1. XVII Annual International AIDS Conference SHAZ! Shaping the Health of Adolescents in Zimbabwe Mudekunye, S. Laver University of Zimbabwe-University of California, San Francisco Research programme in Women’s Health

2. XVII Annual International AIDS Conference 2 Zimbabwe Context Current economic crisis: hyper inflation, 80% unemployment, scarcity of food and goods 6 th highest prevalence of HIV globally Over 1 million orphaned under 18 Adolescent females 2 times more likely than adolescent males to be HIV infected Gender inequities in education and employment fuel HIV risk

3. XVII Annual International AIDS Conference 3 SHAZ!: HIV prevention through the promoting gender equity and reducing economic vulnerability To address HIV risk of adolescent females: economic programs must be combined with RH/life skills education and approaches to promote gender equity

4. XVII Annual International AIDS Conference 4 SHAZ! Research Sites

5. XVII Annual International AIDS Conference 5 Design of SHAZ! Study aim: To evaluate the effectiveness of a combined intervention to reduce economic vulnerability and HIV risk Design: RCT of n=315 participants followed-up for 2 years INTERVENTION: Life Skills/HBC education Vocational Training ISS VS CONTROL: Life Skills/HBC education

6. XVII Annual International AIDS Conference 6 Target population Inclusion criteria Female, aged 16-19 years Orphaned by at least one parent Currently out of school Negative for HIV,HSV-2 and pregnancy Chitungwiza-based

7. XVII Annual International AIDS Conference 7 SHAZ! Intervention Components Life Skills and home-based health care education Livelihoods (vocational training w/ micro grant) Integrated Social Support

8. XVII Annual International AIDS Conference 8 Baseline Results 25% sexually active, 3% used condoms at last sex 16% think they will get HIV in the next year 12% experienced some form of physical or sexual violence Prevalent HIV infection associated (p<0.01) with age, experience of violence, poor mental health, food insecurity and number of lifetime partners

9. XVII Annual International AIDS Conference 9 Economic Opportunities at 18 Months Training courseMain Activity Paid WorkHas own income Braiding11/13 (85%)7/13 (54) Garment Making25/35 (71)13/35 (37) Hairdressing31/32 (97)8/32 (25) Nurse Aid20/26 (77)11/26 (42) Business/receptionist6/6 (100)1/6 (17) Total94/113 (83)40/113 (35) At baseline, 3% reported engaging in paid work; 6% reporting having their own income

10. XVII Annual International AIDS Conference 10 Change in Trends: Increased knowledge and more equitable gender attitudes (significant for several indicators) Number of participants that went to bed hungry dropped from 33% to 17% Decreased reporting of all levels of violence Physical: n=7 at 6 months; n=2 at 12 months Sexual: n=11 at 6 months; n=1 at 12 months Rape: n=6 at 6 months; n=0 at 12 months

11. XVII Annual International AIDS Conference 11 Incident Biological Outcomes Biological Outcomes* N=315100% HIV positive103% HSV-2 positive124% Pregnant205% Among negative at enrollment, # and % positive by 12 month follow-up *Data inclusive of ALL participants, not presented separately by study group

12. XVII Annual International AIDS Conference 12 Integration of HIV prevention and treatment HIV prevention was planned from the onset Support for treatment, and secondary prevention, evolved from a programmatic response based on participants’ needs. –Screening for HIV at each visit –Referrals and registration to OIs (including required tests for registration: CD4 counts and full blood tests) –Life skills also covered aspects of positive living

13. XVII Annual International AIDS Conference 13 Prevention and Care for Positives A sub-study (SHAZ!-Plus) to assess SHAZ! potential to improve care and treatment among HIV positive participants Fifty-one additional participants enrolled: –same criteria except HIV/HSV-2 positive eligible –randomization with exact same components offered

14. XVII Annual International AIDS Conference 14 6 Month Evaluation of Positives Sub-Study 79% of SHAZ!-Plus participants (compared to 82% of main study participants) completed all life skills sessions Retention was 90%, compared to 92% at 6 months in main study 65% disclosed their HIV results to someone compared to 35% at baseline. In qualitative assessments: access to consistent care highlighted as the primary concern in light of long waiting times at the clinic, services not geared directly for adolescents and lack of consistent availability of drugs.

15. XVII Annual International AIDS Conference 15 Future Directions Plans to expand and fully integrate SHAZ! for prevention with adolescent friendly care and treatment for positive participants in partnership with the Chitungwiza HIV/AIDS clinic

16. XVII Annual International AIDS Conference 16 Acknowledgements Study participants Epworth and Chitungwiza Community Advisory Board UZ-UCSF Research Programme and study team National Institutes of Health (NICHD)