Stepping up the Fight An evaluation of the Stepping Stones approach to HIV prevention among adolescents and young people in

September 2019

ACKNOWLEDGEMENTS

National Steering Committee

Mr. Khanya Mabuza Executive Director, National Emergency Response Council on HIV and AIDS (NERCHA) Ms. Nonhlanhla Dlamini Principal Secretary of the Ministry of Tinkhundla Administration and Development (MTAD) Dr. Vusi Magagula Director Health Services, Ministry of Health (MoH) Dr. Caroline Ryan Coordinator, U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) Mr. Tim Rwabuhemba Country Director, The Joint United Nations Program on HIV/AIDS (UNAIDS) Mr. Emmanuel Ndlangamandla Executive Director, Co-ordinating Assembly of Non-Governmental Organizations (CANGO)

National Task Team

Ms. Tengetile Dlamini Research Manager, NERCHA Mr. Dumisane Simelane Eswatini National Youth Council (SNYC) Mr. Muhle Dlamini Eswatini National AIDS Programme (SNAP) Ms. Zandile Mnisi Research Manager, MoH Ms. Zandile Masangane Adolescent Sexual Reproductive Health Focal Person, MoH Mr. Bongani Masango SNAP Mr. Ayanda Sikhondze SNAP Mr. Vulindlela Ginindza MTAD Ms. Thembisile Dlamini Community Mobilization and Networking Advisor, UNAIDS Mr. Lawrence Mashimbye Strategic Information Advisor, UNAIDS Mr. Leonard Kamugisha Chief, Adolescents & Youth Development, The United Nations International Children's Emergency Fund (UNICEF) Dr. Bongani Dlamini Programme Specialist, Sexual and Reproductive Health and Rights (SRHR), HIV & Adolescents and Youth, United Nations Population Fund (UNFPA) Ms. Bindza Ginindza Pact Eswatini Ms. Nqobile Tsabedze Director - Grants Management Unit, CANGO Ms. Lungile Nkambule Monitoring, Evaluation and Research (MER) Manager, CANGO

Stepping up the Fight An evaluation of the Stepping Stones approach to HIV prevention 2 among adolescents and young people in Eswatini

Evaluation Team

Ms. Tengetile Dlamini Research Manager, NERCHA (Principal Investigator [PI]) Mr. Muhle Dlamini SNAP (Co-investigator) Ms. Lungile Nkambule MER Manager, CANGO (Field Officer) Ms. Nqobile Tsabedze Director - Grants Management Unit, CANGO (Field Officer) Dr. Gemma M. Oberth AIDS and Society Research Unit, University of Cape Town (UCT) (Lead Consultant) Mr. Lungelo Vukile Bhembe The Research Company (TRECO) (Local Consultant) Ms. Philile Claudia Dikiza Data Collector Ms. Zamakholo Thandeka Matsebula Data Collector Mrs. Nondumiso Bekile Bhembe Data Collector Mr. Brighten Machawe Mkhatchwa Data Collector Ms. Nothando Mthethwa Data Collector Ms. Happiness Brenda Bennett Data Collector Mr. Ngcebo Moyane Data Collector Mr. Thabiso Cyril Ndzabandzaba Data Collector Ms. Nomalungelo Lulu Howe Data Collector Mrs. Lomakhosi Gcinile Dlamini Msibi Data Collector Ms. Mandisa Dlamini Data Collector Mr. Ndimphiwe Shabangu Data Collector Mr. Makhosonkhe Fortune Soko Data Collector Ms. Nomfundo Hedzane Study Participant Mobilizer, Kukhanyeni Ms. Namile Dlamini Study Participant Mobilizer, Ms. Zandile Shongwe Study Participant Mobilizer, Gege Ms. Welile Ginindza Study Participant Mobilizer, Mhlume Mr. Sibusiso Tsabedze Study Participant Mobilizer, Mr. Menzi Tsabedze Study Participant Mobilizer, Ms. Sesenelisiwe Dlamini Study Participant Mobilizer, Mr. Tiny Madau Study Participant Mobilizer,

Stepping up the Fight An evaluation of the Stepping Stones approach to HIV prevention 3 among adolescents and young people in Eswatini

Study Participants

The National Steering Committee, National Task Team, and Evaluation Team, would like to thank all of the adolescents and young people, as well as their parents and caregivers, who volunteered their time, energy and personal information to support this evaluation.

Study Sponsor

All evaluation costs were supported by UNAIDS, through its Technical Support Mechanism.

Suggested Citation

Government of the Kingdom of Eswatini. Stepping up the Fight: An evaluation of the Stepping Stones approach to HIV prevention among adolescents and young people in Eswatini. Final Report. Mbabane: Government of the Kingdom of Eswatini; August 2019.

Stepping up the Fight An evaluation of the Stepping Stones approach to HIV prevention 4 among adolescents and young people in Eswatini

ABBREVIATIONS

AIDS Acquired immune deficiency syndrome AGYW Adolescent girls and young women ART Antiretroviral therapy ASRH Adolescent sexual and reproductive health CANGO Co-ordinating Assembly of Non-Governmental Organizations CI Confidence interval DHS Demographic and Health Surveys HIV Human immunodeficiency virus FGD Focus group discussion FLAS Family Life Association of Swaziland KII Key informant interview MoH Ministry of Health MTAD Ministry of Tinkhundla Administration and Development NERCHA National Emergency Response Council on HIV and AIDS NHRRB National Health Research Review Board MICS Multiple Indicator Cluster Survey OR Odds ratio PEPFAR The U.S. President's Emergency Plan for AIDS Relief PI Principal Investigator PLHIV People living with HIV PrEP Pre-exposure prophylaxis SGBV Sexual and gender-based violence SHIMS 2 The Second Swaziland HIV Incidence Measurement Survey SNAP Swaziland National AIDS Programme SNYC Swaziland National Youth Council SRH Sexual and reproductive health SRHR Sexual and Reproductive Health and Rights SQL Structured Query Language TRECO The Research Company VMMC Voluntary medical male circumcision UCT University of Cape Town UNAIDS The Joint United Nations Program on HIV/AIDS UNDP United Nations Development Programme UNESCO The United Nations Educational, Scientific and Cultural Organization UNFPA United Nations Population Fund UNICEF The United Nations International Children's Emergency Fund USAID The United States Agency for International Development

Stepping up the Fight An evaluation of the Stepping Stones approach to HIV prevention 5 among adolescents and young people in Eswatini

TABLE OF CONTENTS

ACKNOWLEDGEMENTS ...... 2

TABLE OF CONTENTS ...... 6

LIST OF TABLES AND FIGURES...... 9

EXECUTIVE SUMMARY ...... 11

INTRODUCTION ...... 15 Country context ...... 15 The Stepping Stones program ...... 16 Goal of the Intervention ...... 16 Overview of the intervention...... 16 Program coverage ...... 17 Rationale of the evaluation ...... 17 Study objectives ...... 18 Main research question ...... 19 Sub-questions ...... 19

METHODOLOGY ...... 20 Desk review ...... 20 Quantitative methods ...... 20 Surveys...... 20 Qualitative methods ...... 20 Focus group discussions ...... 20 Key informant interviews ...... 20 Study process ...... 21 Data collectors training ...... 21 Sampling ...... 21 Tools ...... 22 Quality assurance...... 23 Data analysis ...... 24 Validation ...... 24 Dissemination ...... 24 Ethical considerations ...... 25 Ethics approval ...... 25 Confidentiality ...... 25 Data security ...... 25 Risks and benefits to participants ...... 25 Consent ...... 26 Limitations ...... 26

QUANTITATIVE RESULTS AND ANALYSIS ...... 28 Characteristics of survey respondents ...... 28 Results and analysis on knowledge indicators ...... 30 Stepping up the Fight An evaluation of the Stepping Stones approach to HIV prevention 6 among adolescents and young people in Eswatini

Knowledge results and analysis, overall ...... 30 Knowledge results and analysis, by age and sex ...... 31 Knowledge results and analysis, by ...... 31 Knowledge results and analysis, by program exposure ...... 32 Results and analysis on behavioral indicators ...... 33 Behavioral results and analysis, overall ...... 33 Behavioral results and analysis, by age and sex ...... 34 Behavioral results and analysis, by Inkhundla ...... 35 Behavioral results and analysis, by program exposure ...... 37 Results and analysis on attitudinal indicators ...... 40 Attitudinal results and analysis, overall ...... 40 Attitudinal results and analysis, by age and sex ...... 40 Attitudinal results and analysis, by Inkhundla ...... 41 Attitudinal results and analysis, by program exposure ...... 42 Results and analysis on access indicators ...... 43 Access results and analysis, overall ...... 43 Access results and analysis, by age and sex ...... 44 Access results and analysis, by Inkhundla ...... 45 Access results and analysis, by program exposure...... 46 Results and analysis on attribution indicators ...... 48 Results and analysis on sustainability and value-for money ...... 49 Sustainability of program effects over time ...... 49 Value-for-money and potential return on investment ...... 50 Comparison of program output results (targets) and evaluation findings ...... 50

QUALITATIVE RESULTS AND ANALYSIS ...... 53 Characteristics of focus group participants...... 53 Characteristics of key informants ...... 53 Perceptions on program content and opportunities to improve program design .... 53 Most valued topics...... 53 Updating or augmenting the curriculum ...... 57 Expanding the target beneficiaries ...... 58 Engaging parents and caregivers ...... 59 Implementation challenges and strategies to improve program delivery ...... 59 Condensing curriculum into intensive sessions ...... 60 Retaining beneficiaries in the program ...... 60 Reducing barriers to accessing services ...... 61 The capacity and role of facilitators ...... 62 Ensuring sustainable results ...... 63

CONCLUSION ...... 64

RECOMMENDATIONS ...... 65 Recommendations for the Global Fund ...... 65 Recommendations for the Government of Eswatini ...... 65 Recommendations for Stepping Stones program implementers ...... 67 Recommendations for other bilateral, multilateral and technical partners ...... 70

REFERENCES ...... 72 Stepping up the Fight An evaluation of the Stepping Stones approach to HIV prevention 7 among adolescents and young people in Eswatini

ANNEXES ...... 76 Annexes on program description ...... 76 Annex 1. Stepping Stones Curriculum used Global Fund-supported program in Eswatini ...... 76 Annex 2. Total Stepping Stones Enrollment in the Global Fund-supported Program (October 2015 – September 2018) ...... 77 Annexes on survey results ...... 78 Annex 3. Stepping Stones Evaluation Participants Who Answered “Yes/True” to Survey Questions, By Age and Sex ...... 78 Annex 4. Stepping Stones Evaluation Participants Who Answered “Yes/True” to Survey Questions, By Inkhundla ...... 81 Annex 5. Stepping Stones Evaluation Participants Who Answered “Yes/True” to Survey Questions, By Level of Program Completion ...... 84 Annex 6. Stepping Stones Evaluation Participants Who Answered “Yes/True” to Survey Questions, By Year of Program Enrollment ...... 87 Annexes on evaluation tools ...... 89 Annex 7. Survey Tool Used for Stepping Stones Evaluation ...... 89 Annex 8. Focus Group Discussion Guide Used for Stepping Stones Evaluation...... 95

Stepping up the Fight An evaluation of the Stepping Stones approach to HIV prevention 8 among adolescents and young people in Eswatini

LIST OF TABLES AND FIGURES

Tables

Table 1 Priority Research Questions in Eswatini’s National Multisectoral HIV and AIDS Strategic Framework 2018-2022 Explored in Stepping Stones Evaluation

Table 2 Data collection sites for Stepping Stones evaluation

Table 3 Characteristics of Stepping Stones evaluation participants

Table 4 Comparison of program output results (targets) and evaluation findings

Figures

Figure 1 HIV incidence in Eswatini, by age and sex (SHIMS 2, 2016-2017)

Figure 2 Proportion of young women and men age 20-24 years who correctly identify ways of preventing the sexual transmission of HIV and reject major misconceptions about HIV transmission (Stepping Stones participants vs. MICS 2014 national survey data)

Figure 3 Proportion of Stepping Stones participants who responded "True" to survey questions on HIV prevention knowledge (select indicators), by Inkhundla

Figure 4 Proportion of Stepping Stones participants who responded "True" to the survey question: “There is a daily drug available called “PrEP” that can be taken by people who don't have HIV to prevent them from being infected with the virus”, by program exposure

Figure 5 Proportion of young women and men age 20-24 years who used a condom the last time they had sex with a non-marital, non-cohabiting partner (Stepping Stones participants vs. SHIMS 2 national survey data)

Figure 6 Proportion of Stepping Stones participants who engaged in transactional sex, compared to national survey data

Figure 7 Proportion of Stepping Stones participants who responded "Yes" to survey questions on GBV prevention behaviors (select indicators), by Inkhundla

Figure 8 Correlation between being able to identify risk or warning signs of sexual and gender-based violence and saying “no” to an unwanted sexual situation in the past year, by Inkhundla

Figure 9 Correlation between setting/tracking goals for oneself and taking actions to save money, by Inkhundla

Figure 10 Proportion of Stepping Stones participants who responded "Yes" to the survey question: "Did you use a condom the last time you had sex with non- marital, non-cohabiting partner?", by program exposure

Stepping up the Fight An evaluation of the Stepping Stones approach to HIV prevention 9 among adolescents and young people in Eswatini

Figure 11 Proportion of Stepping Stones participants who responded "Yes" to the survey question: "Are you currently using a method of modern contraception?”, by program exposure

Figure 12 Proportion of Stepping Stones participants who have said “no” to an unwanted sexual situation in the past year, by program exposure

Figure 13 Proportion of Stepping Stones participants who responded "Yes" to the survey question: "Have you or your partner fallen pregnant in the past year?”, by program exposure

Figure 14 Proportion of Stepping Stones participants who responded "Yes" to the survey question “has your life improved during the past year?”, by Inkhundla

Figure 15 Proportion of Stepping Stones participants who responded "Yes" to the survey question: "Should men and women have equal rights in society?", by program exposure

Figure 16 Proportion of young men and women age 20-24 years who received HIV testing in the past 12 months (Stepping Stones participants vs. SHIMS 2 national survey data)

Figure 17 Stepping Stones participants who received HIV/SRH services in the past year

Figure 18 Proportion of Stepping Stones participants who responded "Yes" to survey questions on economic empowerment, by age and sex

Figure 19 Proportion of Stepping Stones participants who responded "Yes" to survey questions on access to services (select indicators), by Inkhundla

Figure 20 Proportion of Stepping Stones participants who responded "Yes" to the survey question: "Have you received family planning/contraceptive services in the past year?", by program exposure

Figure 21 Proportion of Stepping Stones participants who received post-violence care if they experienced SGBV in the past one year, by program exposure

Figure 22 Proportion of Stepping Stones participants who reported to the police or other authorities if they experienced sexual or gender-based violence, by program exposure

Figure 23 High rates of HIV testing, condom use, HIV prevention knowledge, contraception use, and economic empowerment among Stepping Stones participants, maintained up to three years post-intervention

Stepping up the Fight An evaluation of the Stepping Stones approach to HIV prevention 10 among adolescents and young people in Eswatini

EXECUTIVE SUMMARY

This evaluation reviewed the outcomes of the Stepping Stones approach to HIV prevention among adolescents and young people in Eswatini, as implemented through CANGO between October 2015 and September 2018. Over that period, CANGO enrolled 22,923 adolescents and young people across 20 Tinkhundla in the program. The evaluation aimed to determine if the Stepping Stones approach was an effective mechanism for reducing negative health outcomes and increasing uptake of HIV, sexual and gender-based violence and sexual and reproductive health services among adolescents and young people.

Data collection took place in eight Tinkhundla: , Nkhaba, Gege, Mhlume, Maphalaleni, Ntontozi, Nkwene and Mahlangatja. Data was collected through a face-to-face survey, comprised of 7 multiple choice and 49 Yes/No or True/False questions that covered five categories: knowledge, behavior, attitudes, access and attribution. The survey data was collected on computer tablets, using SurveyToGo software. Complementing the survey data with qualitative perspectives on program content, quality and delivery, semi-structured focus group discussions (FGDs) and key informant interviews (KIIs) were also conducted.

Overall, participants in the Stepping Stones evaluation exhibited very high levels of HIV prevention knowledge compared to national survey data. Among females, 73% (n=112) of Stepping Stones participants age 20-24 years could correctly identify ways of preventing sexual transmission of HIV and reject major misconceptions about HIV transmission compared to 54% in the 2014 multiple indicator cluster survey (MICS) (Central Statistical Office, 2016). Among males, 80% (n=105) of Stepping Stones participants age 20-24 years could do so, compared to 44% in MICS.

Stepping Stones participants demonstrated above average rates of protective behaviors such as the use of condoms and contraceptives. Outcomes for these indicators were better than other national survey data. Among all Stepping Stones participants age 20-24 years, 72% (n=168) used a condom the last time they had sex with a non-marital, non-cohabiting partner, compared to 70% in the 2016-2017 SHIMS 2 survey (Government of the Kingdom of Eswatini, 2019) (Figure 5). The difference was particularly noteworthy for females, where 69% (n=84) of Stepping Stones participants age 20-24 years used a condom the last time they had sex with a non-marital, non-cohabiting partner, compared to 63% in SHIMS 2. Eighty percent (n=98) of female Stepping Stones participants age 20-24 years were currently using a modern method of contraception, compared to 68% of females of the same age in the 2014 MICS survey (Central Statistical Office 2016).

