An inter-disciplinary approach to understanding and intervening on contextual factors that shape HIV-risk for young women and men in South Africa

Globally, and in South Africa in particular, HIV remains a major public health challenge. In KwaZulu-Natal Province, the functional epicentre of the global HIV-epidemic, young women and girls (18-24) are particularly at risk of acquiring HIV, and young men, are the only group in the country with an rising HIV-incidence. These high rates of HIV-acquisition are driven by harsh social contexts of poverty, inequitable gender norms, and widespread levels of violence, driven by the long legacy of apartheid.

This project seems to achieve three aims: 1) to understand how social contexts shape young people's HIV-acquisition risk; 2) to develop an intervention to support young women and men to take control of their lives and HIV-acquisition risk; and 3) assess the feasibility, acceptability and potential impact of this intervention.

To achieve aim 1 we will use unique existing quantitative data sets to understand how social contexts shape HIV-acquisition risk in young people and then undertake long-term participatory research with 16 youth peer research associates (YPRAs) hired from two sites in KwaZulu-Natal - urban informal settlements and rural KwaZulu-Natal. Through this we will understand in multiple ways how risk manifests itself.

To achieve aim 2 we will work with the YPRAs and the team of researchers to develop an intervention with resonates with young women's and men's live.

To achieve aim 3 we will undertake a pilot evaluation of the intervention, assessing quantitative and qualitatively whether the intervention was felt to be feasible and acceptable by young people, and whether it shows any evidence of effect.

We will share results with the community through producing plain language summaries of the research we produce, and also a short video at endline, all in collaboration with the YPRAs.

Background: South Africa remains the epicentre globally of the HIV-epidemic, driven by harsh contexts of gender inequalities, poverty and community violence. Understandings of how these impact on the syndemic of HIV-acquisition risk, intimate partner violence (IPV), poor mental health and substance misuse, for young women and men remain limited, and there remain no effective HIV-prevention interventions for young people who are out of school.

Aim: To understand how contextual factors shape the syndemic of HIV-acquisition risk, in South Africa, and how these can be challenged in participatory interventions to reduce HIV-risk.

Methods: To understand the relationship between contextual factors and the syndemic of HIV-acquisition risk we will undertake secondary analysis of South African data sets using spatial epidemiological techniques. We will also recruit 16 youth peer research associates (YPRAs) aged 18-24 from two communities, and through participatory methods understand their perspectives. We will then co-develop with the YPRA an intervention that responds to their needs and priorities, and undertake a mixed methods pilot randomised control trial of the intervention. We will assess feasibility, acceptability and potential effects sizes through this pilot.

Outcome: At the end of the project we will have an intervention that is ready for a larger scale evaluation, as well as a better understanding of the contextual factors shape the syndemic of HIV-acquisition risk for young people.

Expertise: An experienced inter-disciplinary team of social psychologists, statisticians, social epidemiologists, gender, mental health, and violence experts, and HIV-clinicians.

Our study is ODA compliant, HIV and co-morbid health outcomes of intimate partner violence (IPV), alcohol use and depression are major public health challenges. South Africa, and the Province of KwaZulu-Natal, remain the epicenter of the HIV-epidemic. Despite expanding access to effective HIV-treatment, young women remain disproportionately at risk of acquiring HIV, and young men are the only group in South Africa with an increasing HIV-incidence. These statistics are driven by the harsh social contexts of poverty, gender inequalities and community level violence, which both impact directly on HIV-incidence, but also indirectly through increasing co-morbid health outcomes of IPV, substance misuse and depression. This study seeks to address this by understanding the relationship in greater detail between contextual factors and health outcomes, and co-developing and piloting an intervention for young people, in collaboration with youth peer research associates (YPRAs), in two communities in KwaZulu-Natal, urban informal settlements and rural northern KwaZulu-Natal.

The inter-disciplinary team delivering this research has multiple potential beneficiaries:
1. YPRAs (16) who will be hired to co-develop and implement the intervention. Though engaging those targeted by the intervention in the development of it, it will ensure it addresses the key concerns and spaces for change young people think they have.
2. Public and communities: There remains ongoing concerns about how to 'end-AIDS' in South Africa, and ongoing campaigns to deal with these challenges. As such our work will help contribute to understanding appropriate strategies;
3. Policy makers continue to try and work to respond to young people's needs and demands around HIV. We have extensive connections within local, national and international policy makers, and will establish an advisory group for the project, to ensure ongoing discussions
4. The South African Department of Health and South African Government. The challenge of HIV remains a central issue in South Africa. Our project will provide further evidence on the drivers of HIV, and what strategies may best be implemented to reduce HIV-risk.
5. Academic beneficiaries: through inter-disciplinary research our programme will directly benefit researchers working on understanding how contexts impact health outcomes, HIV-researchers, and those working on behavioural interventions to prevention HIV.

We have established a wide ranging communication strategy including academic publications and conference attendance, establishing an advisory board comprising of local government actors and community members, developing plain language summaries and a video with the YPRAs for distribution. In addition, we have extensive networks into the Department of Health, and international partners in the WHO and UNAIDS.