INTRODUCTION: Sexual violence (SV) affects millions globally and has a well-documented bidirectional association with HIV. Post-exposure prophylaxis (PEP) is a critical, yet often underutilized, HIV prevention tool in post-SV care. Despite its potential impact to reduce HIV transmission, SV care remains an overlooked service delivery point for HIV prevention. The U.S. Centers for Disease Control and Prevention (CDC), as part of the President's Emergency Plan for AIDS Relief (PEPFAR), supports PEP provision within broader post-violence care (PVC) services. Understanding PEP utilization is crucial for optimizing service delivery and HIV prevention efforts. METHODS: Using Monitoring Evaluation and Reporting data from fiscal years 2018-2023, we conducted a descriptive analysis of clients who received PVC and SV services through CDC-supported programming in 14 sub-Saharan African countries. RESULTS: From 2018 to 2023, the annual number of clients receiving any PVC, and specifically SV, services increased by 233% (in 2018, n = 206,764; in 2023, n = 689,349) and 163% (in 2018, n = 42,848; in 2023, n = 112,838), respectively. Fewer than half of SV clients completed PEP (38% in 2018, n = 16,103; 31% in 2023, n = 35,118). Across all years combined, most SV clients (female: 185,414; male: 59,618) were aged 15-19 years. The age band and sex with the lowest proportion of clients completing PEP were males aged 15-19 (4%, n = 2296). CONCLUSIONS: The findings underscore a critical gap between the scaling of SV services and the completion of PEP within violence response programmes. Innovative implementation science approaches may help to identify and address barriers inhibiting effective PEP delivery and uptake within PVC service delivery programmes. Enhancing PEP uptake and completion can support mitigating the bidirectional relationship between violence and HIV acquisition, particularly among vulnerable populations like adolescents and young adults. Low PEP coverage also reflects missed opportunities, particularly among adolescent girls and young women, who experience disproportionate rates of HIV acquisition.

INTRODUCTION: In Eswatini, HIV incidence among adolescent girls and young women (AGYW), aged 15-24 years, is 10 times that of their male peers. Despite the World Health Organization's 2014 recommendation for post-exposure prophylaxis (PEP) to be available for all HIV exposures, it has been underutilized among youth. PEP is an effective prevention method, and a better understanding of the characteristics, risk factors and behaviours that are associated with PEP awareness, as a precursor to effective use, is needed. METHODS: Using data from the 2022 Eswatini Violence Against Children and Youth Survey, we used logistic regression models to explore the relationships between PEP awareness and a set of hypothesized explanatory variables among AGYW aged 13-24 years who had ever had sex (N = 2648). Explanatory variables included socio-demographic characteristics, sexual risk factors and sexual health behaviours. RESULTS: A slight majority (57.3%) of AGYW who had ever had sex were aware of PEP as an HIV prevention method. PEP awareness increased with age (aOR 1.1, 95% CI 1.0, 1.1) and was higher among AGYW who had a sexual partner whose age was 5 or more years older in the past 12 months (aOR 1.4, 95% CI 1.1, 1.9), those who had ever taken part in an HIV prevention programme (aOR 1.6, 95% CI 1.2, 2.3) and those who had ever heard of pre-exposure prophylaxis (aOR 8.1, 95% CI 6.4, 10.2). Participants who were ever married or partnered (aOR 0.7, 95% CI 0.5, 1.0) and those who engaged in inconsistent condom use with non-spouse/main partner or multiple partners in the past 12 months (aOR 0.8, 95% CI 0.6, 1.00) had lower odds of knowing about PEP in the adjusted model. CONCLUSIONS: We identified sub-optimal PEP awareness among Swazi AGYW who had ever had sex. Our findings suggest that engagement in HIV prevention programmes increased PEP awareness and that knowing about pre-exposure prophylaxis (PrEP) was associated with PEP awareness. Future efforts could include tailored PEP awareness activities and campaigns to resonate with AGYW at elevated risk of HIV and integration of PEP education into routine sexual and reproductive service delivery and school-based HIV curriculum.