Stepping up the Fight An evaluation of the Stepping Stones approach to HIV prevention 11 among adolescents and young people in Eswatini

Access to HIV testing services was found to be remarkably high. Overall, 88% (n=422) of Stepping Stones participants of all ages and sexes reported to have received an HIV test in the past year. When compared to other survey data, Stepping Stones participants far exceed national averages. For example, 92% (n=112) of female Stepping Stones participants age 20-24 years had an HIV test in the past year, compared to 74% of females of the same age surveyed in SHIMS 2. Eighty-one percent (n=90) of male Stepping Stones participants age 20-24 years had an HIV test in the past year, compared to 51% in SHIMS 2.

A missed opportunity was observed for greater coverage of other HIV-related health services, including family planning, sexually transmitted infection (STI) screening and tuberculosis (TB) screening. Access to gender-based violence services as well as financial services was comparably lower than access to health services.

For indicators related to stigma and discrimination, Stepping Stones participants exhibited strong positive attitudes. Ninety-seven percent (n=463) of Stepping Stones participants would buy fresh vegetables from a shopkeeper or vendor who is HIV-positive, and 95% (n=453) think children living with HIV should be able to attend school with children who are HIV-negative. However, on indicators related to gender equality, Stepping Stones participants’ responses are concerning. Just 64% (n=303) of Stepping Stones participants think men and women should have equal rights in society and 14% (n=65) think that a husband or boyfriend is justified in hitting or beating his wife.

There was large variation by age and sex, as well as by geography, for several indicators. Use of a modern method of contraception was 57% (n=21) among adolescent girls age 18- 19 years, 80% (n=98) among young women age 20-24 years, and 84% (n=79) among young women 25 years or older. While both girls and boys equally thought it was important to save money, boys were much more likely than girls to access financial services or have taken action to save money in the past year. In Ntondozi, 96% (n=43) of Stepping Stones participants said their lives had improved in the past year, versus 67% (n=51) in Gege. Fifty- four percent (n=51) of Mhlume Stepping Stones participants were able to identify risk or warning signs of sexual and gender-based violence among their family and/or friends, compared with just 16% (n=9) in Mahlangatja

Engaging in transactional sex was most strongly associated with low condom use (r = -0.71, p<.05). Low pregnancy rates were most strongly associated with believing that the risk of HIV transmission can be reduced by having sex with only one uninfected partner who has no other partners (r = -0.84, p<.01). These results suggest that condom negotiation is limited in Stepping up the Fight An evaluation of the Stepping Stones approach to HIV prevention 12 among adolescents and young people in Eswatini

transactional relationship and that HIV knowledge may be linked to increased HIV testing uptake and reduced pregnancy rates.

All participants rated the program very highly, saying that it helped improve their HIV prevention knowledge, behavior, attitudes and access. However, this attribution does not equally reflect in the actual outcome indicators. In other words, there appears to be a perception among participants that the program is benefitting them more than it actually is. This could reflect additional benefits of the program that were not captured in the evaluation indicators, such as social asset building (making friends), alleviation of boredom/idleness, receiving attendance incentives, among others.

While there is no baseline data available for comparison, this evaluation did measure the effect of greater program exposure on participant outcomes to get some measure of program efficacy. Graduation from the Stepping Stones program (defined as completing at least 9 of the 12 sessions) had modest but positive effects on participants’ PrEP knowledge (+9%), condom use (+3%), contraceptive use (+3%), access to family planning services (+5%), attitudes towards gender equality (+3%), sexual agency (ability to say “no”) (+6%), pregnancy rates (-8%) access to post-violence care (+5%), post-violence access to justice (+3%), HIV risk perception (-10%) and pregnancy risk perception (-9%). Improvements were particularly noteworthy for PrEP knowledge among females (+14%) and sexual agency among males (+19%). Results were statistically significant for PrEP knowledge among females (odds ratio [OR] 1.81 95% confidence interval [CI] 1.09-3.03 p<.05), sexual agency among males (OR 2.23 95% CI 1.28-3.86; p<.05), HIV risk perception among both sexes (OR 0.58 95% CI 0.38-0.88 p<.05) and pregnancy risk perception among both sexes (OR 0.67 95% CI 0.45-0.98 p<.05).

During focus group discussions, participants said that they valued the following topics in the Stepping Stones curriculum most: sex and sexual pleasure (including lubricants), reproductive systems (including menstrual health), sexually transmitted infections, access to family planning and contraceptive services, biomedical prevention (including PEP and PrEP), how to save money and avoid unnecessary debts, how to use a condom properly, fighting HIV stigma and discrimination, and assertiveness training (how to say “no”).

Participants reported that Stepping Stones curriculum could benefit from including additional topics, particularly on gender-based violence legislation and economic empowerment. They also said the age bracket should be expanded, especially to include older male partners of AGYW. Both parents and participants alike expressed a need for structured communication Stepping up the Fight An evaluation of the Stepping Stones approach to HIV prevention 13 among adolescents and young people in Eswatini

sessions where they could discuss program content together, though this should not replace the peer group sessions. Participants and key informants said that the Stepping Stones program could reduce barriers to accessing health care by offering mobile clinical services during group sessions, ensuring there is better integration of HIV and other services, and making a service map available to guide referrals.

Lastly, participants and key informants said the program could be made more sustainable by engaging community leadership, providing refresher or onward opportunities for program graduates, and ensuring that both domestic and external partners invest in the program.

In summary, the Stepping Stones program has positively contributed to HIV prevention efforts in Eswatini. Graduation from the program is associated with modest but positive improvements among adolescent and young people’s knowledge, behaviors, attitudes and access to services. Of note, Stepping Stones participants exhibit dramatically higher HIV prevention knowledge and uptake of HIV testing services compared to national survey data, as well as above average use of condoms and contraceptives. The positive effects of the program appear to be maintained among participants up to three years post-intervention. Impact and cost-savings have been realized, as modelled in Eswatini’s Umgubudla HIV Investment Case. Areas for improvement include updating and augmenting the curriculum as well as optimizing the role of the facilitators. The Stepping Stones program should continue to be implemented in Eswatini, to help the country achieve its HIV prevention targets. Resource permitting, it should be scaled up to maximize impact. For the program to be sustainable, investments are needed from both external and domestic partners.

Stepping up the Fight An evaluation of the Stepping Stones approach to HIV prevention 14 among adolescents and young people in Eswatini

INTRODUCTION

Country context

Eswatini is home to 210,000 people living with HIV (PLHIV), with an adult (age 15-49 years) HIV prevalence of 27.4%—the highest in the world (UNAIDS, 2017). In 2017, Eswatini’s epidemic grew by about 7,300 new infections (Government of the Kingdom of Eswatini, 2019). About a third of these new infections are among young people age 15-24 years.

Low levels of HIV prevention knowledge drive this epidemic among young people. Fewer than half (49.5%) correctly identify ways of preventing the sexual transmission of HIV and reject major misconceptions about HIV transmission (Central Statistical Office, 2016). Other social, structural and behavioral factors also contribute to infection rates.

Adolescent girls and young women (AGYW) age 15-24 years face disproportionate risk and vulnerability to HIV. In the second Swaziland HIV Incidence Measurement Survey (SHIMS 2, 2016-2017), AGYW age 15-24 years had three times the HIV prevalence (13.9% vs. 4.1%), and two times the HIV incidence (1.9% vs. 0.8%) compared to their male peers (Government of the Kingdom of Eswatini, 2019) (Figure 1).

Figure 1. HIV incidence in Eswatini, by age and sex (SHIMS 2, 2016-2017)

3%

2.0% 2% 1.9% 1.7% 1.5% 1.5% 2% 1.3%

1.0% 1.0% 1% 0.8%

1% Weighted Annual Incidence (%) Incidence Annual Weighted

0% Age 15-24 years Age 15-49 years Age 15 years +

Males Females All

Social and structural factors drive the gender-related disparity in the epidemic. High rates of teenage pregnancy and family reasons cause girls to drop out of school, elevating their vulnerability to HIV (Ministry of Education and Training, 2016). Approximately one in three

Stepping up the Fight An evaluation of the Stepping Stones approach to HIV prevention 15 among adolescents and young people in Eswatini

girls age 18-24 years experience some form of sexual violence during childhood, further compounding HIV risk (UNICEF, 2007).

In response, Eswatini’s National Multisectoral HIV and AIDS Strategic Framework 2018- 2022 is geared towards “population-focused delivery” of defined service packages (NERCHA, 2018). For adolescents and young people, the Framework identifies behavioral (i.e. social and behavioral change communication), biomedical (i.e. PrEP), and structural (i.e. economic empowerment, gender-based violence) interventions that should be targeting young people to prevent new HIV infections (NERCHA, 2018).

Since October 2015, Eswatini has been implementing a national HIV prevention program for adolescents and young people called “Stepping Stones”. This program is being rolled out by the Co-ordinating Assembly of Non-Governmental Organizations (CANGO), with funding from the Global Fund to Fight AIDS, Tuberculosis and Malaria (hereafter referred to as the Global Fund). Other implementing partners are also delivering the Stepping Stones program, with funding from The U.S. President's Emergency Plan for AIDS Relief (PEPFAR).

The Stepping Stones program

Goal of the Intervention

The project aim of the Stepping Stones approach in Eswatini was to reduce new HIV infections among young people age 10-24 years who are out of school.

Overview of the intervention

Stepping Stones was developed between 1993 and 1995, mainly in Uganda, and was later adapted for the Eswatini context. Stepping Stones is a structured social behaviour change communication program, designed for use in small co-curricular groups of about 15-20 people. A trained facilitator leads weekly sessions in each per group, using a structured approach as outlined in the Stepping Stones manual. The approach has a 12-session curriculum (see Annex 1), designed to strengthen relationships, promote safer sexual practices and prevent HIV. In particular, the activities focus on communication in relationships, skills building and empowerment, and acknowledges the gendered context of young people’s lives and the broad range of influences on their sexual practices. Participants are considered to have graduated from the program if they complete 75% (n=9) of the weekly sessions.

Stepping up the Fight An evaluation of the Stepping Stones approach to HIV prevention 16 among adolescents and young people in Eswatini

In addition to the weekly peer group sessions, the program encourages three inter-peer group meetings, where more than one peer group comes together and discusses the program and their experiences. These inter-peer group meetings promote communication between the different peer groups, give a chance for group practice of assertively communication with the other sex or another age group, and provide an opportunity to build understanding across sex or age divides. These inter-peer group meetings happen at three intervals in the program: after Sessions C, G and L.

Program coverage

From October 2015 to September 2018, the Global Fund-supported Stepping Stones program enrolled 22,923 adolescents and young people across the following 20 Tinkhundla: Gege, , , Kukhanyeni, Mafutseni, Mahlangatja, Maphalaleni, Matsanjeni, , Mhlume, , , , Ngwemphisi, Nkhaba, Nkwene, Ntontozi, , and .

Of those enrolled, 10,960 were males and 11,963 were females. By age, 157 program participants were age 10-14 years, 5,868 were age15-19 years, 13,744 were age 20-24 years and 3,154 were age 25 years or older. The total program coverage is broken down by age, sex and Inkhundla in Annex 2.

Rationale of the evaluation

This evaluation reviewed the outcomes of the program implemented through CANGO (with funding from the Global Fund) over a specified three-year period (October 2015 – September 2018), and makes recommendations for future program implementation.

Several studies have shown mentorship groups or club-based interventions like Stepping Stones to be an effective mechanism for reducing negative health outcomes and increasing uptake of HIV, sexual and gender-based violence and sexual and reproductive health services among adolescents and young people in a variety of African settings (Cooper, Moolman & Matandela, 2017; Dunbar et al., 2014; Jewkes et al., 2014; Johnson et al., 2018, Speizer et al., 2001; Swartz et al., 2012; Ziraba et al., 2018). However, few have assessed the efficacy of such interventions in Eswatini.

The main rationale for this study was to evaluate the adapted version of the Stepping Stones program (originally developed in South Africa) which has been tailored to the Eswatini

Stepping up the Fight An evaluation of the Stepping Stones approach to HIV prevention 17 among adolescents and young people in Eswatini

context. Previous evaluations have shown the Stepping Stones approach to be evidence- based in South Africa (Jewkes et al., 2006; Jewkes et al., 2007; Jewkes et al., 2008; Jewkes et al., 2010a; Jewkes et al., 2010b; Jewkes et al., 2014; Gibbs et al., 2015), but no formal evaluations have been done for the Eswatini version of the program.

The secondary rationale was to answer (in part) some of the priority research questions in Eswatini’s National Multisectoral HIV and AIDS Strategic Framework 2018-2022 (Ministry of Health and NERCHA, 2018) (Table 1).

Table 1. Priority Research Questions in Eswatini’s National Multisectoral HIV and AIDS Strategic Framework 2018-2022 Explored in Stepping Stones Evaluation

Priority Area Priority research topic/question

 What is the effectiveness of various SBCC platforms in changing behavior? Social behavior  What factors determine the adoption of positive health seeking behavior? change  What are the risk perceptions of different populations and age groups?

 To what extent are poverty and unemployment determinants of HIV infection Life skills and among adolescents and young people? economic  What are the appropriate strategies for economically empowering adolescent empowerment girls and young women?

PrEP  What are the attitudes of adolescent girls and young women towards PrEP?

VMMC  What are the perceptions, attitudes and views towards VMMC?

 What is the effectiveness of various SBCC platforms in changing behavior? Social behavior  What factors determine the adoption of positive health seeking behavior? change  What are the risk perceptions of different populations and age groups?

Increasingly, funding partners and governments are insisting that all investments in the HIV response must be in evidence-based interventions. The findings of this evaluation provide such an evidence base on which increased resources may be mobilized for the Stepping Stones approach to achieve greater impact.

Study objectives

1. To measure level of impact of the Stepping Stones approach to HIV prevention program (on young people’s level of knowledge, sexual and reproductive health (SRH), safer sex practices, gender-responsive relationships, access to care, etc.)

Stepping up the Fight An evaluation of the Stepping Stones approach to HIV prevention 18 among adolescents and young people in Eswatini

2. To identify the existing and potential opportunities for better implementation of the stepping stones approach to HIV prevention program interventions in the priority areas where Stepping Stones is being implemented

3. To inform future HIV prevention programs for young people in the country

4. To ascertain accessibility and or challenges towards accessing health services such as HIV testing, voluntary medical male circumcision (VMMC), access to antiretroviral therapy (ART), STI diagnosis and treatment, etc. amongst young people.

Main research question

What is the impact of the Stepping Stones approach to HIV prevention on the health and wellbeing outcomes of adolescents and young people in Eswatini?

Sub-questions

This evaluation responds to a series of sub-questions related to knowledge, behaviour, attitudes, and access to services among Stepping Stones beneficiaries.

The evaluation study design enabled the evaluation team to answer questions related to program outcomes (i.e. What proportion of Stepping Stones beneficiaries used a condom at last sex?) as well as program process (i.e. Are Stepping Stones program graduates more likely than non-graduates to use a condom at last sex?).

Most questions were derived from indicators for monitoring the 2016 Political Declaration on Ending AIDS, adapted from UNAIDS Guidance for Global AIDS Monitoring 2019 (UNAIDS, 2018). Some indicators were adapted from the Multiple Indicator Cluster Survey (MICS), and others from the Demographic and Health Surveys (DHS). Some questions were taken directly from the Stepping Stones manual, to assess retention of certain messages in the sessions. There were occasional custom indicators, designed to contribute knowledge to the priority research questions in the Eswatini National Multisectoral HIV and AIDS Strategic Framework 2018-2022 (Ministry of Health and NERCHA, 2018, p. 84) (recall Table 1).

For the full list of questions asked of study participants, see the survey tool in Annex 7.

Stepping up the Fight An evaluation of the Stepping Stones approach to HIV prevention 19 among adolescents and young people in Eswatini

METHODOLOGY

Desk review

An in-depth literature review was performed, covering the national context, program design, program delivery, and knowledge gaps to be addressed by the evaluation. This review informed the development of a full research protocol, submitted for ethics approval.

Quantitative methods

Surveys

The main method of data collection for the Stepping Stones evaluation was face-to-face surveys with program beneficiaries. These were conducted using a computerized survey tool, loaded onto tablets using SurveyToGo version 1.32.229.2. This software functions online and offline, so it was suitable for field work data collection in remote and rural sites. The survey took about 10-15 minutes per participant. Participants sat in a quiet and private space with a data collector to complete the survey.

