Uptake of multi-level HIV interventions and HIV-related behaviours among young people in rural South Africa.

Combination HIV prevention packages have reduced HIV incidence and improved HIV-related outcomes among young people. However, there is limited data on how package components interact to promote HIV-related prevention behaviours. We described the uptake of HIV prevention interventions supported by Determined, Resilient, Empowered, AIDS-free, Motivated and Safe (DREAMS) Partnership and assessed the association between uptake and HIV-related behaviours among young people in rural KwaZulu-Natal, South Africa. We analysed two cohorts followed from May 2017 to December 2019 to evaluate the impact of DREAMS, covering 13-29 year-old females, and 13-35 year-old males. DREAMS interventions were categorised as healthcare-based or social. We described the uptake of interventions and ran logistic regression models to investigate the association between intervention uptake and subsequent protective HIV-related outcomes including no condomless sex and voluntary medical male circumcision (VMMC). For each outcome, we adjusted for socio-demographics and sexual/pregnancy history and reported adjusted odds ratios (aOR) and 95% confidence intervals (CI). Among 5248 participants, uptake of healthcare interventions increased from 2018 to 2019 by 8.1% and 3.7% for males and females respectively; about half of participants reported receiving both healthcare and social interventions each year. The most utilised combinations of interventions included HIV testing and counselling, school-based HIV education and cash transfers. Participation in social interventions only compared to no intervention was associated with reduced condomless sex (aOR = 1.60, 95%CI: 1.03-2.47), while participation in healthcare interventions only was associated with increased condomless sex. The uptake of interventions did not significantly affect subsequent VMMC overall. Among adolescent boys, exposure to school-based HIV education, cash transfers and HIV testing and counselling was associated with increase in VMMC (aOR = 1.79, 95%CI: 1.04-3.07). Multi-level HIV prevention interventions were associated with an increase in protective HIV-related behaviours emphasizing the importance of accessible programs within both school and community settings for young people.

Impact of DREAMS interventions on attitudes towards gender norms among adolescent girls and young women: Findings from a prospective cohort in Kenya.

The DREAMS partnership aims to deliver a comprehensive package to reduce HIV incidence among adolescent girls and young women (AGYW), including through shifting gender norms. We evaluate DREAMS' effect on attitudes towards gender norms in two Kenyan settings. AGYW aged 15-22 in Nairobi (n = 852) and Gem (n = 761) were randomly selected for cohort enrolment in 2017-18 and followed-up to 2019. We described the proportion of AGYW and their male peers with equitable attitudes towards gender norms, using an adapted version of the GEM scale. We estimated the association between self-reported invitation to DREAMS (in 2017-18) and AGYW's attitudes towards two dimensions of gender norms, and then applied a causal inference framework to estimate the difference in the proportion of AGYW with equitable attitudes under the counterfactual scenarios that all versus none were DREAMS beneficiaries. We estimated that overall, 90.2% versus 87.1% of AGYW would have equitable norms around sexual and reproductive health decision-making in Nairobi if all versus none were DREAMS beneficiaries (+3.1; 95%CI:-2.5, +9.0). In Gem, we estimated a risk difference of +1.0 (89.6% vs 88.6%, 95%CI: -3.6,+5.6). There was no evidence for an effect of DREAMS on attitudes towards violence-related norms (Nairobi: 82.7% vs 82.2%, +0.5; 95%CI: -5.3,+6.5; Gem: 44.3% vs 48.2%, -3.9; 95%CI: -11.7,+3.0). We found no evidence of an impact of DREAMS invitation on individual attitudes towards gender norms. In some cases, equitable attitudes at enrolment left limited scope for improvement, and additional effort may be required to shift inequitable violence attitudes among both AGYW and their male peers.

Evaluating the Intensity of Exposure to MTV Shuga, an Edutainment Program for HIV Prevention: Cross-Sectional Study in Eastern Cape, South Africa.

BACKGROUND: MTV Shuga is an edutainment campaign designed to equip young people with knowledge, motivation, and informed choices to protect themselves from HIV infection. From 2019 to 2020, a total of 10 episodes of a new dramatic series, MTV Shuga "Down South 2" (DS2), were broadcast via television and the internet, alongside complementary media activities. OBJECTIVE: This study aims to investigate whether the intensity of DS2 exposure was linked with positive HIV prevention outcomes in a setting with high HIV prevalence and relatively low levels of HIV testing. METHODS: We analyzed data from a web-based survey of participants aged 15 to 24 years in South Africa in 2020. The survey was promoted via social media platforms of schools, universities, and communities in Eastern Cape, South Africa. The primary exposure of interest was the intensity of exposure to DS2, measured by the number of episodes of DS2 watched on the television or the internet or listened to on the radio (out of 10 episodes). Individuals who had not watched or listened to any DS2 episode were classified according to other MTV Shuga content that they had accessed. We estimated associations between the intensity of DS2 exposure and HIV-related outcomes, including knowledge of HIV status, awareness of HIV self-testing (HIVST) and pre-exposure prophylaxis (PrEP), uptake of HIVST, and demand for HIVST and PrEP, adjusting for potential confounders using multivariable logistic regression. RESULTS: Among the 3431 survey participants, 827 (24.1%) were exposed to DS2. Specifically, 18.1% (622/3431) watched or listened to only 1 DS2 episode, and 2.4% (82/3431), 1.7% (58/3431), and 1.8% (62/3431) watched or listened to 2 to 4, 5 to 7, and 8 to 10 DS2 episodes, respectively. Increasing the exposure to DS2 was associated with improvements in most outcomes. Exposure to multiple episodes (eg, 2-4, 5-7, and 8-10) was associated with successively higher odds of knowing one's HIV status, awareness of PrEP and HIVST, and uptake of HIVST compared with no MTV Shuga exposure, albeit with statistical uncertainty around some estimates. The interest in using HIVST or PrEP was high overall (>80%), with no measurable differences by DS2 intensity. CONCLUSIONS: We found evidence consistent with a dose-response relationship between MTV Shuga DS2 exposure and outcomes, including knowledge of HIV status, awareness and uptake of HIVST, and awareness of PrEP among young people in Eastern Cape. This indicates that greater engagement with a youth-focused edutainment campaign can improve HIV testing and prevention options in a setting and population with high need. However, only a few participants accessed multiple DS2 episodes despite its availability on multiple media platforms. We conclude that there is potential to benefit more young people by increasing access to and interest in the show.

