Integration of HIV 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 family planning (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 PrEP and is furthest ahead with scale-up, while Malawi’s program is just beginning to roll out.¹⁰

Across countries, contraception and PrEP are primarily accessed in public facilities, though the private sector, including healthcare providers in private practice, non-governmental organizations (NGOs) and faith-based clinics and pharmacies, are 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

High HIV prevalence and incidence among AGYW, and the large percentage of the latter who gave birth before age 18, 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,^15,16 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.^17,18

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

Research teams

In Kenya⁴⁰ and Zimbabwe,⁴¹ the landscaping analyses were completed in 2020 by multi-disciplinary teams from the Ministries of Health (MOH) in each country and the HIV Prevention Market Manager project (PMM). Research teams identified sites, settings and key informants, developed data collection tools and carried out data collection and analysis. In Kenya, the research team was comprised of representatives from the National AIDS and STI Control Programme (NASCOP) and the Department of Family Health in Kenya and AVAC. In Zimbabwe, the research team was comprised of representatives from the Department of AIDS & TB at the Ministry of Health and Child Care (MoHCC), Pangaea Zimbabwe AIDS Trust (PZAT) and AVAC. Advocates in each country organized and led community dialogues with AGYW and, in Zimbabwe, organizations working with AGYW.

In Malawi,⁴² the landscaping analysis 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. The analysis was conducted to inform the Blantyre Prevention Strategy, launched in May 2020 to catalyze local development of an innovative and data-driven HIV prevention delivery system at the district level. The district of Blantyre was chosen as the initial geography, due to the seemingly intractable HIV epidemic and continuing high numbers of new infections there. The research team conducted a literature review, identified government documents and key informants, conducted interviews and data collection, and analyzed findings.

Data collection and analysis

In Kenya and Zimbabwe, research teams identified a cross-section of health facilities (public/private/youth-friendly (YF), high/low volume), settings (rural/urban) and key informants to provide a representative snapshot of HIV/SRH integration at country level. In total, 73 semi-structured, one-hour interviews were conducted with national, provincial, county and district-level MOH representatives; frontline HIV, SRH and MCH healthcare providers; implementing partners and donors. Six one-day community dialogues were held in-person with AGYW and NGOs. Twenty health facility assessments were conducted in five regions in Kenya and four provinces in Zimbabwe. Interviews were requested via email or telephone and health facility visits by letter or email, per MOH protocols. Interviews and facility assessments were primarily conducted in-person and virtually where not feasible, including due to COVID-19 restrictions.

Interviews were recorded and notes taken simultaneously, and facility assessment data were logged in a spreadsheet. To understand opportunities and barriers to HIV/SRH integration, qualitative interview findings were grouped by stakeholder perspectives and recurring themes identified at the government, health facility and community levels. 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/SRH integration and YF service delivery at each facility. PMM standardized interview guides, health facility assessment checklists and analysis of data across the two countries.

In Malawi, the research team conducted a review of national policies and implementation of HIV and SRH programs in the southern district of Blantyre and approximately 70 semi-structured interviews with key informants, which included: Blantyre district health officials; representatives from national and international NGOs, advocacy organizations, and implementing partners working on HIV, SRH and AGYW; healthcare providers at district health facilities; representatives from community-based organizations focused on women’s health and AGYW; organizations associated with the Blantyre Prevention Strategy; officials from U.S. government agencies in Malawi and from other key donors; and DREAMS ambassadors and AGYW peer educators. Interviews were conducted by WhatsApp, Zoom, telephone and email. Participants were recruited through the network of organizations and district and national officials associated with the Blantyre Prevention Strategy, local and international NGOs and researchers and community-based organizations with whom they worked. The research team standardized interview protocols and analysis of data.

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

Standard informed consent procedures were followed and oral informed consent was sought and obtained by respective research team members in each country before interviews were conducted (MOH and AVAC in Kenya; MOH and PZAT in Zimbabwe; MOH and Georgetown University Center for Innovation in Global Health in Malawi). Interview transcripts, notes, recordings and health facility assessments were only accessible by the research teams.

The three assessments were comparatively analyzed in this article by findings on policies and enabling environments, health systems, service delivery and gaps to implementation of HIV/SRH integration. Findings were validated through a review of literature and policies in each country.

Ethics approval

No ethics approval was sought for this article, as it analyzes the aggregate findings from completed assessments and did not entail additional data collection.

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, however, continues to present challenges, especially in reaching AGYW with YFHS and safe spaces, and in translating policies to local/district levels.