Qualitative methods

Focus group discussions

Complementing the survey responses with qualitative perspectives on program content, quality and delivery, FGDs were also conducted. Each FGD aimed to have not more than 10 participants and two data collectors (one facilitating the discussion and one taking notes). FGDs were guided by a set of short, clear, probing questions to help the data collectors lead the discussion. Each FGD took approximately 45 minutes to an hour to complete. The discussions were semi-structured, meaning the probing questions were used or not used, as deemed relevant by the discussion facilitator. FGD data was captured either in SiSwati or in English, by hand. Back-up recordings were captured using a Dictaphone or cellphone. The recordings were used to assist with transcription fidelity.

Key informant interviews

Complementing the survey and FGD data, the evaluation team conducted key informant interviews (KIIs) with national level policy-makers and program managers as well as

Stepping up the Fight An evaluation of the Stepping Stones approach to HIV prevention 20 among adolescents and young people in Eswatini

Inkhundla-level program implementers. The aim of these interviews was to get an overall sense of the program, its accomplishments, and its challenges, from the perspective of those responsible for its design and delivery. All key informants were guaranteed anonymity.

Study process

Data collectors training

A three-day data collectors training was held to orient the 13 data collectors on the objectives of the evaluation and equip them to use the data collection tools.

Sampling

Since Eswatini has a homogeneous HIV epidemic as well as homogenous socio-cultural make-up, it was not expected that different Tinkhundla would exhibit significant variations in program outcomes. Therefore, for ease of data collection, eight data collection sites—8 out of the 20 Tinkhundla where the program was implemented—were selected to conduct the face-to-face surveys and focus group discussions. At least 1 site per region was included, for equity. Each site visit took up to 1 full day to complete.

Based on a formula that factored in travel distance (efficiency) and number of enrollments (significance to the program), the following sites were selected for data collection (Table 2).

Table 2. Data collection sites for Stepping Stones evaluation

Region Inkhundla

Manzini Ekukhanyeni

Hhohho Nkhaba

Shiselweni Gege

Lubombo Mhlume

Hhohho Maphalaleni

Manzini Ntontozi

Shiselweni Nkwene

Manzini Mahlangatja

Stepping up the Fight An evaluation of the Stepping Stones approach to HIV prevention 21 among adolescents and young people in Eswatini

In total, 22,923 adolescents and young people were enrolled in the Global Fund-supported Stepping Stones program between October 2015 and September 2018. Therefore, a minimum sample size of 378 individual surveys needed to be conducted to ensure a 95% confidence interval of the total population size (all those enrolled in the program). The evaluation aimed to sample at least 400 participants (50 per Inkhundla), so that the results could be generalizable to all beneficiaries of the program.

CANGO engaged eight mobilizers (one per Inkhundla) to recruit participants. Guidance was given to the mobilizers to recruit a purposeful sample of 50 Stepping Stones participants who were part of the program from October 2015 to September 2018, aiming for balance by age, gender, and level of program completion. See Table 3 in the results section for more details on the characteristics of the evaluation participants.

All survey respondents also participated in FGDs, divided sex. Parents of Stepping Stones participants were also engaged in FGDs, though they did not complete surveys (which were designed for beneficiaries only). The evaluation aimed to conduct five FGDs per Inkhundla.

Lastly, key informants were selected based on a list provided by CANGO, while others were conducted in an ad hoc manner during site visits in the field. The evaluation aimed to conduct 10-15 key informant interviews.

All data collection – including surveys, FGDs and KIIs – took place in May 2019.

Tools

The survey tool was comprised of 7 multiple choice respondent characteristic questions, and 49 Yes/No or True/False questions which covered five categories: (1) Knowledge, (2) Behavior, (3) Attitudes, (4) Access and (5) Stepping Stones Attribution. The full survey tool is contained in Annex 7 of this evaluation report.

The FGD guide was a paper-based tool, with eight open-ended questions to structure the discussion. Questions covered participants’ experiences, perceptions on curriculum content and thoughts on how to improve program delivery. The FGD guide is contained in Annex 8 of this evaluation report.

Stepping up the Fight An evaluation of the Stepping Stones approach to HIV prevention 22 among adolescents and young people in Eswatini

A key informant interview guide was developed, though the types of questions asked varied depending on the informant. Questions included strengths and weaknesses of the Stepping Stones program, lessons from other similar programs, and ways of improving sustainability.

Quality assurance

The quality of data collection and data analysis for the Stepping Stones evaluation was ensured through several mechanisms and strategies.

First, the data collectors training held from 15-17 May 2019 helped to ensure the quality of the data collected. This training equipped the data collectors with in-depth knowledge of the evaluation aims, tools, process and intended use of the information.

Further, the simplicity of the tools helped to minimize human error during data collection. The survey tool (Annex 7) and focus group discussion guide (Annex 8) were designed with this in mind. The survey tool involved mostly true/false or yes/no answers, to make data collection very simple and straightforward. The focus group discussion guide had just a few guiding questions, to keep it simple, but they were very targeted and specific to the information required for the evaluation.

The use of electronic data collection methods (tablets) limited potential data loss and human error. Since there is no data entry step (no transcription of data from paper to computer), this eliminates one possible way that errors could have occurred.

To ensure a systematic approach to data collection in each Inkhundla, the consultancy team conducted site visits, providing an additional layer oversight and quality assurance during data collection. Two evaluation team debriefing meetings were held during the data collection phase to discuss challenges, techniques, observed trends and recommendations for improvement. Members of the National Task Team attended these meetings.

After collection was complete, the data was reviewed and cleaned to remove any computational or entry errors.

Stepping up the Fight An evaluation of the Stepping Stones approach to HIV prevention 23 among adolescents and young people in Eswatini

Data analysis

Once all the survey data was captured and cleaned, SurveyToGo generated a dataset for analysis. Basic descriptive statistics, including frequency tests, were performed using Microsoft® Excel for Mac Version 16.16.11 (190609).

For all indicators, survey data was analyzed by age and sex, by Inkhundla, by program exposure, and by year of enrollment. For select indicators and age brackets, survey data was analyzed in comparison to national-level statistics.1

For indicators on which large program effects were observed, odds ratios were calculated using MedCalc® Statistical Software version 18.11. The odds ratio (OR), its standard error and 95% confidence interval are calculated according to Altman (1991).

To test for significance, the P-value was calculated according to Sheskin (2004). A standard normal deviate (z-value) is calculated as ln(OR)/SE{ln(OR)}, and the P-value is the area of the normal distribution that falls outside ±z.

Transcripts for FGDs and KIIs were analyzed manually. Common themes and recommendations were grouped and coded.

Validation

The results of the evaluation were further validated by key stakeholders to provide inputs and comments for a quality report.

Dissemination

The results of this evaluation have four main intended uses: (1) To inform national HIV prevention programming in Eswatini, (2) To inform national HIV policy-making and policy review processes in Eswatini, (3) To inform future investments in HIV prevention in Eswatini, and (4) To inform HIV prevention efforts in other countries with similar epidemiology. A dissemination plan has been developed with target audiences, key messages, results packaging and roles and responsibilities of various national stakeholders.

1 It is acknowledged that national survey data does not serve as a true control group since national survey respondents have likely had exposure to one or more HIV prevention programs, including (possibly) Stepping Stones.

Stepping up the Fight An evaluation of the Stepping Stones approach to HIV prevention 24 among adolescents and young people in Eswatini

Ethical considerations

Ethics approval

A research protocol was developed and submitted to the National Health Research Review Board (NHRRB) in Eswatini for approval. No contact with human subjects occurred prior to obtaining ethics approval from the NHRRB. The protocols were submitted on 11 February 2019 (Reference Number: SHR099/2019). The Research Protocol Clearance Certificate was received from the NHRRB on 18 April 2019.

The following ethical considerations were made during the evaluation:

Confidentiality

At the data collectors training, all evaluation team members and data collectors signed confidentiality agreements. These agreements ensured that all members of the evaluation team (including data collectors) agreed to take all possible steps to protect the confidentiality of the information received and follow the data entry and verification processes.

Adolescents and young people who participated in this evaluation did so anonymously. Participants’ names were not recorded anywhere in the survey tool or in focus group discussion (FGD) documentation.

Data security

All evaluation data was stored by CANGO in a secure Structured Query Language (SQL) database. The person responsible for safekeeping the program data was the MER Manager at CANGO. Outside of CANGO, the exported evaluation data was shared only with the study PI and the consultancy team. As noted above, all members of the evaluation team signed confidentiality agreements to further ensure data security.

Risks and benefits to participants

Risks to evaluation participants were minimal, however, their participation in the study did involve sharing sensitive personal information both with data collectors as well as with peers (in the focus group discussions). Participation in the study was entirely voluntary and

Stepping up the Fight An evaluation of the Stepping Stones approach to HIV prevention 25 among adolescents and young people in Eswatini

participants were able to opt out of the study at any time. Opting out of the study due to discomfort with the nature of questions asked did not result in forfeit of transport allowance.

Benefits to the study participants included a direct and immediate benefit of being able to talk about important issues in their lives as well as gaining peer and mentor support during the interviews and FGDs. Participation in the study also gave the participants an opportunity to re-connect with CANGO, potentially opening up other avenues of support that the organization can provide. Further, after completion of the survey portion of the study, participants were given information about HIV and sexual and reproductive health and rights, including the correct answers to the knowledge questions in the survey. This may have benefited their awareness about HIV and SRH and improved their access to services. Participants were also be given a transport reimbursement of E50-100 (depending on distance travelled) to support their participant in the evaluation.

In the longer term, participants’ engagement in the study may contribute to an enhanced ability of CANGO, the Government of Eswatini, and other partners to improve the delivery of interventions to optimize HIV prevention and other SRH outcomes for adolescent and young people in Eswatini. Improved SRH programming in Eswatini can reduce HIV incidence, teenage pregnancy, school drop-outs and sexual and gender-based violence, so that adolescents and young people can be healthy and productive members of society.

Consent

At the recruitment stage, prospective participants were given a participant information sheet, which covered the description of the research study, what the participant’s involvement would entail, potential risks, likely benefits, and contact details of the study PIs for further information. This was clearly explained to prospective participants, underscoring the fact that their participation in the study is voluntary. It was made clear that they could decline to participate at the recruitment stage, with no consequence to them, or that they could also decide to stop participating at any stage in the process, also at no consequence.

During data collection, information about their involvement in the study was reiterated, and all study participants physically a consent form before answering any survey questions.

Limitations

Since the study only sampled adults who were age 18 years or older (for ethical considerations and for ease of consent-giving at data collection sites), this meant that the

Stepping up the Fight An evaluation of the Stepping Stones approach to HIV prevention 26 among adolescents and young people in Eswatini

effects of the program on those age 10-14 years was not captured. This was deemed acceptable by the National Task Team since 10-14-year-olds made up less than 1% of total Stepping Stones enrollments. The evaluation team deemed it to be unnecessarily burdensome to gain parental consent for those under the age of 18, when the program did not reach many people in this age group.

This evaluation sampled participants in 8 out of the 20 Tinkhundla where Stepping Stones was delivered. While this was deemed a fair representation, it means results from some Inkundla are not included. However, as noted, there is not a great deal variance in epidemiology and socio-cultural environment in Eswatini, so it was not expected that the outcomes would vary dramatically from one Inkhundla to the next. To mitigate this limitation somewhat, at least one Inkhundla from each of Eswatini’s four regions was selected, so if regional variance emerges, it could be highlighted.

External variables such as household income or caregiver situation may affect the outcomes of participants, but these data are not collected by the program and can therefore not be controlled for in this particular analysis.

Further study limitations include the reliance on self-reported data. The data are also subject to social desirability bias resulting from the personal nature of questions, and the evaluation’s use of face-to-face communications to collect this data. These factors were controlled for somewhat during the data collectors training.

Stepping up the Fight An evaluation of the Stepping Stones approach to HIV prevention 27 among adolescents and young people in Eswatini

QUANTITATIVE RESULTS AND ANALYSIS

Characteristics of survey respondents

The evaluation methodology aimed to recruit 50 survey participants per Inkhundla, for a total sample of 400 participants. In practice, a total of 477 participants were surveyed. Some mobilizers recruited more than 50 participants and some less. No participant was turned away if they had travelled to take part on the evaluation.

The highest number of participants was in Mhlume (n=94) and the lowest was in Ntondozi (n=45). The total sample size for this evaluation therefore exceeds the minimum number needed (n=378) to ensure statistical significance (95% confidence interval) for the total population size (n=22,923 Stepping Stones enrollees). The results of the survey can therefore be said to be generalizable to all adolescents and young people who were enrolled in the Stepping Stones program between October 2015 and September 2018.

The average age of evaluation participants was 24 years (23 years for females, 24 years for males). Eleven percent (n=53) of participants were adolescents age 18-19 years, 49% (n=233) were young people age 20-24 years, and 40% (n=191) were age 25 years or older.

The sample of participants was relatively gender-balanced overall, with 47% (n=224) being male and 53% (n=253) being female. However, the sampling balance of males and females varied depending on the Inkhundla. In Gege, 72% (n=55) of participants were female, whereas in Maphalaleni, 72% (n=34) of participants were male.

Ninety percent (n=428) of participants were unmarried and 10% (n=49) were married. Four percent (n=4) had no education, 17% (n=82) had some primary education, 77% (n=369) had some secondary education and 22% (n=22) had some tertiary education.

Twenty-two percent (n=106) attended Stepping Stones in 2016, 43% (n=207) attended in 2017, and 34% (n=164) attended in 2018.

Forty-seven percent (n=223) completed fewer than 9 Stepping Stones sessions (considered non-graduates of the program) and 53% (n=254) completed 9 Stepping Stones sessions or more (considered program graduates).2 Non-graduates tended to be slightly older, were less educated, more likely to be married, and a greater majority female.

2 CANGO program data indicates that 79% of enrolled participants completed at least 9 sessions. This evaluation intentionally over-sampled non-graduates to be able to compare their outcomes to graduates.

Stepping up the Fight An evaluation of the Stepping Stones approach to HIV prevention 28 among adolescents and young people in Eswatini

Table 3. Characteristics of Stepping Stones evaluation participants

Kukhanyeni Nkhaba Gege Mhlume Mahlangatja Nkwene Maphalaleni Ntondozi TOTAL Indicator Number (%)

Quantitative Data

Number of survey 62 (13%) 48 (10%) 76 (16%) 94 (20%) 56 (12%) 49 (10%) 47 (10%) 45 (9%) 477 (100%) participants Sex

Male 33 (53%) 29 (60%) 21 (28%) 37 (39%) 32 (57%) 15 (31%) 34 (72%) 23 (51%) 224 (47%)

Female 29 (47%) 19 (40%) 55 (72%) 57 (61%) 24 (43%) 34 (69%) 13 (28%) 22 (49%) 253 (53%) Age

18-19 9 (15%) 6 (13%) 6 (8%) 12 (13%) 5 (9%) 4 (8%) 4 (9%) 7 (16%) 53 (11%) 20-24 30 (48%) 19 (40%) 33 (43%) 44 (47%) 25 (45%) 35 (71%) 24 (51%) 23 (51%) 233 (49%)

25+ 23 (37%) 23 (48%) 37 (49%) 38 (40%) 26 (46%) 10 (20%) 19 (40%) 15 (33%) 191 (40%) Year of SS

Enrollment 2016 14 (23%) 14 (29%) 22 (29%) 15 (16%) 11 (20%) 14 (29%) 10 (21%) 6 (13%) 106 (22%)

2017 14 (23%) 26 (54%) 42 (55%) 33 (35%) 29 (52%) 23 (47%) 12 (26%) 28 (62%) 207 (43%) 2018 34 (55%) 8 (17%) 12 (16%) 46 (49%) 16 (29%) 12 (24%) 25 (53%) 11 (24%) 164 (34%)

Marital Status Married 12 (9%) 11 (23%) 4 (5%) 6 (6%) 3 (5%) 3 (6%) 6 (13%) 4 (9%) 49 (10%)

Unmarried 50 (81%) 37 (77%) 72 (95%) 88 (94%) 53 (95%) 46 (94%) 41 (87%) 41 (91%) 428 (90%)

Education None 1 (2%) 0 (0%) 0 (0%) 3 (3%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 4 (4%)

Primary 7 (11%) 5 (10%) 8 (11%) 15 (16%) 16 (29%) 14 (29%) 11 (23%) 6 (13%) 82 (17%) Secondary 52 (84%) 38 (79%) 66 (87%) 72 (77%) 38 (68%) 34 (69%) 35 (74%) 34 (76%) 369 (77%)

Tertiary 2 (3%) 5 (10%) 2 (3%) 4 (4%) 2 (4%) 1 (2%) 1 (2%) 5 (11%) 22 (22%) Year of SS

Enrollment 2016 14 (23%) 14 (29%) 22 (29%) 15 (16%) 11 (20%) 14 (29%) 10 (21%) 6 (13%) 106 (22%)

2017 14 (23%) 26 (54%) 42 (55%) 33 (35%) 29 (52%) 23 (47%) 12 (26%) 28 (62%) 207 (43%) 2018 34 (55%) 8 (17%) 12 (16%) 46 (49%) 16 (29%) 12 (24%) 25 (53%) 11 (24%) 164 (34%) Number of SS Sessions Completed Less than 9 35 (56%) 27 (56%) 43 (57%) 42 (45%) 21 (38%) 19 (39%) 22 (47%) 14 (31%) 223 (47%)

9 or more 27 (44%) 21 (44%) 33 (43%) 52 (55%) 35 (62%) 30 (61%) 25 (53%) 31 (69%) 254 (53%)

Qualitative Data

Site-level key informant 1 (11%) 1 (11%) 0 (0%) 3 (33%) 2 (22%) 1 (11%) 1 (11%) 0 (0%) 10 (100%) interviews Type of KII

SS Facilitator 1 (100%) 1 (100%) 0 (0%) 3 (75%) 1 (50%) 1 (100%) 1 (100%) 0 (0%) 8 (80%)3

Bucopho 0 (0%) 0 (0%) 0 (0%) 1 (25%) 1 (50%) 0 (0%) 0 (0%) 0 (0%) 2 (20%) Focus group 8 (25%) 4 (13%) 3 (9%) 4 (13%) 3 (9%) 2 (6%) 5 (16%) 3 (19%) 32 (100%) discussions Type of FGD

Girls 2 (25%) 2 (50%) 2 (67%) 2 (50%) 1 (33%) 0 (0%) 2 (40%) 1 (33%) 12 (38%)

Boys 3 (38%) 1 (25%) 1 (33%) 0 (0%) 1 (33%) 1 (50%) 2 (40%) 1 (33%) 10 (31%)

Mixed 0 (0%) 0 (0%) 0 (0%) 1 (25%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 1 (3%)

Parents 3 (38%) 1 (25%) 0 (0%) 1 (25%) 1 (33%) 1 (50%) 1 (20%) 1 (33%) 9 (28%)

3 Note: Two additional key informant interviews were conducted with Stepping Stones facilitators at the pilot site in Mafutseni .