Eswatini has made substantial progress responding to its HIV epidemic and reducing violence against children. However, adolescent girls and young women with disabilities might be at increased risk for experiencing violence and for HIV infection, compared with those without disabilities. Data from the 2022 Eswatini Violence Against Children and Youth Survey were analyzed to compare HIV infection and violence-related measures by functional disability status (e.g., difficulties in performing functional activities such as seeing, walking, or communicating) among adolescent girls and young women. In 2022, in Eswatini, 14.0% of adolescent girls and young women aged 13-24 years had a reported functional disability. Compared with those without a functional disability, adolescent girls and young women with a functional disability had higher lifetime prevalences of experiencing sexual, physical, and emotional violence. They were also more likely to know where to seek help for experiences of violence. After adjusting for sociodemographic characteristics, HIV testing and infection status, HIV risk factors, sexual risk behaviors, and HIV treatment and prevention services did not differ by functional disability status. Prioritizing accessible, disability-inclusive prevention programs and services might help reduce experiences of violence among adolescent girls and young women with disabilities. Partnering with disability-led and disability-serving organizations and directly with adolescent girls and young women with disabilities to plan and implement programs and services that are disability-inclusive could help ensure that adolescent girls and young women with disabilities are aware of and can access these resources.

Malawi faces challenges with retaining women in prevention of mother-to-child HIV transmission (PMTCT) services. We evaluated Cooperative for Assistance and Relief Everywhere, Inc. (CARE's) community score card (CSC) in 11 purposively selected health facilities, assessing the effect on: (1) retention in PMTCT services, (2) uptake of early infant diagnosis (EID), (3) collective efficacy among clients, and (4) self-efficacy among health care workers (HCWs) in delivering quality services. The CSC is a participatory community approach. In this study, HCWs and PMTCT clients identified issues impacting PMTCT service quality and uptake and implemented actions for improvement. A mixed-methods, pre- and post-intervention design was used to evaluate the intervention. We abstracted routine clinical data on retention in PMTCT services for HIV-positive clients attending their first antenatal care visit and EID uptake for their infants for 8-month periods before and after implementation. To assess collective efficacy and self-efficacy, we administered questionnaires and conducted focus group discussions (FGDs) pre- and post-intervention with PMTCT clients recruited from CSC participants, and HCWs providing HIV care from facilities. Retention of HIV-positive women in PMTCT services at three and six months and EID uptake was not significantly different pre- and post-implementation. For the clients, the collective efficacy scale average improved significantly post-intervention, (p = 0.003). HCW self-efficacy scale average did not improve. Results from the FGDs highlighted a strengthened relationship between HCWs and PMTCT clients, with clients reporting increased satisfaction with services. However, the data indicated continued challenges with stigma and fear of disclosure. While CSC may foster mutual trust and respect between HCWs and PMTCT clients, we did not find it improved PMTCT retention or EID uptake within the short duration of the study period. More research is needed on ways to improve service quality and decrease stigmatized behaviors, such as HIV testing and treatment services, as well as the longer-term impacts of interventions like the CSC on clinical outcomes.

BACKGROUND: Coverage of prevention of mother-to-child transmission of HIV (PMTCT) services has expanded rapidly but approaches to ensure service delivery is patient-centered have not always kept pace. To better understand how the inclusion of women living with HIV in a collective, quality improvement process could address persistent gaps, we adapted a social accountability approach, CARE's Community Score Card© (CSC), to the PMTCT context. The CSC process generates perception-based score cards and facilitates regular quality improvement dialogues between service users and service providers. METHODS: Fifteen indicators were generated by PMTCT service users and providers as part of the CSC process. These indicators were scored by each population during three sequential cycles of the CSC process which culminates in a sharing of scores in a collective meeting followed by action planning. We aggregated these scores across facilities and analyzed the differences in first and last scorings to understand perceived improvements over the course of the project (z-test comparing the significance of two proportions; one-tailed p-value ≤ .05). Data were collected over 12 months from September 2017 to August 2018. RESULTS: Fourteen of the fifteen indicators improved over the course of this project, with eight showing statistically significant improvement. Out of the indicators that showed statistically significant improvement, the majority fell within the control of local communities, local health facilities, or service providers (7 out of 8) and were related to patient or user experience and support from families and community members (6 out of 8). From first to last cycle, scores from service users' and service providers' perspectives converged. At the first scoring cycle, four indicators exhibited statistically significant differences (p-value ≤ .05) between service users and service providers. At the final cycle there were no statistically significant differences between the scores of these two groups. CONCLUSIONS: By creating an opportunity for mothers living with HIV, health service providers, communities, and local government officials to jointly identify issues and implement solutions, the CSC contributed to improvements in the perceived quality of PMTCT services. The success of this model highlights the feasibility and importance of involving people living with HIV in quality improvement and assurance efforts. TRIAL REGISTRATION: Trial registration: ClincalTrials.gov NCT04372667 retrospectively registered on May 1st 2020.