Eastern and Southern Africa contain 63% of the world’s population living with HIV; Girls are particularly vulnerable, contracting HIV at young ages, and diverging from their male peers since they often date older partners who are exponentially more likely to have HIV. In Botswana nearly 45% of forty year-old men are infected with HIV, 9x higher than young boys. When surveyed, we found that 90% of young people in Botswana are unaware of the risks of older partners. Girls enter relationships with older partners thinking they are safer because they are “old, wise, and mature,” but in reality these relationships have lethal risks. Indeed, this is indicative of a widespread problem: over 60% of girls in East and Southern Africa lack comprehensive HIV knowledge.
Traditionally, the dominant approach to address these problems has been abstinence education. While optimal in theory, many young people do not abstain and, in the absence of alternative safe sex education, they engage in risky, unprotected sex. We believe shifting from a “no risk” to “low risk” educational message has significant health impacts. Dating younger partners who have a 5% HIV rate - 10x lower than older partners - and more equal power dynamics is a radically safer option. More rigorous research across a variety of contexts is needed to generate and influence evidence-based recommendations for quality comprehensive sexual and reproductive health and rights curriculum in sub-Saharan Africa.
Zones, our flagship program, encourages youth to safely date age-mates instead of riskier older partners. The program is delivered by peer educators in schools and is realistic, simple, scalable, and inspired by rigorous evidence. Zones was inspired by a 1-hour class delivered in government schools in Kenya and shown to reduce teen pregnancy— also a proxy for unprotected sex and HIV—by 28% in one year through a randomized control trial (RCT). Youth Impact revitalized this promising evidence-based program and delivered it in Botswana. However, the context had changed and additional testing was needed to see if the program still worked. To this end, Youth Impact partnered with the University of Botswana, Ministry of Basic Education, Botswana-Baylor Children’s Clinical Center of Excellence, J-PAL and Evidence Action to conduct an RCT on an adapted version of the Kenya program, which we called "No Sugar", to see if it worked in the Botswana context. The trial covered 42,000 students across a third of the nation. We had two implementers: teachers and peer educators. This was designed to inform the most cost-effective scale-up model. The trial ran from 2015-2016. The results were promising: there was a reduction in our main measure of pregnancy of 40%, similar to the original Kenya trial. At the same time, the results indicated a need to adapt the program further before scale-up. For example, the messenger mattered: youth were more effective at delivering the intervention than teachers. Also, "sugar daddies" were younger than expected. Since 2016, we have been transforming this evidence base into a version 2.0 of the program called "Zones." Through a rapid, rigorous iteration approach called "Rapid Impact Assessments (RIAs),” we have built a strong, effective curriculum that demonstrates significant and sustained increases in HIV knowledge and reductions in risky sexual behavior. The percentage of students who correctly knew that older partners have the highest risk of HIV has grown from 70% to 97%. Additionally, we’ve seen large and significant reductions in risky sexual behavior (e.g., intimate activities with older partners) with reductions up to 50%. These impacts are the “holy grail” of the RIA process, since they happen quickly (within 1-2 months) and are critical sexual behavior change outcomes that will lead to even larger effects on long-term behavioral outcomes, such as reductions in pregnancy, school dropout due to pregnancy, and HIV/STI incidence. We are drawing on this wealth of rigorous evidence to implement the highest impact program possible.