Integration of HIV prevention and sexual and reproductive health in the era of anti-retroviral-based prevention: findings from assessments in Kenya, Malawi and Zimbabwe

HIV prevention and SRH trends and landscape

Across countries, data reveal high HIV prevalence among young women, with especially high rates in Zimbabwe and Malawi (see Figure 1).³ Data show significant strides in HIV testing among pregnant women, prevention of mother-to-child transmission (PMTCT) coverage and relatively high modern contraceptive prevalence rates for all women, pointing to SRH and maternal child health (MCH) services as strong entry points for integrated services.^4,5 Unmet need for FP is higher in Kenya and Malawi than in Zimbabwe, and the contraceptive method mix in Kenya and Malawi skews toward injectables, while in Zimbabwe, the oral contraceptive pill is the most common method.^6–9 Kenya was the first of these countries to introduce oral PrEP and is furthest ahead with scale-up, while Malawi’s program is just beginning to roll out.¹⁰

Figure 1. Comparison of demographic and epidemiological data in Kenya, Malawi and Zimbabwe.

Across countries, contraception and oral PrEP are primarily accessed in public facilities, though the private sector, including healthcare providers in private practice, non-governmental organizations (NGOs), faith-based clinics and pharmacies, is an important source of FP services, pointing to opportunities for integration with oral PrEP. In Kenya, 60% of contraceptives are obtained in the public sector and 34% in the private sector, while oral PrEP is delivered primarily in HIV clinics (57%) and safe spaces (25%, many NGO-run).^11,12 Similarly, in Zimbabwe, 73% of contraceptives are obtained in the public sector and 22% via the private sector; oral PrEP is primarily obtained in public HIV clinics.¹³ In Malawi, 79% of contraceptives are accessed in public facilities, 8% from Banja la Mtsogolo (BLM), the local Marie Stopes affiliate, and 6% from the private sector.¹⁴ Notably, the COVID-19 pandemic has expanded innovations in service delivery, broadening access to oral PrEP and FP through decentralized, differentiated and private sector channels in an effort to mitigate disruptions to accessing services at public health facilities.

High HIV prevalence and incidence among AGYW in Kenya (2.1% and 1.9%), Malawi (3.7% and 3.1%) and Zimbabwe (5.2% and 4.2%),^15,16 and the large percentage of AGYW in these countries who gave birth before age 18 (23.3%, 34.7% and 22%, respectively),¹⁷ signal the need to better reach this population with HIV prevention and SRH information and services. High rates of early marriage in Malawi and low rates of secondary school enrolment for girls in Malawi and Zimbabwe underscore that structural and social barriers often undermine health outcomes. Limited data on AGYW points to a need for sex- and age-disaggregated data to better tailor programs. While the unmet need for FP among women of reproductive age ranges from 10% in Zimbabwe to 15% in Malawi, this figure is higher among AGYW (ranging from 12.6% in Zimbabwe to 24.9% in Malawi). Unmet need for FP among women living with HIV has been shown to be slightly lower than among women in the general population,^18,19 though studies cite missed opportunities to provide FP through anti-retroviral treatment (ART) clinics as a contributing factor to the ongoing unmet need within this population.^20,21

Research teams for rapid assessments

In Kenya⁴⁷ and Zimbabwe,⁴⁸ the rapid assessments were completed in 2020 by multi-disciplinary teams from the MOH and the HIV Prevention Market Manager project (PMM), represented by AVAC. In Kenya, the research team included representatives from the National AIDS and STI Control Programme (NASCOP), Department of Family Health and AVAC. In Zimbabwe, the research team included representatives from the Department of AIDS & TB, Pangaea Zimbabwe AIDS Trust (PZAT) and AVAC. MOH representatives identified sites, key informants and led data collection at country level. AVAC led development of data collection tools, analysis of findings and participated in data collection in Kenya. Advocates in each country organized and led community dialogues with AGYW and, in Zimbabwe, organizations working with AGYW.

In Malawi,⁴⁹ the rapid assessment was completed in 2020 by representatives from the Department of HIV/AIDS and Department of Reproductive Health at the MOH and Georgetown University Center for Innovation in Global Health to inform the Blantyre Prevention Strategy, launched in May 2020 to catalyze local development of an innovative, data-driven HIV prevention delivery system at the district level. The district of Blantyre was chosen due to the seemingly intractable HIV epidemic and continuing high numbers of new infections there.