Stepping up the Fight An evaluation of the Stepping Stones approach to HIV prevention 29 among adolescents and young people in Eswatini

The following sections highlight key findings on knowledge, behavior, attitudes, access and attribution indicators in the Stepping Stones survey. The full results of the survey are contained in the Annexures of this report, by age and sex (Annex 3), by Inkhundla (Annex 4), by program exposure (Annex 5) and by year of program enrollment (Annex 6).

Results and analysis on knowledge indicators

Knowledge results and analysis, overall

Overall, Stepping Stones participants exhibited high levels of HIV prevention knowledge, with 76% (n=363) correctly identifying ways of preventing sexual transmission of HIV and rejecting major misconceptions about HIV transmission.4 Among females, correct answers were given by 73% (n=27) of adolescent girls age 18-19 years, 69% (n=84) of young women age 20-24 years, and 73% (n=69) of young women age 25 years and older. Among males, it was 69% (n=11) of adolescent boys age 18-19 years, 80% (n=89) of young men age 20-24 years, and 86% (n=83) of young men age 25 years and older.

When compared to national survey data, Stepping Stones participants had above average HIV prevention knowledge (Figure 2). Among 20-24-year-olds, 74% of Stepping Stones participants had accurate HIV prevention knowledge compared to 49% in MICS 2014.

Figure 2. Proportion of young women and men age 20-24 years who correctly identify ways of preventing the sexual transmission of HIV and reject major misconceptions about HIV transmission (Stepping Stones participants vs. MICS 2014 national survey data)

100% 80% 74% 80% 69% 54% 60% 49% 44% 40%

20%

0% Females Males All Stepping Stones participants (2016-2018) (age 20-24 years) MICS National Survey Data 2014 (age 20-24 years)

4 The numerator for this indicator is the number of respondents who gave correct answers to all five questions relating to the transmission of HIV and misconceptions about HIV: (1) The risk of HIV transmission can be reduced by having sex with only one uninfected partner who has no other partners; (2) A person can reduce the risk of getting HIV by using a condom every time they have sex; (3) A healthy-looking person can have HIV, (4) A person can get HIV by hugging or shaking hands with a person who is infected; and (5) A person can get HIV by sharing food with someone who is infected.

Stepping up the Fight An evaluation of the Stepping Stones approach to HIV prevention 30 among adolescents and young people in Eswatini

Knowledge results and analysis, by age and sex

There was notable age and sex variation in participants’ responses to survey questions on knowledge of HIV risk reduction from having one partner, as well as on PrEP knowledge. Eighty-one percent (n=13) of adolescent boys age 18-19 years believed that the risk of HIV transmission can be reduced by having sex with only one uninfected partner who has no other partners, compared to 90% (n=100) of young men age 20-24 years and 98% (n=98) of young men 25 years or older. The same pattern was not observed for girls. Adolescent girls (92%; n=34) were more likely to believe the statement than young women (84%; n=182).

Forty-one percent (n=15) of adolescent girls age 18-19 years had knowledge about PrEP, compared to 70% (n=85) of young women age 20-24 years and 64% (n=60) of young women 25 years or older. PrEP knowledge among males was lower, at 56% (n=125). This suggested that the programmatic and national targeting of PrEP messaging to young women is likely effective, though messaging to adolescent girls may need strengthening. While PrEP is not currently part of the Stepping Stones curriculum, CANGO did make an effort to update facilitators’ knowledge on a regular basis, including about the latest HIV prevention technologies. This approach likely enabled PrEP knowledge to improve among participants.

Knowledge results and analysis, by Inkhundla

Overall, fewer participants could correctly identify ways of preventing the sexual transmission of HIV and reject major misconceptions about HIV transmission in Kukhanyeni (71%; n=44), Gege (71%; n=54) and Nkwene (69%; n=34). More could do so in Mahlangatja (80%; n=45), Maphalaleni (87%; n=41) and Ntondozi (82%; n=37) (Figure 3). Intensified HIV prevention knowledge interventions may be needed in these places.

Figure 3. Proportion of Stepping Stones participants who correctly identify ways of preventing the sexual transmission of HIV and reject major misconceptions about HIV transmission, by Inkhundla

100% 87% 82% 78% 80% 76% 80% 71% 73% 71% 69% 60%

40%

20%

0% Kukhanyeni Nkhaba Gege Mhlume Mahlangatja Nkwene Maphalaleni Ntondozi TOTAL (n=62) (n=48) (n=76) (n=94) (n=56) (n=49) (n=47) (n=45) (n=477)

Stepping up the Fight An evaluation of the Stepping Stones approach to HIV prevention 31 among adolescents and young people in Eswatini

Variation by Inkhundla on knowledge of PrEP and of HIV risk from having an older partner was stark. For PrEP, 69% (n=31) of Stepping Stones participants in Ntondozi demonstrating awareness of the HIV prevention method, compared to 46% (n=22) in Nkhaba. For having older partners, 77% (n=72) of Stepping Stones participants in Mhlume demonstrated awareness of this risk, compared to just 52% (n=25) in Nkhaba.

Knowledge results and analysis, by program exposure

Overall, little variation was observed on knowledge indicators when comparing non- graduates and graduates. For instance, 96% (n=213) of non-graduates knew that VMMC can reduce the risk of acquiring HIV, compared to 94% (n=239) of graduates. Ninety-six percent (n=126) of non-graduates agreed with an accurate definition of physical and sexual violence, compared with 98% (n=248) of graduates. Participants may enter the program with high levels of existing HIV knowledge, either from other programs or national media.

Many non-graduates (78%; n=174) and graduates (74%; n=189) could correctly identify ways of preventing the sexual transmission of HIV and reject major misconceptions about HIV transmission. Given that Stepping Stones participants perform above average on this indicator when compared to national survey data (recall Figure 2), it is likely that exposure to the program improves HIV prevention knowledge, regardless of graduation.

Graduation from the Stepping Stones program did have a large effect on improved PrEP knowledge, particularly for females (Figure 4). Female graduates were up to three times more likely than non-graduates to have PrEP knowledge (OR 1.81 95% CI 1.09–3.03 p<.05).

Figure 4. Proportion of Stepping Stones participants who responded "True" to the survey question: “There is a daily drug available called “PrEP” that can be taken by people who don't have HIV to prevent them from being infected with the virus”, by program exposure

80% 69% 70% 65% 58% 60% 56% 53% 55% 50% 40% 30% 20% +14% + 5% + 9% 10% 0% Females Males All Participants who completed fewer than 9 Stepping Stones sessions (non-graduates) Participants who completed 9 Stepping Stones sessions or more (graduates)

Stepping up the Fight An evaluation of the Stepping Stones approach to HIV prevention 32 among adolescents and young people in Eswatini

Results and analysis on behavioral indicators

Behavioral results and analysis, overall

Overall, Stepping Stones participants demonstrated slightly above average rates of protective behaviors related to the use of condoms and contraceptives, compared to national survey data. Among all Stepping Stones participants age 20-24 years, 72% (n=168) used a condom the last time they had sex with a non-marital, non-cohabiting partner, compared to 70% in the 2016-2017 SHIMS 2 survey (Government of the Kingdom of Eswatini, 2019) (Figure 5). The difference was particularly noteworthy for females, where 69% (n=84) of Stepping Stones participants age 20-24 years used a condom the last time they had sex with a non-marital, non-cohabiting partner, compared to 63% in SHIMS 2.

For Stepping Stones participants who did not use a condom the last time they had sex, the most commonly cited reasons were that they did not have one (24%; n=27) or that they trust their partner (19%; n=22).

Figure 5. Proportion of young women and men age 20-24 years who used a condom the last time they had sex with a non-marital, non-cohabiting partner (Stepping Stones participants vs. SHIMS 2 national survey data)

80% 76% 76% 69% 72% 70% 70% 63% 60% 50% 40% 30% 20% 10% 0% Females Males All

Stepping Stones participants (2016-2018) (age 20-24 years) SHIMS 2 National Survey Data (2016-2017) (age 20-24 years)

Eighty percent (n=98) of female Stepping Stones participants age 20-24 years were currently using a modern method of contraception5, compared to 68% of females of the same age in the 2014 MICS survey (Central Statistical Office 2016).6

5 These figures represent a proportion of all those who were surveyed. They are not a calculation of unmet need. 6 The Stepping Stones curriculum is deliberate about teaching dual protection for both HIV/STIs (e.g. condoms) and pregnancy (e.g. hormonal contraception). This evaluation did not ask questions about the use of dual protection. Future assessments of the Stepping Stones program should seek to measure this outcome.

Stepping up the Fight An evaluation of the Stepping Stones approach to HIV prevention 33 among adolescents and young people in Eswatini

Stepping Stones participants were far less likely to have engaged in certain HIV risk behaviors – notably, transactional sex – when compared to national survey data (Figure 6). This difference was particularly large for females. Twenty-one percent of AGYW age 15-24 years in the MOH and UNFPA (2016) adolescent sexual and reproductive health service utilization survey indicated they had ever been paid to have sex. Acknowledging that the indicators are not directly comparable, just 5% of female Stepping Stones participants reported they received money, goods or other favors in exchange for sex in the past year.

Figure 6. Proportion of Stepping Stones participants who engaged in transactional sex, compared to national survey data

25% 21% 20%

15% 11% 10% 7% 5% 5% 0% Females Males

Stepping Stones participants (2016-2018) (average age: 24 years) MOH & UNFPA ASRH Service Utilization Survey (2016) (age 15-24 years)

Behavioral results and analysis, by age and sex

There was notable age and sex variation in participants’ responses to survey questions on contraceptive use as well as sexual agency.

Fifty-seven percent (n=21) of adolescent girls age 18-19 years were currently using a modern method of contraception, compared to 80% (n=98) of young women age 20-24 years and 84% (n=79) of young women 25 years or older. Similarly, 56% (n=9) of adolescent boys age 18-19 years were currently using a modern method of contraception compared to 86% (n=95) of young men age 20-24 yeas and 78% (n=76) of young men 25 years or older. Low levels of access contraception use reflect in high teenage pregnancy rates. Adolescent girls age 18-19 years (41%; n=15) were just as likely to report a pregnancy in the past year as young women age 20-24 years (41%; n=50) and young women age 25 years and older (41%; n=39). The same was found to be true for males. Adolescent boys age 18-19 years (13%; n=2) were just as likely to report that their partner had become pregnant in the past year as young men age 20-24 years (13%; n=14) and young men age 25 years and older (14%; n=14). To improve outcomes, the Stepping Stones program may need to address the specific age-related barriers to accessing contraceptives that adolescents face.

Stepping up the Fight An evaluation of the Stepping Stones approach to HIV prevention 34 among adolescents and young people in Eswatini

Seventy percent (n=26) of adolescent girls age 18-19 years said “no” to an unwanted sexual situation7 in the past year, compared to 55% (n=67) of young women age 20-24 years and 52% (n=49) of young women 25 years or older. Notably, the results for this indicator were the opposite for boys, with sexual agency increasing with age. Thirty-one percent (n=5) of adolescent boys age 18-19 years said “no” to an unwanted sexual situation in the past year compared to 45% (n=50) of young men age 20-24 yeas and 39% (n=38) of young men 25 years or older.

Behavioral results and analysis, by Inkhundla

The largest geographic variation on behavioral aspects of the survey was on SGBV indicators, followed by saving money and falling pregnant. For SGBV prevention behavioral indicators, Mlhume participants had the highest positive responses and Mahlangatja participants had the lowest (Figure 7). In Mhlume, 66% (n=62) of Stepping Stones participants said “no” to an unwanted sexual situation in the past year, compared with 36% (n=20) in Mahlangatja. Similarly, 54% (n=51) of Mhlume Stepping Stones participants were able to identify risk or warning signs of sexual and gender-based violence among their family and/or friends, compared with just 16% (n=9) in Mahlangatja. Stepping Stones participants from Gege also performed poorly on these indicators. Intensified SGBV behavioural interventions may be needed in Gege and Mahlangatja.

Figure 7. Proportion of Stepping Stones participants who responded "Yes" to survey questions on GBV prevention behaviors (select indicators), by Inkhundla

70% 66%

60% 54% 53% 54% 50% 49% 49% 50% 43% 45% 40% 37% 36% 36% 40% 33% 35% 30% 30% 22% 20% 16%

10%

0% Have you said “no” to an unwanted sexual situation Have you been able to identify risk or warning signs in the past year? of sexual and gender-based violence among your family and/or friends and give them information about where they can access services and support in the past year?

Kukhanyeni (n=62) Nkhaba (n=48) Gege (n=76) Mhlume (n=94) Mahlangatja (n=56) Nkwene (n=49) Maphalaleni (n=47) Ntondozi (n=45) TOTAL (n=477)

7 The definition of a “sexual situation” was left open-ended in the survey. This could include anything from flirting, kissing or touching, to sexual intercourse.

Stepping up the Fight An evaluation of the Stepping Stones approach to HIV prevention 35 among adolescents and young people in Eswatini

Contrasts by Inkhundla were also observed for pregnancy and for saving money. In Gege, 43% (n=33) of Stepping Stones participants reported they or their participants had fallen pregnant in the past year, compared to 18% (n=8) in Ntondozi. In Mahlangatja, 88% (n=49) of Stepping Stones participants said they had taken actions to save money in the past year, compared to 62% (n=47) in Gege. Again, intensified HIV prevention efforts may be needed in Gege, given the poor outcomes on a range of indicators.

Statistically significant correlations between several behavioral indicators were identified, by Inkhundla. Where Stepping Stones participants were able to identify risks or warning signs of SGBV, they were more likely to have said “no” to an unwanted sexual situation in the past year (Figure 8). These results suggests that Stepping Stones’ participants ability to identify SGBV risks may translate into greater empowerment and protective behaviors.

Figure 8. Correlation between being able to identify risk or warning signs of sexual and gender-based violence and saying “no” to an unwanted sexual situation in the past year, by Inkhundla (r = 0.72, p<.05)

60%

Mhlume 50% Kukhanyeni

40% Nkhaba based violence based violence - Maphalaleni Ntondozi 30% Gege

Nkwene 20% Mahlangatja

among your friends your family and/or among 10% signs of sexual ofsigns sexual and gender Have you been able to identify risk or warning warning risk identify you able been or to Have 0% 30% 35% 40% 45% 50% 55% 60% 65% 70%

Have you said “no” to an unwanted sexual situation in the past year?

Where Stepping Stones participants set goals for themselves and tracked their progress, they were more likely to have taken actions to save money (Figure 9). These findings suggest an important link between Stepping Stones activities on goal setting and economic empowerment. Taking action to save money was also moderately associated with increased condom use (r = 0.56), though the relationship was not statistically significant.

Stepping up the Fight An evaluation of the Stepping Stones approach to HIV prevention 36 among adolescents and young people in Eswatini

Figure 9. Correlation between setting/tracking goals for oneself and taking actions to save money, by Inkhundla (r = 0.74, p<.05)

100%

95%

Mahlangatja 90% Nkhaba Ntondozi Nkwene Kukhanyeni 85%

past past year? 80% Maphalaleni Mhlume 75% Gege 70%

Have you taken actions the in save money to actions you taken Have 60% 65% 70% 75% 80% 85% 90%

Have you set goals for yourself, and tracked your progress towards those goals, in the past year?

