Youth-friendly sexual health services and peer support for improved sexual and reproductive health outcomes among adolescents and young adults in South Africa: results of a factorial randomized controlled trial

Background: Adolescents and young adults in South Africa have high burdens of STIs and unintended pregnancy. We evaluated the impact of peer support and/or expanded sexual and reproductive health (SRH) services on STIs, contraception, and pregnancy in rural KwaZulu-Natal, South Africa.

Methods: We analyzed secondary outcomes from a 2x2 factorial randomized controlled trial conducted March 2020-August 2022 among 16-29-year-olds, comparing: 1) enhanced Standard of Care (SoC): access to mobile youth-friendly HIV prevention(AYFS); 2) SRH: self-collected STI testing and referral to AYFS with expanded SRH services; 3) Peer-support: peer navigator facilitation of AYFS attendance; 4) SRH + peer-support. At 12 months all participants were offered STI testing; female participants self-reported contraceptive use and pregnancy.

Results: Among 1743 trial participants (51% female), 927 (53%) had 12-month STI results; 209 (22.5%) tested positive: 163 (17.6%) chlamydia, 54 (5.8%) gonorrhea, 44 (4.8%) trichomoniasis. STI prevalence was somewhat lower among those exposed to peer-support (aOR adjusted for sex, age, location: 0.77, 95%CI 0.56-1.06) or SRH (aOR 0.74, 0.56-1.06) and, compared to SoC, was reduced in those exposed to both (aOR 0.59, 0.38-0.94). In SRH arms, 64/469 (13.6%) had a new STI at 12 months, with no difference by peer-support (p = 0.97). Among females, 336/634 (53.0%) reported using contraception and 47/667 (7.1%) pregnancy, with little difference by study arm.

Conclusions: Peer support and STI testing with expanded SRH each had no more than small effects on STIs, contraception, or pregnancy. Combined or more intensive interventions, e.g., repeat screening, enhanced partner notification, and deeper understanding of structural drivers, are needed.