Data collection for rapid assessments

In Kenya and Zimbabwe, research teams identified a cross-section of ten health facilities in each country, primarily in the public sector, across high and low volume sites in both urban and rural settings, including youth-friendly (YF) sites. Twenty health facility assessments were conducted in six regions in Kenya and six provinces in Zimbabwe (see Figure 2).

Figure 2. Health facility assessment sites in Kenya and Zimbabwe.

Key informants were identified from national, sub-national, facility and community levels to provide a representative snapshot of HIV prevention/SRH integration at country level. In total, 73 semi-structured, one-hour interviews were conducted with national, provincial, county and district-level MOH representatives; HIV, SRH and MCH healthcare providers; implementing partners and donors. Six one-day community dialogues were held in-person with AGYW and NGOs. Interviews were requested via email or telephone and health facility visits by letter or email, per MOH protocols. They were primarily conducted in-person and virtually where not feasible, including due to COVID-19 restrictions.

In Malawi, the research team conducted a review of national policies and implementation of HIV and SRH programs in Blantyre district and approximately 70 semi-structured interviews, including with: Blantyre district health officials; NGOs, advocacy organizations and implementing partners; healthcare providers at district health facilities; community-based organizations; organizations associated with the Blantyre Prevention Strategy; U.S. government officials in Malawi and other donors; DREAMS ambassadors and AGYW peer educators. Participants were recruited through organizations and officials associated with the Blantyre Prevention Strategy, NGOs and researchers and community-based organizations with whom they worked. Given travel and social distancing restrictions due to COVID-19, in-person interviews were substituted with interviews through WhatsApp calls to key informants’ cell phones (which are used widely in Malawi), video calls (Zoom or Teams), telephone and email.

Interviews began with an introduction of the researchers and explanation of the research purpose and focus of discussion. Oral informed consent was sought to participate in the interview as well as to audio-record the conversation, where feasible, and confidentiality protocols were explained. Informed consent was then obtained by research teams in each country. Interviews were recorded and notes taken simultaneously, and facility assessment data from Kenya and Zimbabwe were logged in a spreadsheet. Interview transcripts, notes, recordings and health facility assessments were only accessible by the research teams.

Data analysis for rapid assessments

PMM used standardized interview guides and health facility assessment checklists to conduct the rapid assessment and analysis of data across Kenya and Zimbabwe. The research teams compiled detailed notes after each interview using a standard template, referencing recorded interviews to ensure accuracy and attention to detail, and to document supporting quotes. Health facility assessments collected quantitative data on HIV, FP/SRH and YF services available (e.g., methods and hours offered, whether and how services are integrated, commodity stock-outs, YF accommodations) and staffing and general infrastructure (e.g., facility size, number and cadres of staff across HIV, SRH and YF service areas) to analyze the level of HIV prevention/SRH integration and YF service delivery at each facility. To understand opportunities for and barriers to HIV prevention/SRH integration, each team conducted thematic analysis of detailed notes through a workshop once data collection was completed to identify common themes and outlier perspectives across the interviews, grouped by stakeholder perspectives at the government, health facility and community levels. Findings were triangulated across qualitative and quantitative data.

To understand the spectrum of services in the Blantyre district, the research team analyzed HIV and SRH information and services offered through public sector facilities and youth-friendly health services (YFHS), as well as in the private sector, including national and international NGOs and NGOs with the U.S.-led DREAMS initiative. The analysis highlighted social and structural barriers for sustained and effective use of prevention interventions, including through the education system and gender-based violence (GBV) programs, and new and evolving challenges presented by the COVID-19 pandemic.

Comparative analysis across countries

To comparatively analyze the three assessments, AVAC and Georgetown University reviewed the final reports of the three assessments to surface patterns, or “themes,” across the assessments and where they differed. Through this review, we identified four cross-cutting, overarching themes around which we structured the comparative analysis: policies and enabling environments, health systems, service delivery and gaps to implementation of HIV prevention/SRH integration. We sorted all pertinent findings from the assessments into these thematic areas, and analyzed similarities and differences in findings, including identifying models of integration. Inconsistencies across the data were contextualized by incorporating additional literature or publicly available country-level sociopolitical data, as well as existing policies from each country, to embed the analysis within a situational context. Findings from the contextual analysis were layered onto the results from the comparative analysis.