Evaluating use of mass-media communication intervention 'MTV-Shuga' on increased awareness and demand for HIV and sexual health services by adolescent girls and young women in South Africa: an observational study.

OBJECTIVE: To investigate the effect of exposure to MTV Shuga:Down South' (MTVShuga-DS) during the scale-up of combination HIV-prevention interventions on awareness and uptake of sexual reproductive health (SRH) and HIV-prevention services by adolescent girls and young women (AGYW). DESIGN: One longitudinal and three cross-sectional surveys of representative samples of AGYW. SETTING: AGYW in four South African districts with high HIV prevalence (>10%) (May 2017 and September 2019). PARTICIPANTS: 6311 AGYW aged 12-24. MEASURES: Using logistic regression, we measured the relationship between exposure to MTV Shuga-DS and awareness of pre-exposure prophylaxis (PrEP), condom use at last sex, uptake of HIV-testing or contraception, and incident pregnancy or herpes simplex virus 2 (HSV-2) infection. RESULTS: Within the rural cohort 2184 (85.5%) of eligible sampled individuals were enrolled, of whom 92.6% had at least one follow-up visit; the urban cross-sectional surveys enrolled 4127 (22.6%) of eligible sampled individuals. Self-report of watching at least one MTV Shuga-DS episode was 14.1% (cohort) and 35.8% (cross-section), while storyline recall was 5.5% (cohort) and 6.7% (cross-section). In the cohort, after adjustment (for HIV-prevention intervention-exposure, age, education, socioeconomic status), MTVShuga-DS exposure was associated with increased PrEP awareness (adjusted OR (aOR) 2.06, 95% CI 1.57 to 2.70), contraception uptake (aOR 2.08, 95% CI 1.45 to 2.98) and consistent condom use (aOR 1.84, 95% CI 1.24 to 2.93), but not with HIV testing (aOR 1.02, 95% CI 0.77 to 1.21) or acquiring HSV-2 (aOR 0.92, 95% CI 0.61 to 1.38). In the cross-sections, MTVShuga-DS was associated with greater PrEP awareness (aOR 1.7, 95% CI 1.20 to 2.43), but no other outcome. CONCLUSIONS: Among both urban and rural AGYW in South Africa, MTVShuga-DS exposure was associated with increased PrEP awareness and improved demand for some HIV prevention and SRH technologies but not sexual health outcomes. However, exposure to MTVShuga-DS was low. Given these positive indications, supportive programming may be required to raise exposure and allow future evaluation of edu-drama impact in this setting.

Impact of DREAMS interventions on experiences of violence among adolescent girls and young women: Findings from population-based cohort studies in Kenya and South Africa.

DREAMS aims to reduce HIV incidence among adolescent girls and young women (AGYW) by tackling drivers of HIV risk including gender-based violence. We evaluate the impact of DREAMS on recent experiences of violence perpetuated by men against AGYW. AGYW cohorts were randomly selected from demographic platforms in South Africa (rural KwaZulu-Natal) and Kenya (Nairobi informal settlements and rural Gem sub-county). AGYW aged 13-22 years were enrolled in 2017 (Nairobi, KwaZulu-Natal) or 2018 (Gem), with annual follow-up to 2019. We described proportions of AGYW who self-reported experiences of violence perpetrated by males in the 12 months preceding the interview, overall and by form (physical, sexual, emotional). We investigated associations with DREAMS (invitation to participate during 2017-2018) through multivariable propensity score-adjusted logistic regression and estimated the causal effect of DREAMS on experiences of violence, under counter-factual scenarios in which all versus no AGYW were DREAMS beneficiaries. Among 852, 1018 and 1712 AGYW followed-up in 2019 in Nairobi, Gem and KZN, respectively, proportions reporting any violence in 2019 were higher in Nairobi (29%) than Gem (18%) and KwaZulu-Natal (19%). By sub-type, emotional and physical violence were more frequently reported than sexual violence. We found no evidence of an impact attributable to DREAMS on overall levels of violence, in any setting. Nor was there evidence of impact on sub-types of violence, with one exception: an increase in physical violence in Nairobi if all, versus no, AGYW were DREAMS beneficiaries (16% vs 11%; +5% difference [95% CI: +0.2%, +10.0%]). Experiences of gender-based violence were common among AGYW, especially in urban settings, and DREAMS had no measurable impact on reducing violence within three years of implementation. Violence prevention programming that reaches more men and the broader community, sustained for longer periods, may yield greater gains in violence reduction than AGYW-focused programming. Additionally, more investment in implementation research is needed to bridge trial-based study findings from efficacy to population-level effectiveness.

