HIV prevention for South African youth

HIV prevention for South African youth: which interventions work? A systematic review of current evidence.

In South Africa, HIV prevalence among youth aged 15-24 is among the world's highest. Given the urgent need to identify effective HIV prevention approaches, this review assesses the evidence base for youth HIV prevention in South Africa. The authors conducted systematic, analytical review of HIV prevention interventions targeting youth in South Africa since 2000. With critical assessment of interventions in 4 domains: 1) study design and outcomes, 2) intervention design (content, curriculum, theory, adaptation process), 3) thematic focus and HIV causal pathways, 4) intervention delivery (duration, intensity, who, how, where). Eight youth HIV prevention interventions were included; all were similar in HIV prevention content and objectives, but varied in thematic focus, hypothesised causal pathways, theoretical basis, delivery method, intensity and duration. Interventions were school- (5) or group-based (3), involving in- and out-of-school youth. Primary outcomes included HIV incidence (2), reported sexual risk behaviour alone (4), or with alcohol use (2). Interventions led to reductions in STI incidence (1), and reported sexual or alcohol risk behaviours (5), although effect size varied. All but one targeted at least one structural factor associated with HIV infection: gender and sexual coercion (3), alcohol/substance use (2), or economic factors (2). Delivery methods and formats varied, and included teachers (5), peer educators (5), and older mentors (1). School-based interventions experienced frequent implementation challenges. Key recommendations include: address HIV social risk factors, such as gender, poverty and alcohol; target the structural and institutional context; work to change social norms; and engage schools in new ways, including participatory learning.

Editors’ note: This is a must read article for everyone keen to understand what are the characteristics of HIV prevention strategies that work in high HIV prevalence settings with young people, here defined as 12 to 24 years of age. In this masterful summary of the design, content, conceptual underpinning, and delivery of ‘second generation’ HIV programmes for youth, clear lessons emerge. The first-generation programmes struck out in part because they were based on the idea that ‘knowledge translates into healthy behaviour’. Although the second-generation programmes reviewed here were mostly based on social cognitive models that assume individual agency, several did include socio-cultural factors and three used Paolo Freire-based empowerment models. Third-generation programmes will need to focus even more broadly on strategies to change the structural context of HIV risk for youth, address school environments and stimulate active engagement of schools, and have better measurement of both programme delivery and HIV incidence or proxy measures in longer-term follow-up. There have been big shifts in social norms and sexual behaviours in high-income low prevalence settings. Achieving even bigger shifts to slow HIV incidence among young people in South Africa today is critical to the country’s future, let alone to that of individual young people, their families, and their communities.