Ethics approval

No ethics approval was sought for this article, as it analyzes the aggregate findings from completed rapid assessments and did not entail additional primary data collection. Ethics approval was not obtained for the rapid assessments, as interviews and health facility asessments collected programmatic data and did not access personal data, and data was used for the purpose of informing national program understanding of the landscapes.

Enabling environment and policy implementation

Our analyses revealed that the policy environment in all three countries is conducive to expanded integration of HIV prevention and SRH, though most policies on integration preceded oral PrEP rollout (and therefore do not address its integration into SRH services). Operationalizing policies and translating them to local/district levels continues to present challenges, especially in reaching AGYW with YFHS and safe spaces, due in large part to public-sector resource constraints that entrench HIV and SRH silos, rely on referral systems and limit provider training to offer integrated oral PrEP/FP services and deliver them in a non-judgmental, confidential and affordable way.

Sub-national MOH departments for HIV and FP/reproductive health (RH) were cited as critical for cascading operational changes down to facilities, yet the assessments found that they often work in silos, resulting in parallel budgets, workplans and M&E systems. One county RH coordinator in Kenya likened it to “operat[ing] like water and oil, but this is changing.”⁵⁰ The assessments found that structures supporting collaboration across local HIV and FP/RH departments have led to the formation of mechanisms to implement integration, though the extent of these structures varied across countries.

Although policies and strategies on HIV prevention/SRH existed in Kenya, services were not consistently integrated in practice. Prior to the rapid assessment, the government largely had separate programs supporting the operational rollout of SRH and HIV prevention services at national and sub-national levels.⁵¹ In response to assessment findings, the MOH built on these existing structures to join HIV prevention and SRH leaders to renew commitment to integration: NASCOP and the Department of Family Health formed a national HIV prevention/SRH integration sub-committee in 2020. The sub-committee analyzed 16 HIV prevention and SRH policies and consulted stakeholders in all 47 counties in Kenya and, based on findings that most policies preceded oral PrEP and required updating to be more comprehensive, produced a policy circular on HIV prevention/SRH integration containing concise directives for county officials and health facilities, and a package of resources to aid implementation.⁵² Integration pilots are planned in 2021 in five counties.

In Zimbabwe, close coordination across HIV and SRH leadership was noted by key informants to have historically been a strength. Government-led, program-specific (e.g., PrEP) technical working groups (TWGs) are integrated, as are the Prevention Partnership and Adolescent Reproductive and Sexual Health Partnership Forums.⁵³ Importantly, these platforms include representation from implementing partners and potential beneficiaries, including AGYW.

While Malawi has a national-level SRHR and HIV and AIDS integration sub-committee, the assessment found that until recently, separate TWGs at the City and the District level resulted in fragmented programs, with City Councils responsible for urban catchment areas and District Councils responsible for rural ones, with the absence of a forum for routine involvement of community members, including AGYW and other beneficiaries. The establishment of joint City and District TWGs with routine community engagement is an opportunity to coordinate effective integrated services at the district-level. There was broad agreement among key informants in Malawi interviewed that strengthening district-level leadership is key to operationalizing national integration policies,⁵⁴ consistent with findings in Kenya and Zimbabwe.

“Coordination is a big challenge… The districts are eager to understand and provide input to the programs that are ongoing, including how targets are set for partners in their district, and they want to be in the lead in coordinating and directing projects and funding, but they lack adequate staffing and bandwidth. With limited time and human resource capacity, it’s difficult for them to engage as much as they might like in supervising partner activities.” -USAID/Malawi official⁵⁵

“Whatever model, we need to strengthen the DHO [District Health Office] -it’s the unit to ensure continuity. Supervision coupled with strengthening the relevant DHO office is what’s needed for the long run.” -University of Malawi, College of Medicine, professor⁵⁶

Siloed delivery, M&E and supply chain systems

Across countries, HIV prevention and SRH programs are funded, managed and implemented vertically through separate HIV and FP/RH departments within the MOH and delivered in separate physical spaces by different providers in facilities. The assessments found that referrals are commonly used to fill gaps in services offered and alleviate perceived burden on providers, though key informants noted that this can erect barriers for young clients.