Facilitators and barriers to engaging with the DREAMS initiative among young women who sell sex aged 18-24 in Zimbabwe: a qualitative study.

BACKGROUND: Adolescent girls and young women (AGYW) are at high risk of contracting HIV and exchanging sex for financial or material support heightens their risk. In Zimbabwe, the DREAMS initiative integrated education and employment opportunities within HIV health promotion and clinical services for vulnerable young women, including those who sell sex. While most participants accessed health services, fewer than 10% participated in any social programmes. METHODS: We conducted semi-structured qualitative interviews with 43 young women aged 18-24 to understand their experiences of engaging with the DREAMS programme. We purposively sampled participants for diversity in level of education, type and location of selling sex. We analysed the data by applying the Theoretical Domains Framework to explore facilitators and barriers to engaging with DREAMS. RESULTS: Eligible women were motivated by hopes of escaping poverty, and their longer-term engagement was sustained through exposure to new social networks, including friendships with less vulnerable peers. Barriers included opportunity costs and expenses such as transport or equipment required for job placements. Participants also described pervasive stigma and discrimination related to their involvement in selling sex. Interviews highlighted the young women's struggles in a context of entrenched social and material deprivation and structural discrimination that hindered their ability to take up most of the social services offered. CONCLUSIONS: This study demonstrates that while poverty was a key driver of participation in an integrated package of support, it also constrained the ability of highly vulnerable young women to benefit fully from the DREAMS initiative. Multi-layered HIV prevention approaches such as DREAMS that seek to alter complex and longstanding social and economic deprivation address many of the challenges faced by YWSS but will only succeed if the underlying drivers of HIV risk among YWSS are also addressed.

Young people's access to sexual and reproductive health prevention services in South Africa during the COVID-19 pandemic: an online questionnaire.

INTRODUCTION: The South African government responded swiftly to the first wave of novel coronavirus (SARS-CoV-2) with a nationwide lockdown. Initial restrictions from March-July 2020 required people to stay at home unless accessing essential, life-saving services. We sought to understand how the COVID-19 pandemic and resulting lockdowns affected young people's access to sexual and reproductive health services in a high-prevalence HIV setting. METHODS: We analysed data from a cross-sectional web-based questionnaire conducted with 15-24 year-olds from September-December 2020 in Eastern Cape, South Africa. The questionnaire was promoted through social media platforms. Participants were asked whether and how the COVID-19 pandemic and related restrictions affected their access to sexual and reproductive health services, through closed-ended and open-ended questions. Descriptive statistics using proportions were used to summarise responses, and open text was analysed using thematic analysis. RESULTS: Of 3431 respondents, the proportions reporting 'more difficulty' accessing HIV testing services, HIV self-screening kits, condoms, pre-exposure prophylaxis and antiretroviral treatment since the COVID-19 pandemic were 16.8%, 13.7%, 13.9%, 11% and 7%, respectively. In 796 open-text responses, participants described challenges accessing HIV services due to clinics being overwhelmed and prioritising patients with COVID-19, resulting in young people being turned away. Some were afraid of contracting COVID-19 at or en route to clinics. Others were unable to reach clinics because of restricted transport or financial insecurity. DISCUSSION: Young people in Eastern Cape rely on local clinics for services, and large proportions of young males and females faced difficulties or fears accessing clinics during the COVID-19 lockdown. Clinics became overwhelmed or inaccessible, limiting young people's access to sexual and reproductive health services. In high HIV risk contexts, prevention services and tools must be more accessible to young people, outside of clinics and within the communities and spaces that young people can access without fear or cost.

'It is guiding us to protect ourselves': a qualitative investigation into why young people engage with a mass-media HIV education campaign.

This study explores how and why young people engage with MTV Shuga, a popular mass media campaign in South Africa, to understand what makes effective HIV edutainment. Young MTV Shuga viewers from the Eastern Cape, South Africa and their parents participated in remote individual interviews and focus groups in 2020. Qualitative data were transcribed and analysed using a thematic iterative approach. Young participants engaged with MTV Shuga for relatable, tolerant and complex stories about young people navigating HIV and relationships. These stories, which made viewers aware of sexual health services, inspired young people to reflect on how they might engage with different sexual health scenarios. MTV Shuga initiated conversations among peers, partners and some families about HIV that made them feel supported and equipped to tackle problems in their own lives. Complex, relatable, non-judgemental and youth-centred storylines can make HIV edutainment engaging to youth audiences. This approach allows space for reflection and inspires discussion and debate, turning young people from passive recipients of HIV messaging to active decision-makers. Television-based interventions can disseminate resources and knowledge into communities, however, watching them with parents can expose young people to judgement. HIV edutainment should therefore be available through different mediums so young people can engage in tolerant environments.