While strong policies provide the framework for implementation, dedicated structures are required to support coordination of implementation of policies throughout the health system. Sub-national MOH departments for HIV and FP/reproductive health (RH) are critical for cascading operational changes down to facilities, yet 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.”⁴³ Collaboration across local HIV and FP/RH departments has led to the formation of mechanisms to implement integration. Structures to support this varied across the countries included in this analysis.

Prior to the assessment, Kenya had separate mechanisms supporting the rollout of SRH and HIV services at national and sub-national levels.⁴⁴ In response to early assessment findings, the MOH in Kenya built on these existing structures to join HIV prevention and SRH leaders to renew commitment to integration: Kenya’s National AIDS and STI Control Programme (NASCOP) and Department of Family Health formed a national HIV/SRH integration sub-committee in 2020. The sub-committee analyzed 16 HIV/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/SRH integration containing concise directives for county officials and health facilities, and a package of resources to aid implementation.⁴⁵ Integration pilots are being planned in 2021 in five counties.

In Zimbabwe, close coordination across HIV and SRH leadership has 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.⁴⁶ Importantly, these platforms include representation from implementing partners and potential beneficiaries, including AGYW.

In Malawi, 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. While Malawi has a national-level SRHR and HIV and AIDS integration sub-committee, the establishment of joint City and District TWGs with routine community engagement presents an opportunity to coordinate effective integrated services at the district-level. There was broad agreement among key informants in Malawi interviewed for the assessment that district-level leadership is key to operationalizing national integration policies,⁴⁷ consistent with findings in Kenya and Zimbabwe.

Siloed delivery, M&E and supply chain systems

Across countries, HIV and SRH programs are funded, managed and delivered vertically through separate HIV and FP/RH departments within the MOH and delivered in separate physical spaces by different providers in facilities, and referrals are commonly used to fill gaps in services offered.

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.^53–56 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 and SRH to be done separately. Moreover, there is a large imbalance in funding, where HIV is exponentially better-resourced than other SRH services. In Kenya, for instance, few counties have FP-specific budget lines and external donor investments in FP have decreased over time.⁵⁷

As a result, data systems for monitoring and evaluation (M&E) and supply chain management are generally not integrated.⁶⁰ At facility level, HIV and SRH data are collected at different delivery areas and through separate registers, though providers 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”).^61,62 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 remains unintegrated across sites. Furthermore, much of the data collected on HIV testing and treatment or prevention services, including 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.^63,64 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.”⁶⁵

In addition, conducting analyses of FP and HIV/PrEP data for program-monitoring or decision-making requires special analysis, though strategic information officers at MOH-level are typically siloed. Those working in HIV departments 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. There is a need to revise and strengthen M&E systems to document the provision of HIV services in SRH service areas and vice versa, and to integrate systems up the chain to national level, to enhance the ability to look at data in an integrated fashion. Electronic monitoring systems, currently being rolled out in Kenya, Malawi and Zimbabwe, provide an opportunity to track individual client health records across services and facilities. Data should be made available in real time and disaggregated by age to improve targeting of at-risk AGYW for evidence-based decision-making. Furthermore, M&E systems should be revised to incorporate new indicators on HIV/SRH integration as defined by governments, such as identifying at-risk AGYW through the presence of STIs and early or unintended pregnancy.⁶⁶

Bi-directional integration of data systems can support the integrated management of HIV and FP commodities; however, siloed supply chain systems for HIV and SRH commodities supporting public sector facilities and pharmacies are also a barrier to integration which needs to be addressed.⁶⁷ For example, PEPFAR, the largest HIV donor, currently does not allow funds to be used to procure contraceptive commodities other than condoms. Renewed donor efforts are needed to address these health system challenges to integration in order to move toward the provision of integrated services.

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.^68–70 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.

Task-shifting for HIV testing and oral PrEP delivery could expand opportunities to offer combination prevention alongside SRH services. Similarly, task-shifting for contraceptive commodities, including for long-acting reversible contraceptives (LARCs) and for the self-injectable contraceptive, subcutaneous depot medroxyprogesterone acetate (DMPA-SC), could broaden access for at-risk women and girls. Currently, oral PrEP is generally delivered by ART nurses and staff specifically certified to prescribe PrEP. 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 can follow.⁷¹ Diffusing the capacity to provide services across staff in this way could be perceived as alleviating nurses’ workloads, while offering a more comprehensive HIV/SRH package. A systematic review of evidence from low- and middle-income countries found task-shifting led to cost savings and efficiency gains across settings and health areas.⁷²

