In Eastern and Southern Africa, evidence suggests that adolescents (10-19 years) and young people (10-24 years) are still heavily affected by HIV/AIDS. In 2017, adolescents and young people accounted for 37% of all new HIV infections and 15% of all people living with HIV . Overall, AIDS-related deaths have also increased by 50% among adolescents and young people between 2005 and 2017, despite the overall number of AIDS-related deaths declining by 48% during the same period .
In South Africa, approximately 260,000 children aged 0 to 14 years lived with HIV in 2018. HIV prevalence among young women (15-24 years) was significantly higher (11.3%) than among young men (3.7%), signifying the vulnerability of girls to the HIV pandemic . This HIV burden among adolescents and young people comes in the context of limited access to HIV and Sexual and Reproductive Health Rights (SRHR) services among this age group . Any effort aimed at addressing HIV, therefore, needs to target this age group if it is to achieve milestones such as the Sustainable Development Goal (SDG) of ending the HIV epidemic by 2030 .
For over two decades, the Department of Basic Education in South Africa has been implementing HIV education in schools through various interventions, notably the institutionalisation of Life Skills and Life Orientation as part of the curriculum . The continued increase in HIV incidence among young people, however, indicates complexities in these interventions in addressing HIV risk among children and young people . Visser has indicated that for school-based HIV prevention strategies to be effective, they need to go beyond educating the individual to understanding young people’s sexual risk behaviour and the underlying drivers for these behaviours . This includes addressing interpersonal and community factors such as improving child-parent communication, peer group norms, addressing substance abuse, and shifting unequal gender norms. This is consistent with behaviour change theories within the ecological approach, such as social identity theory, which emphasizes the importance of social norms in determining behaviour change [5,6,7]. Child-focused interventions that complement curriculum-based interventions while guided by these social and behaviour change theories therefore have the potential to tackle these drivers of adolescent behaviours. Save the Children International’s advice when programming for children is that it is imperative to put the child at the centre . There is a growing recognition that as children transition into adulthood, especially in high-risk situations such as HIV/AIDS, they need safe spaces where they can communicate, socialize, learn and practice life skills and receive psychosocial support [9,10,11,12,13].
The Soul Buddyz Clubs (SBC) programme is one such programme that addresses interpersonal and community factors and gives voice to and promotes action by and for children’s health and well-being. Soul Buddyz Clubs are school-based and target primary school preteens and young adolescents in poor communities based in rural and peri-urban areas, commonly referred to as Townships and Informal settlements in South Africa. By 2020, over 8000 SBC clubs, that reached approximately 190 000 pupils, had been established across schools in South Africa over the past eighteen years. The clubs emerged from a health and development communication perspective with the strategic goal of empowering children through education and life skills, increasing their efficacy to deal with adolescent sexuality and HIV prevention, and becoming agents of change, embedding the principle of child participation. As an extracurricular activity, SBC activities are supported by volunteer facilitators (educators at schools where the clubs are implemented) and are aimed at increasing knowledge and skills about health and wellbeing and strengthening the existing Life Orientation and Life Skills curriculum taught in schools [4, 14, 15]. According to Centers for Disease Control and Prevention (CDC), comprehensive school health is based on a curriculum that includes an array of topics such as personal, family, community, consumer and environmental health; sexual health education; mental and emotional health; injury prevention and safety; nutrition; prevention and control of disease; and alcohol, tobacco and other drugs – that are delivered by well-trained teachers [16, 17].
The role of teachers as facilitators of the Soul Buddyz Clubs has been fundamental to their success and sustainability since 2003, when clubs were initiated. The objectives of the clubs are to provide learners with edutainment that allows them to have fun while learning, promoting positive attitudes and behaviours that relate to HIV, such as self-efficacy for safer sexual behaviour, condom use, gender-based violence and alcohol and drug use . Club activities range from regular after-school club meetings, discussions and debates on important themes, competitions and projects on topics of interest including HIV/AIDS testing, treatment and stigma and discrimination; sexual and reproductive health; healthy lifestyle (nutrition, diet and physical activity); medical male circumcision (MMC); Tuberculosis, bullying; and community participation. Facilitators are provided with training on the programme that is premised on the comprehensive school health education guidelines, as well as additional resources and materials, including booklets, magazines, and posters, which are used to steer these discussions . The clubs promote action by children, facilitating their ability to organise themselves and be agents of change for children’s issues.
Existing literature on school-based programmes aimed at improving the sexual and reproductive health of adolescents indicates that school- or community-based sexuality and HIV/AIDS education programmes increase knowledge, may reduce the number of sexual partners and increase condom and contraceptive use [19,20,21]. There are also reported improvements in attitudes towards people living with HIV/AIDS, intention to abstain or use a condom and self-efficacy for condom use; increase in talking to others (friends, peers/parents/boyfriend/girlfriend) about sexual risk and delay sexual debut [20, 22]. Contrary to fears expressed by parents, school-based sexuality education programs do not lead to early sexual debut or increased sexual activity [23,24,25,26]. A review by Mason-Jones et al. revealed that combined (sexual and reproductive) educational and incentive-based programmes had a positive effect on sexually transmitted infections (STIs) (herpes simplex virus infection) . Ross et al. indicated that incentive-based interventions are likely to reduce adolescent pregnancy .
While there are several programmes for adolescents in South Africa (e.g., DREAMS; YOLO, loveLife), there is a gap in programmes targeting 10–14-year-olds. SBC is one of the few established programmes that targets this age group, a key age to target for prevention amidst the argument that even though the majority have not yet begun sexual activity, there is growing evidence that pubescents are exposed to sexual risk and vulnerability at a younger age. For example, the HSRC survey found that sexual debut < 15 years increased from 8.5% in 2008 to 13.6% in 2017. This is the case for both males and females: from 11.3% to 19.5% for males and 5.9% to 7.6% in females . Furthermore, sexual coercion associated with sexual debut has been an issue of concern, as highlighted in a study in KwaZulu-Natal by Maharaj & Munthree, which found that nearly 46% of all adolescent girls and young women (14-24 years) reported that their first sexual encounter had been coerced and that this group was more likely to have had an STI or unintended pregnancy .
There is paucity of evidence on the effectiveness of extracurricular school-based programmes in promoting HIV prevention. A soccer-based programme implemented in Uganda and Zimbabwe that aimed to promote voluntary medical male circumcision (VMMC) among schoolboys reported increases in male circumcision (10% and 26%) [30, 31], as well as almost three times the increased likelihood of performing VMMC . Studies that documented support required by adolescents affected by HIV/AIDS in schools revealed that within the context of high rates of psychological, behavioural and emotional problems among youth, support by teachers’ peers and the general school environment amidst experiences of discrimination, social exclusion, labelling and bullying in school was not adequate [33, 34].
The objective of this paper is to investigate the role and effectiveness of an extracurricular school-based programme on HIV knowledge, attitudes and practices, as well as biomedical outcomes (HIV testing and MMC) among children. The paper seeks to demonstrate the value of participatory interventions that are child-centred and provide an open and interactive environment while addressing HIV risk and life skills.