A new study from Africa Health Research Institute (AHRI) shows that combining HIV prevention with sexual and reproductive health services, and offering home-based sexually transmitted infection (STI) self-sampling, increased the uptake of differentiated and person-centred HIV prevention methods, including pre-exposure prophylaxis (PrEP), among a population representative sample of adolescents and young adults in South Africa. This age group has historically shown a low uptake of PrEP, partly due to challenges in creating demand.

The study, led by AHRI director for implementation science Prof Maryam Shahmanesh, is published in the journal The Lancet HIV.

From 2020 to 2022, AHRI enrolled 1 743 people between the ages of 16 and 29 living in the rural uMkhanyakude district in KwaZulu-Natal. Trial participants were randomly allocated to one of four groups: those in the standard-of-care group were referred to youth-friendly services for differentiated HIV prevention (condoms, universal HIV test and treat with antiretroviral therapy, and PrEP if eligible); those in the sexual and reproductive health services group received baseline self-collected specimens for STI testing and referral to integrated sexual and reproductive health and HIV prevention services; those in the peer support group were referred to peer navigators for health promotion, condom provision, and facilitation of attendance for differentiated HIV prevention services; and those in the final group received a combination of sexual and reproductive health services and peer support.

Key findings include:

  • Integrating services: the study found that combining HIV prevention with sexual and reproductive health services significantly enhances engagement. Offering home-based STI self-sampling was particularly effective, increasing the uptake of HIV prevention services by 60% among young people.
  • Broad acceptance: the approach was well-received by both young men and women, addressing a major gap in previous efforts that primarily focused on women.
  • High uptake: nearly 20% of those attending the clinics were eligible for and started PrEP.
  • Retention support: while peer support didn’t directly boost PrEP uptake, it played a crucial role in helping young people stay engaged with ongoing sexual and reproductive health services. Peer navigators expressed a desire to provide more personalised referrals and address the unmet social needs of young people.

(Above: Peer support played a crucial role in helping young people stay engaged with ongoing sexual and reproductive health services) 

In response to feedback from peer navigators, the intervention has been co-developed further to decentralise HIV prevention and include support for unmet social needs. This optimised intervention, called ‘Thetha Nami ngithethe nawe’ (Let’s talk), focuses on peer-led mobilisation into integrated sexual and reproductive health and HIV services. The impact of this intervention on HIV prevention at a population level is currently being evaluated.

“This study provides some of the earliest evidence of the value of STI testing as a means to create demand and identify those who would benefit the most from PrEP – and not just to monitor STIs among those already using PrEP,” said Prof Shahmanesh. “As HIV rates decline, innovative and scalable strategies like this will be essential to reach those still at risk and will assist in tackling unmet sexual health needs among adolescents and young adults.”

(Top photo: AHRI’s mobile clinics, providing  youth-friendly differentiated HIV prevention and sexual and reproductive health services)