Task-shifting FP to community-based delivery is endorsed in all three countries, and far more advanced compared to oral PrEP. It has contributed to notable increases in contraceptive use in all three countries and in referrals for HIV testing and HIV/STI-related referrals, and increased dual prevention methods for women living with HIV.^73,74 In Zimbabwe, community health workers (CHWs) can be key to creating demand among AGYW, with CHWs discretely supplying FP methods in rural communities.⁷⁵ 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 commodities to young people in communities and provide referrals to facilities for other services.^76,77 Linkages between services in the community and health facilities are often weak for AGYW, indicating a need to expand and integrate the services that CHWs are authorized to provide.

Figure 2. Task-shifting for administering contraceptives & HIV prevention interventions in SSA⁷⁸.

In Kenya and Zimbabwe, SRH healthcare providers cited a lack of training as the primary hindrance to providing HIV services, including screening and education about PrEP, in SRH settings.^79,80 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,⁸¹ while in Malawi⁸² and Zimbabwe,⁸³ severe health care worker shortages were underscored as barriers to integration. Training on the basics of oral PrEP and on screening high-risk individuals for eligibility would vastly improve the capacity of providers in SRH service areas to identify and refer potential clients for oral PrEP.

“Sometimes a person can come to a facility where there is no one who can provide HIV testing, and end up receiving family planning services only because there was no one who could test her. Too few people are being trained, which leads to clients opting for other services because there is no one who can provide the service they want at the time of visit.”-Nurse, Zimbabwe⁸⁴

Limited engagement of the private sector

Leveraging the private sector⁸⁵ to enhance uptake is an important service delivery option that has the potential to increase access to HIV prevention, as it is already a well-established channel for SRH 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 from pharmacies and 29% of injectables from private hospitals/clinics.⁸⁶ In Malawi and Zimbabwe, the private sector comprises about one-fifth of delivery channels for FP^87,88 – an opportunity to integrate HIV prevention services – 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 services for AGYW, but donor dependency may impede the sustainability of these channels.⁸⁹ The Malawian MOH has implemented public-private partnerships (PPPs) to ensure that clients are offered a full package of HIV/SRH services and fill gaps where public sector services are not attracting young people. Similarly, in Zimbabwe, the Ministry of Health and Child Care 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.⁹⁰ Government-NGO collaboration in Malawi includes the 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.⁹¹

Pharmacies are a critical channel for FP services in all three countries and an option with major potential 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 Zimbabwe⁹² and OCP and emergency contraception (EC) are available over-the-counter, but cost and fear of stigma are major challenges. 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.⁹³ Pharmacy provision of PrEP alongside FP could be an avenue for AGYW who can afford it, and may mitigate the stigma they often experience in facilities, although cost will be prohibitive for many AGYW.

Youth-friendly health services (YFHS)

Ensuring access to YFHS is a best practice for promoting uptake and effective use of HIV/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.^94,95 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/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/SRH integration (see Figure 3).^98,99 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/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 3. 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, FP and HIV care and treatment are available.^100,101 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^102–104 and Malawi¹⁰⁵ 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, but availability of HIV prevention interventions, including oral PrEP, is limited. Further, access barriers remain: YFHS are sometimes only available during certain days or times,^106,107 and providers reported that AGYW with children are often referred to general primary care,¹⁰⁸ a missed opportunity to provide them with the YFHS that they may prefer. Despite a recognition of the need for specific services for AGYW, the reach of YFHS remains very limited in Malawi.¹⁰⁹ 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. The need for capacity-building for providers, as well as for youth and peer educators, is evident to mobilize AGYW to access SRH and HIV prevention services.¹¹⁰

Across countries, YFHS supported by implementing partners are typically well-resourced “one-stop shops” or safe spaces for integrated HIV/SRH services, often with layered programming aimed at empowering AGYW (e.g., peer clubs and social asset-building).^111–114 In our assessments, these sites showed the highest level of HIV/SRH integration and high utilization by AGYW. Most studies in the published literature focus on either SRH or HIV utilization and outcomes, rather than on integrated services or comprehensive HIV/SRH outcomes.¹¹⁵ There is also a need to identify a core set of indicators to measure variables that may have a greater impact on the use of services by young people, such as confidentiality, privacy and accessibility of quality services.¹¹⁶ Studies of YFHS for HIV have shown improvements among adolescents living with HIV around adherence and retention,^117,118 as well as uptake of HIV testing and PrEP for those who qualify.^119,120 Conducting more rigorous studies using a refined set of indicators that directly assess the benefit of delivering integrated services on both HIV and SRH outcomes, is critical to measure and compare the impact and effectiveness of YFHS, compared to the standard of care.

