Retention and performance of peer educators and sustainability of HIV prevention services for adolescents in the Zimbabwe Smart-LyncAges project: an ecological study.

Introduction: in 2016, the partner-funded Smart-LyncAges participatory learning project explored the feasibility of a youth-friendly package including incentivized peer educators (PEs) to enhance adolescent sexual and reproductive health (ASRH) and voluntary medical male circumcision (VMMC) linkages. After 12 months of implementation, funding reduction resulted in reduced direct project monitoring and discontinuation of monetary incentives for PEs. We assessed if reduced funding after one year of implementation affected the performance and retention of PEs and uptake of VMMC and HIV testing in ASRH services by adolescents in Bulawayo City (urban) and Mount (Mt) Darwin District (rural) in Zimbabwe. Methods: our study was an ecological study using routine data collected from March 2016 to February 2017 (intensive support) and March 2017 to February 2018 (reduced support). All the ASRH and VMMC sites in Mt Darwin and Bulawayo were involved. Participants included 58 PEs and all adolescents accessing VMMC and ASRH services. Retention of PEs measured by the submission of monthly reports and uptake of VMMC and HIV testing were the primary outcome measures. Results: the Smart-LyncAges project engaged 58 PEs with 80% aged 20-24 years. Two-thirds were male and 60% were engaged in peer education before the project. Retention of PEs was not negatively affected by funding reduction, with 70% retained up to 11 months after funding reduction. However, their performance, measured by submission of monthly activity reports and the number of adolescents reached with VMMC and HIV messages, declined while uptake of both VMMC and HIV testing was sustained. Conclusion: sustained uptake of services was possibly due to heightened awareness of service availability and demand generation in the first year of implementation. Peer-led interventions are effective for health information dissemination. Monetary incentives determine performance, but are not the only reason for retention.