Importantly, Stepping Stones participants who received money, goods or other favors in exchange for sex in the past year were less likely to report use of a condom the last time they had sex with a non-marital, non-cohabiting partner (r = -0.71, p<.05). Engaging in transactional sex had the strongest association with low condom use across all indicators in the survey, and the relationship is statistically significant. This likely indicates limited condom negotiation power in transactional relationships. Going forward, the Stepping Stones program may need to specifically address the challenges with negotiating condom use when in a transactional relationship or transactional sexual situation.

Stepping Stones participants who believed that the risk of HIV transmission can be reduced by having sex with only one uninfected partner who has no other partners were far less likely to have fallen pregnant in the past year (r = -0.84, p<.01). This relationship has very strong statistical significance. This finding suggests that having accurate HIV prevention knowledge may have a strong impact on reducing pregnancy rates.

Behavioral results and analysis, by program exposure

Condom use at last sex was higher among graduates of the Stepping Stones program compared to non-graduates (69%; n=175 v. 66%; n=147), with the positive difference being especially distinct among females (69%; n=91 v. 61%; n=76) (Figure 10).

Stepping up the Fight An evaluation of the Stepping Stones approach to HIV prevention 37 among adolescents and young people in Eswatini

Figure 10. Proportion of Stepping Stones participants who responded "Yes" to the survey question: "Did you use a condom the last time you had sex with non-marital, non-cohabiting partner?", by program exposure

100% 90% 80% 73% 69% 71% 69% 70% 66% 61% 60% 50% 40% 30% + 8% + 2% + 3% 20% 10% 0% Females Males All

Participants who completed fewer than 9 Stepping Stones sessions (non-graduates) Participants who completed 9 Stepping Stones sessions or more (graduates)

Similarly, use of a modern contraceptive method was higher among graduates of the Stepping Stones program compared to non-graduates (81%; n=205 v. 66%; 78=173), with the positive difference being particularly distinct for females (80%; n=105 v. 75%; n=93) (Figure 11).

Figure 11. Proportion of Stepping Stones participants who responded "Yes" to the survey question: "Are you currently using a method of modern contraception?”, by program exposure

100% 90% 80% 80% 81% 78% 81% 80% 75% 70% 60% 50% 40% + 5% 30% + 1% + 3% 20% 10% 0% Females Males All Participants who completed fewer than 9 Stepping Stones sessions (non-graduates) Participants who completed 9 Stepping Stones sessions or more (graduates)

Stepping up the Fight An evaluation of the Stepping Stones approach to HIV prevention 38 among adolescents and young people in Eswatini

Graduation from the program also had a moderate positive effect on increased sexual agency (ability to say “no” to an unwanted sexual situation), with 50% of graduates reporting sexual agency compared to 44% of non-graduates (Figure 12). The effect was statistically significant for male program graduates, who were twice as likely to report sexual agency compared to non-graduates (OR 2.23 95% CI 1.28 -3.86 p<.05).

Figure 12. Proportion of Stepping Stones participants who have said “no” to an unwanted sexual situation in the past year, by program exposure

70% 60% 55% 56% 50% 50% 50% 44% 40% 31% 30% 20% + 1% +19 % + 6% 10% 0% Females Males All

Participants who completed fewer than 9 Stepping Stones sessions (non-graduates) Participants who completed 9 Stepping Stones sessions or more (graduates)

Graduation from the program is also associated with moderately decreased pregnancy rates (Figure 13), though not statistically significant. The large discrepancy between females and males suggests that the females are not getting pregnant by their male peers.

Figure 13. Proportion of Stepping Stones participants who responded "Yes" to the survey question: "Have you or your partner fallen pregnant in the past year?”, by program exposure

50% 44% 40% 38% -8 % 32% 30% 24% 20% 18% -6 % 10% 10% -8 %

0% Females Males All

Participants who completed fewer than 9 Stepping Stones sessions (non-graduates) Participants who completed 9 Stepping Stones sessions or more (graduates)

Stepping up the Fight An evaluation of the Stepping Stones approach to HIV prevention 39 among adolescents and young people in Eswatini

There was no observed relationship between condom use and pregnancy rates (r = 0.09; p<.1) or between contraceptive use and pregnancy rates (r = 0.09; p<.05). This suggests that pregnancies among Stepping Stones participants may be wanted or planned. To reduce rates of pregnancy among young people, the Stepping Stones program may need to amplify messages that shift socio-cultural norms and expectations on childbearing, while continuing to increase demand and access for condoms and other modern forms of contraception.

Results and analysis on attitudinal indicators

Attitudinal results and analysis, overall

Results on attitudinal indicators are encouraging on some sub-topics and concerning on others. For example, on indicators related to stigma and discrimination, Stepping Stones participants exhibited strong positive attitudes, with a composite score of 96% across the two stigma indicators. Ninety-seven percent (n=463) of Stepping Stones participants would buy fresh vegetables from a shopkeeper or vendor who is HIV-positive, and 95% (n=453) thought children living with HIV should be able to attend school with children who are HIV- negative.

However, on indicators related to gender equality, Stepping Stones participants’ responses are concerning. Just 64% (n=303) of Stepping Stones participants think men and women should have equal rights in society and 14% (n=65) think that a husband or boyfriend is justified in hitting or beating his wife. Females were just as likely as males to think that a husband or boyfriend is justified in hitting or beating his wife.

Attitudinal results and analysis, by age and sex

There was notable age and sex variation in participants’ responses to survey questions on gender-based violence, gender quality and HIV risk perception.

Thirty percent (n=11) of adolescent girls age 18-19 years believed that a husband or boyfriend is justified in hitting or beating his wife, compared to 11% (n=14) of young women age 20-24 years and 12% (n=11) of young women 25 years or older. Similar variation was observed for males. Thirty-one percent (n=5) of adolescent boys age 18-19 years believed that a husband or boyfriend is justified in hitting or beating his wife, compared to 11% (n=12) of young men (age 20-24 years) and 12% (n=12) of young men 25 years or older.

Stepping up the Fight An evaluation of the Stepping Stones approach to HIV prevention 40 among adolescents and young people in Eswatini

Fourteen percent (n=5) of adolescent girls age 18-19 years believed that their current sexual behavior put them or your partner(s) at risk of HIV infection, compared to 18% (n=22) of young women age 20-24 years and 28% (n=26) of young women 25 years or older. The variation is even starker for boys. No (0%) adolescent boys age 18-19 years believed that their current sexual behavior put them or your partner(s) at risk of HIV infection, compared to 33% (n=37) of young men age 20-24 years and 26% (n=25) of young women 25 years or older. Risk perception variation by age is largely aligned with patterns of HIV incidence and prevalence, suggesting that Stepping Stones participants have a relatively accurate perception of their age-related HIV risk.

Forty-nine percent (n=18) of adolescent girls age 18-19 years believed that men and women have equal rights in society, compared to 68% (n=83) of young women age 20-24 years and 64% (n=60) of young women 25 years or older. Similar variation was observed for adolescent boys age 18-19 years (56%; n=9) compared to young men age 20-24 years (69%; n=77). Young men age 25 years or older had similar attitudes towards gender equality as adolescent boys (58%; n=56).

Attitudinal results and analysis, by Inkhundla

The largest geographic variation on attitudinal indicators was whether Stepping Stones participants lives improved during the past year. In Ntondozi, 96% (n=43) of Stepping Stones participants reported that their lives had improved, compared with 67% (n=51) in Gege (Figure 14). Despite this large variation – which may reflect location-based inequalities in Eswatini (proximity to major cities and access to opportunities) – reported life improvement was high overall. In total, 81% (n=388) of Stepping Stones participants said they thought their lives had improved during the past year.

Figure 14. Proportion of Stepping Stones participants who responded "Yes" to the survey question “has your life improved during the past year?”, by Inkhundla

96% 100% 89% 89% 84% 81% 81% 77% 81% 80% 67% 60%

40%

20%

0% Kukhanyeni Nkhaba Gege Mhlume Mahlangatja Nkwene Maphalaleni Ntondozi TOTAL (n=62) (n=48) (n=76) (n=94) (n=56) (n=49) (n=47) (n=45) (n=477)

Stepping up the Fight An evaluation of the Stepping Stones approach to HIV prevention 41 among adolescents and young people in Eswatini

Variation was also observed for whether Stepping Stones participants think men and women have equal rights in society. In Kukhanyeni, 74% (n=46) of participants believed in gender quality, compared to 54% (n=26) in Nkhaba.

Attitudinal results and analysis, by program exposure

Graduation from the Stepping Stones program had a moderate positive effect on participants’ attitudes towards gender equality, particularly for males (Figure 15). Sixty-seven percent (n=83) of male Stepping Stones program graduates thought that men and women have equal rights in society compared to 59% (n=59) of non-graduates. For comparative reference, 64% of men interviewed for Round 5 of the Afrobarometer survey (Afrobarometer, 2013) felt that women should have equal rights and be treated the same way as men.

Figure 15. Proportion of Stepping Stones participants who responded "Yes" to the survey question: "Should men and women have equal rights in society?"

80% 66% 67% 70% 63% 60% 59% 60% 60% 50% 40% 30%

20% + 5% + 8% + 3% 10% 0% Females Males All

Participants who completed fewer than 9 Stepping Stones sessions (non-graduates) Participants who completed 9 Stepping Stones sessions or more (graduates)

Graduates of the Stepping Stones program had statistically significant decreases in the perception that their current behavior puts them at risk of HIV (both sexes) (OR 0.58 95% CI 0.38-0.88 p<.05) as well as the perception that their current behavior puts them at risk of pregnancy (both sexes) (OR 0.67 95% CI 0.45-0.98 p<.05). This finding warrants further investigation. It could be linked to the improved HIV prevention knowledge and enhanced HIV protective behaviors that graduates exhibit. However, it is important to ensure that this perception does not translate into increased risk behaviors in future. It may be useful for future evaluations of the Stepping Stones program (and other evaluations of similar programs) to include an analysis of whether any risk compensation is occurring, particularly among those with lower risk perceptions.

Stepping up the Fight An evaluation of the Stepping Stones approach to HIV prevention 42 among adolescents and young people in Eswatini

Results and analysis on access indicators

Access results and analysis, overall

Access to health services among Stepping Stones participants varied depending on the type of service. For HIV testing, access to these services among Stepping Stones participants was very high. Overall, 88% (n=422) of Stepping Stones participants reported receiving an HIV test in the past year. Access to HIV testing services was higher for females (94%; n=237) than it was for males (83%; n=185). When compared to national survey data on HIV testing uptake from SHIMS 2, Stepping Stones participants far exceed national averages (Figure 16). For example, 92% (n=112) of female Stepping Stones participants age 20-24 years had an HIV test in the past year, compared to 74% of females of the same age surveyed in SHIMS 2. Eight-one percent (n=90) of male Stepping Stones participants age 20-24 years had an HIV test in the past year, compared to 51% in SHIMS 2.

Figure 16. Proportion of young men and women age 20-24 years who received HIV testing in the past 12 months (Stepping Stones participants vs. SHIMS 2 national survey data)

100% 92% 87% 90% 81% 80% 74% 70% 63% 60% 51% 50% 40% 30% 20% 10% 0% Females Males All

Stepping Stones participants (2016-2018) (age 20-24 years)

SHIMS 2 National Survey Data 2016-2017 (age 20-24 years)

While coverage of HIV testing among Stepping Stones participants is very high, a missed opportunity was observed for greater coverage of other linked services, including family planning, STI screening and TB screening (Figure 17). While 88% (n=422) of Stepping Stones participants received an HIV test in the past year, just 63% (n=300) received family planning or contraceptive services, 52% (n=248) received TB screening, 49% (n=233) received STI screening and 19% (n=92) received cancer screening (such as a breast exam, pap smear or testicular exam) over the same time period. The “cascade” of service access in Figure 17 highlights a need for greater services integration, or “one-stop-shop” models of care for young people in Eswatini.

Stepping up the Fight An evaluation of the Stepping Stones approach to HIV prevention 43 among adolescents and young people in Eswatini

Figure 17. Stepping Stones participants who received HIV/SRH services in the past year

100% 93% 88% 90% 83% 80% 70% 70% 63% 58% 60% 55% 54% 52% 48% 49% 50% 38% 40% 27% 30% 19% 20% 10% 10% 0% Females Males All

Stepping Stones participants who received an HIV test in the past year Stepping Stones participants who received family planning/contraceptive services in the past year Stepping Stones participants who received STI screening in the past year Stepping Stones participants who received TB screening in the past year Stepping Stones participants who received cancer screening in the past year

Among participants who did access health services, 87% (n=414) reported that the services they received were friendly, suggesting that the referrals from the program are appropriately targeted to youth-competent service providers.

Access to gender-based violence services as well as financial services was comparably lower than access to health services. The effects of the program on these services is discussed below.

Access results and analysis, by age and sex

There was notable age and sex variation in participants’ responses to survey questions on access to family planning services as well as access to financial services.

Forty-nine percent (n=18) of adolescent girls (age 18-19 years) had accessed family planning or contraception services in the past year, compared to 74% (n=90) of young women age 20-24 years and 76% (n=71) of young women 25 years or older. A similar, variation was observed for males. Forty-four percent (n=6) of adolescent boys age 18-19 years had accessed family planning or contraception services in the past year, compared to 81% (n=90) of young men age 20-24 years and 84% (n=81) of young men 25 years or older.

Stepping up the Fight An evaluation of the Stepping Stones approach to HIV prevention 44 among adolescents and young people in Eswatini

Eleven percent (n=4) of adolescent girls age 18-19 years had accessed financial services (i.e. from a bank or an insurance broker) in the past year, compared to 22% (n=27) of young women age 20-24 years and 26% (n=24) of young women 25 years or older. Similar, though less extreme, variation was observed for males. Twenty-five percent (n=4) of adolescent boys age 18-19 years had accessed financial services in the past year compared to 32% (n=36) of young men age 20-24 years and 34% (n=33) of young men 25 years or older.

While all participants thought it was important to save money, boys were much more likely than girls to have actually saved money (77%; n=172 vs. 65%; n=167) as well as to have accessed financial services (33%; n=73 vs. 22%; n=55). There may be a need to augment the Stepping Stones program with dedicated and intensified economic empowerment activities for adolescent girls and young women.

Figure 18. Proportion of Stepping Stones participants who responded "Yes" to survey questions on economic empowerment, by age and sex

120% 97% 98% 100%100% 100% 96% 94% 94% 77% 80% 74% 66%68% 59% 60%

40% 32%34% 26% 22% 25% 20% 11%

0% Do you think it is important to Have you taken actions to Have you accessed financial save money? save money in the past year? services in the past year (this can include services from a bank or insurance broker)?

Adolescent Girls (age 18-19 years) Young Women (age 20-24 years) Young Women (age 25 years or older) Adolescent Boys (age 18-19 years) Young Men (age 20-24 years) Young Men (age 25 years or older)

Access results and analysis, by Inkhundla

The largest geographic variation on access indicators was observed for family planning and financial services (Figure 19).

Stepping up the Fight An evaluation of the Stepping Stones approach to HIV prevention 45 among adolescents and young people in Eswatini

In Gege, 78% (n=59) of Stepping Stones participants said they received family planning/contraceptive services in the past year, compared to 47% (n=21) in Ntondozi. These figures likely reflect access to antenatal care as a result of pregnancy rates, which were the highest among Gege survey participants (43%; n=33) and lowest among Ntondozi participants (18%; n=8).

For financial services, 43% (n=24) of Stepping Stones participants in Mahlangatja received financial services in the past year, compared to just 17% (n=13) in Gege and 16% (n=7) in Ntondozi.

Figure 19. Proportion of Stepping Stones participants who responded "Yes" to survey questions on access to services (select indicators), by Inkhundla

90% 78% 80% 71% 68% 70% 62%61% 62% 60% 57% 51% 47% 50% 43% 40% 32% 29% 30% 30% 27% 27% 21% 20% 17% 16%

10%

0% Have you received family Have you accessed financial services in the planning/contraceptive services in the past past year (this can include services from a year? bank or insurance broker)?

Kukhanyeni (n=62) Nkhaba (n=48) Gege (n=76) Mhlume (n=94) Mahlangatja (n=56) Nkwene (n=49) Maphalaleni (n=47) Ntondozi (n=45) TOTAL (n=477)

Access results and analysis, by program exposure

Uptake of HIV testing was very high for both graduates and non-graduates of the Stepping Stones program. Ninety percent (n=200) of non-graduates and 87% (n=222) of graduates said they had received an HIV test in the past year. The difference between graduating and not graduating was not statistically significant for HIV testing access.

Stepping up the Fight An evaluation of the Stepping Stones approach to HIV prevention 46 among adolescents and young people in Eswatini

While not statistically significant, graduation from the Stepping Stones program had a moderate positive effect on participants’ access to family planning/contraceptive services (65%; n=166 vs. 60%; n=134), post-violence care (16%; n=40 vs. 11%; n=25), and reporting of an SGBV experience to the police (8%; n=21 vs. 5%; n=11) (Figures 20, 21 and 22).

Of note, 74% (n=97) of female Stepping Stones program graduates received family planning/contraceptive services in the past year compared to 66% (n=82) of non-graduates (Figure 20). Male graduates were also more likely (56%; n=69) to have received family planning/contraceptive services in the past year compared to non-graduates (52%; n=52).

