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Background: Although multi-level combination HIV prevention has been promoted for adolescent girls and young women (AGYW) in sub-Saharan Africa, there is limited evidence on how clinical, behavioral, structural, and multi-level interventions compare to one another and to no intervention.
Methods: Girl Power is a study assessing four different models of service delivery for AGYW in Lilongwe, Malawi:
1) standard of care (no intervention),
2) youth-friendly health services (YFHS) (clinical intervention),
3) YFHS + empowerment (clinical + behavioral interventions),
4) YFHS + empowerment + cash transfer (clinical + behavioral + structural interventions).
Four comparable public sector clinics were selected and randomly assigned to one model of service delivery. During the six-month enrollment period, the four clinics were compared for uptake of HIV testing and counseling (HTC) and condom uptake (number of times a participant received any condoms). Number of times services were received per 100 AGYW were calculated and compared across clinics.
Results: 250 AGYW 15-24 years old were enrolled in each clinic (N=1000 total). Median age was 19 years. Rates of HTC uptake were 14, 89, 90, and 113 per 100 AGYW at clinics 1, 2, 3, and 4, respectively
(p< 0.001); rates of condom uptake were 5, 42, 51, and 84 per 100 AGYW in clinics 1, 2, 3, and 4, respectively (p< 0.001). Uptake was higher in clinic 2 than clinic 1 for both HTC (p< 0.001) and condoms
(p< 0.001). Uptake was similar at clinics 2 and 3 for both HTC (p>0.999) and condoms (p=0.116). Uptake was higher in clinic 4 than clinic 3 for both HTC (p=0.009) and condoms (p< 0.001).

Figure 1. Number of times services were received
[Figure 1. Number of times services were received]


Conclusions: A YFHS clinical package contributed to high rates of HTC and condom uptake. A cash transfer contributed further. For AGYW in sub-Saharan Africa, combination prevention programs can substantially impact HIV service uptake.

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