“There is a tendency at facility level to look at HIV services as quite involving. As such, there is a tendency to push and refer, rather than to embrace integration. At the same time, in CCCs [comprehensive care clinics] we are already overwhelmed and yet we are asked to do family planning.” -County AIDS and STI Coordinator (CASCO), Kenya⁵⁷

“For young people it is even harder. You know how difficult it is to be shuffled from one place to another for services. It is disturbing coming to seek reproductive health service[s] then you have to explain your issue over and over to different nurses. It is embarrassing. So they leave without accessing the service. We have missed opportunities.” -MoHCC official, Zimbabwe⁵⁸

“If we are providing PrEP as a hospital but they have to go to OI [Opportunistic Infection, or HIV clinic] to get, it becomes a barrier. You tell them please go to OI, and you give them directions, then you call OI to check if the client has arrived; they don’t get there.” -YF provider, Zimbabwe⁵⁹

Our assessments and other studies have found that this siloed service delivery cascade creates barriers to uptake, exacerbates stigma and does not respond to the priorities or multiple vulnerabilities faced by AGYW.^60–63 This system is largely entrenched due to international donor support for a significant portion of these programs, requiring target setting, provider training and staffing, and reporting for HIV prevention and SRH metrics to be done separately. Key informants raised the large imbalance in funding, where HIV is exponentially better-resourced than FP and other SRH services, as a barrier to integration. To illustrate, HIV funding from the United States President’s Emergency Plan for AIDS Relief (PEPFAR) in 2020 was $33 million in Kenya, $177 million in Malawi, and $225 million in Zimbabwe,⁶⁴ and the Global Fund has allocated $272 million in Kenya, $393 million in Malawi and $425 million in Zimbabwe for HIV from 2020–2022.⁶⁵ Meanwhile, the combined total funding from UNFPA and the United States Agency for International Development (USAID) for contraceptive commodities across 69 countries was just $200 million in 2019.⁶⁶ In Kenya, few counties have FP-specific budget lines and external donor investments in FP have decreased over time.⁶⁷

“Sometimes the investments of partner-funded programs can lead to less integration. There is this tendency like … me I work with [an implementing partner], I am supposed to do HIV preventive services. MCH is none of my business.” -MCH nurse, Kenya⁶⁸

“There will be a funder who will fund HIV prevention, but won’t fund family planning or reproductive health activities. Or there will be a funder who will fund reproductive health and leave behind issues to do with HIV. For instance, the funder may say I won’t buy test kits for HIV but I will buy contraceptives for young people. ” -MoHCC official, Zimbabwe⁶⁹

As a result, data systems for supply chain management and monitoring and evaluation (M&E) are generally not integrated.⁷⁰ Siloed supply chain systems for HIV and SRH commodities supporting public sector facilities and pharmacies have been found to be a barrier to integration,⁷¹ reinforced by donor funding for separate programs. For example, PEPFAR, the largest HIV donor, currently does not allow funds to be used to procure contraceptive commodities other than condoms, requiring enhanced coordination across programs and donors to deliver both HIV prevention and FP services in the same setting.⁷²

At facility level, HIV prevention and SRH data are collected at different delivery areas and through separate registers, though providers interviewed emphasized that integrating M&E could be an impetus for delivering integrated services (“if it is not reportable, then it is [perceived by providers to be] unimportant”).^73,74 Though some indicators may be shared across registers (e.g., Malawi has an integrated register for Antenatal Care and Maternity Delivery, which captures HIV information), patient tracking and monitoring was reported to be unintegrated across sites.

Furthermore, much of the data collected on HIV testing, oral PrEP and specific contraceptive methods are not always available by specific age bands, target populations or service areas, and data completeness and quality are ongoing challenges.^75,76 As one implementing partner in Malawi noted, “We’re missing out on a lot of data on the SRH entry point, since they [facilities] don’t have to report on those indicators. We’re not capturing how many we’re reaching and what the issues are.”⁷⁷ Conducting joint analyses of FP and PrEP data for program-monitoring or decision-making requires special analysis to bridge separate M&E systems, though strategic information officers at MOH-level are also typically siloed. Those working in HIV departments confirmed they cannot readily access FP data and vice versa, and mechanisms in DHIS-2 (e.g., built-in pivot tables and standard reporting functions) do not support integrated analyses. One key informant advocated for M&E systems to be revised to incorporate new indicators on HIV prevention/SRH integration as defined by governments, such as identifying AGYW at risk of HIV through the presence of STIs and early or unintended pregnancy.⁷⁸

Healthcare provider capacity to offer integrated services to AGYW

Across countries and studies, healthcare provider capacity-building is underscored as the most critical need for integrating HIV prevention services, including HIV testing and PrEP, in SRH service delivery points.^79–81 Generally, HIV healthcare providers are trained through pre-service education in SRH/FP, but SRH/FP providers lack similar training in HIV services and require training to test for HIV and screen for and provide oral PrEP.

