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

Sub-Saharan Africa, particularly Eastern and Southern Africa, is disproportionately affected by HIV. Of the estimated 5000 daily new infections globally in 2018, approximately 61% were in Sub-Saharan Africa. A third of these infections were among adolescents and young people (AYP) aged 15-24. In Eastern and Southern Africa, 1 in 4 new infections were among adolescent girls and young women (AGYW) aged 15-24, who account for only 10% of the population [1]. In addition to a high risk of HIV infection, AYP, especially AGYM, are at high risk of other sexually transmitted infections (STIs); though at lower risk compared to young women, young men report higher risk sex and are less engaged with health services [2‐5]. This data points to a need for information and education on STIs/HIV, such as through provision of comprehensive sexuality education (CSE), and access to diagnostic services, including HIV testing services (HTS).

Data on access to essential sexual and reproductive health (SRH) services, including HTS, shows AYP are underserved. In Zambia, the age group 15-19 have the lowest coverage of HIV testing and correct knowledge of HIV: 59% of girls and 46% of boys aged 15-19 reported ever testing compared to 91% of women and 77% of men aged 20-24yrs [6]. Access is hindered by numerous individual-level and structural-level factors, including negative staff attitudes, and lack of youth-friendly services [7, 8]. In Zambia, a community-based door-to-door universal HIV testing-and-treatment community-randomized study (HPTN071/PopART) found gaps in reaching AYP, particularly young men aged <25 [9]. To address these gaps, the P-ART-Y study was nested within PopART to reach adolescents. P-ART-Y found that knowledge of HIV status in intervention communities was >80% compared to ˜30% in control communities; while better than regional estimates, this still leaves many AYP unreached by HTS [10‐12]. In response to these unmet needs, the Yathu Yathu (“For us, by us”) intervention was co-designed with AYP to provide community-based, peer-led SRH services for AYP aged 15-24 in two urban communities in Lusaka, Zambia [13].

In March, 2020, the World Health Organization declared the SARS-CoV-2(COVID-19) outbreak a “public health emergency of international concern” [14]. The first case in Zambia was reported on 16^th March, 2020 resulting in closure of schools, mandatory mask-wearing and restrictions of public gatherings, among other measures [15]. Early estimates of the impact of COVID-19 predicted that access to SRH services would be negatively affected, this conclusion was drawn from lessons learnt during outbreaks of other diseases, such as Ebola [16‐18] and cholera. Using data collected in the Yathu Yathu study, we describe adaptations to service delivery in response to the COVID-19 epidemic, implications on AYP’s access to Yathu Yathu and uptake of HTS, and AYP’s perceptions and experiences of accessing SRH services adapted in response to COVID-19.

Despite adaptations in response to COVID-19 that resulted in restrictions in attendance, in the period after COVID-19 related closures, over 3,000 AYP visited the Yathu Yathu hubs for the first time. Approximately 73% accessed HTS, and attendance to social media platforms increased during the COVID-19 closure. Even with restrictions due to COVID-19, HIV testing was the most accessed service and uptake of HTS at first visit remained high. These findings show that HTS can be provided during COVID-19 without affecting demand. Qualitative data showed that, while AYP were disappointed by the restrictions, they understood the need for the restrictions and were happy with continued service provision, including via social media.

Adaptation, defined as a “process of making modifications or changes to the design or implementation of an intervention”, is important for optimizing implementation [10, 11]. Adaptations are important for meeting a specific target group needs or as a response to a contextual stimulant, such as disease outbreaks [12]. However, adaptations can result in changes to the fidelity of the intervention, reach and the dose delivered and received [13]. This is evidenced in Yathu Yathu, with AYP not accessing services due to adaptations made to limit the number of participants and so impacting reach and dose received among those reached. On the other hand, adaptations may be necessary to maintain the integrity of an intervention due to unforeseen circumstances, such as COVID-19. In the case of Yathu Yathu, with the simple service delivery adaptations described, we have shown that community-based provision of SRH services is safe, feasible and acceptable to AYP even in the midst of an epidemic. Another adaptation was use of social media platforms, which have already been documented as a useful way to share SRH information in Zambia, Kenya, South Africa and South Asia [23‐25]. In Yathu Yathu, social media evolved to a platform to provide CSE in response to restrictions on in-person provision of this service. With a changing social context and more young people (71%) reported to be on social media compared to those aged over 24 (48%) [24], this presented an important opportunity to share information. However, in Sub-Saharan Africa, use of mobile phones is still limited, with only 20% of the population owning a phone compared to Europe and North America at 78% [24]. Concerns about creating a “digital divide” due to lack of access to smartphones, was evidenced by the lower number of adolescents aged 15-17 engaging with the virtual platforms. This, thus, highlights the importance of continued physical access to ensure that this key age group is not left behind in their access to critical SRH services. Here, we also see that young people aged 20-24, who are more likely to be economically independent, and so have greater access to social media, were able to benefit more. This is similar to findings from countries such as South Africa, Nigeria and Ghana as part of the SmartSex social media platform for provision of sexuality education [25]. On the other hand, this age group had fewer visits to the hubs than the adolescents aged 15-17, with some citing “being busy” and therefore found this avenue as a “helpful” addition to hub services.

