YATHU YATHU ("For us by us"): A Cluster Randomised Trial of community-based SRH and HIV services for adolescents and young people in Zambia

当今世界上有超过18亿青少年和年轻人（10-24岁），比世界历史上任何时候都多。其中大多数生活在发展中国家，非洲许多国家50%的人口年龄在18岁以下。艾滋病毒是这一年龄组的第二大死亡原因，新感染人数继续上升。艾滋病毒感染、意外怀孕和早婚限制了数百万年轻妇女的潜力，但年轻人往往无法获得预防这些问题的服务。在赞比亚，青少年（10-19岁）占总人口的25%。赞比亚的青少年生育率在撒哈拉以南非洲（世界上最高的地区）排名第五，20岁以下妇女中有44.7%报告意外怀孕。本研究选取的卢萨卡社区15-24岁妇女的艾滋病毒流行率为6.4%，同龄青年男子的艾滋病毒流行率为1.6%，此后迅速上升。《2017-2021年赞比亚青少年健康战略》将性健康和生殖健康（SRH）以及艾滋病毒列为卫生服务规划的两大优先事项，其使命是“确保公平获得适当、高质量和具有成本效益的青少年友好型卫生平台，并确保青少年响应性卫生系统尽可能接近人民。”当我们问赞比亚的年轻人他们想要什么样的性健康和生殖健康服务时，他们毫不含糊地告诉我们，他们想要的是专门为他们设计的服务，由他们提供（“Yathu Yathu；由我们提供给我们”），而不是传统的卫生设施，因为卫生服务提供者对年轻人的态度仍然是耻辱的。为此，我们设计了一种以社区为基础、以同伴为主导的干预措施，利用创新技术，包括预防积分“忠诚卡”，以激励和衡量服务的获取和使用，并通过虚拟支持小组支持接受和坚持服务。在研究期开始时，我们会继续与青少年社区谘询委员会讨论，以完善以社区为本的朋辈领导服务的地点、内容和提供方式。本研究旨在评估在赞比亚卢萨卡的两个城市社区建立和提供以社区为基础的同伴主导的性健康和生殖健康服务的过程，包括艾滋病毒检测、治疗和预防。该研究将比较生活在随机分配可获得这些以社区为基础的同伴主导服务的10个社区地区的15-24岁青少年和年轻人接受性健康和生殖健康服务的情况，与随机分配可通过传统卫生设施提供服务的10个地区的情况进行比较。这项研究将衡量以社区为基础的同伴领导的服务是否增加了人们对艾滋病毒状况的了解，以及相对于标准护理领域的性健康生殖健康服务的覆盖范围。为了测量艾滋病毒状况的知识，我们将在干预实施18个月后在所有地点进行横断面调查，并比较干预和标准护理地点之间的这些结果。为了衡量覆盖率，我们将使用创新的预防积分卡系统在服务接入点和使用点常规收集的数据。创新的芯片预防积分“Yathu卡”将使服务用户能够收集SRH“预防”积分，这些积分可以兑换商品和服务，以鼓励接受服务并衡量获取情况。这项研究还将评估以手机为基础的支持小组的使用情况，以使青少年和年轻人能够坚持药物治疗，例如用于治疗艾滋病毒或作为暴露前预防（PreP）的抗逆转录病毒疗法。这项研究将由赞比亚研究机构Zambart与来自伦敦卫生与热带医学学院和英国帝国理工学院的研究人员合作进行，赞比亚卫生部、家庭健康协会和SHM基金会也将参与这项研究。

There are more than 1.8 billion adolescents and young people (aged 10-24) alive today, more than ever before in world history. Most of these live in developing countries, with many countries in Africa having 50% of the population less than 18 years old. HIV is the second leading cause of death in this age group and the number of new infections continues to rise. HIV infection, unwanted pregnancies and early marriage limit the potential of millions of young women yet services to prevent these are often not accessible to young people. In Zambia, adolescents (10-19 years old) represent 25% of the total population. Zambia has the 5th highest adolescent birth rate in sub-Saharan Africa (the region with the highest rates in the world) and 44.7% of women under 20 reported an unplanned pregnancy. HIV prevalence rates in the Lusaka communities chosen for this study are 6.4% among 15-24 year old women and 1.6% amongst young men of the same age, rising rapidly thereafter. The Zambian Adolescent Health Strategy 2017-2021 recognises sexual and reproductive health (SRH) and HIV as the two leading priorities for health service planning with a mission "to ensure equity of access to appropriate, quality and cost-effective adolescent-friendly health platforms and an adolescent responsive health system as close to the people as possible." When we ask young people in Zambia what SRH services they want they unequivocally tell us that they want services specifically designed for them, provided with them ("Yathu Yathu; For us by us") away from traditional health facilities where attitudes of health providers can still be stigmatising towards young people. In response, we have designed a community-based, peer-led intervention that makes use of innovative technology, including prevention points "loyalty card" to incentivise and measure service access and use, and support for uptake and adherence to services using virtual support groups. At the start of the study period, we will continue discussion with adolescent community advisory boards to refine the location, content and delivery of the community-based peer-led services. This study aims to evaluate the process of establishing and delivering community-based peer-led SRH services, including HIV testing, treatment and prevention, in two urban communities in Lusaka, Zambia. The study will compare the uptake of SRH services by adolescents and young people aged 15-24 living in areas of the ten communities which were randomly allocated to have access to these community-based, peer-led services, compared to ten areas randomly allocated to have services provided via traditional health facilities. The study will measure whether the community-based peer-led services increased knowledge of HIV status and coverage of SRH services relative to standard of care areas. To measure knowledge of HIV status, we will conduct a cross-sectional survey in all sites 18-months after the intervention implementation and compare these outcomes between the intervention and standard of care sites. To measure coverage, we will use the data routinely collected at point of service access and use by the innovative prevention points cards system. The innovative chip-enabled prevention points "Yathu card" will enable service users to collect of SRH "prevention" points, which can be exchanged for goods and services, to encourage uptake of services and measure access. The study will also evaluate the use of mobile phone based support groups to enable adolescents and young people to adhere to medication such as anti-retroviral therapy used either as treatment for HIV or as pre-exposure prophylaxis (PreP).The research will be carried out by Zambart a Zambian research organisation in collaboration with researchers from the London School of Hygiene and Tropical Medicine and Imperial College in the UK in partnership with the Zambian Ministry of Health, Society for Family Health and the SHM foundation.