Delivering an mHealth Adherence Support Intervention for Patients With HIV: Mixed Methods Process Evaluation of the Philippines Connect for Life Study.

BACKGROUND: The Philippines HIV epidemic is one of the fastest growing epidemics globally, and infections among men who have sex with men are increasing at an alarming rate. Connect for Life Philippines is a mobile health (mHealth) intervention that supports antiretroviral therapy (ART) adherence in this key population through individualized voice calls and SMS text messages. OBJECTIVE: The objective of this process evaluation is to assess the intervention reach, dose delivered and received, fidelity, and acceptability and to describe contextual factors affecting the implementation of an mHealth adherence support intervention for patients on ART in a clinic in Metro Manila, Philippines. METHODS: A mixed methods process evaluation approach was used in an observational cohort study. Quantitative data sources for the process evaluation were call and SMS text message logs obtained from the mHealth platform and questionnaires collected at 12-, 24-, and 48-week study visits. Qualitative data were collected from process reports and through a series of focus group discussions conducted with a subset of participants during the intervention development phase, after an initial 8-week pilot phase, and at the end of the study. RESULTS: The 462 study participants received 31,095 interactive voice calls and 8234 SMS text messages during the study. Owing to technical issues, intervention fidelity was low, with only 22.1% (102/462) of the participants receiving reminders via voice calls and others (360/462, 77.9%) receiving only SMS text messages during the intervention. After 48 weeks in the study, 63.5% (293/462) of the participants reported that they would be quite likely or very likely to recommend the program to a friend, and 53.8% (249/462) of the participants reported that they benefited quite a bit or very much from the intervention. Participants who were on ART for <6 months at the beginning of the study and those who received the daily or weekly pill reminders were more likely to report that they benefited from the intervention (P=.02 and P=.01, respectively). CONCLUSIONS: The Connect for Life intervention had high participant satisfaction and acceptability, especially among those who received high dose of the intervention. However, poor reliability of local telecommunication networks had a large impact on the intervention's usability, fidelity, and dose received.

A qualitative exploration of the salience of MTV-Shuga, an edutainment programme, and adolescents' engagement with sexual and reproductive health information in rural KwaZulu-Natal, South Africa.

Young people, particularly adolescent girls and young women, represent a growing proportion of those living with HIV. Edutainment programmes have been widely used throughout the world to "educate" and "entertain" audiences and tackle serious social issues in bold and engaging ways. This paper examines the extent to which an edutainment programme, MTV-Shuga, was reported to influence young people's engagement with sexual and reproductive health (SRH) information in rural KwaZulu-Natal, South Africa. In 2019 we conducted eight community-based screenings of MTV-Shuga episodes followed by 25 individual in-depth interviews and 13 focus group discussions with young people aged between 15 and 30. Interviews were audio recorded and transcribed verbatim. Data analysis was thematic and complemented by constant comparison and deviant case analysis techniques. In this rural and poor setting with a high burden of HIV, young people exhibited high levels of awareness of SRH and HIV but had constrained access to services, and limited ability to engage with parents or guardians on SRH matters. MTV Shuga provided an entertaining guide of ways to navigate the risks that they faced in a way that resonated with them. The findings highlight the importance of enabling young people in rural areas to watch MTV Shuga with peers in a safe space in which discussion of the content is facilitated. There is also value in encouraging parents to watch MTV Shuga as a means of enabling discussions between children and adults in their lives about SRH matters.

Strategies to Identify and Reach Young Women Who Sell Sex With HIV Prevention and Care Services: Lessons Learnt From the Implementation of DREAMS Services in Two Cities in Zimbabwe.

BACKGROUND: Young women who sell sex (YWSS), are underserved by available HIV prevention and care services. The Determined, Resilient, Empowered, AIDS-free, Mentored and Safe (DREAMS) Partnership aimed to reduce the risk of HIV acquisition among vulnerable populations of adolescent girls and young women, including YWSS, in 10 sub-Saharan African countries. We describe 2 methods, respondent-driven sampling (RDS) and peer outreach, used to refer YWSS for DREAMS services in Zimbabwe, and compare the characteristics and engagement of YWSS referred to these services by each method. We hypothesized that RDS would identify YWSS at higher risk of HIV and those who were less engaged with HIV prevention and care services than peer outreach. OBJECTIVE: We aimed to compare respondent-driven sampling and peer outreach in recruiting and referring high-risk populations for HIV prevention and care services. METHODS: We used RDS, a sampling method designed to reach a representative sample of the network of key populations, and peer outreach, a programmatic approach to identify, reach, and refer YWSS for DREAMS between April and July 2017, and January 2017 and July 2018, respectively, in 2 cities in Zimbabwe. For RDS, we conducted detailed mapping to understand sex work typology and geography, and then purposively selected 10 "seed" participants in each city to initiate RDS. For peer outreach, we initiated recruitment through 18 trained and age-matched peer educators using youth-tailored community mobilization. We described the characteristics and service engagement of YWSS who accessed DREAMS services by each referral approach and assessed the association of these characteristics with referral approach using the chi-square test. Analysis was performed with and without restricting the period when RDS took place. We estimated the relative incremental costs of recruiting YWSS using each strategy for referral to DREAMS services. RESULTS: Overall, 5386 and 1204 YWSS were referred for DREAMS services through peer outreach and RDS, respectively. YWSS referred through RDS were more likely to access DREAMS services compared to YWSS referred through peer outreach (501/1204, 41.6% vs 930/5386, 17.3%; P<.001). Regardless of referral approach, YWSS who accessed DREAMS had similar education levels, and a similar proportion tested HIV negative and reported not using a condom at the last sex act. A higher proportion of YWSS accessing DREAMS through RDS were aged 18-19 years (167/501, 33.3% vs 243/930, 26.1%; P=.004) and more likely to be aware of their HIV status (395/501, 78.8% vs 396/930, 42.6%; P<.001) compared to those accessing DREAMS services through peer outreach. The incremental cost per young woman who sells sex recruited was US $7.46 for peer outreach and US $52.81 for RDS. CONCLUSIONS: Peer outreach and RDS approaches can reach and refer high-risk but different groups of YWSS for HIV services, and using both approaches will likely improve reach. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-DOI 10.1186/s12889-018-5085-6.

