Table 1.

Drivers of risk and barriers to effective uptake of multi-level HIV prevention for adolescents and young adults in rural KZN drawn from survey data (n = 4918) and studies conducted 2016–2018 [1, 6, 8, 37, 40, 43–49, 51–56]

Unmet need and challenges	Consequences of unmet need
Social vulnerability of youth	• High unemployment (85% of school-leavers are unemployed)
	• Migration (30% moved location in past year)
	• Transactional sex (13% in past year)
Sexual health needs	• 20% of women and 10% of men had a curable STI.
	• 75% of these reporting no symptoms,
	• 40% of the women had bacterial vaginosis.
	• Home-based self-sampling and treatment for STIs was acceptable and desirable to young people
	• Teenage pregnancy levels are persistently high, with an annual incidence of teenage pregnancy of 6.4% (5.7–8.6) (unpublished data)
	• The majority of young women 15–24 start contraception after their first pregnancy.
	• Poor sexual health and knowledge despite the importance of fertility
Unmet mental health needs	• High levels of common mental disorders (CMD) which increase with age (rising to 32% of those aged 20–22).
Challenges to uptake of HIV prevention interventions	• Multiple service providers
	• Increasing uptake of community-based interventions (social asset building; community mobilisation and parenting programmes) over the 2 year period
	• Less success in reaching older adolescents, those out of school, and those who move
	• Young boys felt excluded – apart from Voluntary Medical Male Circumcision.
	• Limited uptake of regular HIV testing – despite over 94% knowing where to get ART and wide-spread availability of free point of care HIV testing, < 50% of 15–24-year olds tested for HIV within the previous 12 months, with pregnancy being the strongest predictor of HIV-testing in women.
	• Poor uptake of HIV care: < 20% of men aged 15–30 who tested positive linked to care.
	• Social costs (time and cost of travel, waiting times, stigma and attitude of health care providers to adolescent sexuality) of HIV testing and care outweighing any perceived benefits.
Sources of youth resilience	• Access to good sexual and reproductive health information
	• Supportive network of peers, schools, and family members
	• Social cohesion that support hope, a sense of belonging and altruism
	• Interventions that were consistent and re-enforced existing cultural and social norms