YATHU YATHU ("For us by us"): A Cluster Randomised Trial of community-based SRH and HIV services for adolescents and young people in Zambia

There are more than 1.8 billion adolescents and young people (aged 10-24) alive today, more than ever before in world history. Most of these live in developing countries, with many countries in Africa having 50% of the population less than 18 years old. HIV is the second leading cause of death in this age group and the number of new infections continues to rise. HIV infection, unwanted pregnancies and early marriage limit the potential of millions of young women yet services to prevent these are often not accessible to young people. In Zambia, adolescents (10-19 years old) represent 25% of the total population. Zambia has the 5th highest adolescent birth rate in sub-Saharan Africa (the region with the highest rates in the world) and 44.7% of women under 20 reported an unplanned pregnancy. HIV prevalence rates in the Lusaka communities chosen for this study are 6.4% among 15-24 year old women and 1.6% amongst young men of the same age, rising rapidly thereafter. The Zambian Adolescent Health Strategy 2017-2021 recognises sexual and reproductive health (SRH) and HIV as the two leading priorities for health service planning with a mission "to ensure equity of access to appropriate, quality and cost-effective adolescent-friendly health platforms and an adolescent responsive health system as close to the people as possible." When we ask young people in Zambia what SRH services they want they unequivocally tell us that they want services specifically designed for them, provided with them ("Yathu Yathu; For us by us") away from traditional health facilities where attitudes of health providers can still be stigmatising towards young people. In response, we have designed a community-based, peer-led intervention that makes use of innovative technology, including prevention points "loyalty card" to incentivise and measure service access and use, and support for uptake and adherence to services using virtual support groups. At the start of the study period, we will continue discussion with adolescent community advisory boards to refine the location, content and delivery of the community-based peer-led services. This study aims to evaluate the process of establishing and delivering community-based peer-led SRH services, including HIV testing, treatment and prevention, in two urban communities in Lusaka, Zambia. The study will compare the uptake of SRH services by adolescents and young people aged 15-24 living in areas of the ten communities which were randomly allocated to have access to these community-based, peer-led services, compared to ten areas randomly allocated to have services provided via traditional health facilities. The study will measure whether the community-based peer-led services increased knowledge of HIV status and coverage of SRH services relative to standard of care areas. To measure knowledge of HIV status, we will conduct a cross-sectional survey in all sites 18-months after the intervention implementation and compare these outcomes between the intervention and standard of care sites. To measure coverage, we will use the data routinely collected at point of service access and use by the innovative prevention points cards system. The innovative chip-enabled prevention points "Yathu card" will enable service users to collect of SRH "prevention" points, which can be exchanged for goods and services, to encourage uptake of services and measure access. The study will also evaluate the use of mobile phone based support groups to enable adolescents and young people to adhere to medication such as anti-retroviral therapy used either as treatment for HIV or as pre-exposure prophylaxis (PreP). The research will be carried out by Zambart a Zambian research organisation in collaboration with researchers from the London School of Hygiene and Tropical Medicine and Imperial College in the UK in partnership with the Zambian Ministry of Health, Society for Family Health and the SHM foundation.