Figure 20. Proportion of Stepping Stones participants who responded "Yes" to the survey question: "Have you received family planning/contraceptive services in the past year?", by program exposure

80% 74% 70% 66% 65% 60% 56% 60% 52% 50% 40% 30% 20% + 8% + 4% + 5% 10% 0% Females Males All

Participants who completed fewer than 9 Stepping Stones sessions (non-graduates) Participants who completed 9 Stepping Stones sessions or more (graduates)

Figure 21. Proportion of Stepping Stones participants who received post-violence care if they experienced SGBV in the past one year, by program exposure

18% 16% 16% 16% 15% 14% 12% 11% 12% 10% 10% 8% 6% + 4% + 5% + 5% 4% 2% 0% Females Males All

Participants who completed fewer than 9 Stepping Stones sessions (non-graduates)

Participants who completed 9 Stepping Stones sessions or more (graduates)

Stepping up the Fight An evaluation of the Stepping Stones approach to HIV prevention 47 among adolescents and young people in Eswatini

Figure 22. Proportion of Stepping Stones participants who reported to the police or other authorities if they experienced sexual or gender-based violence, by program exposure

12% 10% 10% + 5% 8% 8% 7% 6% 6% 5%

4% + 4% 2% + 3% 2%

0% Females Males All

Participants who completed fewer than 9 Stepping Stones sessions (non-graduates) Participants who completed 9 Stepping Stones sessions or more (graduates)

Among Stepping Stones participants who experienced sexual or gender-based violence, those who received post-violence care were also more likely to report the experience to the police or other authorities (r = 0.74, p<.05). This finding is statistically significant. It likely suggests the best practice of a “one-stop-shop” model of post-violence care and access to justice is being received among Stepping Stones participants who experience SGBV.

It likely indicates the importance of the Stepping Stones program’s activities to impart correct knowledge in HIV transmission and dispel myths for developing accurate risk perception and creating demand for services such as HIV testing.

Results and analysis on attribution indicators

All participants rated the program very highly, saying that it helped improve their HIV prevention knowledge, behavior, attitudes and access. Nearly all (99.6%; n=475) participants said that participating in the Stepping Stones program improved their knowledge. Slightly fewer (99%; n=471) said that the program helped them to make better decisions about their behavior. Ninety-seven percent (n=464) said the program changed their attitudes. Lastly, 94% (n=450) said that the Stepping Stones program facilitated their access to services. There was very little variation on the responses to these indicators by age and sex, by Inkhundla or by program exposure. It is curious that these strong positive attribution scores do not necessarily reflect equally in the actual indicators on knowledge, behavior, attitudes and access. There appears to be a

Stepping up the Fight An evaluation of the Stepping Stones approach to HIV prevention 48 among adolescents and young people in Eswatini

perception among participants that the program is benefitting them more than it actually is. This could reflect additional benefits of the program that were not captured in the evaluation indicators, such as social asset building (making friends), alleviation of boredom/idleness, receiving attendance incentives, among others. Some of these additional benefits were captured during the focus group discussions (discussed below).

Results and analysis on sustainability and value-for money

Sustainability of program effects over time

When comparing responses to survey questions among those who were enrolled in the program in 2016, 2017 and 2018, the vast majority of indicators were stable over time, suggesting that the Stepping Stones program has a lasting positive effect on those reached. Up to three years post-intervention, Stepping Stones participants maintained high rates of HIV testing, condom use, HIV prevention knowledge, contraception use, and economic empowerment (Figure 23). Given that key program effects appear sustainable over time, the program should seek to engage new individuals during each enrollment period. Other implementers of the Stepping Stones program have a mix of new and repeat beneficiaries. The findings of this evaluation indicate that repeating the program with the same beneficiaries may not be a good use of resources.

Figure 23. High rates of HIV testing, condom use, HIV prevention knowledge, contraception use, and economic empowerment among Stepping Stones participants, maintained up to three years post-intervention

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 2016 2017 2018 (3 years post-intervention) (2 years post-intervention) (1 year post-intervention)

Stepping Stones participants who received an HIV test in the past year Stepping Stones participants who used a condom the last time they had sex Stepping Stones participants with knowledge that VMMC can reduce the risk of acquiring HIV Stepping Stones participants who currently use a method of modern contraception Stepping Stones participants who have taken actions to save money in the past year

Stepping up the Fight An evaluation of the Stepping Stones approach to HIV prevention 49 among adolescents and young people in Eswatini

Participants from 2016 and 2017 were just as likely to correctly identify ways of preventing the sexual transmission of HIV, and who reject major misconceptions as participants from 2018. Condom use at last sex was consistent across the three years, at 70% (n=74) for those enrolled in 2016, 68% (n=140) for 2017 and 70% (n=114) for 2018. HIV testing also remained high over time, at 91% (n=96) for those enrolled in 2016, 87% (n=181) for 2017 and 88% (n=145) for 2018. Access to other health services, such as TB screening, STI screening and family planning, were also relatively consistent over time, up to three years post-intervention.

Despite similar rates of condom and contraceptive use, and similar rates of falling pregnant, Stepping Stones participants’ risk perceptions appears to fade over time. A quarter (25%; n=27) of 2016 participants thought their current sexual behavior puts them or their partner(s) at risk of becoming pregnant, compared to 31% (n=67) of 2017 participants and 37% (n=60) of 2018 participants. The same trend was not observed for HIV risk perception, which remained relatively constant up to three years post-intervention. Participants who have been out of the Stepping Stones for some time may need refresher information about the risks of unwanted and/or teenage pregnancy, so that their reduced risk perception does not eventually translate into increased risk behaviors. Other implementing partners of Stepping Stones, including Pact Eswatini, have developed refresher sessions for the program.

Value-for-money and potential return on investment

While the scope of the Stepping Stones evaluation did not permit new modelling exercises or cost-effectiveness analyses, the results can be put in the context of Eswatini’s Umgubudla HIV Investment Case (Government of the Kingdom of Eswatini & NERCHA, 2016).

The Umgubudla shows that universal access to ART can reduce new HIV infections by 42% in 2022 and by 43% in 2030, and will be cost-saving from the year 2035 onward (or earlier with economies of scale). HIV testing is a critical entry point to reach maximum benefits of HIV treatment. Extrapolating evaluation results on HIV testing to the entire program, Stepping Stones helped diagnose up to 1681 females and 418 males who had HIV and did not know it – 12% of the current national gap (all ages).8 Without Stepping Stones, SHIMS 2 testing rates suggest that up to 1091 females and 210 males may have been diagnosed, or 8% of the national gap. Stepping Stones therefore made a large contribution to universal access to ART Eswatini and to the related future cost-savings in the Umgubudla.

8 Applies age-specific HIV prevalence from SHIMS 2 to the 11,963 females and 10,960 males in the program to estimate total positives. Assumes 75.5 of females and 60.3% of males already know their status (SHIMS 2). HIV testing rates for Stepping Stones overall and for SHIMS 2 age 15-24 years were then applied to the remaining figures (those undiagnosed) to get total potential diagnoses. National gap is calculated as 210,000 PLHIV, minus the 92% who already know their status.

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The Umgubudla also says that the empowerment of young women, involvement of men, and intensifying comprehensive knowledge will stop the tide of HIV. This strategic area is modelled to reduce new infections by 12% and avert 500 AIDS deaths by 2022, and save $5 million by 2030. Given an estimated 78249 female participants took actions to save money in the past year, and positive effects were found for HIV prevention knowledge (72% of 20-20- year-olds in Stepping Stones had comprehensive knowledge, compared to 49% in MICS 2014), and attitudes towards gender equality (67% of male Stepping Stones program graduates thought that men and women have equal rights in society compared to 59% of non-graduates), Stepping Stones has also contributed to impact and cost-saving in this area.

The Umgubudla shows that the low annual cost ($20 per woman) of family planning among PLHIV makes it the most feasible and cost-effective intervention for reducing new infections in children. An incremental reduction in the unmet need for family planning among PLHIV from 65% to 10% in 2022 and to 5% in 2030 will reduce new infections from mother-to-child transmission by 62% over the investment period. Results from this evaluation suggest that Stepping Stones helped an estimated 1174 HIV-positive 20-24-year-olds access and use modern methods of contraception. Without the Stepping Stones, MICS 2014 data suggest this figure would be 998.10 Stepping Stones has therefore contributed to reducing the unmet need for family planning among HIV-positive women, and helped realize the associated impact through this cost-effective intervention.

The total cost of implementing the Stepping Stones program in the 20 Tinkhundla from October 2015 to September 2018 was US $1,578,336 (or US $526,112 per year). This is just 0.4% of Eswatini’s annual HIV resource needs (US $150 million), according to the National Multisectoral HIV and AIDS Strategic Framework 2018 – 2022 (NERCHA, 2018). The contribution of Stepping Stones to the Umgubudla strategic areas described above, for such a small proportional amount, suggest a good return on investment for the program.

This is a crude analysis and should be interpreted in that light. A more in-depth value-for- money analysis is needed to determine if there are technical or allocative efficiencies to be gained in relation to the specific investments made in the Global Fund-supported Stepping Stones program. Nevertheless, the results of this evaluation do suggest that Stepping Stones has contributed in a number of ways to the impact and cost-savings/cost- effectiveness as modelled in Eswatini’s Umgubudla HIV Investment Case.

9 Extrapolates the result that 65.4% of female Stepping Stones program participants took actions to save money in the past year and applies it to the entire program reach of 11,963 female enrollees. 10 Assumes an HIV prevalence of 20.9% among the 7019 20-24-year-old females who were enrolled in Stepping Stones, and applies 80% contraception use among this age group for Stepping Stones evaluation data and 68% for MICS.

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Comparison of program output results (targets) and evaluation findings

The Stepping Stones program had five program output results, or specific targets, that the program aimed to achieve. Table 4 shows a comparison of those program output results (targets) and the findings of this evaluation, along with an appraisal of progress made.

Table 4. Comparison of program output results (targets) and evaluation findings

Program output Evaluation finding(s) Appraisal results (targets)

20 Tinkhundla centres The Stepping Stones program was successfully implementing youth HIV Excellent progress implemented in 20 target Tinkhundla. prevention activities

From October 2015 and September 2018, CANGO 24,000 adolescents and enrolled 22,923 out-of-school adolescents and young young people understand people age 10-24 years in the Stepping Stones program. risks and practice safer Good progress behaviours (including Evaluation findings suggest that 76% of them (an condom use and reducing estimated 17,421 people) can correctly identify ways of intergenerational sex) preventing sexual transmission of HIV and reject major misconceptions about HIV transmission.

Evaluation findings suggest that in the past year, an Excellent progress estimated: for HIV testing

16,800 Adolescents and • 20,172 adolescents and youth (88%) received an HIV Good progress for youth receive • 14,441 adolescents and youth (63%) received family SRH/FP appropriate high impact planning or contraceptive service

health services (HTC, • 11,920 adolescents and youth (52%) received TB Moderate progress Care and Treatment, screening for TB and STI VMMC, Condom, SRH/ FP, • 11,232 adolescents and youth (49%) received STI screening referrals) screening • 4,355 adolescents and youth (19%) received cancer Poor progress for screening cancer screening Good progress overall 90% Young people living

with HIV know their HIV Evaluation findings suggest that 88% of all Stepping Excellent progress status and are linked to Stones participants reported receiving an HIV test in the for females appropriate HIV care and past year (94% for females, 83% for males).

support structures Moderate progress for males

Evaluation findings suggest the program did not have an effect on reducing acceptance of GBV. 14% (n=65) of Stepping Stones participants believe that a husband or boyfriend is justified in hitting or beating his wife. Program graduates are just as likely to believe this to be true as Reduced acceptance of non-graduates. Similar rates were found for males and GBV and Violence against females. Poor progress children in the communities However, participants did demonstrate improved perspectives on gender equality, and improved access to post violence care. Augmenting the curriculum to include information on the new Sexual Offences and Domestic Violence (SODV) Act may help accelerate progress on this indicator.

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QUALITATIVE RESULTS AND ANALYSIS

This section offers depth and nuance to the evaluation. It complements the survey results with data from FGDs with Stepping Stones participants and their parents/caregivers, as well as KIIs with program implementers, government stakeholders and facilitators. It also aims to answer additional questions about program content, quality and delivery modalities.

Characteristics of focus group participants

In total, 32 FGDs were conducted, including 12 FGDs with girls, 10 with boys, 1 with a mixed group of boys and girls, and 9 with parents and caregivers. On average, 4 FGDs were conducted per Inkhundla, with relative balance across each site. The highest number of FGDs was conducted in Kukhanyeni (n=8) and the lowest in Nkwene (n=2).

Characteristics of key informants

Twenty key informant interviews were conducted. Key informants were comprised of the Principal Recipient of the Global Fund-supported Stepping Stones program (grant managers) (n=2), the sub-recipient (implementers) (n=2), other implementers of programs targeting adolescents and young people in Eswatini (n=3), the Ministry of Health (n=1), Stepping Stones facilitators (those delivering the curriculum to the beneficiaries on a weekly basis) (n=10) and local Bucopho (Chiefdom Councilors) (n=2).

Perceptions on program content and opportunities to improve program design

Most valued topics

During FGDs, participants were asked what topics discussed in the Stepping Stones program were of greatest value to them.

The most common responses were:

 Sex and sexual pleasure, including the use of lubricants  Reproductive systems, including menstrual health  Sexually transmitted infections and seeking early care and treatment  Access to family planning and contraceptive services, avoiding teenage pregnancy  Availability of biomedical HIV prevention technologies, such as PEP and PrEP  How to save money and avoid unnecessary debts

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 How to use a condom properly  Fighting HIV stigma and discrimination  Assertiveness training and how to say “no”

“I knew there was a female condom but I never knew how to use it – until our facilitator demonstrated to us.”

Ntondozi Girls FGD, 30 May 2019

“It was interesting to know that some of us were wrongly using a condom. We were then taught on how to use one – that you do not tear a condom with your teeth, as you might damage it.” Ntondozi Boys FGD, 30 May 2019

“We know how to say ‘no, I don’t want sex’ [stands up and demonstrates assertive posture]. I am also now able to address people who are older than me about contraceptives.” Mhlume Girls FGD, 23 May 2019

“I never wanted to fall pregnant. I was able to start family planning because Stepping Stones lessons motivated me to do so.”

Mhlume (Simunye Community) Girls FGD, 23 May 2019

“I had the perception that saving was only for those who are working but the Stepping Stones program helped me see that I can also save money.”

Mahlangatja Girls FDG, 29 May 2019

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“I am now able to reach out to sick people without being judgmental and thinking that they are all HIV-positive just because they are not well.”

Maphalaleni Girls FGD, 27 May 2019

Both male and female focus group participants said that the ability to speak freely and openly was an incredibly valuable aspect of the Stepping Stones program for them.

Female participants often cited family planning as one of their favorite topics in the program. Many said they learned about alternative methods that they did not know existing before. Males also mentioned this, indicating that they did not know there were male-controlled family planning options before entering the program.

Females were more likely than males to say they valued learning about relationships in the Stepping Stones program, as well as learning about risks associated with transactional sex.

Female participants noted how the program dispelled gender-related socio-cultural norms or ideas, which were previously preventing them from reducing their HIV risk.

“I learned that as a woman, you should talk or discuss about sexual issues with your partner. It’s not always the man that must talk. I also learned that a woman can also bring along with them condoms in their bags, because most men do not want a condom once they are in a steady relationship.”

Gege (Nsubazi Community) Girls FGD, 22 May 2019

Several male participants mentioned that they learned about the female reproductive system, including the menstrual cycle. This had value to them, as it demystified something they knew very little about before the program.

Male participants also spoke about learning to understand and interpret body language from their partners, including when a woman wants to have sex and when she does not. Other said it was really valuable that the groups were co-curricular, so they got to hear women’s

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perspectives on sex and other topics, which they are not exposed to otherwise. Others still really appreciated learning about gender equality and respect.

“Us males have this thing that we think we are the only ones that need to be respected, yet, respect is a two-way process. Females as well need to be shown respect. That way, Stepping Stones raised an awareness amongst us males to respect our counterparts.”

Mahlangatja Boys FGD, 29 May 2019

These results underscore the critical importance of maintaining Stepping Stones as a cocurricular program, including both girls and boys. Working across genders is stated as a key principle in the Guidelines for Adapting Stepping Stones (Gordon & Welbourn, 2017). Funding partner emphasis on AGYW should not alter this aspect of program design. Working across genders is needed to reduce socially constructed power imbalances, gender inequality and gender-based violence. The PEPFAR-supported Stepping Stones program – which works only with boys – should consider working with boys and girls in light of these results, and line with the Stepping Stones guidelines).

Many male FGD participants (particularly in Ntondozi, Nkhaba, Kukhanyeni and Mahlangatja) spoke about learning about abuse, how to seek access to justice and how and where to go for help. Many expressed overcoming gender-related knowledge, attitudes and access barriers for boys facing abuse. In the focus groups, many boys elaborated on their survey responses, saying that before the program, they did not know men and women had equal rights in society.