While many are donor-funded, understanding which aspects of YFHS are most impactful and valued by AGYW can inform approaches to integration in the public sector;^121–124 operational research evaluating the effects of these models on uptake of both HIV prevention and SRH services is needed.

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. Similar investments are needed for 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.¹²⁵ Kenya, Malawi and Zimbabwe have integrated PMTCT and SRH, where HIV testing and ART is routinely provided to pregnant and breastfeeding women (PBFW) upon HIV diagnosis during antenatal care (ANC) and post-partum visits.¹²⁶ However, there is a critical gap in primary prevention for PBFW who test negative for HIV during ANC, an important opportunity to expand integrated HIV/SRH services.

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.¹²⁷ 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.¹²⁸ Despite significant progress, vertical transmission rates remain higher than expected,¹²⁹ 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.¹³⁰ 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.^131–133

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.^134–136

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. But PrEP could become a basic intervention with greater confidence and evidence in PrEP use for this population. Oral PrEP is primarily offered in HIV clinics, contributing to low uptake and missing an opportunity to reach 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.¹³⁷ With the exception of implementation research studies,^138,139 PrEP is not offered in SRH services, and integration of PrEP is instead 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) sites¹⁴⁰ and YF facilities.¹⁴¹ Until 2021, PrEP had been provided in Malawi in limited scope through NGOs,¹⁴² but public sector clinics have begun to deliver PrEP to high-risk adolescents, and plan to scale up. There is a critical need to expand access to PrEP beyond HIV-focused clinics, as clients are being lost when referred, and to strengthen staff capacity and infrastructure to provide additional services.

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 – key elements needed to better integrate oral PrEP into broader SRH programs.

Targeting AGYW with demand generation

Demand generation activities for both HIV prevention and SRH to reach AGYW have not been scaled, despite supportive policies.^143,144 Mobilizing demand for HIV prevention and SRH by providing information for AGYW, as well as for their partners, peers and communities, is necessary to increase access to services.¹⁴⁵ 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.”¹⁴⁶ Sensitizing the broader community could de-stigmatize seeking services for AGYW, a prominent barrier.

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.¹⁵⁰ 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.¹⁵¹ 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,¹⁵² as well as for gender-based violence (GBV), PrEP and other services.¹⁵³ The DREAMS program has seen an increase in PrEP uptake among AGYW in DREAMS districts.¹⁵⁴

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.¹⁵⁵ 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.¹⁵⁶

Strategies to reduce unmet need or create demand tend to focus on specific FP or HIV prevention products (e.g., PrEP, long-acting contraception¹⁵⁷), rather than comprehensively considering integrated needs across all existing HIV prevention and FP options for AGYW. Demand generation is not typically well-funded nor integrated, so individual programs only provide information about certain services, reinforcing silos between HIV and SRH.¹⁵⁸ Designing demand generation initiatives aimed at building awareness of comprehensive HIV prevention and SRH will arm AGYW with holistic information to make decisions about their health and mitigate stigma in their networks. In Zimbabwe and Kenya, HIV communication strategies that promote integrated messages have been developed, but implementation remains under-resourced.^159,160 Across countries, demand generation has historically been underfunded and will require dedicated investments from donors and governments to be effectively implemented.

Structural environment

Integrating HIV prevention and SRH services is necessary but not sufficient to meet the needs of AGYW. Though largely outside the scope of these assessments, structural barriers – including gender inequalities and discriminatory cultural norms – that increase their risks of HIV, unintended pregnancy, STIs and early marriage, and prevent access to economic and educational opportunities, must simultaneously be addressed.

GBV increases HIV risk, and women and girls who experience violence are at greater risk for HIV.¹⁶¹ Kenya, Malawi and Zimbabwe have recognized that addressing GBV is critical to their HIV responses.¹⁶² 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;¹⁶³ in Zimbabwe, 9% of girls experience sexual violence and 17% physical violence prior to age 18¹⁶⁴ and in Malawi, one in five girls is sexually abused before age 18.¹⁶⁵ 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, facilities that address GBV and offer integrated HIV/SRH services could be leveraged to minimize structural barriers. 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.¹⁶⁶ 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, underscoring the value of delivering integrated health and social services to reach those most at-risk.¹⁶⁷

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: