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Adolescent girls and young women (AGYW) in South Africa are at a three times higher risk of acquiring HIV than their male counterparts. The HIV prevention cascade is a tool which can be used to measure coverage of HIV prevention services, although there is limited empirical evidence to demonstrate its application in low-resourced settings. The unifying framework is a conceptualisation of the HIV prevention cascade which theorises that both motivation and access are required for an individual to effectively use an HIV prevention method. We applied this framework to data from a random sample of 127,951 beneficiaries of a combination HIV prevention programme for AGYW aged 15–24 in South Africa to measure the steps to, and identify key barriers to, effective use of male condoms and oral pre-exposure prophylaxis (PrEP) among this vulnerable population. Barriers to each step were analysed using univariate and multivariable logistic regression. Among self-reported HIV-negative AGYW who had sex in the past 6 months, effective use of condoms (15.2%), access to PrEP (39.1%) and use of PrEP (3.8%) were low. AGYW were: less likely to be motivated to use condoms if they believed that they had a faithful partner (aOR 0.44, 95% CI 0.22–0.90) or disliked condoms (aOR 0.26, 95% CI 0.11–0.57), less likely to access condoms if the place where AGYW accessed them was far away (aOR 0.25, 95% CI 0.10–0.64), more likely to effectively use condoms if they received counselling on how to use them (aOR 2.24, 95% CI 1.05–4.76), less likely to be motivated to use PrEP if they did not believe PrEP was efficacious (aOR 0.35, 95% CI 0.17–0.72), more likely to be motivated if they felt confident that they could use PrEP, and more likely to have access to PrEP if they had ever been offered PrEP (aOR 2.94, 95% CI 1.19–7.22). This combination HIV prevention programme and similar programmes should focus on risk-reduction counselling interventions for AGYW and their male partners to improve effective use of condoms and ensure easy access to condoms and PrEP by making them available in youth-friendly spaces. Our findings demonstrate that the application of HIV prevention cascades can inform AGYW HIV prevention programming in low-resourced settings.

Introduction The HIV prevention cascade could be used in developing interventions to strengthen implementation of efficacious HIV prevention methods, but its practical utility needs to be demonstrated. We propose a standardized approach to using the cascade to guide identification and evaluation of interventions and demonstrate its feasibility for this purpose through a project to develop interventions to improve HIV prevention methods use by adolescent girls and young women (AGYW) and potential male partners in east Zimbabwe. Discussion We propose a six‐step approach to using a published generic HIV prevention cascade formulation to develop interventions to increase motivation to use, access to and effective use of an HIV prevention method. These steps are as follows: (1) measure the HIV prevention cascade for the chosen population and method; (2) identify gaps in the cascade; (3) identify explanatory factors (barriers) contributing to observed gaps; (4) review literature to identify relevant theoretical frameworks and interventions; (5) tailor interventions to the local context; and (6) implement and evaluate the interventions using the cascade steps and explanatory factors as outcome indicators in the evaluation design. In the Zimbabwe example, steps 1‐5 aided development of four interventions to overcome barriers to effective use of pre‐exposure prophylaxis (PrEP) in AGYW (15‐24 years) and voluntary medical male circumcision in male partners (15‐29). For young men, prevention cascade analyses identified gaps in motivation and access as barriers to voluntary medical male circumcision uptake, so an intervention was designed including financial incentives and an education session. For AGYW, gaps in motivation (particularly lack of risk perception) and access were identified as barriers to PrEP uptake: an interactive counselling game was developed addressing these barriers. A text messaging intervention was developed to improve PrEP adherence among AGYW, addressing reasons underlying lack of effective PrEP use through improving the capacity (“skills”) to take PrEP effectively. A community‐led intervention (community conversations) was developed addressing community‐level factors underlying gaps in motivation, access and effective use. These interventions are being evaluated currently using outcomes from the HIV prevention cascade (step 6). Conclusions The prevention cascade can guide development and evaluation of interventions to strengthen implementation of HIV prevention methods by following the proposed process.

Introduction To achieve significant progress in global HIV prevention from 2020 onward, it is essential to ensure that appropriate programmes are being delivered with high quality and sufficient intensity and scale and then taken up by the people who most need and want them in order to have both individual and public health impact. Yet, currently, there is no standard way of assessing this. Available HIV prevention indicators do not provide a logical set of measures that combine to show reduction in HIV incidence and allow for comparison of success (or failure) of HIV prevention programmes and for monitoring progress in meeting global targets. To redress this, attention increasingly has turned to the prospects of devising an HIV prevention cascade, similar to the now‐standard HIV treatment cascade; but this has proven to be a controversial enterprise, chiefly due to the complexity of primary prevention. Discussion We address a number of core issues attendant with devising prevention cascades, including: determining the population of interest and accounting for the variability and fluidity of HIV‐related risk within it; the fact that there are multiple HIV prevention methods, and many people are exposed to a package of them, rather than a single method; and choosing the final step (outcome) in the cascade. We propose two unifying models of prevention cascades‐one more appropriate for programme managers and monitors and the other for researchers and programme developers‐and note their relationship. We also provide some considerations related to cascade data quality and improvement. Conclusions The HIV prevention field has been grappling for years with the idea of developing a standardised way to regularly assess progress and to monitor and improve programmes accordingly. The cascade provides the potential to do this, but it is complicated and highly nuanced. We believe the two models proposed here reflect emerging consensus among the range of stakeholders who have been engaging in this discussion and who are dedicated to achieving global HIV prevention goals by ensuring the most appropriate and effective programmes and methods are supported.

Introduction Adolescent girls and young women (AGYW), including those who sell sex in sub‐Saharan Africa, are especially vulnerable to HIV. Reaching them with effective prevention is a programmatic priority. The HIV prevention cascade can be used to track intervention coverage, and identify gaps and opportunities for programme strengthening. The aim of this study was to characterise gaps in condom use and identify reasons underlying these gaps among young women who sell sex (YWSS) in Zimbabwe using data from enrolment into an impact evaluation of the DREAMS programme. DREAMS provided a package of biomedical, social and economic interventions to AGYW aged 10 to 24 with the aim of reducing HIV incidence. Methods In 2017, we recruited YWSS aged 18 to 24 using respondent‐driven sampling in six sites across Zimbabwe. We measured knowledge about efficacy of, access to, and effective (consistent) use of condoms with the most recent three sexual partners, separately by whether YWSS self‐identified as female sex workers (FSW) or not. Among YWSS without knowledge about efficacy of, not having access to, and not effectively using condoms, we described the potential reasons underlying the gaps in the condom cascade. To identify socio‐demographic characteristics associated with effective condom use, we used logistic regression modelling. All analyses were RDS‐II weighted and restricted to YWSS testing HIV‐negative at enrolment. Results We enrolled 2431 YWSS. Among 1842 (76%) YWSS testing HIV‐negative, 66% (n = 1221) self‐identified as FSW. 89% of HIV‐negative YWSS demonstrated knowledge about efficacy of condoms, 80% reported access to condoms and 58% reported using condoms consistently with the three most recent sexual partners. Knowledge about efficacy of and effective use of condoms was similar regardless of whether or not YWSS self‐identified as FSW, but YWSS self‐identifying as FSW reported better access to condoms compared to those who did not (87% vs 68%; age‐ and site‐adjusted (adjOR) = 2.69; 95% CI: 2.01 to 3.60; p < 0.001). Women who reported experiencing sexual violence in the past year and common mental disorder in the past week were less likely to use condoms consistently (43% vs. 60%; adjOR = 0.49; 95% CI: 0.35 to 0.68; p < 0.001) and (51% vs. 61%; adjOR = 0.76; 95% CI: 0.60 to 0.97; p = 0.029), respectively. Conclusions Despite high knowledge about efficacy of and access to condoms, there remain large gaps in self‐reported consistent condom use among YWSS. Addressing the structural determinants of YWSS’ inconsistent condom use, including violence, could reduce this gap. YWSS who do not self‐identify as FSW have less access to condoms and may require additional programmatic intervention.

Introduction Adolescent girls and young women (AGYW) in sub‐Saharan Africa have emerged as a priority population in need of HIV prevention interventions. Secondary distribution of home‐based HIV self‐test kits by AGYW to male partners (MP) is a novel prevention strategy that complements pre‐exposure prophylaxis (PrEP), a female‐controlled prevention intervention. The objective of this analysis was to qualitatively operationalize two HIV prevention cascades through the lens of relationship dynamics for secondary distribution of HIV self‐tests to MP and PrEP for AGYW. Methods From April 2018 to December 2018, 2200 HIV‐negative AGYW aged 16‐24 years were enrolled into an HIV prevention intervention which involved secondary distribution of self‐tests to MP and PrEP for AGYW; of these women, 91 participants or MP were sampled for in‐depth interviews based on their degree of completion of the two HIV prevention cascades. A grounded theory approach was used to characterize participants’ relationship profiles, which were mapped to participants’ engagement with the interventions. Results In cases where AGYW had a MP with multiple partners, AGYW perceived both interventions as inviting distrust into the relationship and insinuating non‐monogamy. Many chose not to accept either intervention, while others accepted and attempted to deliver the self‐test kit but received a negative reaction from their MP. In the few cases where AGYW held multiple partnerships, both interventions were viewed as mechanisms for protecting one’s health, and these AGYW exhibited confidence in accepting and delivering the self‐test kits and initiating PrEP. Women who indicated intimate partner violence experiences chose not to accept either intervention because they feared it would elicit a violent reaction from their MP. For AGYW in relationships described as committed and emotionally open, self‐test kit delivery was completed with ease, but PrEP was viewed as unnecessary. MP experience with the cascade corroborated AGYW perspectives and demonstrated how men can perceive female‐initiated HIV prevention options as beneficial for AGYW and a threat to MP masculinity. Conclusions Screening to identify AGYW relationship dynamics can support tailoring prevention services to relationship‐driven barriers and facilitators. HIV prevention counseling for AGYW should address relationship goals or partner’s influence, and engage with MP around female‐controlled prevention interventions.

Background Gender norms against adolescent girls and young women (AGYW)’s having pre-marital sex and using condoms in marriage are included as barriers to motivation to use condoms in HIV prevention cascades. Representative data on gender norms are needed to test this assumption. Methods General-population survey participants in Manicaland, Zimbabwe (ages≥15, N=9803) reported agreement/disagreement with statements on gender norms. AGYW at risk of HIV infection reported whether community views discouraged condom use. Multivariable logistic regression was used to measure associations between AGYW’s perceiving negative gender norms and condom HIV prevention cascades. Results 57% of men and 70% of women disagreed that ‘If I have a teenage daughter and she has sex before marriage, I would be ok with this’; and 41% of men and 57% of women disagreed that ‘If I have a teenage daughter, I would tell her about condoms’. 32% and 69% of sexually-active HIV-negative unmarried AGYW, respectively, said negative community views were important in their decisions to use condoms and their friends were not using condoms. In each case, those who agreed had lower motivation to use condoms. Fewer unmarried AGYW with friends not using condoms used condoms themselves (39% vs. 68%; age- and site-adjusted odds ratios (aOR)=0.29, 95%CI, 0.15-0.55). 21% of men and 32.5% of women found condom use in marriage acceptable. 74% and 93% of married AGYW at risk, respectively, said negative community views influenced their decisions to use condoms and their friends did not use condoms. Fewer married AGYW reporting friends not using condoms were motivated to use condoms but no difference was found in their own condom use (4.1% vs. 6.9%; aOR=0.57, 95%CI, 0.08-2.66). Conclusions Negative gender norms can form a barrier to motivation to use condoms in unmarried and married AGYW at risk of HIV infection, and, for unmarried AGYW, to condom use.

Background Intimate partner violence (IPV) is widespread in the WHO African region with generalised HIV epidemics and may contribute to ongoing HIV transmission through its associations with behaviours associated with HIV acquisition risk and low use of prevention methods particularly in marital relationships. Methods We conducted a male condom HIV prevention cascade analysis using data from a general-population survey in Manicaland, Zimbabwe (July 2018-December 2019) to develop an understanding of how interventions that reduce IPV might be built upon to also reduce HIV incidence. Multivariable logistic regression was used to measure associations between currently-married HIV-negative women’s experience of IPV and: (1) being in the priority population for HIV prevention methods (i.e. married women engaging in behaviours associated with HIV acquisition risk or with a spouse who engages in similar behaviours or is living with HIV), and (2) male condom use by women in this priority population. Male condom HIV prevention cascades, with explanatory barriers for gaps between successive cascade bars (motivation, access and effective use), were compared for women in the priority population reporting and not reporting IPV. Results We found a positive association between IPV and being in the priority population for HIV prevention methods (72.3% versus 58.5%; AOR = 2.26, 95% CI:1.74–2.93). Condom use was low (< 15%) for women in the priority population and did not differ between those reporting and not reporting IPV. The HIV prevention cascades for women reporting and not reporting IPV were similar; both showing large gaps in motivation and capacity to use male condoms effectively. Women reporting motivation and access to male condoms were more likely to report their partner being a barrier to condom use if they experienced IPV (84.8% versus 75.5%; AOR = 2.25, 95% CI:1.17–4.31). Conclusion The findings of this study support the case for trials of integrated IPV/HIV prevention interventions that are tailored to improve HIV risk perception among HIV-negative married women and to make condom provision more acceptable for this group.

Background The Avahan India AIDS Initiative was implemented to provide HIV prevention services to key populations including female sex workers (FSWs) who carry the burden of India’s concentrated HIV epidemic. Established in 2003 and handed over to the Indian government in 2009, the Initiative included peer-led outreach education, condom promotion and distribution and STI treatment. This study aimed to determine if HIV prevention cascades could be generated using routine monitoring and evaluation data from the Avahan program and to assess their value in identifying and responding to program gaps for FSWs. Methods Two data sources were used namely the Integrated Behavioural and Biological Assessment reports and the Centralized Management Information System dataset. Indicators selected for the cascades were: FSWs at risk, belief that HIV can be prevented, condom access and consistent condom use with an occasional partner. Six districts were selected and stratified by HIV prevalence at baseline and two cascades were generated per district reflecting changes over time. Results Consistent condom use with occasional partners in this population increased in all six districts during program implementation, with statistically significant increases in four of the six. No patterns in the cascades were detected according to HIV prevalence either at baseline (2005) or at follow-up (2009). Cascades were able to identify key programmatic bottlenecks at baseline that could assist with focusing program efforts and direct resources at district levels. In some districts the belief that HIV could not be prevented contributed to inconsistent condom use, while in others, low levels of condom access were a more important barrier to consistent condom use. Conclusion This HIV prevention cascade analysis among FSWs in India suggests that cascades could assist in identifying program gaps, focus intervention efforts and monitor their effect. However, cascades cannot replace a detailed understanding of the multiple factors at individual, community and structural levels that lead to consistent condom use in this key population. Careful indicator selection coupled with innovative data collection methods will be required. Pilot projects are proposed to formally evaluate the value of HIV prevention cascades at district level.

Increased coverage of voluntary medical male circumcision (VMMC) is needed in countries with high HIV prevalence. We applied an HIV-prevention cascade to identify gaps in male circumcision coverage in Zambia. We used survey data collected in 2013 and 2014/15 to describe circumcision coverage at each time-point, and prevalence of variables related to demand for and supply of VMMC. We explored whether circumcision coverage in 2014/15 was associated with demand and supply among uncircumcised men in 2013. Results show that circumcision coverage was 11.5% in 2013 and 18.0% in 2014/15. Levels of having heard of circumcision and agreeing with prevention benefits was similar at both time-points (79.8% vs 83.2%, and 49.7% vs 50.7%, respectively). In 2013, 39.3% of men perceived services to be available compared to 54.7% in 2014/15. Levels of having heard of circumcision in 2013 was correlated with and higher perceived service availability associated with coverage in 2014/15. VMMC coverage was low in these study sites. Knowledge of prevention tools and of service availability are necessary to increase coverage but alone are insufficient.

Introduction Couples’ voluntary HIV counselling and testing (CVCT) is a high‐impact HIV prevention intervention in Rwanda and Zambia. Our objective was to model the cost‐per‐HIV infection averted by CVCT in six African countries guided by an HIV prevention cascade framework. The HIV prevention cascade as yet to be applied to evaluating CVCT effectiveness or cost‐effectiveness. Methods We defined a priority population for CVCT in Africa as heterosexual adults in stable couples. Based on our previous experience nationalizing CVCT in Rwanda and scaling‐up CVCT in 73 clinics in Zambia, we estimated HIV prevention cascade domains of motivation for use, access and effectiveness of CVCT as model parameters. Costs‐per‐couple tested were also estimated based on our previous studies. We used these parameters as well as country‐specific inputs to model the impact of CVCT over a five‐year time horizon in a previously developed and tested deterministic compartmental model. We consider six countries across Africa with varied HIV epidemics (South Africa, Zimbabwe, Kenya, Tanzania, Ivory Coast and Sierra Leone). Outcomes of interest were the proportion of HIV infections averted by CVCT, nationwide CVCT implementation costs and costs‐per‐HIV infection averted by CVCT. We applied 3%/year discounting to costs and outcomes. Univariate and Monte Carlo multivariate sensitivity analyses were conducted. Results We estimated that CVCT could avert between 54% (Sierra Leone) and 62% (South Africa) of adult HIV infections. Average costs‐per‐HIV infection averted were lowest in Zimbabwe ( $550) and highest in South Africa ($ 1272). Nationwide implementations would cost between 7% (Kenya) and 21% (Ivory Coast) of a country’s President’s Emergency Plan for AIDS Relief (PEPFAR) budget over five years. In sensitivity analyses, model outputs were most sensitive to estimates of cost‐per‐couple tested; the proportion of adults in heterosexual couples and HIV prevention cascade domains of CVCT motivation and access. Conclusions Our model indicates that nationalized CVCT could prevent over half of adult HIV infections for 7% to 21% of the modelled countries’ five‐year PEPFAR budgets. While other studies have indicated that CVCT motivation is high given locally relevant promotional and educational efforts, without required indicators, targets and dedicated budgets, access remains low.