes
Feasibility
We evaluated the feasibility of integrating HIV prevention into the BRAC ELA curriculum using metrics of enrollment, participation and delivery of HIV prevention education and services. We aimed to enroll ≥40 participants and evaluated attendance as a metric for participation. We assessed the ability of peer mentors, with support from a local clinician, to deliver the HIV education curriculum and to conduct a field trip to the local health center. Lastly, we evaluated feasibility of delivering on-site HIV testing at the clubs and referrals for PrEP and PEP to the local health facility.
Preliminary effectiveness
We evaluated preliminary effectiveness by comparing the following metrics at baseline and six-month follow-up: (1) uptake of referral to the local health center for PrEP or PEP; (2) HIV knowledge: defined as the proportion of correct answers to HIV-related questions; and (3) self-reported sexual behavior.
Ethical statement
Ethical approval was obtained by the University of California San Francisco and Makerere University School of Public Health, and research permit from the Uganda National Council for Science and Technology (UNCST). Written informed consent was obtained from all participants.
Results
Feasibility
Feasibility measures, study interventions and outcomes are described in . In August 2019, community mobilization by BRAC staff was conducted. The study team held a community meeting with village leaders and key stakeholders to discuss the establishment of the clubs. The BRAC staff then recruited participants with the help of village leaders. Forty-two participants enrolled in the study (24 AGYW and 18 ABYM), representing 55% of the 76 village residents aged 15–24 years. Out of 62 club meetings offered, the mean number of visits was 18 (SD = 18.7). Peer mentors delivered the baseline HIV prevention course over one week, alongside the local clinician. Peer mentors delivered follow-up refresher courses monthly on key topics in HIV prevention. Nineteen of 42 (19/42, 45%) participants attended the field trip to the local clinic. Club mentors offered PrEP and PEP referrals by providing referral cards that enabled club members to be seen at the clinic faster.
Table 1. Feasibility metrics, interventions, and outcomes during the implementation of youth clubs implementing the BRAC ELA curriculum with club-based HIV testing and referrals for PrEP and PEP in a rural village in Ibanda district, Uganda.
Youth club participants
The mean age of all participants was 20.1 years (SD = 2.5). Overall, 24% (10) of participants were enrolled in school, 74% (31) had dropped out, and one participant had never been enrolled in school. Youth enrolled in school had lower attendance compared to those who had dropped out (mean number of visits of 3.9 and 21.3, respectively). Out-of-school senior members of the ELA program were eligible for participating in the vocational activities. Of those eligible, 18 club participants (18/32, 56%) attended at least one of the vocational training exercises. Thirty-nine participants (93%) were available for the follow-up survey.
Among ABYM, 10 (56%) and 7 (39%) reported having ever heard of PrEP and PEP, respectively, at baseline. A greater proportion of female club members reported ever having heard of PrEP (n = 16, 67%) and PEP (n = 15, 63%) ().
Table 2. Study participant characteristics and HIV knowledge and sexual behavior at baseline in a pilot study on the feasibility and preliminary effectiveness of a club-based intervention for HIV prevention among youth in Ibanda, Uganda (n = 42).
Preliminary effectiveness
At baseline, no participants accepted referral to PrEP, whereas 5 of 18 (28%) sexually active, HIV-negative AGYW accepted referral to PrEP during the last month of the pilot. During follow-up, one ABYM of 18 (6%) was referred to PEP. At baseline, 95% of the participants (24/24 AGYW and 16/18 ABYM) had reported having ever been tested for HIV. At baseline, 24/42 (57%: 15/24 AGYW and 9/18 ABYM) participants tested for HIV at the club. At end of study, 13/39 (33%: eight AGYW and five ABYM) of HIV-negative at baseline club members tested for HIV. Three participants self-reported being HIV-positive at baseline: 1 of 16 ABYM (6%) and 2 of 24 AGYW (8%). Two ABYM (one sexually active) did not answer the question about HIV status. None of the study participants who were tested seroconverted during the pilot.
At baseline, most participants reported that condom use during sex can prevent HIV (93%, n = 39) and that VMMC can reduce the risk of HIV infection (88%, n = 37), but fewer had knowledge of PrEP and PEP (62% and 52%, respectively). All HIV knowledge questions yielded higher correct or positive responses at follow-up compared to baseline, except for knowledge of VMMC ().
Table 3. Changes in HIV knowledge from baseline to six months post-intervention start among study participants in a pilot youth club in Ibanda, Uganda.
At baseline, 45% (15/33) of sexually active participants reported that they did not use a condom during their most recent sexual intercourse, versus 26% (8/31) at follow-up. Fewer sexually active AGYW reported engaging in transactional sex at baseline as compared to follow-up (13/20 (65%) vs. 5/19 (26%)).