“It was very soothing to learn that as males we have rights too, and can report abuse, as we grew up knowing that only females are protected in this country.”

Nkhaba Boys FGD, 21 May 2019

Recall that 67% (n=83) of male Stepping Stones graduates thought that men and women have equal rights in society, compared to 59% (n=59) of non-graduates. This FGD data helps to triangulate the survey data, confirming that attitudes towards gender equality have improved. It also suggests that these attitudes may have improved, in part, through the cocurricular nature of the program.

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Female focus group participants framed this issue slightly different. They said they learned how to identify warning signs of abuse and not to think that abuse in relationships is normal.

Male focus group participants also spoke about how the program specifically helped reduce gender-related barriers to accessing health services, such as STI screening and HIV testing. They spoke about how boys and men often face unique social and cultural expectations around masculinity, which make them avoid going to clinics, present late with problems, or fear knowing their HIV status. They said the Stepping Stones program helped them overcome these barriers.

“Most of us as boys fear taking an HIV test, so we got to understand that it is important to know your status and it is advisable that one tests early to begin ART treatment early.”

Kukhanyeni Boys FGD, Mbeka Community, 20 May 2019

Updating or augmenting the curriculum

In one focus group (Nkhaba Boys FGD, 21 May 2019) participants raised that they would like for the curriculum to address issues of sexual orientation and gender identity, including topics for men who have sex with men.

In two focus groups (Nkwene Boys FGD, 28 May 2019; Mhlume Mixed FGD, 23 May 2019) participants requested sessions that focused on drugs, alcohol and other substance use issues, including issues of addiction as well as wasting money on alcohol and drugs.

In six of the focus groups (Kukhanyeni Boys FGD, 20 May 2019; Maphalaleni Boys FGD, 27 May 2019; Mhlume Girls FGD, 23 May 2019; Mhlume Mixed FGD, 23 May 2019; Nkhaba Boys FGD, 21 May 2019; Ntondozi Boys FGD, 30 May 2019), participants said they wished the curriculum included information on the new Sexual Offences and Domestic Violence (SODV) Act.

In seventeen of the focus groups, participants clamored for economic empowerment opportunities such as entrepreneurship training, business proposal writing, and access to small business loans. Many said they wished this aspect was a greater part of the program, of that there were referral opportunities to other programs and learning opportunities related to economic empowerment.

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“Can we please have training on entrepreneurship that is from writing a business [proposal] to implementing it? We really need that empowerment so that we can become better people and contribute positively in the country.” Nkhaba Boys FGD, 21 May 2019

“We have realized the issue of unemployment. Most of us are unemployed and depend on our parents for sustenance. We would like for Stepping Stones to offer us lessons on how we could develop ourselves and provide us with training on starting businesses, especially in farming because that’s what is available to us in our communities.”

Gege Girls FGD, 22 May 2019

In South Africa, the Stepping Stones approach has been integrated with an economic empowerment program called “Creating Futures”. The Stepping Stones and Creating Futures integrated program has been shown to be effective in preliminary pilot studies (Jewkes et al., 2014) and is currently undergoing a randomized control trial (Gibbs et al., 2017). This kind of program integration could be something for Eswatini to also consider.

Expanding the target beneficiaries

Many FGD participants said the age limits were too restrictive and that the program should be open to people older than the age of 24 years. While the program needs to remain targeted to the most vulnerable adolescents and young people, there may be an opportunity to include people older than 24 years, particularly if they are older male sexual partners of younger female program beneficiaries. The use of a risk assessment tool (like those used by HC4) may help with targeted mobilization of participants. Expansion of the age brackets may also warrant tailoring the groups and the messaging to be more age-specific (i.e. 10-14-year- olds together; 15-19-year-olds together; 20-24-year-olds together and those 25+ together).

“The age restriction is a problem because other age groups may also find these topics relevant to them. For example, a 14-year-old girl dating a 27-year-old man. The older partner has been excluded from the program. It is highly likely that this person is misinformed on the topics shared here.”

Ntondozi Boys FGD, 30 May 2019

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Engaging parents and caregivers

There is evidence that the program is opening up dialogues between parents/caregivers and children. However, many beneficiaries said they wish there was an aspect of the program for their parents (like parents’ groups). When asked if they wanted sessions together with their parents/caregivers (i.e. the “Let’s Talk” model), most participants said no, they wanted to maintain their peer groups. However, participants did want their parents/caregivers to have improved knowledge so that what they learn in Stepping Stones can be reinforced at home, and so their parents/caregivers will be more accepting of them as sexual beings. One participant expressed this frustration, saying “I went with condoms to the home and my father chased me away” (Mhlume Girls FGD, 23 May 2019).

“Culturally, it has been hard to talk to our children about sex. With the Stepping Stones program, we as parents have been able to hold discussions on the subject of sex because it’s what they have been learning.”

Mother, Nkhaba Parents FGD (Lugubeni Community), 21 May 2019

“We would want our parents to talk to us about sex and love in an open way, but we can’t. We wish there was a session to break the barrier between the children and the parents. We would like some of the sessions to include our parents.”

Nkhaba Girls FGD, 21 May 2019

Stepping Stones is designed to include parents and caregivers, as well as other older community stakeholders. Working across generations is stated as a key principle in the Guidelines for Adapting Stepping Stones (Gordon & Welbourn, 2017). This is needed to build understanding, empathy and strong relationships of mutual support and understanding. Based on this evaluation’s results, and in line with Stepping Stones guidelines, Stepping Stones implementers should seek to include peer groups of older generations.

Implementation challenges and strategies to improve program delivery

Along with program content, data gathered during focus group discussions was helpful for understanding how program delivery modalities for Stepping Stones could be improved. Key informants also provided useful suggestions for strategies to improve program delivery.

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Condensing curriculum into intensive sessions

Some key informants at the national level voiced concern that the 12-week curriculum was sometimes condensed, with sessions covered back-to-back in order to meet targets and ensure beneficiaries graduated. Some felt this might compromise program quality. Importantly, the Guidelines for Adapting Stepping Stones state that as long as total contact time is not reduced, the sessions can be delivered intensively, covering 2-3 sessions in a full-day workshop (Gordon & Welbourn, 2017). No Stepping Stones participant or facilitators felt that program quality was compromised as a result of condensing the curriculum.

Retaining beneficiaries in the program

Data from the focus group discussions provided nuance and depth to the survey results. In particular, beneficiaries shared insights and ideas about what motivates them to attend – and keep attending – the Stepping Stones program.

While airtime was given to participants over the evaluation period to keep them incentivized to attend, this is no longer being implemented since it proved costly as well as prone to mismanagement. Many participants said that other non-monetary barrier reduction items would help them stay motivated to attend the program. They cited menstrual health products, t-shirts with health messaging and graduation certificates as possible ideas.

Participants also asked for refreshments to be included after the sessions, or to have a tea break in the middle, as the sessions are long and they sometimes end up losing their concentration due to hunger. Others say they have to walk long distances to the sessions, so food would help them stay energized.

Further, participants requested learning tools to help them retain information from the sessions. “We need stationary to write important points. Stepping Stones was done a long time ago I have forgotten some of the things” (Ntondozi Boys FGD, 30 May 2019).

Key informants at the national level expressed concern that the curriculum was too long, and that retention in the program was a challenge. However, based on what participants said during FGDs, the length of the program appears appropriate. Most participants said the number of weeks in the program was the right number, and the length did not present an issue. Some said that they wished the program was ongoing, or that there were refresher sessions.

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Reducing barriers to accessing services

Most participants said that condoms were readily and feely available (though non-availability of condoms was still the top-cited reason given for not using one). They said they could get them from their Stepping Stones facilitators, or the local shop. Condom access was not expressed as a difficulty for Stepping Stones participants. Some said they preferred it when their Stepping Stones facilitators were the ones providing condoms to them, instead of having to face embarrassment when accessing them at the shops. Based on this finding, the program could seek to ensure that other health commodities are offered in the same manner through the program facilitators, including home pregnancy tests and HIV self-test kits.

“Stepping Stones practiced what they preached. For example, we were taught to practice safe sex, and whenever one would request for condom, they were readily available.”

Ntondozi Boys FGD, 30 May 2019

Participants expressed three main ways that the Stepping Stones program could reduce barriers to accessing health services: (1) offering mobile clinical services during group sessions, (2) ensuring there is better integration of HIV and other services, and (3) making a service map available to guide referrals. In one focus group (Mafutseni Girls FGD, 16 May 2019 [pre-test]), payment was cited as a barrier to accessing services, with the high price of a pap smear (E200) at FLAS facilities noted. However, payment was not cited as a major barrier in the other Tinkhundla.

While mobile clinical services were meant to be provided alongside the Stepping Stones sessions, this evaluation revealed that this was not always possible. Participants would say things like “there should be a mobile clinic during the sessions so we test” (Ntondozi Boys FGD, 30 May 2019) and “We would like mobile services [large roar of agreement]. We can have the Stepping Stones classes and then access services in the van” (Mhlume Girls FGD, 23 May 2019). Key informant interviews indicate that it was a coordination challenge to endure the mobile clinical services were there at the right time. This should be improved going forward, to maximize access to health services among participants.

The need for better service integration is a theme from both the survey results (recall Figure, 17 showing missed opportunities for integrated services), and the focus groups. Participants also expressed a need for better knowledge on other HIV-related issues.

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“We know the need to check for HIV, but we ignore to check [for] the other diseases that may connect to it. So, there is still need for us to be taught about those diseases as well.”

Maphalaleni Boys FGD, 29 May 2019

The capacity and role of facilitators

FGD participants said that not all Stepping Stones facilitators had good knowledge on the issues and some could not answer their questions (Kukhanyeni Boys FGD, 20 May 2019). Other FGD participants also said that when facilitators covered the “What about circumcision and HIV?” section of the Stepping Stones curriculum, it was not introduced well. According to the participants in that group, those that took it up did it because they wanted to have sex without a condom. They were told that you won’t get HIV if you are circumcised, so the messaging was not correct (Kukhanyeni Boys FGD, 20 May 2019). Improving facilitator capacity is important for the program to run well and for outcomes to be improved. Facilitators who were interviewed said would like to have job aids, such as diagrams and models (for condom demonstrations) to help them do their jobs well. Other implementing partners of Stepping Stones, including those delivering the PEPFAR-funded Inskika program, have job aids for facilitators.

Facilitators also expressed interest and willingness to collect and analyze program data on outcomes in an ongoing manner. They noted that this would keep them more connected to the participants and the program, and enable them to course correct problems in real time. Facilitators could play a role in monitoring and tracking referrals to – and uptake of – health services, including HIV testing, VMMC and PrEP, as well as other outcome indicators such as pregnancy, experiences of gender-based violence, returning to school, among others.

During key informant interviews, many facilitators talked about providing intensive one-on- one support, such as home visits or navigation to health services. This is not currently captured in the program data, though it appeared to have great value to the beneficiaries. “I found it important that my facilitator took an initiative of visiting me at my home when I was not attending, and that made me feel valued (Ntondozi Girls FGD, 30 May 2019)”. The program could consider recording this type of one-on-one support, and measuring if it improves overall program outcomes. Other implementing partners of Stepping Stones,

including Pact Eswatini, take a family approach to the program and do formal home visits.

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“Our facilitator really motivated us not to give up, saying that failing in one project doesn’t necessarily means you won’t be able to achieve other goals. That really helped us to review our goals and find ways to achieve them no matter the time period it takes.”

Maphalaleni Girls FGD, 27 May 2019

Ensuring sustainable results

Many Stepping Stones facilitators who were interviewed expressed frustration at not being able to offer the participants anything after the program ended. One male facilitator in Nkhaba said “A roadmap for next steps would be really good, especially for opportunities on business training.” Other types of continuity planning tools were also requested, such as referrals for onward youth development, or linkages to other donor-funded programs for orphans and vulnerable children (acknowledging this would be age-dependent).

Stepping Stones participants’ parents in a Kukhanyeni FGD (20 May 2019) said that “Along the way they lose or forget what they learned.” This may indicate the need for refresher sessions, which could be intermittent, post-graduation, or could even be done remotely by phone or by text message. Recall that the survey results also showed that risk-perception (for pregnancy) appears to fade over time, providing further rationale for such refresher sessions.

Key informants from implementing partners and national stakeholders said that integration of the program into communities is important for sustainability. They noted that ownership of the program by community leaders would increase the likelihood that the principles of understanding, empathy, and strong relationships of mutual support between gender and generations would continue on, even after the Global Fund leaves.

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CONCLUSION

The Stepping Stones program has positively contributed to HIV prevention efforts in Eswatini. Graduation from the program is associated with modest but positive improvements among adolescent and young people’s knowledge, behaviors, attitudes and access to services. Of note, Stepping Stones participants exhibit dramatically higher HIV prevention knowledge and uptake of HIV testing services compared to national survey data, as well as above average use of condoms and contraceptives. The positive effects of the program appear to be maintained among participants up to three years post-intervention. Impact and cost-savings have been realized, as modelled in Eswatini’s Umgubudla HIV Investment Case. Areas for improvement include updating and augmenting the curriculum as well as optimizing the role of the facilitators. The Stepping Stones program should continue to be implemented in Eswatini, to help the country achieve its HIV prevention targets. Resource permitting, it should be scaled up to maximize impact. For the program to be sustainable, investments are needed from both external and domestic partners.

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RECOMMENDATIONS

Recommendations for the Global Fund

 Maintain or increase investments in the Stepping Stones approach to HIV prevention for adolescents and young people in Eswatini. This evaluation demonstrates modest but positive effects of the program, particularly on key HIV prevention indicators such as PrEP knowledge, uptake of HIV testing, condom use, contraceptive use, access to family planning services, attitudes towards gender equality, sexual agency, pregnancy rates and access to post-violence care. The Global Fund should continue its investments in this program in Eswatini so that more young people can be reached and the positive outcomes can be realized at scale in the country. Resource permitting, the program should be scaled-up to maximize impact.

 Use the results and recommendations of this evaluation to inform decision- making on catalytic investments for the 2020-2022 funding cycle. The findings of this evaluation should be used to inform decision-making on the envelope of matching funds for HIV prevention among AGYW that is made available to Eswatini in the 2020-2022 funding cycle. The Global Fund should use the positive results in this evaluation to rationalize increased AGYW matching funds for the country, in order to enable further scale-up and augmentation of the Stepping Stones approach.

 Use the granular outcome data generated from this evaluation to complement other assessments or reviews of Global Fund AGYW investments. This includes the ongoing outcomes measurement in Global Fund-supported AGYW programs in Botswana, Cameroon, Eswatini, Namibia, Lesotho and Mozambique (TGF-19-027).

Recommendations for the Government of Eswatini

 Disseminate the results of this evaluation to all key stakeholders involved in HIV prevention for adolescents and young people in Eswatini. This includes non- Global Fund program implementers, such as those implementing the PEPFAR- supported Stepping Stones program. Findings should be shared and discussed in the relevant national technical working groups, country coordinating mechanism, task teams for other evaluations, among other spaces. The Government of Eswatini

Stepping up the Fight An evaluation of the Stepping Stones approach to HIV prevention 65 among adolescents and young people in Eswatini

should ensure that the findings and recommendations from this evaluation are used to improve HIV prevention for adolescents and young people country-wide.

 Address age-related barriers to accessing family planning and contraceptive services for adolescents to prevent teenage pregnancy. The evaluation found that adolescents age 18-19 years were far less likely to be using a modern method of contraception compared to young people age 20 or older. As a result, teenage pregnancy rates were found to be high – the same as for young people age 20-24 and for those 25 and older. Policies and guidelines should be updated to specifically address age-related barriers to accessing family planning and contraceptive services for adolescents. This may include lowering the age of consent to access services, expanding the number of adolescent-friendly service providers, or integrating family planning into other health and non-health services offered to adolescents.

 Intensify HIV prevention efforts for adolescents and young people in lower performing Tinkhundla. For example, Kukhanyeni, Nkhaba and Gege performed much lower than other Tinkhundla on a range of knowledge and behavioral indicators in this evaluation, including sexual agency (saying “no” to unwanted sex), ability to identify risk or warning signs of SGBV, pregnancy rates, and taking actions to save money. The Government of Eswatini should prioritize intensified HIV prevention efforts for young people in these places. A further study of the socio-economic determinants and differences across the Tinkhundla may also be useful.

 Improve integration of health service provision, providing HIV testing, STI screening, TB screening, family planning and cancer screening as part of a comprehensive package for adolescents and young people. This evaluation found that many (almost 90%) Stepping Stones participants had received an HIV test in the past year, but far fewer had received other related health services such as family planning/contraceptive services and TB, STI and cancer screening was far lower. Some would have received these services through mobile clinics offered by Stepping Stones, but others – especially those who have been out of the program for two or three years – would have accessed them at public health facilities. Results suggest a missed opportunity for comprehensive delivery of health services to young people. The Government of Eswatini should enhance service integration at all service delivery points to ensure young people receive the complete package.