Awareness and uptake of the Determined, Resilient, Empowered, AIDS-free, Mentored and Safe HIV prevention package over time among population-based cohorts of young women in Kenya and South Africa.

OBJECTIVES: To evaluate uptake of a complex intervention for HIV prevention among general populations of adolescent girls and young women (AGYW) in three diverse settings. DESIGN: Cohorts of ∼1500 AGYW were randomly selected from demographic platforms in Kenya (Nairobi and Siaya) and South Africa (uMkhanyakude, KwaZulu-Natal). METHODS: AGYW aged 13/15-22 years were enrolled in 2017 (Nairobi and uMkha-nyakude) or 2018 (Siaya), with annual follow-up to 2019. We describe awareness of DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored and Safe), self-reported invitation to participate, and uptake of DREAMS interventions by: categories and levels of the PEPFAR core package;number of 'primary' interventions (seven in Kenya;five in South Africa). Analyses were stratified by year invited and age at cohort enrolment. RESULTS: Proportions aware and invited to DREAMS increased across all settings, to ≥ 83% aware and ≥ 53% invited by 2018 (highest among AGYW aged 13-17 years, e.g. 63 vs. 40% among 18-22 s, uMkhanyakude). HIV testing, school-based interventions and social protection were the most accessed categories, while differences in uptake by DREAMS invitation were greatest for novel DREAMS interventions, for example, social asset building (76% among those invited in 2017 and 2018 vs. 9% among those never-invited in Nairobi). Although few DREAMS invitees accessed all intended primary interventions by 2019 (2% of 15-17 s and 5% of 18-22 s in Gem), many accessed at least three interventions, including combinations across individual, family and community levels. CONCLUSION: Over time, DREAMS reached high proportions of AGYW in all settings, particularly younger AGYW. Participation in combinations of interventions improved but uptake of the complete primary packages remained low.

The association of exposure to DREAMS on sexually acquiring or transmitting HIV amongst adolescent girls and young women living in rural South Africa.

OBJECTIVE: We investigate how risk of sexually acquiring or transmitting HIV in adolescent girls and young women (AGYW) changed following the real-world implementation of DREAMS (Determined, Resilient, Empowered, AIDS free, Mentored and Safe) HIV prevention programme. DESIGN: A representative population-based prospective cohort study of AGYW living in rural KwaZulu-Natal. METHODS: Between 2017 and 2019, we interviewed a random sample of AGYW aged 13-22 years annually. We measured exposure to DREAMS as self-reported receipt of an invitation to participate and/or participation in DREAMS activities that were provided by DREAMS implementing organizations. HIV and herpes simplex virus type 2 (HSV-2) statuses were ascertained through blood tests on Dried Blood Spot (DBS). We used multivariable regression analysis to assess the association between exposure to DREAMS and risk of acquiring HIV: measured as incident HSV-2 (a proxy of sexual risk) and incident HIV;and the risk of sexually transmitting HIV: measured as being HIV positive with a detectable HIV viral load (≥50 copie/ml) on the last available DBS. We adjusted for sociodemographic, sexual relationship, and migration. RESULTS: Two thousand one hundred and eighty-four (86.4%) of those eligible agreed to participate and 2016 (92.3%) provided data for at least one follow-up time-point. One thousand and thirty (54%) were exposed to DREAMS;HIV and HSV-2 incidence were 2.2/100 person-years [95% confidence interval (CI) 1.66-2.86] and 17.3/100 person-years (95% CI 15.5-19.4), respectively. There was no evidence that HSV-2 and HIV incidence were lower in those exposed to DREAMS: adjusted rate ratio (aRR) 0.96 (95% CI 0.76-1.23 and 0.83 (95% CI 0.46-1.52), respectively. HIV viral load was detectable for 169 (8.9%) respondents;there was no evidence this was lower in those exposed to DREAMS with an adjusted risk difference, compared with those not exposed to DREAMS, of 0.99% (95% CI-1.52 to 3.82]. Participants who lived in peri-urban/ urban setting were more likely to have incident HIV and transmissible HIV. Both HSV-2 incidence and the transmissible HIV were associated with older age and ever having sex. Findings did not differ substantively by respondent age group. CONCLUSION: DREAMS exposure was not associated with measurable reductions in risk of sexually acquiring or transmitting HIV amongst a representative cohort of AGYW in rural South Africa.

