Step 1: Formative evidence
viral suppression
Our extensive review of the literature and discussions with colleagues revealed only three interventions to promote ART uptake among adolescents and young adults in sub-Saharan Africa. Hlanganani HIV+ Youth Support Group sought to improve linkage to care for newly diagnosed young people ages 16–24 years old in peri-urban districts in the region around Cape Town, South Africa [In Kenya, a youth “Red Carpet Program” was implemented in public healthcare facilities and schools for youth newly diagnosed with HIV [In Zimbabwe, an intervention sought to link 18–24 year-olds with HIV to treatment by using trained peer counselors [Other interventions designed to improve care engagement for adolescents and young adults with HIV have focused on adherence and viral suppression for youth already on ART rather than ART initiation. For example, ART adherence and viral suppression were higher among adolescents attending adolescent-friendly clinics in South Africa [The scarcity of interventions promoting ART uptake among newly diagnosed young adults highlighted the need for evidence-based interventions among this group. Of the interventions we found, we chose to adapt Hlanganani for several reasons. First, it had a control group and showed promising early findings of high linkage to care in the intervention arm. Second, it engaged youth in the greater Cape Town area, who provided a critical model for our population of youth in Cape Town. Finally, the other two interventions were broader in scope, which made them less easily translatable to our pilot intervention. The “Red Carpet Program” in Kenya was implemented across 25 schools and 50 healthcare facilities. The CATS intervention in Zimbabwe focused on supporting the overall development of youth with HIV across 24 districts in the country. Nonetheless, we found common themes across all three programs, including the emphasis on peer-led interventions and the need to be aware of potential mental health challenges among youth.We chose to adapt rather than adopt the Hlanganani intervention in order to address some key limitations of the original intervention at the individual, social, and structural levels. At the individual level, it remained unclear–without an intention-to-treat analysis–if the intervention was truly efficacious. At the social level, the intervention only provided support for participants to initiate care, but no additional social support once a youth entered treatment. At the structural level, feasibility was limited by a remote location for sessions (only 68% completed all three sessions), and treatment was not offered in the intervention (only referral to care)–likely contributors to attrition in the care cascade. In addition, Hlanganani was piloted in 2010, before South Africa’s Universal Test and Treat guidelines were implemented in 2016, which called for first-line ART initiation among all persons with HIV regardless of CD4 count [