Although adaptations made in response to COVID-19 resulted in reduced numbers of participants visiting the hubs and potentially without their friends, AYP still welcomed the availability of the services and were not discouraged from accessing services. Before the COVID-19 closures, adolescent boys and girls aged 15-19 accessed more services compared to those aged 20-24 years. This was seen even after closures. Considering that, in Zambia, this age group has the lowest correct knowledge of HIV (˜40%) and between 45%-60% report never having tested for HIV [6], having access to SRH services, may be key in ensuring gains made in HIV infection reduction targets are maintained [1, 26, 27]. Encouragingly, for this underserved age group, more girls than boys consistently accessed services. This was also seen for the young women aged 20-24 years compared to young men. Despite young men not accessing services as often as women, the proportion accessing HTS was similar across both sexes implying that the hubs are acceptable for both to access services. This is in contrast to other studies that found that attendance to spaces was dominated by young men [7, 28]. Surprisingly, HIVST uptake did not increase as expected after COVID-19 related closures [29]. This could be explained by shortages in HIVST test kits, which were sourced from government health facilities, during implementation. In addition, this could be explained by findings from previous analysis of our pilot intervention data, which suggests that provision of youth friendly services results in a preference for fingerprick HIV testing [30]. The increased number of visits for STI screening and HTS may be distorted by the PPC component of the intervention, where AYP may wish to “gain” points to be able to access rewards as opposed to a perceived need for the service itself. On the other hand, the increase may be due to reduced access to services, such as condoms, during closures, and/or increases in sexual violence, coupled with closure of schools, resulting in increased exposure to HIV and STIs [16, 31].

Our study is subject to limitations. It was not possible to determine if the individuals reached through the Facebook page were study participants who received a PPC, as there were no restrictions on who could engage with the page. As such, the increase in followers may not reflect an increase in the reach among our study population. As COVID-19 resulted in a number of restrictions including to information on sexual and reproductive health, we felt it would be unethical to not provide information to all AYP. This would have resulted in a higher number of new followers who were not necessarily from our study area thereby distorting the usefulness of social media to our study. This could be overcome by having a restricted group only open to participants if needed. However, most followers were young people in our target age group, residing in Lusaka. Another limitation is that, as we did not compare uptake of HTS in the hubs to uptake of HTS in the control zones (health facilities). As such, we do not know whether AYP would have had access to HTS elsewhere and cannot attribute the increase in uptake of HIV testing at population level to the COVID-19 closures. COVID-19 control measures may have resulted in limited access to healthcare services, including HTS, at local health facilities. This could have positively influenced access to HTS at the hubs once they re-opened. However, we cannot attribute the increase in uptake of HTS to the re-opening of hubs as we cannot determine what could have happened in the absence of closures. To overcome this limitation, we restricted the analysis to uptake of HTS at the very first visit to the hubs to ensure we didn’t include AYP already engaged with the hubs; particularly as other research has shown that uptake of HTS is associated with more frequent use of health services in young people aged 15-24yrs old in a similar setting [32]. However, this analysis is planned at the end of the trial, which was extended by an additional 10 months due to COVID-19. The strengths of this research are that we collected and used real-time data on adaptations in a complex and changing environment. The PPC is a valuable resource which allowed us to collect this data.

As the world battles COVID-19, ensuring AYP have access to essential SRH services and information has become more crucial to maintain the gains made in adolescent health in Sub-Saharan Africa [33, 34]. Making simple adaptations, such as enforcing social distancing and infection control protocols, has been shown to work in maintaining access to SRH in countries like Uganda [23]. With continued visits and uptake of SRH services, we have shown that making simple adaptations to service delivery of SRH services within a community-based setting, with additional use of social media to support information provision, can successfully ensure continued provision and use of SRH services and HTS by AYP.