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 Make the Stepping Stones approach more sustainable by:

o Investing domestic resources. The Government of Eswatini should consider dedicating a portion of its co-financing commitments specifically to the Stepping Stones program in the country’s next Global Fund funding request.

o Including it in national strategies and plans. The Government of Eswatini should consider including the Stepping Stones approach in minimum packages and good practice approaches described in the new National Multi- Sectoral Strategic Framework for HIV & AIDS, the Core Package for HIV Prevention Guidelines for Implementers, among other key strategies and plans.

o Strengthening the leadership and coordination role of the Ministry of Health, and fostering inter-ministerial collaboration. For the Stepping Stones to truly be a national approach, leadership and coordination of the approach should be clearly designated, ideally within the Sexual and Reproductive Health Office within the Ministry of Health. There should be a clear focal point who is responsible for ensuring standardized quality of implementation, country-wide. Further, inter-ministerial collaboration should be sought, particularly with the Ministry of Tinkhundla Administration and Development and with the Ministry of Education and Training. the Ministry of Tinkhundla Administration and Development has a development fund, which could be linked to Stepping Stones to give entrepreneurship opportunities to participants. The Ministry of Education and Training should be involved in the country’s plans to roll out Stepping Stones in Tertiary institutions.

Recommendations for Stepping Stones program implementers

 Update and augment the Stepping Stones curriculum to include:

o Additional or intensified exercises on negotiating condom in transactional relationships. Stepping Stones participants who received money, goods or other favors in exchange for sex were less likely to report condom use, indicating limited condom negotiation power in transactional

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relationships. The Stepping Stones program should be augmented to include additional or intensified roleplay or empowerment exercises that tackle this.

o Intensified economic empowerment activities, especially those tailored for AGYW. This evaluation found that there is strong demand for intensified economic empowerment activities within the Stepping Stones program. Implementers should consider exploring the “Stepping Stones and Creating Futures” integrated curriculum, which has shown promise in South Africa. Increased referrals to youth development programs, especially post-Stepping Stones graduation, is also recommended. Further, while both sexes thought it was equally important to save money, male Stepping Stones participants were far more likely to access financial services than female participants. Tailored economic empowerment activities specifically for AGYW should be added to the Stepping Stones approach, addressing unique gender-related barriers.

o Include legal and policy context for gender-based violence and gender equality sessions. During focus group discussions, many participants felt the Stepping Stones program should include information on laws and policies surrounding gender-based violence and gender equality in Eswatini, specifically the new SODV Act.

 Seek ways of including peer groups of older generations in the program, including parents and caregivers. Both participants and their parents/caregivers alike expressed a need for structured ways of communicating about the Stepping Stones program and its content. Positive messages conveyed in the program are not always reinforced at home. Implementers should seek ways of involving peer groups of older generations in the program. This involvement should not replace the peer group sessions. Optimally, there should be an opportunity for parents/caregivers and their children to learn separately, followed by structured sessions together, in line with the Guidelines for Adapting Stepping Stones (Gordon & Welbourn, 2017). The aim should be to try and break down communication barriers so that support can continue at home.

 Maintain the cocurricular structure of Stepping Stones, working with both boys and girls. This evaluation found a number of positive improvements on indicators related to gender equality and gender-based violence. FGD data links these

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outcomes to the cocurricular structure of the program. The Guidelines for Adapting Stepping Stones emphasize working across genders (Gordon & Welbourn, 2017). Despite the Global Fund’s focus on AGYW, the Stepping Stones program should remain cocurricular in order to maximize impact among both sexes. The PEPFAR- supported Stepping Stones program should revisit its decision to work only with girls.

 Enhance the role and capacity of Stepping Stones facilitators by:

o Ensuring they have accurate and up-to-date knowledge and tools for the relevant topics. Participants expressed that facilitators are not always able to answer, and sometimes give misinformation. Facilitators also expressed a want and need for more tools, including job aids (especially for condom demonstrations), so that they can meet the needs of the beneficiaries.

o Empowering them to collect and analyze frequent and granular participant outcome data during program implementation. Stepping Stones facilitators expressed an interest in playing a greater role in the monitoring and evaluation of the program. Stepping Stones facilitators should be empowered to collect and analyze outcome data on reports of violence, pregnancy, return to school, use of contraception, referrals to health services, uptake of health services, among other indicators. The evaluation revealed that Stepping Stones facilitators are have this data (in their heads), but are not recording or assessing it in a systematic way. Collecting and analyzing outcome data during program implementation will enable implementing partners to conduct implementation science and quality improvements in real time.

o Formalizing the one-on-one intensive support that they provide by counting it as part of program data and outcomes analysis. Many facilitators provided intensive one-on-one support to program beneficiaries. During key informant interviews, many told anecdotal stories of health services referrals and even personal accompaniments/navigations for certain services. This is important support that is not currently captured or assessments by the program. The facilitators should be encouraged to keep track of this type of one-on-one intensive support, counting interactions and assessing whether the intimate support improves participant outcomes.

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 Change barrier reduction items to improve participant retention. Airtime should not be used as an incentive for program attendance since it is costly, prone to mismanagement, and does not support program objectives. Depending on available recourses and ease of distribution, non-monetary barrier reduction items should be delivered to participants, including sanitary pads (to ensure girls are able to attend the sessions each week of the month), refreshments (so they can concentrate), t- shirts (with HIV prevention messages on them), stationary (to record what they learn) and/or certificates for graduates (as motivation).

 Increase access to health and other services by ensuring mobile clinical services are available during group sessions (resource permitting), and/or develop a referral directory/map for youth-friendly services. This evaluation found that service access to the comprehensive package was limited, integration of services is poor, and access to services could be improve by ensuring mobile clinics are there when young people have gathered for group sessions. A “one-stop-shop” mobile clinic model should be available to participants at least quarterly, resource permitting. Verbal screening for TB, STIs and GBV would not increase the cost of the clinical service package, and could be done by group facilitators. If resources do not permit regular mobile clinics, Stepping Stones facilitators should be empowered to distribute HIV self-test kits (especially to increase testing rates among boys) and home pregnancy tests (along with the condoms they already distribute) and perform verbal screening of comorbidities. In addition to this, a clear service referral directory (with addresses, maps, focal points and phone numbers) should guide participants to youth friendly services.

Recommendations for other bilateral, multilateral and technical partners

 Provide additional technical support to CANGO and other Stepping Stones implementers to enable them to action the recommendations in this evaluation. This could possibly include technical support to do a viability assessment, to determine ways of integrating other materials (e.g. Stepping Stones and Creating Futures), learning from other implementing partners’ experiences (e.g. Pact, HC4), and the feasibility of operationalizing some of the other recommendations in this report. Additional technical support may also be needed to update and augment the Stepping Stones curriculum and manual based on this evaluation’s findings. Lastly, additional technical support may also include technical support to train Stepping

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Stones facilitators in monitoring and evaluation techniques to enable them to collect and analyze participant data during program implementation.

 Make use of the skills, capacity and experience that was developed among the thirteen data collectors for this evaluation. The investments in the data collectors training, as well as the on-the-job learning that was gained by the Stepping Stones evaluation data collectors, should be harnessed for other kinds of technical support provision in Eswatini, including other evaluations, assessments or consultancies supported by Eswatini’s technical partners and UN family.

 Use the findings of this evaluation to inform global, regional and national technical guidance. This includes using the findings of this evaluation to inform Eswatini’s ongoing process of developing a risk reduction module. The findings should also be shared with organizations’ headquarters so that they can be used to provide guidance to other countries with similar epidemics, as well as inform updates on global normative guidance for HIV prevention among adolescents and young people.

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Jewkes, R., Gibbs, A., Jama-Shai, N., Willan, S., Misselhorn, A., Mushinga, M., ... & Skiweyiya, Y. (2014). Stepping Stones and Creating Futures intervention: shortened interrupted time series evaluation of a behavioural and structural health promotion and violence prevention intervention for young people in informal settlements in Durban, South Africa. BMC public health, 14(1), 1325.

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ANNEXES

Annexes on program description

Annex 1. Stepping Stones Curriculum used Global Fund-supported program in Eswatini

Session Title Purpose of Session Session Activities Introducing Ourselves, Expectations, Ground Rules, Trust and To help a peer group form itself. To help participants develop skills Session A: Let’s Communicate Confidentiality, Listening Pairs, Body Language, Loving me, loving of listening and analysis of communication and cooperation you, My goals in life, Hand in Hand To help participants explore images and realities of the ideal man Mime the Lie, Men and Women - the Ideal and the Reality, Images of Session B: How we act and woman-how these are shaped by the actions of all of us and Others, Body Mapping, Closing Circle and Song the implications this can have for the individuals concerned A first look at images of sex and sexual health problems and an Word Games, What is Love?, Sexual relationships: happy and Session C: Sex and love exploration of what we look for and give in love unhappy, Joys and problems with sex, Closing Circle First Peer Group Meeting Session D: Conception and To explore problems and concerns about conception and Menstruation, Conception, Contraception, Unplanned pregnancy, Contraception contraception Closing circle Muddling Messages, STIs, Everything you want to know about Session E: HIV To explore our knowledge about HIV and “safer sex” HIV/AIDS but were afraid to ask, Prrr and Pukutu, Testing for HIV, Closing Circle To continue our discussions about safer sex and to familiarize HIV transmission game, Taking risks, All About Condoms, How do I Session F: Safer Sex and Caring in participants with use of the condom and other forms of feel, Caring for people with HIV/AIDS or affected by HIV, One New a Time of AIDS contraception Thing Second Peer Group Meeting Hand Push, Attack, Avoid and Manipulate, ‘I Statements’, Taking Session H: Let’s Support Ourselves To find new skills to change the ways in which we behave Control, Closing Circle Yes and No I.2 Saying ‘no’, Opening a Fist, Assertive Responses, Session I: Let’s Assert Ourselves To develop more assertiveness skills Closing Circle Losing something, O Sipho!, Why do We Behave as We Do?, Testing Session J: Let’s Look Deeper To study why we behave in the ways we do the Water To help participants to think about what they spend money on and What I would do with E100, How we spend money, Getting into and Session K: Money Choices why, and to help them make plans to save money and overcome dealing with debt, Making buying choices, Closing Circle debt. To help participants to develop the ability to deal with different Rhythm Clap, How do we cope with crises in our lives, Learning to Session L: Saving and Coping with types of shocks and crises and to create awareness of the save money, Planning to achieve my goal, Closing Circle, Workshop Shocks importance of saving. expectations & closing Final Meeting of the Peer Groups

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Annex 2. Total Stepping Stones Enrollment in the Global Fund-supported Program (October 2015 – September 2018)

Sex (age in years)

Region Inkhundla Male Male Male Male Males Female Female Female Female Females (10 -14) (15 -19) (20 -24) 25+ Total (10 -14) (15 -19) (20 -24) 25+ Total Number

Shiselweni Gege 1 129 510 180 820 6 216 596 193 1011 Hhohho Hhukwini 1 61 128 5 195 1 83 148 36 268 Shiselweni Kubuta 0 113 258 81 452 0 77 208 87 372 Manzini Kukhanyeni 1 173 592 133 899 3 183 413 107 706 Manzini Mafutseni 3 64 184 46 297 2 64 219 38 323 Manzini Mahlangatja 0 167 394 87 648 0 164 315 103 582 Hhohho Maphalaleni 0 118 432 77 627 0 111 341 86 538 Shiselweni Matsanjeni 10 127 285 77 499 24 192 547 182 945 Lubombo Mayiwane 1 129 250 13 393 1 175 403 30 609 Lubombo Mhlume 1 89 308 142 540 1 138 345 121 605 Manzini Mtfongwaneni 4 99 226 36 365 3 83 183 45 314 Hhohho Ndzingeni 3 121 216 71 411 4 92 165 25 286 Shiselweni Ngudzeni 0 150 359 58 567 0 202 311 49 562 Manzini Ngwemphisi 2 251 607 47 907 5 371 868 60 1304 Hhohho Nkhaba 1 97 239 33 370 8 96 212 42 358 Shiselweni Nkwene 0 62 147 53 262 1 100 301 139 541 Manzini Ntontozi 3 114 378 47 542 5 132 377 45 559 Shiselweni Sandleni 18 439 806 185 1448 34 496 711 123 1364 Shiselweni Somntongo 4 119 230 76 429 1 104 212 93 410 Shiselweni Zombodze 1 69 176 43 289 4 98 144 60 306 TOTAL 54 2691 6725 1490 10960 103 3177 7019 1664 11963

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Annexes on survey results

Annex 3. Stepping Stones Evaluation Participants Who Answered “Yes/True” to Survey Questions, By Age and Sex

Females Males

Survey Question Sex (age in years) Adolescent Girls Young Women Young Women Adolescent Boys Young Men Young Men (18-19) (20-24) (25+) (18-19) (20-24) (25+) (n=37) (n=122) (n=94) (n=16) (n=111) (n=97) Number (%)

PART 1: KNOWLEDGE

The risk of HIV transmission can be reduced by having sex 34 (92%) 105 (86%) 77 (82%) 13 (81%) 100 (90%) 95 (98%) with only one uninfected partner who has no other partners A person can reduce the risk of getting HIV by using a 34 (92%) 120 (98%) 90 (96%) 16 (100%) 110 (99%) 96 (99%) condom every time they have sex

A healthy-looking person can have HIV 31 (84%) 106 (87%) 85 (90%) 14 (88%) 102 (92%) 89 (92%)

A person can get HIV by hugging or shaking hands with a 0 (0%) 5 (4%) 1 (1%) 0 (0%) 1 (1%) 3 (3%) person who is infected A person can get HIV by sharing food with someone who is 0 (0%) 7 (6%) 3 (3%) 2 (13%) 4 (3%) 6 (6%) infected. Voluntary medical male circumcision can reduce the risk of 34 (92%) 116 (95%) 86 (91%) 15 (94%) 110 (99%) 91 (94%) acquiring HIV. There is a daily drug available called “PrEP” that can be taken by people who don't have HIV to prevent them from 15 (41%) 85 (70%) 60 (64%) 9 (56%) 57 (51%) 59 (61%) being infected with the virus. Having many sexual partners at the same time can increase 34 (92%) 117 (96%) 87 (93%) 13 (81%) 107 (96%) 95 (98%) your risk of acquiring HIV. Having a sexual partner (or partners) who are much older 21 (57%) 82 (67%) 65 (69%) 10 (63%) 81 (73%) 59 (61%) than you can increase your risk of acquiring HIV. You can get sexually transmitted infections (STIs) from 22 (59%) 82 (67%) 55 (59%) 6 (38%) 57 (51%) 54 (56%) sitting on a toilet seat It is legal to discriminate against a person on the grounds 4 (11%) 12 (10%) 5 (5%) 1 (6%) 3 (3%) 5 (5%) that they have HIV.

It is legal to force a person to have an HIV test. 9 (24%) 42 (34%) 27 (29%) 2 (13%) 18 (16%) 15 (15%)

A woman can’t get pregnant until she is 16. 1 (3%) 23 (19%) 16 (17%) 2 (13%) 20 (18%) 13 (13%)

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A woman can only get pregnant if she has sex often. 6 (16%) 35 (29%) 21 (22%) 4 (25%) 26 (23%) 26 (27%)

Using the injection or the pill as contraception provides no 26 (70%) 81 (66%) 63 (67%) 10 (63%) 80 (72%) 69 (71%) protection against HIV or STIs. Physical and sexual violence may include: slapping, beating, pinching, hair pulling, threatening or attacking with a 36 (97%) 120 (98%) 89 (95%) 16 (100%) 108 (97%) 93 (96%) weapon, locking a partner in a room, or forcing a partner to have sex or do something sexual they do not want to do. It is abusive towards men if wives or girlfriends do not do domestic work at home, such as cooking, ironing and 16 (43%) 48 (39%) 44 (47%) 6 (38%) 50 (45%) 54 (56%) cleaning. PART 1: BEHAVOUR Did you use a condom the last time you had sex with non- 21 (57%) 84 (69%) 62 (66%) 10 (63%) 84 (76%) 67 (69%) marital, non-cohabiting partner? Are you currently using a method of modern contraception? 21 (57%) 98 (80%) 79 (84%) 9 (56%) 95 (86%) 76 (78%)

Have you or your partner fallen pregnant in the past year? 15 (41%) 50 (41%) 39 (41%) 2 (13%) 14 (13%) 14 (14%) Have you received money, goods or other favors in 3 (8%) 4 (3%) 6 (6%) 3 (19%) 8 (7%) 4 (4%) exchange for sex in the past year? Have you had a sexual partner who was 10 or more years 5 (14%) 22 (18%) 17 (18%) 2 (13%) 8 (7%) 11 (11%) older than you in the past year? Have you said “no” to an unwanted sexual situation in the 26 (70%) 67 (55%) 49 (52%) 5 (31%) 50 (45%) 38 (39%) past year? Have you been able to identify risk or warning signs of sexual and gender-based violence among your family and/or 11 (30%) 40 (33%) 30 (32%) 5 (31%) 48 (43%) 39 (40%) friends and give them information about where they can access services and support in the past year? Have you taken actions to save money in the past year? 22 (59%) 81 (66%) 64 (68%) 15 (94%) 82 (74%) 75 (77%) