Food insecurity, poverty, and parental HIV/AIDS have been identified as important drivers of HIV risk and vulnerability among adolescent girls, yet few studies have evaluated the impact of a household-level intervention among adolescent girls. To address this gap, our interdisciplinary team will analyze the preliminary impact of a multisectoral agricultural intervention on adolescent girls’ sexual and reproductive health, and to elucidate the causal pathways for adolescent girls (mental health, education, and empowerment) and their caregivers (physical and mental health, parenting) through which the intervention may lead to these outcomes. If proven efficacious in the pilot and subsequent larger trial, the proposed intervention may: 1) halt or slow down the cycle of incident HIV, other sexually transmitted infections, and unintended pregnancies to improve the lives of adolescent girls in similar settings, and 2) help achieve several top Sustainable Development Goals (SDG) including SDG 1 (zero poverty), SDG 2 (zero hunger), SDG 3 (good health and wellbeing), and SDG 5 (gender equality).
HIV-related mortality among adolescents is on the rise and over half of incident HIV cases globally are among adolescents, particularly among girls. Food insecurity (FI) and poverty are important drivers of HIV vulnerability among adolescent girls, and contribute to worse sexual and reproductive health (SRH) outcomes including higher rates of HIV, other sexually transmitted diseases, and unintended pregnancy. While most approaches to improving adolescent SRH outcomes have focused on individual-centered approaches alone, integrated family-level interventions that address the underlying context for risk behaviors such as poverty and FI may be more effective in reducing adverse SRH outcomes. Our team has successfully developed and piloted a household-level multisectoral agricultural and finance intervention in Nyanza Region, Kenya called Shamba Maisha (SM) designed to increase household FI and improve health in HIV-affected households. SM includes a loan used to get a human-powered water pump, agricultural supplies, and education in financial management and sustainable farming practices. In mid-2016, we launched a large cluster-randomized controlled trial of SM (RO1 MH107330, & RO1 MH109506), targeting 704 adults and 352 young children to test the effectiveness of this intervention on adult and pediatric health outcomes. Consistent with NIH, UNAIDS, and WHO’s research priorities for adolescent health, we propose to leverage the infrastructure provided by this cluster RCT to recruit adolescent girls residing in SM households and assess the preliminary impact of SM on adolescent girls’ SRH outcomes at study endline. The central hypothesis is that improvements in household FI and wealth will contribute to reduced sexually transmitted infections, HIV, and unintended pregnancies among adolescent girls. We will enroll 200 adolescent girls ages 15-19 and their caregivers residing in households of SM participants (1:1 ratio intervention and control arms) from 12 communities in a pilot study with the following specific aims: Aim 1: To determine the preliminary impact of SM on the primary adolescent SRH outcomes of interest for the subsequent larger study. We hypothesize that adolescents living in intervention households will experience a lower prevalence of STIs (herpes simplex virus-2 and HIV), unintended pregnancies, and fewer sexual risk-taking behaviors. Aim 2: To determine the impact of SM on the intermediate outcomes that are theorized to be on the causal pathway between SM and SRH outcomes among HIV-affected adolescent girls. Based on our novel conceptual framework, we hypothesize that SM will improve household FI and wealth, which will contribute to improved SRH outcomes through mental health (less depression, anxiety), empowerment (improved self-esteem, self-concept), and educational (increased educational attainment) pathways. We also hypothesize that improved caregiver health and parenting will contribute to improved adolescent girls’ SRH. Aim 3: To translate lessons learned into the design of an enhanced intervention to maximize impact on adolescent girls’ SRH for future scale-up in Kenya and similar settings in SSA.