Discussion
In a pilot study, we found that integration of HIV education and biomedical HIV prevention services into an existing, evidence-based youth empowerment and livelihood club intervention (ELA curriculum) was feasible, with preliminary evidence of effectiveness in increasing HIV prevention behaviors, including PrEP and PEP uptake. Novel components of this intervention include the combined interventions of vocational training, HIV and pregnancy testing, PrEP and PEP referrals from a peer mentor-led youth club, and a youth-tailored field trip to a local clinic to introduce and ease barriers to PrEP/PEP. Club attendance was higher among youth who had dropped out of school, who are a group at increased risk of HIV (Stoner et al., Citation2017). Our findings suggest preliminary effectiveness of this integrated club model in increasing PrEP uptake among AGYW, increasing knowledge about HIV prevention, and decreasing risky sexual behavior.
Integration of HIV prevention education and services into youth clubs offering vocational and life-skills training, as well as social activities, has the potential to increase engagement in HIV prevention by leveraging youth demand for income-generating training. Several studies, prior to widespread implementation of PrEP, have evaluated similar approaches. For example, the “Street Smart” pilot program that provided HIV prevention education along with vocational training among youth (aged 13–23) in Uganda observed a decreased self-reported number of sexual partners and increase in abstinence and condom use after two years (Rotheram-Borus et al., Citation2012). The SHAZ intervention in Zimbabwe enrolled AGYW into a vocational training program with micro-grants and social support with life-skills and health training, and found that those who received the intervention reported reduced transactional sex and increased condom use after two years (Dunbar et al., Citation2014). More recently, an evaluation of programs implementing the DREAMS initiative found an overall decrease in new HIV diagnoses among AGYW across multiple settings in which DREAMS was implemented (Birdthistle et al., Citation2021). BRAC implemented ELA models in Uganda, Tanzania, South Sudan, Liberia, and Sierra Leone. The feasibility of this pilot is important given the potential for rapid scale-up by linking an existing ELA curriculum with Ministry of Health clinics providing PrEP/PEP. As prevention options increase, such as the dapivirine vaginal ring (DVR) and long-acting injectable PrEP, having more entry points, such as this club-based model, to reach AGYW and ABYM will be critical to maximize prevention coverage for at-risk youth.
Although PrEP referral from the club was feasible and increased among sexually active HIV-negative AGYW, the lack of PrEP uptake among ABYM suggests that other approaches may be needed for at-risk ABYM. Given the well-documented challenges in engaging men and boys in HIV testing and prevention services, efforts to reach ABYM for early introduction to HIV prevention services and education are essential to achieving HIV targets across the globe (UNAIDS, Citation2017). Our findings suggest that youth clubs incorporating HIV education and prevention services for ABYM are feasible and offer an opportunity for early engagement. Our preliminary finding that clinic field trips and introduction to PrEP clinic staff can increase AGYW PrEP uptake is consistent with prior evidence that youth-friendly services can increase PrEP use among AGYW (Celum et al., Citation2019).
Knowledge of HIV prevention increased from baseline to follow-up, suggesting that youth clubs offering life-skills education and vocational training may be an effective way to reach at-risk youth who drop out of school. The decrease in self-reported risky sexual behavior reported also suggests that our club-based model may lead to behavioral changes among participants. The decline in risky sexual behavior may also explain why some participants did not feel the need to initiate PrEP. In rural, resource-limited settings, dissemination of information regarding emerging prevention options among adolescents remains a challenge (Idele et al., Citation2014). Our pilot combined HIV education, club-based HIV testing, in-person introductions to providers offering PrEP/PEP and a visit to a local clinic, so as to improve both general understanding of HIV infection and practical knowledge of how to access prevention services.
This study has limitations. First, the club pilot was conducted in one village, limiting generalizability. However, these pilot data provide initial evidence of feasibility, supporting further evaluation of this approach in other settings. Second, the duration of the pilot was six months, limiting our ability to evaluate potential long-term impacts. In addition, our effectiveness measures relied on self-reported outcomes, and are subject to social desirability bias and underreporting of risk behavior. Additional studies that assess effectiveness of ELA curriculum with HIV prevention interventions on STI/HIV incidence are necessary. Nonetheless, our findings of preliminary effectiveness, particularly in PrEP adoption, are encouraging and merit further evaluation on BRAC’s ELA model and also other club or group-based adolescent interventions with similar purposes.
Conclusion
The integration of the BRAC-ELA curriculum with HIV prevention interventions at youth clubs was feasible and suggests preliminary effectiveness in increasing PrEP uptake among AGYW and HIV-related knowledge among youth, and in reducing self-reported risky sexual behaviors among club participants. Evaluation of effectiveness of this strategy for HIV prevention among youth merits further study.
Disclosure statement
No potential conflict of interest was reported by the author(s).
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Funding
References
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