DREAMS impact on HIV status knowledge and sexual risk among cohorts of young women in Kenya and South Africa.

OBJECTIVES: We sought evidence of DREAMS' impact on uptake of services and sexual risk among adolescent-girls-and-young-women (AGYW). DESIGN: Cohorts of AGYW aged 13-22 years were randomly selected in 2017-2018 and followed-up to 2019; 1081 in Nairobi, Kenya;1171 in Gem, western Kenya;and 2184 in uMkhanyakude, South Africa. METHODS: Outcomes were knowledge of HIV status, condomless sex (past 12 months), lifetime partners, transactional sex (past 12 months), and awareness and use of condoms and pre-exposure-prophylaxis (PrEP). Using a causal inference framework, we estimated the proportions with each outcome if all vs. none were DREAMS invitees by 2018. RESULTS: Among AGYW followed up in 2019, the percentage invited to DREAMS by 2018 was 74, 57, and 53% in Nairobi, Gem, and uMkhanyakude, respectively. By 2018, the estimated percentages of AGYW who would know their HIV status, comparing the scenarios that all vs. none were DREAMS invitees, were 86 vs. 56% in Nairobi, 80 vs. 68% in Gem, and 56 vs. 49% in uMkhanyakude. By 2019, awareness of condoms and PrEP was high among DREAMS invitees, but recent participation in condom promotion activities was less than 50% and recent PrEP use was around 0-10%. In Gem, there was evidence of a reduction attributable to DREAMS in condomless sex, and among younger AGYW in the number of lifetime partners;in Nairobi evidence of a reduction in condomless sex among sexually active older AGYW;and in uMkhanya-kude no evidence that DREAMS changed these outcomes. CONCLUSION: Alongside sustaining high levels of knowledge of HIV status, more is needed to link AGYW into prevention methods such as PrEP and condoms.Comprehensive HIV prevention promotes safer sexual partnerships, but poverty, social norms, and inequalities limit AGYW's prevention choices.

Effects of a multimedia campaign on HIV self-testing and PrEP outcomes among young people in South Africa: a mixed-methods impact evaluation of 'MTV Shuga Down South'.

INTRODUCTION: Innovative HIV technologies can help to reduce HIV incidence, yet uptake of such tools is relatively low among young people. To create awareness and demand among adolescents and young adults, a new campaign of the pan-African MTV Shuga series ('Down South 2'; DS2), featured storylines and messages about HIV self-testing (HIVST) and pre-exposure prophylaxis (PrEP) through television, radio and accompanying multimedia activities in 2019-2020. METHODS: We conducted a mixed-methods evaluation of the new MTV Shuga series among 15-24 years old in Eastern Cape, South Africa, in 2020. Quantitative and qualitative methods were used to investigate complementary evaluations questions, namely, whether and how the DS2 campaign works. A web-based survey, promoted via social media platforms of schools, universities and communities, assessed exposure to MTV Shuga and knowledge of HIV status; secondary outcomes included awareness and uptake of HIVST and PrEP. We used multivariable logistic regression to estimate associations between exposure to DS2 and each outcome, adjusting for sociodemographic factors, media assets and exposure to other media campaigns. An embedded qualitative evaluation explored mechanisms of DS2's impact through deductive and inductive thematic analysis of in-depth individual and group interviews. RESULTS: Among 3431 online survey participants, 43% had engaged with MTV Shuga and 24% with DS2 specifically. Knowledge of HIV status was higher among those exposed to DS2 (71%) vs those who were not (39%; adjusted OR=2.26 (95% CI 1.78 to 2.87)). Exposure was also associated with increased awareness of HIVST (60% vs 28%; aOR=1.99 (1.61 to 2.47)) and use of HIVST (29% vs 10%; aOR=2.49 (1.95 to 3.19)). One-third of respondents were aware of PrEP, with higher proportions among those exposed versus non-exposed to DS2 (52% vs 27%; aOR=1.90 (1.53 to 2.35)). Qualitative insights identified mechanisms by which DS2 increased awareness, confidence and motivation to use HIVST and PrEP, but had less influence on service access. CONCLUSIONS: We found evidence consistent with a positive causal impact of the MTV Shuga DS2 campaign on HIV prevention outcomes among young people in a high-prevalence setting. As diverse testing and PrEP technologies become accessible, an immersive edutainment campaign can help to expand HIV prevention choices and close age and gender gaps in HIV testing and prevention goals.

Impact of the DREAMS Partnership on social support and general self-efficacy among adolescent girls and young women: causal analysis of population-based cohorts in Kenya and South Africa.

