Discussion
SECONDARY, COVID-19 INFECTION
Delivery of community-based, peer-led, and incentivised SRH services to AYP was effective in increasing knowledge of HIV status compared to the control arm, with the largest effect among adolescent boys aged 15 to 19. Despite a large impact on this primary outcome, there was no evidence of impact on linkage to HIV prevention or care services nor evidence for an impact on met need for contraceptive services, or births, among AGYW. Our findings demonstrate that Yathu Yathu provides an important opportunity to reach AYP with HIV testing services. Additional efforts are required to translate increased knowledge of HIV status into improved linkage to HIV prevention and care services and to increase AGYW’s met need for contraceptive services.Delivery of HIV testing services through the Yathu Yathu strategy had a large impact on uptake of testing. This is consistent with results from the P-ART-Y study, which included the 2 Yathu Yathu study communities and showed substantially increased knowledge of HIV status among adolescents who had been offered door-to-door HIV testing services [Testing for HIV is the critical first step into the HIV care continuum or to HIV prevention services. Despite removing barriers to HIV prevention services, including a lack of youth-friendly services at health facilities, we found no impact on uptake of these services. Among the small number of AYP self-reporting their HIV–positive status, coverage of ART was high in both trial arms, suggesting that current ART services are performing well for young people who know their HIV–positive status. Our findings are similar to, yet higher than, those reported in the 2016 Population-based Impact Assessment (80%) [Few AYP reported ever using PrEP. Low use may be attributable, in part, to weak referral mechanisms between Yathu Yathu and the health facility, poor delivery of PrEP at the health facilities or low acceptability of PrEP among potential users. With barriers to existing health services well established among AYP [The majority of ABYM who reported ever being circumcised had been circumcised before the implementation of Yathu Yathu, likely reflecting the national VMMC campaign launched by the Ministry of Health in 2007 and scaled up in 2015 [We found no evidence that Yathu Yathu increased condom use at last sex. Condom use is affected by several factors [Our trial had limitations. Approximately 35% of AYP randomly selected for participation in the endline survey could not be contacted, due either to moving (out of the zone in which they were resident in 2019, or out of the community) or to not being contactable at the time of the survey. If these individuals were more or less likely to know their HIV status compared with survey participants, for example, if mobile individuals were less likely to have accessed the Yathu Yathu hubs than stable residents, our findings may be biased. However, as the difference between trial arms in our primary outcome was large, it is probable that we would still have identified an intervention effect even if these individuals (who could not be contacted) had been included in the survey. Furthermore, the participation rate in the survey among AYP who remained resident in their zones and therefore eligible for participation in the survey was high, and similar in both study arms.Although we were concerned our trial might be subject to contamination, with AYP in control zones able to access services at the hubs in intervention zones, we found little evidence that AYP in control zones attended the hubs. All our outcomes were based on self-report and are subject to social desirability bias. Responses in the Yathu Yathu arm may have been more subject to this bias, as AYP learnt of the importance of HIV testing through Yathu Yathu. The teams conducting the survey were different from those delivering the services and the AYP were unaware of the primary outcome of the trial, both should have limited this bias. Delivery of Yathu Yathu was affected by COVID-19, with implementation halted over 3 months, and after July 2020, implementation was adapted to limit the number of individuals allowed to attend the hubs at any given time. These restrictions, uncertainty among AYP as to whether the hubs would be closed permanently and fear of COVID-19 infection at the hubs may have reduced AYP’s willingness and ability to access Yathu Yathu services and may have implications for our findings. In the absence of the pandemic, we might have observed higher uptake of services and a greater effect of Yathu Yathu on secondary outcomes.Despite limitations, Yathu Yathu had a large impact on knowledge of HIV status and reached a large proportion of AYP participating in the endline survey. With adolescents in particular experiencing barriers to accessing health facilities and given the large observed effect on knowledge of HIV status among young men, delivery of HTS through community-based hubs should be made available to adolescents and considered in settings where health facilities are failing to reach young men. The lack of an effect on the secondary outcomes, many of which reflect services available through linkage to the health facility, likely reflects known barriers to accessing the health facility; findings that are similar to a study in Malawi, which found higher uptake of SRH services when delivered through youth-friendly services [Our CRT provides rigorous evidence that delivery of community-based, peer-led, and incentivised SRH services by peers is feasible, even in the context of a pandemic. We showed that the strategy reaches a high proportion of AYP and is highly effective in increasing knowledge of HIV status among a population underserved by available health services. Even in the context of COVID-19, essential SRH services continued to be delivered through Yathu Yathu with adaptations to implementation [