Evaluation of the SKILLZ intervention to promote HIV testing and contraception uptake in adolescent girls in Lusaka, Zambia: A cluster-randomized trial

Adolescent girls are at disproportionately high-risk for HIV and unintended pregnancy. Effective interventions to increase uptake of HIV testing and contraceptives are urgently needed. Our cluster-randomized controlled trial in 46 schools in Lusaka, Zambia evaluated the SKILLZ intervention: (a) 12 after-school sessions of sexuality and sexual and reproductive health (SRH) education culminating in a community "graduation" soccer event where a pop-up clinic offered HIV testing and contraception; (b) for those HIV positive, coach-assisted linkage to HIV care, interpersonal group psychotherapy, or youth-friendly SRH services; and (c) community-based distribution of HIV self-testing and contraceptives. We surveyed randomly sampled Grade 11 girls at baseline, 6, and 12 months to measure self-reported uptake of HIV/SRH products and services. We estimated intention-to-treat modified poisson regressions on uptake of (a) HIV testing and any contraceptive method within the previous 6 months, (b) HIV testing by modality and contraceptive uptake by method, and (c) new adoption and discontinuation. Between March 2021 and June 2022, 1,019 girls were enrolled from 23 control schools and 1,134 enrolled from 23 intervention schools; 79% of surveyed girls in intervention schools participated in SKILLZ, 71% attended at least 8/12 sessions to "graduate". At 6 months, 600 (59%) participants in intervention schools and 307 (37%) participants in control schools self-reported HIV testing within the previous 6 months (risk difference: 22%, 95% CI: 14, 29); 281 (37%) participants in intervention schools and 200 (30%) participants in control schools had reported using contraception within the previous 6 months (6%, 95% CI: -2, 14). Effects on HIV testing and contraception are sustained at 12 months. SKILLZ increased reported uptake of HIV testing and contraception among in-school adolescent girls. Further research is needed to understand treatment mechanisms and heterogeneity to tailor the intervention before implementation at scale. The trial is registered with ClinicalTrials.gov, NCT04429061.