Integration of HIV and sexual and reproductive health in the era of anti-retroviral-based prevention: findings from assessments in Kenya, Malawi and Zimbabwe [version 1; peer review: 3 approved with reservations]

Background: Though substantial progress has been made to curb the HIV epidemic, high rates of new HIV infections persist among adolescent girls and young women (AGYW) in sub-Saharan Africa, reflecting critical gaps in reaching them with integrated HIV prevention and sexual and reproductive health (SRH) services. With the scale-up of oral pre-exposure prophylaxis (PrEP) and multiple novel HIV prevention products on the horizon, countries have a unique opportunity to expand innovative approaches to deliver comprehensive, integrated HIV/SRH services. Methods: This article is a comparative analysis of findings from rapid landscaping analyses in Kenya, Malawi and Zimbabwe to highlight cross-country trends and context-specific realities around HIV/SRH integration. The analyses in Kenya and Zimbabwe were completed by Ministries of Health (MOH) and the HIV Prevention Market Manager project and include 20 health facility assessments, 73 key informant interviews and six community dialogues. In Malawi, the analysis was Open Peer Review


Introduction
Though substantial progress has been made to curb the HIV epidemic over the past decade, high rates of new HIV infections persist, especially among adolescent girls and young women (AGYW) in sub-Saharan Africa (SSA), who in 2019 had approximately three times the HIV incidence rate of their male counterparts. 1 To meet global HIV prevention goals and improve health outcomes, prevention programs need to reach AGYW. The 2019 results of the Evidence for Contraceptive Options in HIV Outcomes study (ECHO) underscored a critical gap in targeting AGYW with integrated HIV prevention and sexual and reproductive health (SRH) services. 2 The SARS-CoV-2 (COVID-19) pandemic has amplified the urgency for integration, as dire social and economic impacts heightened AGYW risk of HIV and STI infection and unintended pregnancy, disrupted critical HIV and SRH services, and further constrained health systems and healthcare workers in many low-and middle-income settings. With the scale up of oral pre-exposure prophylaxis (PrEP) and introduction of multiple novel HIV prevention products on the horizon, health systems are at a turning point, with an opportunity to expand new and innovative approaches to reach AGYW with comprehensive HIV/SRH services, including expanding access to existing and future PrEP products.
This article analyzes the progress that Kenya, Malawi and Zimbabwe have made towards the integration of HIV prevention and SRH (HIV/SRH integration). Examples from each country highlight promising approaches to HIV/SRH integration, identifying opportunities for improved service delivery and pinpointing persistent gaps that effectively limit the impact of high-potential interventions. By examining cross-country experiences, this article aims to highlight regional trends and contextspecific realities around advancing HIV/SRH integration. Lessons can inform the scale-up of HIV/SRH integration in other high HIV-burden countries, though increased government and donor investment and political support will be required.
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][7][8][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

Methods
This article is a comparative analysis of findings from three completed rapid landscaping analyses in Kenya, Malawi and Zimbabwe, to understand the current state of HIV/SRH integration in each country and to elucidate cross-country trends. The analyses collected programmatic data and insights to inform national programs. While original data from key informant interviews and health facility assessments are not contained in this article, because the analyses form the basis of this article, their methodologies are elaborated upon below.

Research teams
In Kenya 40 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 40  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.

Results
In this article, we grouped results according to: Enabling Environment and Policy Implementation; Health Systems; Service Delivery and Key Gaps. We highlighted promising national coordination mechanisms, health systems considerations and service delivery approaches to improve HIV/SRH integration, and summarized persistent barriers across countries.

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 nationallevel 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.
" 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 capacitybuilding 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.  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 Zimbabwe 92 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.

Service delivery
While integrated service delivery is not widespread across countries, due to a shared gap between policy and practice, Kenya, Malawi and Zimbabwe have employed different approaches to improving services for adolescents and pregnant women that offer lessons for scale up of HIV/SRH integration.

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.
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 Malawi 105 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  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][135][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) sites 140 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.

Key gaps
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 contraception 157 ), 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. 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