Currently, oral PrEP is primarily delivered by ART nurses and staff specifically certified to prescribe PrEP at HIV service delivery points. In Kenya and Zimbabwe, SRH healthcare providers cited a lack of training as the primary hindrance to providing screening and education about PrEP in SRH settings.^82,83 These providers expressed a lack of confidence to even bring up PrEP during FP counseling or if a high risk for HIV was detected. In Kenya, it was also reported that highly trained FP nurses in the public sector are often transferred to facilities in need of improving service delivery,⁸⁴ while in Malawi⁸⁵ and Zimbabwe,⁸⁶ severe health care worker shortages were underscored as further limiting the number of trained FP providers. Healthcare providers called for greater investment in human resources, including training and supervision, to fill gaps in capacity to integrate PrEP in FP/SRH services.

In addition to a need to strengthen hard skills such as PrEP delivery, this analysis found that negative provider attitudes toward AGYW seeking PrEP and FP services are a key barrier to access in the public sector across countries. In community dialogues in Kenya and Zimbabwe, AGYW described facing stigma from healthcare providers, particularly if they were suspected to be or engaging in sex work or living with HIV, and that privacy and confidentiality are often disregarded, which can demotivate them from returning. In Malawi, the assessment found that sexually-active AGYW, in particular if they are unmarried or have not given birth, are similarly disparaged by providers in public facilities. These findings echo published literature on provider bias toward young people,^88,89 pointing to a need for training on “soft skills” such as YF communication as a component of provider capacity-building.

Task-shifting has been widely employed to expand the number and cadres of providers trained in FP across countries, and is far more advanced compared to oral PrEP (see Figure 3). Task-shifting for PrEP counseling is prevalent in Zimbabwe, where lay providers can counsel on PrEP after completing PrEP-specific trainings, a model other countries where task-shifting for PrEP is inceptive can follow.⁹⁰ Task-shifting FP to community-based delivery is endorsed in all three countries. It has contributed to notable increases in contraceptive use across countries and in referrals for HIV testing and HIV/STI-related service referrals, and increased dual prevention methods for women living with HIV.^91,92 In Zimbabwe, community health workers (CHWs) can be key to creating demand for FP among AGYW, with CHWs discretely supplying FP methods in rural communities.⁹³ In Malawi, health surveillance assistants (HSAs) provide integrated service delivery at the community level, while community-based distribution agents (CBDAs) provide information and distribute basic FP commodities to young people in communities and provide referrals to facilities for other services.^94,95 Linkages between services in the community and health facilities were often found to be weak for AGYW, indicating a need to expand and integrate the services that CHWs are authorized to provide.

Figure 3. Task-shifting for administering contraceptives & HIV prevention interventions in SSA⁹⁶.

Limited engagement of the private sector

Leveraging the private sector⁹⁷ to enhance PrEP uptake is an under-utilized service delivery option, as it is already a well-established channel for FP but has limited HIV prevention delivery across countries. Private sector services are an important source of health care in Kenya, where 34% of modern contraceptive methods are obtained via private providers, including 45% of oral contraceptive pills (OCPs) from pharmacies and 29% of injectables from private hospitals/clinics.⁹⁸ In Malawi and Zimbabwe, the private sector comprises about one-fifth of delivery channels for FP,^99,100 but access to private practitioners is limited to those who can afford it. NGOs, which are typically subsidized by donor funds, have been important private players in providing integrated SRH and HIV prevention services for AGYW, but donor dependency may impede the sustainability of these channels.¹⁰¹ The Malawian MOH has implemented public-private partnerships (PPPs) to ensure that clients are offered a full package of HIV prevention/SRH services and fill gaps where public sector services are not attracting young people. Government-NGO collaboration in Malawi includes work with Banja La Mtsogolo (BLM), which operates a “nested” approach in 14 sites and public sector strengthening in 29 sites to improve capacity for FP providers at public facilities, especially for LARCs.¹⁰² Similarly, in Zimbabwe, the MoHCC is implementing a PPP framework that aims to leverage resources from the public and private sectors to directly reduce the impact of HIV, AIDS and tuberculosis (TB) in the country.¹⁰³

Pharmacies are a critical channel for FP services in all three countries and an option for expanding HIV prevention commodities such as oral PrEP, once PrEP delivery is permitted. For example, 13.5% of contraceptives are accessed through pharmacies in Zimbabwe¹⁰⁴ and OCPs and emergency contraception (EC) are available over-the-counter, but cost and fear of stigma are reported to be major challenges for AGYW. PrEP is also available in pharmacies with a prescription, but stock-outs exist and it remains largely unaffordable. In Kenya, pharmacy-based OCP and PrEP-dispensing is allowed and pharmacies are already offering HIV testing. Kenyatta University, KEMRI and the University of Washington’s Pharmacy-based PrEP initiation implementation study is evaluating pharmacy prescription and refilling of PrEP through oversight of a remote physician and prescriptions offered based on rapid HIV testing.¹⁰⁵ Though nascent, these efforts move PrEP delivery toward closer alignment with where many women access FP.

Youth-friendly health services (YFHS)

Ensuring access to YFHS is a best practice for promoting uptake and effective use of HIV prevention/SRH services among AGYW across SSA. Kenya, Malawi and Zimbabwe have policies that promote the expansion of YF service delivery, yet wide-scale implementation is hindered by limited resources in the public sector.

In Zimbabwe and Kenya, dialogues held with AGYW highlighted major breaches of confidence, discriminatory behavior, lack of respect for life choices and being turned away by healthcare providers when seeking SRH or HIV prevention services.^106,107 In response, AGYW indicated they want guaranteed access to YFHS, defined as the full choice of products, access to free or affordable health services, to be treated with respect when accessing these services and provided with privacy and confidentiality throughout the process.

Health facility assessments in Kenya and Zimbabwe found that where available, YFHS provide the strongest examples of comprehensive, integrated HIV prevention/SRH service delivery for adolescents and young people, and were found to mitigate stigma and increase access. Integration and YFHS were found to move together along a continuum, with more YF models exhibiting a greater level of HIV prevention/SRH integration (see Figure 4).^110,111 Low-volume facilities tend to be less YF and are integrated by default due to limited number of staff. High-volume sites tend to offer HIV and FP services in separate areas and rely on referrals to deliver comprehensive services. YF sites typically offer fully, intentionally integrated HIV prevention/SRH and other services specifically for AGYW; these are often highly supported by implementing partners and donors, which equips them with additional resources and incentivizes meeting AGYW-focused targets. In the facility assessment in Kenya, facilities were generally less integrated and YF: four facilities fell in level 1, the least integrated/YF category; two facilities in level 2; three facilities in level 3; one facility in level 4 and PEPFAR-funded safe spaces represent level 5, the most integrated/YF level. In Zimbabwe, greater levels of integration and youth-friendliness were found, with no facilities found in level 1; three facilities in level 2; one facility in level 3; three facilities in level 4 and three facilities in level 5.

Figure 4. The integration-youth friendly (YF) continuum.

In Kenya, YFHS in the public sector are primarily available through stand-alone youth clinics and YF rooms or corners, where HIV testing, PrEP and FP are available.^112,113 YFHS are not widely embedded in public SRH units and primary health facilities and will require equipping facilities with YF corners and training healthcare providers. By contrast, Zimbabwe^114–116 and Malawi¹¹⁷ have moved toward integrating YFHS in public sector facilities, a model that is less expensive than stand-alone clinics and theoretically offers YFHS at all service delivery points, including FP/SRH, but availability of oral PrEP is limited. Further, access barriers remain: YFHS are sometimes only available during certain days or times,^118,119 and providers reported that AGYW with children are often referred to general primary care,¹²⁰ a missed opportunity to provide them with YFHS. Despite a recognition of the need for specific services for AGYW, the reach of YFHS remains very limited in Malawi.¹²¹ Since the implementation of the YFHS program began in 2007, one comprehensive evaluation has been conducted to assess program coverage. The evaluation revealed that only half of CBDAs and 64% of peer educators had been trained in YFHS, including counseling on contraception and HIV/AIDS, and only 68% of health center providers had been trained to offer YFHS.

Across countries, YFHS supported by implementing partners are typically well-resourced “one-stop shops” or safe spaces for integrated HIV prevention/SRH services, often with layered programming aimed at empowering AGYW (e.g., peer clubs and social asset-building).^122–125 In our assessments, these sites showed the highest level of HIV prevention/SRH integration and high utilization by AGYW. While most studies on YFHS in the published literature focus on either SRH or HIV prevention service utilization and outcomes – rather than on integrated services or comprehensive HIV prevention/SRH outcomes¹²⁶ – studies of YFHS for HIV have shown improvements among adolescents living with HIV around adherence and retention,^127,128 as well as uptake of HIV testing and PrEP for those who qualify.^129,130

Integrating PrEP delivery into PMTCT programs

Successful integration of PMTCT with MCH was supported by investments in human resources (e.g., training, task-shifting and hiring additional staff), largely from HIV donors, but the assessments found that similar investments have not been allocated to integrating other HIV prevention and SRH services.

While primary HIV prevention among women of reproductive age and prevention of unintended pregnancies is an established prong of PMTCT programs, most countries have emphasized the prong related to preventing vertical transmission.¹³¹ Kenya, Malawi and Zimbabwe have integrated PMTCT and SRH, where HIV testing and ART are routinely provided to pregnant and breastfeeding women (PBFW) upon HIV diagnosis during antenatal care (ANC) and post-partum visits.¹³² However, there is a critical gap in primary prevention for PBFW who test negative for HIV during ANC.

Malawi was the first country to pioneer Option B+ in late 2011, which offered all HIV-infected PBFW free, lifelong ART, regardless of CD4 count or clinical stage. Option B+ demonstrated the impact of integrated HIV services, especially for women living with HIV – an important advance recognized in the WHO global guidance.¹³³ Kenya and Zimbabwe adopted Option B+ in 2012 and 2013, respectively, and by 2019 all three countries achieved high HIV testing rates and with ART coverage exceeding 90 percent.¹³⁴ Despite significant progress, vertical transmission rates remain higher than expected,¹³⁵ due in part to new infections among women who had tested negative in early pregnancy, highlighting the need for early and repeated ANC visits, with repeated HIV testing throughout ANC, and ensuring PrEP provision for women who test negative.¹³⁶ Adolescent PBFW tend to have much lower rates of PMTCT and ANC uptake and face numerous challenges, including stigma from providers and communities and lack of social support.^137–139

Although integrating ART and ANC services has contributed to reduced infections among children, preventing primary HIV infections among women has not been prioritized. In response, national strategic HIV plans in all three countries have underscored the need to address gaps in the unmet need for FP among women living with HIV, scale up PMTCT sites and services in general and ensure they are adolescent-friendly, strengthen community mobilization and community-based support systems for retention and improve quality of care in integrated SRH, HIV, TB and RMNCAH services.^140–142

By extension, oral PrEP rollout for PBFW has been slow due to limited safety data in this population until more recently and from lagging HIV prevention services for this population. Oral PrEP is primarily offered in HIV clinics, contributing to low uptake in the absence of reaching women via SRH channels, which tend to be preferred and accessed by more women. In Kenya, Comprehensive HIV Care Clinics (CCCs) and DREAMS safe spaces are the primary delivery channels of PrEP for AGYW.¹⁴³ With the exception of implementation research studies,^144,145 PrEP is not offered in SRH services, and integration of PrEP is instead typically achieved through referral. Similarly, in Zimbabwe, while FP is well-integrated into HIV services, Opportunistic Infection (OI, or HIV treatment) clinics are the primary delivery channels for PrEP. SRH units rarely provide PrEP or offer referrals for PrEP services, except for pilot Zimbabwe National Family Planning Council (ZNFPC) sites¹⁴⁶ and YF facilities.¹⁴⁷ Until 2021, PrEP had been provided in Malawi in limited scope through NGOs,¹⁴⁸ but public sector clinics have begun to deliver PrEP to high-risk adolescents, and plan to scale up. Assessments found that clients are being lost when referred for PrEP, indicating that referrals fall short of meeting women’s needs. Still, SRH provider capacity and infrastructure to provide additional PrEP services remains limited (see Health Systems section above).

Despite the remaining challenges, significant increases in ART coverage for women have been propelled by integrating ART into the points where women traditionally access health services. This was spurred by task-shifting, simplified delivery and linkages to community-based services and accelerated donor support – elements that could better integrate oral PrEP into broader SRH programs.

Targeting AGYW with demand generation

This analysis found that demand generation activities for both HIV prevention and SRH to reach AGYW have not been scaled, despite supportive policies.^149,150 One implementing partner in Malawi emphasized, “One of the most important things is that we need an avenue to reach girls, we need to have activities that matter to them (social assets, economic strengthening), where they can meet and we can bring services to them.”¹⁵¹ Mobilizing demand for HIV prevention and SRH by providing information for AGYW, as well as for their partners, peers and communities, who are influential in their decision-making, was cited as necessary to increase access to services and combat stigma.¹⁵²

Demand generation strategies across countries rely on platforms and interlocutors whom AGYW trust, including youth or girls’ clubs, peer education or outreach activities (e.g., DREAMS ambassadors), as well as school-based activities.¹⁵⁶ These programs have demonstrated some successes in reaching AGYW in different age groups and different contexts with information about SRH and HIV prevention in accessible, non-stigmatizing ways, often through peer-led activities and community-based interventions. According to USAID, in 2020, DREAMS reached over 1.6 million AGYW with prevention services.¹⁵⁷ These strategies include education for 9-14 year-old boys and girls on primary prevention, complemented by outreach to their families and communities to bolster support for adolescents. DREAMS ambassadors, in particular, play a key role in linking AGYW to economic strengthening interventions,¹⁵⁸ as well as for gender-based violence (GBV), PrEP and other services.¹⁵⁹ The DREAMS program has seen an increase in PrEP uptake among AGYW in DREAMS districts.¹⁶⁰

Although strong programs exist to reach AGYW, there are generally low levels of information about HIV prevention in communities, and knowledge of HIV prevention hovers around 50% for AGYW across countries.¹⁶¹ Coupled with myths and misconceptions on side effects and impact on fertility, this lack of and mis-information engenders fear and hinders social support for AGYW to use HIV prevention and SRH services.¹⁶²

Strategies to reduce unmet need or create demand tend to focus on specific FP or HIV prevention products (e.g., PrEP, long-acting contraception¹⁶³), rather than comprehensively considering integrated needs across all existing HIV prevention and FP options for AGYW. Moreover, demand generation is not typically well-funded nor integrated, so individual programs only provide information about certain services, reinforcing silos between HIV prevention and SRH.¹⁶⁴ In Zimbabwe and Kenya, HIV communication strategies that promote integrated messages have been developed, but implementation remains under-resourced.^165,166 Key informants across countries underscored that demand generation will require dedicated investments from donors and governments to be effectively implemented.

Structural environment

Integrating HIV prevention and SRH services is one approach to better meet the needs of AGYW. Though largely outside the scope of these assessments, structural barriers – including gender inequalities and discriminatory cultural norms – compound their risks of HIV, unintended pregnancy, STIs and early marriage, and prevent access to economic and educational opportunities.

GBV increases HIV risk, and women and girls who experience violence are at greater risk for HIV.¹⁶⁷ Kenya, Malawi and Zimbabwe have recognized that addressing GBV is critical to their HIV responses.¹⁶⁸ Data from recent Violence Against Children Surveys (VACS) show high rates of violence across countries: in Kenya, 16% of girls experience sexual violence and 39% experience physical violence before age 18;¹⁶⁹ in Zimbabwe, 9% of girls experience sexual violence and 17% physical violence prior to age 18¹⁷⁰ and in Malawi, one in five girls is sexually abused before age 18.¹⁷¹ In Kenya and Zimbabwe, higher HIV prevalence rates were found among women who experienced childhood violence, underscoring the link between violence and HIV risk.

In Malawi and Zimbabwe, dedicated facilities exist that address GBV and offer integrated HIV prevention/SRH services. In Malawi, “Chikwanekwanes” (literally, “everything under one roof”) provide medical, legal and psychosocial services for survivors of sexual violence, including HIV testing, post-exposure prophylaxis (PEP) and follow-up testing, STI management and EC when indicated.¹⁷² In Zimbabwe, Sexual Gender-Based Violence (SGBV) clinics, also known as “one-stop centres,” provide PEP, FP, counseling and YFHS in seven districts (in addition to psychosocial, legal and police support), though PrEP is not offered. In 2020, the United Nations Population Fund (UNFPA) allocated an additional $2.5 million to the GBV response in Zimbabwe, which included scaling up mobile one-stop centres to bring integrated, free services into communities, pointing to the value of integrating health and social services to reach those most at-risk.¹⁷³

Underlying data

Data underlying the results are available as part of the article and no additional source data are required. The assessments in Kenya, Malawi and Zimbabwe that are comparatively analyzed in this article are accessible via the following sources: