Peer-led service delivery model to increase HIV prevention and contraception in pregnant and lactating adolescent girls and young women in Zimbabwe

IIn Zimbabwe HIV remains the leading cause of death. In 2020, 1 in 8 adults were living with HIV. Of these, in 2023: 95% were diagnosed with HIV, 94% of those diagnosed were on antiretroviral therapy (ART), and 89% of those on ART had an undetectable viral load ("suppressed"). These are very close to the Joint United Nations Programme on HIV/AIDS targets for 2030: (a) 95% of those living with HIV (PLWH) being diagnosed, (b) 95% of those diagnosed being on ART, and (c) 95% of those on ART suppressed. These targets were based on the rationale that PLWH suppressed on ART have near normal life-expectancy and cannot sexually transmit the virus. The number of cases in Zimbabwe are falling, but not rapidly enough, and in 2022 the annual number of new cases was still substantial: 13,000 in people aged 15 and over. Adolescent girls and young women (AGYW; aged 15-24) are disproportionately affected by HIV. The World Health Organization (WHO) recommends Pre-Exposure Prophylaxis (PrEP; use of specific antiretrovirals in people without HIV to prevent HIV infection), as an additional choice for people at substantial risk of HIV. Zimbabwe Guidelines for HIV Prevention, Testing, and Treatment of HIV indicate that "adolescent girls and young women should be offered PrEP". Despite being recommended, we found that 1 in 5 sexually active AGYW had not heard about PrEP and only in 1 out of 5 had been offered it. We identified, in our formative work, a particularly vulnerable group: AGYW enrolled from antenatal/postnatal clinics. This group was the least aware of their own risk of getting HIV. Awareness of PrEP was also low in AGYW, with the exception of some groups, such as young women who sell sex and those were engaged in donor-funded programmes, while the least aware were unmarried participants. These appeared to be the most vulnerable as they did not have support to discuss HIV prevention or sexual and reproductive health more broadly. Married women could talk to their mothers or older friends/family and felt able to talk to health workers, yet unmarried women could not do this because it was socially unacceptable for them to be having sex. An approach to increase risk perception, raise awareness of PrEP and contraception, and improve accessibility to these is required. We propose a community-based peer-led intervention, where young mentor mothers (YMM) promote uptake of HIV prevention, and PrEP in particular, among all pregnant and lactating AGYW (PL-AGYW) and contraception, post-birth. YMM living with HIV have been found to be effective at supporting their peers for prevention of mother-to-child transmission of HIV. We propose expanding the definition of YMM (to include those with or without HIV), and roles - to promote behaviour to prevent HIV and unintended pregnancies. The intervention will be implemented at three clinics in Matabeleland South and catchment areas supported by an organization who partners with the Zimbabwe Ministry of Health and Child Care in implementing HIV services,(Organization for Public Health Interventions and Development). We will evaluate the appropriateness, feasibility, acceptability, uptake, cost and cost-effectiveness of this intervention. The research will be led by Dr Valentina Cambiano, Associate Professor in Infectious Disease Modelling and Biostatistics at University College London (UCL) and will draw together experts from UCL, the Liverpool School of Tropical Medicine, the Centre for Sexual Health and HIV/AIDS Research Zimbabwe and Zimbabwe, the Organization for Public Health Interventions and Development and international policy makers. This research will address key questions relevant to low- and middle- income countries with a high HIV burden.