Discussion
The There are also critical opportunities to expand access to integrated services through the private sector, particularly through pharmacies, which are a critical channel for FP services in all three countries and have major potential for expanding oral PrEP. In many resource-constrained settings, retail pharmacies fill an important gap in the health care system, providing access to treatment of urgent conditions, monitoring of chronic conditions, point-of-care testing and preventative care, 180-184 and have been shown to increase access for young people. 185 Delivery of oral PrEP through pharmacies is utilized in the US, Europe and Asia, and studies have shown that oral PrEP can be successfully provided completely by pharmacists in these settings, with oversight by a remote physician. 186 A recent stakeholder consultation in Kenya showed that providers and implementers were strongly supportive of developing and testing a model for pharmacy-based oral PrEP delivery to increase oral PrEP access. 187 The consultative group developed a pathway for pilot testing pharmacy-based oral PrEP delivery in Kenya. Expanding PrEP delivery beyond health clinics and aligning FP and HIV prevention delivery channels has the potential to increase uptake of both PrEP and contraception, and respond to women's desire for convenient and less stigmatized services.
A growing number of HIV prevention products -including a vaginal ring, injectable PrEP and multi-purpose prevention technologies -are pending regulatory approval and will be available in the next two to three years. Aligning the delivery channels where these products will be offered with contraception or as part of ANC visits would likely make access much easier for AGYW. Integrated services are more convenient, treat women holistically and reduce the burden placed on AGYW to access healthcare that meets their multiple and changing needs. Several studies have shown that when oral PrEP is co-delivered alongside FP, uptake of both increases. 188,189 Accordingly, introducing new products for HIV prevention within integrated services could increase their uptake and continued use. FP healthcare providers are more familiar with administering a range of modalities, from pills to injections to vaginally inserted products, compared to HIV healthcare providers. FP healthcare providers also interact more frequently with women over a lifetime and, with adequate training and support, could be well-placed to address multiple health concerns. Advancing HIV prevention and SRH integration now could lay the groundwork for the faster and more equitable introduction of a range of technologies in the future. Putting AGYW at the center of care demands acting on commitments to HIV/SRH integration. Most importantly, AGYW are calling for services that are respectful, comprehensive, educational and empathetic, not patronizing or fragmented. 190,191 Shared needs identified through rapid assessments in Kenya, Malawi and Zimbabwe were greater investments in provider capacity-building and demand generation to expand integrated service delivery, while country-specific needs for integration centered on health systems adaptations, donor support and scope of PrEP implementation. Further research is required to: 1) identify which interventions and delivery models are preferred by AGYW and correlated with better HIV and SRH outcomes; 2) determine the cost-effectiveness of integrating HIV prevention into SRH facility-and communitybased delivery channels, expanding private sector access of HIV and SRH products through pharmacies and 3) pinpoint effective strategies for capacitating and supporting healthcare providers at the frontlines of delivering integrated care.

Conclusions
While the call for HIV/SRH integration is not new, integration of HIV prevention and SRH has lagged, and integrated policies and programs preceding the introduction of oral PrEP have largely not been adapted. In Kenya, Malawi and Zimbabwe, YFHS and PMTCT programs offer the strongest examples of integration that can be leveraged and expanded to effectively reach AGYW. Provider capacity-building, synchronization of HIV and SRH services, demand generation and structural barriers warrant deeper attention if HIV prevention and SRH integration are to be realized at scale.
As new HIV prevention products are introduced, thus expanding the method mix and increasing awareness of HIV prevention more broadly, demand for integrated HIV/SRH services is likely to grow. Investing now in integrating HIV prevention and SRH across areas of health systems that will have synergistic effects, such as improving early and repeated ANC visits, streamlined SRH supply chains and expanding access to YFHS programs and pharmacy-based delivery, will alleviate pressure in the future; in addition, it will create a pathway for a more sustainable, government-led response amid a more complex prevention landscape and an inevitable decrease in external funding. Prioritizing integration can strengthen the response to the HIV epidemic while improving the health outcomes and lives of AGYW.

Data availability
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: • Integration of HIV prevention and sexual and reproductive health services in Kenya is available at https://www. avac.org/resource/integration-hiv-prevention-andsexual-reproductive-health-services-kenya.
• Integration of HIV prevention and sexual and reproductive health services in Zimbabwe is available at https://www.avac.org/resource/integration-hiv-preventionand-srh-services-zimbabwe.
• Opportunities and Challenges for the Integration of HIV and SRH Services in Malawi is currently unpublished and available upon request under restricted access.
To request access to this assessment, please email Sara Allinder at Sara.Allinder@georgetown.edu and Anna Carter at Anna.Carter@georgetown.edu.
determinant of effective integration is commendable. Nonetheless, a substantial barrier to effective integration is provider attitudes. Perceived workload and moral opposition towards AGYW using HIV prevention and SRH interventions are some of the major roadblocks to integration that warrants greater attention for a comprehensive view of health system and service delivery gaps. Further, while the authors acknowledge there are capacity building gaps for providers, of greater need are the soft skills such as communication and counseling skills, which are critical in providing services sensitively to AGYW.
The authors attempt to situate the article within the broader HIV prevention and sexual and reproductive health discourse. However, the findings are primarily focused on PrEP and contraception/family planning. Other HIV prevention and SRH interventions e.g. STIs are barely addressed. I would suggest that the authors include a statement to define the scope of the article. In my view, the authors use PrEP and FP to highlight integration issues that are broadly relevant to HIV prevention and sexual reproductive health.
My major concern is the description of the methodology and the ethics statement points out that this article was based on secondary data analysis. For instance, the authors point out "...While original data from key informant interviews and health facility assessments are not contained in this article, because the analyses form the basis of this article, their methodologies are elaborated upon below...". Two major issues related to methodology: If the article is based on secondary data analysis, it makes sense for the authors to sufficiently describe the secondary data collection and analysis procedures, compared to the primary data collection and analysis that is given prominence in the article. 1.
The presentation of the findings extensively highlights excerpts from interviews with participants, which is characteristic of primary data, as opposed to secondary data analysis. Wouldn't it make sense to revise the methodology and acknowledge the use of primary data from key informant interviews? 2.

Is the work clearly and accurately presented and does it cite the current literature? Yes
Is the study design appropriate and is the work technically sound? Yes

If applicable, is the statistical analysis and its interpretation appropriate? Not applicable
Are all the source data underlying the results available to ensure full reproducibility? Partly Are the conclusions drawn adequately supported by the results? Yes