INTRODUCTION: The Determined, Resilient, Empowered, AIDS-free, Mentored and Safe (DREAMS) Partnership aimed to influence psychosocial processes that promote empowerment among adolescent girls and young women (AGYW), and reduce HIV incidence. We estimated the impact of DREAMS on aspects of AGYW's collective and individual agency (specifically, social support and self-efficacy), in three settings where DREAMS was implemented from 2016 until at least end 2018. METHODS: Research cohorts of ~1500 AGYW aged 13-22 were randomly selected from demographic platforms in Kenya (Nairobi; Gem) and South Africa (uMkhanyakude) and followed up from 2017 to 2019. Social support was based on questions about female networks and access to safe places to meet with peers; general self-efficacy was measured using a scale previously validated in other settings. We conducted multivariable logistic regression, and estimated the causal effect of invitation to DREAMS on each outcome in 2018 and 2019 by comparing counter-factual scenarios in which all, vs no, AGYW were DREAMS invitees. RESULTS: In Nairobi, Gem and uMkhanyakude, respectively, 74%, 57% and 53% were invited to DREAMS by 2018. Social support was higher among DREAMS invitees versus non-invitees (eg, adjusted OR 2.0 (95% CI 1.6 to 2.6), Gem, 2018). In 2018, DREAMS increased social support in all settings and age groups, for example, from 28% if none were DREAMS invitees to 43% if all were invitees (+15% (95% CI 10% to 20%)) in Gem. Effects were strongest in Kenya, but weakened in 2019, particularly among older AGYW. In uMkhanyakude, DREAMS invitees had greater self-efficacy compared with non-invitees in 2018 (+9% (95% CI 3% to 13%), 2018) but less so in 2019. In Kenyan settings, there was weak evidence for impact on self-efficacy among younger AGYW in Gem (+6% (95% CI 0% to 13%)) and older AGYW in Nairobi (+9% (95% CI -3% to +20%)) in 2019. CONCLUSIONS: DREAMS impacted on social support and, less consistently, on self-efficacy. Weakening effects over time may reflect changes in access to safe spaces and social networks as AGYW age and change circumstances, and withdrawal of DREAMS from uMkhanyakude in 2018, highlighting the importance of programme sustainability and improving programming for older participants.

Early impact of the DREAMS partnership on young women's knowledge of their HIV status: causal analysis of population-based surveys in Kenya and South Africa.

BACKGROUND: Knowledge of one's HIV status is the gateway to treatment and prevention, but remains low among young people. We investigated the early impact (2016-2017) of Determined, Resilient, Empowered, AIDS-free, Mentored and Safe (DREAMS), a multisectoral HIV prevention package, on knowledge of HIV status among adolescent girls and young women (AGYW). METHODS: In 2017, randomly selected AGYW were enrolled into surveys, N=1081 aged 15-22 years in Nairobi slum settlements, and N=2174 aged 13-22 years in rural KwaZulu-Natal. We estimated the causal effect of being a DREAMS beneficiary on knowledge of HIV status (those who self-reported as HIV-positive or tested HIV-negative in the past year), accounting for an AGYW's propensity to be a DREAMS beneficiary. RESULTS: In Nairobi, knowledge of HIV status was higher among DREAMS beneficiaries compared with non-beneficiaries (92% vs 69%, adjusted OR=8.7; 95% CI 5.8 to 12.9), with DREAMS predicted to increase the outcome by 28%, from 65% if none were a DREAMS beneficiary to 93% if all were beneficiaries. The increase attributable to DREAMS was larger among younger participants: 32% and 23% among those aged 15-17 and 18-22 years, respectively. In KwaZulu-Natal, knowledge of status was higher among DREAMS beneficiaries aged 13-17 years (37% vs 26% among non-beneficiaries), with a 9% difference due to DREAMS (95% CI 4.8% to 14.4%), and no evidence of effect among 18-22 years (-2.8%; 95% CI -11.1% to 5.7%). CONCLUSION: DREAMS substantially increased knowledge of HIV status among AGYW in Nairobi, and among younger but not older AGYW in KwaZulu-Natal. Adolescent girls can be reached early (before age 18) with community-based HIV testing programmes in diverse high-prevalence settings, with a large impact on the proportion who know their HIV status.

Antiretroviral therapy based HIV prevention targeting young women who sell sex: a mixed method approach to understand the implementation of PrEP in a rural area of KwaZulu-Natal, South Africa.

Pre-Exposure Prophylaxis (PrEP) is a potential game-changer for HIV. We used PrEP introduction for Young Women Who Sell Sex (YWSS) in a rural South Africa district to understand community norms and PrEP coverage in YWSS. Between 2017 and 2018, we measured awareness and uptake of PrEP in a representative cohort of 2184 Adolescent Girls and Young Women (AGYW) aged 13-22. We conducted group discussions with young people and community members (19); key informant interviews (9), in-depth interviews with 15-24 year-olds (58) and providers (33). Interviews were analysed using thematic analysis. PrEP awareness increased from 2% to 9%. Among 965 AGYW sexually-active by 2018, 13.4% (95%CI: 11.4%-15.7%) reported transactional sex and 10.6% (95%CI: 8.85-12.7%) sex for money. Of the 194 YWSS, 21 were aware of PrEP, but none had used it. Youth were enthusiastic about PrEP as tool for HIV prevention; whilst older community members were cautious about a technology they had limited experience with but could benefit select groups. Teachers and healthcare providers were concerned that PrEP would lower personal responsibility for sexual health. In conclusion, the narrow and limited introduction of PrEP to YWSS reduced the accessibility and reach. Introducing PrEP as part of sexual healthcare may improve demand and access for YWSS.

Evaluating the impact of DREAMS on HIV incidence among adolescent girls and young women: A population-based cohort study in Kenya and South Africa.

BACKGROUND: Through a multisectoral approach, the DREAMS Partnership aimed to reduce HIV incidence among adolescent girls and young women (AGYW) by 40% over 2 years in high-burden districts across sub-Saharan Africa. DREAMS promotes a combination package of evidence-based interventions to reduce individual, family, partner, and community-based drivers of young women's heightened HIV risk. We evaluated the impact of DREAMS on HIV incidence among AGYW and young men in 2 settings. METHODS AND FINDINGS: We directly estimated HIV incidence rates among open population-based cohorts participating in demographic and HIV serological surveys from 2006 to 2018 annually in uMkhanyakude (KwaZulu-Natal, South Africa) and over 6 rounds from 2010 to 2019 in Gem (Siaya, Kenya). We compared HIV incidence among AGYW aged 15 to 24 years before DREAMS and up to 3 years after DREAMS implementation began in 2016. We investigated the timing of any change in HIV incidence and whether the rate of any change accelerated during DREAMS implementation. Comparable analyses were also conducted for young men (20 to 29/34 years). In uMkhanyakude, between 5,000 and 6,000 AGYW were eligible for the serological survey each year, an average of 85% were contacted, and consent rates varied from 37% to 67%. During 26,395 person-years (py), HIV incidence was lower during DREAMS implementation (2016 to 2018) than in the previous 5-year period among 15- to 19-year-old females (4.5 new infections per 100 py as compared with 2.8; age-adjusted rate ratio (aRR) = 0.62, 95% confidence interval [CI] 0.48 to 0.82), and lower among 20- to 24-year-olds (7.1/100 py as compared with 5.8; aRR = 0.82, 95% CI 0.65 to 1.04). Declines preceded DREAMS introduction, beginning from 2012 to 2013 among the younger and 2014 for the older women, with no evidence of more rapid decline during DREAMS implementation. In Gem, between 8,515 and 11,428 AGYW were eligible each survey round, an average of 34% were contacted and offered an HIV test, and consent rates ranged from 84% to 99%. During 10,382 py, declines in HIV incidence among 15- to 19-year-olds began before DREAMS and did not change after DREAMS introduction. Among 20- to 24-year-olds in Gem, HIV incidence estimates were lower during DREAMS implementation (0.64/100 py) compared with the pre-DREAMS period (0.94/100 py), with no statistical evidence of a decline (aRR = 0.69, 95% CI 0.53 to 2.18). Among young men, declines in HIV incidence were greater than those observed among AGYW and also began prior to DREAMS investments. Study limitations include low study power in Kenya and the introduction of other interventions such as universal treatment for HIV during the study period. CONCLUSIONS: Substantial declines in HIV incidence among AGYW were observed, but most began before DREAMS introduction and did not accelerate in the first 3 years of DREAMS implementation. Like the declines observed among young men, they are likely driven by earlier and ongoing investments in HIV testing and treatment. Longer-term implementation and evaluation are needed to assess the impact of such a complex HIV prevention intervention and to help accelerate reductions in HIV incidence among young women.

Young Adults' Responses to an African and US-Based COVID-19 Edutainment Miniseries: Real-Time Qualitative Analysis of Online Social Media Engagement.

BACKGROUND: In April 2020, as cases of the novel COVID-19 spread across the globe, MTV Staying Alive Foundation created the educational entertainment miniseries MTV Shuga: Alone Together. In 70 short episodes released daily on YouTube, Alone Together aimed to disseminate timely and accurate information to increase young people's knowledge, motivation, and actions to prevent COVID-19. OBJECTIVE: We sought to identify Alone Together viewer's perspectives on the global COVID-19 pandemic and national lockdowns by examining the words, conversations, experiences, and emotions expressed on social media in response to the Alone Together episodes. We also assessed how viewers used the series and its online community as a source of support during the global pandemic. METHODS: A total of 3982 comments and 70 live chat conversations were extracted from YouTube between April and October 2020 and analyzed through a data-led inductive thematic approach. Aggregated demographic and geographical data were collected using YouTube Analytics. RESULTS: The miniseries had a global reach across 5 continents, with a total of 7.7 million views across MTV Shuga platforms. The series had over 1 million views over 70 episodes on YouTube and an average of 5683 unique viewers per episode on YouTube. The dominant audience was adults under the age of 35 years and women. Across diverse countries such as Nigeria, Ghana, the United States, and the UK, viewers believed that COVID-19 was serious and expressed that it was socially responsible to follow public health measures. Storylines of the series about the impact of self-isolation on mental health, exposure to violence in lockdowns, and restricted employment opportunities due to the pandemic resonated with young viewers. Tuning in to the miniseries provided viewers with reliable information, entertainment, and an online community during an isolating, confusing, and worrying time. CONCLUSIONS: During the first wave of COVID-19, viewers from at least 53 countries connected on social media via the MTV miniseries. The analysis showed how digitally connected people under the age of 35 years, predominantly women, felt compelled to follow COVID-19 safety measures despite the pandemic's impact on their social, educational, and financial needs. Viewers used social media to reach out to fellow viewers for advice, solace, support, and resources. Organizations, governments, and individuals have been forced to innovate during the pandemic to ensure people can access services safely and remotely. This analysis showed that women under 35 years of age were especially receptive to receiving support from online communities and media services. Peer influence and support online can be a powerful public health tool as people have a great capacity to influence each other and shape norms around public health. However, online services are not accessible to everyone, and COVID-19 has increased disparities between digitally connected and unconnected younger adults.