Youth-Friendly Sexual Health Services and Peer Support for Improved Sexual and Reproductive Health Outcomes Among Adolescents and Young Adults in South Africa: Results of a Factorial Randomized Controlled Trial.
Peer support and STI testing with expanded SRH each had no more than small effects on STIs, contraception, or pregnancy, but combined exposure to both interventions reduced STI prevalence compared with standard of care.
Key Findings
Results
Among participants with 12-month STI results, 22.5% tested positive for at least one STI.
927 of 1743 trial participants (53%) had 12-month STI results available.
209 of 927 (22.5%) tested positive overall.
Chlamydia was most prevalent at 17.6% (163 participants), followed by gonorrhea at 5.8% (54 participants) and trichomoniasis at 4.8% (44 participants).
The trial was conducted from March 2020 to August 2022 among 16- to 29-year-olds in rural KwaZulu-Natal, South Africa.
The study population was 51% female.
Results
The combination of peer support and expanded SRH services significantly reduced STI prevalence compared with standard of care.
Participants exposed to both interventions had an adjusted odds ratio (aOR) of 0.59 (95% CI, 0.38–0.94) for STI compared with standard of care.
Peer support alone showed a non-significant reduction (aOR 0.77; 95% CI, 0.56–1.06).
Expanded SRH alone also showed a non-significant reduction (aOR 0.74; 95% CI, 0.56–1.06).
The odds ratios were adjusted for sex, age, and location.
The trial used a 2×2 factorial randomized controlled trial design.
Results
Among participants in the SRH arms, 13.6% had a new STI at 12 months, with no difference by peer support status.
64 of 469 participants (13.6%) in SRH arms had a new STI at 12 months.
There was no statistically significant difference by peer support (P = 0.97).
This finding suggests peer support did not add benefit for incident STI within the SRH arm specifically.
Results
Contraceptive use and pregnancy rates among female participants showed little difference across study arms.
336 of 634 female participants (53.0%) reported using contraception at 12 months.
47 of 667 female participants (7.1%) reported pregnancy.
The authors noted 'little difference by study arm' for both contraception and pregnancy outcomes.
Contraceptive use and pregnancy were self-reported outcomes.
Methods
The study evaluated four intervention arms in a 2×2 factorial randomized controlled trial targeting adolescents and young adults in rural South Africa.
Arm 1: Enhanced standard of care with access to mobile youth-friendly HIV prevention (AYFS).
Arm 2: SRH intervention — self-collected STI testing and referral to AYFS with expanded SRH services.
Arm 3: Peer support — peer navigator facilitation of AYFS attendance.
Arm 4: SRH + peer support combined.
1743 participants aged 16–29 years were enrolled; STI outcomes were secondary outcomes of the trial.
Discussion
The authors concluded that combined or more intensive interventions are needed to meaningfully reduce STIs and improve reproductive health outcomes.
Suggested strategies include repeat screening, enhanced partner notification, and deeper understanding of structural drivers.
The authors describe each individual intervention as having 'no more than small effects on STIs, contraception, or pregnancy.'
The high STI burden (22.5% prevalence at 12 months) underscores the need for more effective approaches in this population.
What This Means
This research tested whether offering young people in rural South Africa expanded sexual health services, peer navigator support, or both could reduce sexually transmitted infections (STIs), increase contraceptive use, and lower pregnancy rates. The study enrolled 1,743 people aged 16–29 in a rigorous randomized trial and followed them for 12 months. It found that STI rates were high — more than 1 in 5 participants who were tested had an STI, most commonly chlamydia. Neither expanded services alone nor peer support alone significantly reduced STIs, but receiving both together was associated with a meaningful reduction in STI prevalence compared to standard care.
For female participants, about half reported using contraception and roughly 1 in 14 reported a pregnancy, with little variation across the different intervention groups. This suggests that the tested approaches had limited impact on contraceptive behavior and pregnancy rates. The peer navigator support also did not add additional benefit for new STI diagnoses among those already receiving the expanded SRH services.
This research suggests that while combining youth-friendly services with peer support shows some promise for reducing STIs, single or moderate-intensity interventions are not sufficient on their own to substantially change sexual health outcomes in this high-burden setting. The authors highlight the need for more intensive strategies — such as repeated STI screening, better partner notification practices, and addressing the deeper social and structural factors that drive STI transmission and unintended pregnancy among young people in South Africa.
Jarolimova J, Busang J, Chimbindi N, Okesola N, Smit T, Harling G, et al.. (2025). Youth-Friendly Sexual Health Services and Peer Support for Improved Sexual and Reproductive Health Outcomes Among Adolescents and Young Adults in South Africa: Results of a Factorial Randomized Controlled Trial.. Sexually transmitted diseases. https://doi.org/10.1097/OLQ.0000000000002203