HIV, HSV-2, and other sexual and reproductive health harms among schoolgirls in western Kenya

Adolescent girls face severe sexual and reproductive health (SRH) health risks in low-and middle-income countries (LMIC). Despite global efforts to address girls SRH in LMIC, they continue to suffer high rates of HIV, HSV-2, and adolescent pregnancy. Inadequate support of girls’ menstrual hygiene exacerbates these harms. Rigorous evaluations of objectively measured interventions that can improve girls’ SRH are needed to assess efficacy and cost-effectiveness. This study employed a 4-arm cluster randomised trial design to evaluate the impact of a menstrual solution, the menstrual cup, and/or termly cash transfers conditional on school attendance, on the SRH outcomes of 4137 adolescent girls attending 96 secondary schools in western Kenya. These interventions were given directly to participants and tested over the course of 3 years of secondary school. Two desk reviews of the individual interventions were conducted, which found that these interventions were acceptable to schoolgirls in LMIC and showed potential to improve SRH outcomes. Following enrolment, this study first explored girls’ baseline SRH conditions and characteristics. Girls self-reported accounts and baseline laboratory-confirmed biomarkers indicated that girls were frequently harassed for sex and had a high risk of adolescent pregnancy and HSV-2. Post baseline the study followed girls under intervention through to their final school exams taken at the end of their fourth year. At end of study, our trial measured the impact of both interventions separately, and in combination, on reducing key individual SRH outcomes including HIV, HSV-2, and adolescent pregnancy, as well as a composite measure of HIV and HSV-2 incidence and all-cause school dropout. Cash transfer interventions showed no effect on reducing HIV or HSV-2 incidence or pregnancy risk. Menstrual cups were found to be protective against HSV-2, school dropout, and adolescent pregnancy with no evidence of serious adverse events. Lastly, due to the onset of the COVID-19 pandemic during study follow-up, pandemic-level effects on adolescent pregnancy were measured by comparing girls in the trial who graduated prior to the pandemic with those who completed their schooling post-pandemic. The COVID-19 pandemic impacted adolescent girls’ SRH, with girls experiencing containment measures having twice the rate of pregnancy relative to girls graduating prior to the pandemic. These findings underscore the need for programs and interventions that help buffer the effects of population-level emergencies on school-going adolescents. Our study highlights that adolescent girls’ SRH needs in LMIC are not met and require effective solutions that protect from harms including HIV, HSV-2, and pregnancy. Menstrual cups appear to be a cost-effective sustainable intervention that shows promise for adolescent SRH programming