Adolescent livelihoods approaches to HIV prevention among young women and girls in sub-Saharan Africa: Lessons learned from SHAZ! (Shaping the Health of Adolescents in Zimbabwe)

Background: Gender inequities are linked to increased HIV risk among women and girls. Adolescent livelihood approaches have the potential to equalize gender imbalances and decrease risk. We evaluated the feasibility and potential efficacy of one such intervention: SHAZ!. Methods: A sample of 315 16-19 year old females, who were out of school, HIV/HSV-2 uninfected and not pregnant, were randomized to an intervention arm combining life skills education with vocational training (VT) and a micro-grant, or a control arm receiving life skills only. Participants were followed every 6 months for 2 years. We examined feasibility, changes in gender-power and economic factors using generalized estimating equations, and differences in biological outcomes using cox proportional hazards modeling. Results: Overall retention at two years was 80%, with no differences by study arm. Completion of life skills training was 94% overall, with 54% of intervention participants passing their VT course and receiving the micro-grant. Statistically significant improvements were seen in economic factors among participants in both arms (e.g. 66% had adequate food intake at baseline compared to 76% at end line, p<0.01). Among intervention participants compared to controls, marginally significant changes were noted in relationship power [estimate 0.07, 95% CI (-0.01, 0.15)] and in unintended pregnancy [OR=0.61, 95% CI (0.37, 1.01)], while reports of gender-based violence were significantly reduced [OR=0.42, 95% CI (0.18, 0.99)]. There was no difference in HIV/HSV-2 incidence. Conclusions: Findings suggest that SHAZ! was feasible and potentially efficacious, in spite of the overarching economic context. Refinements are required to improve VT pass-rates.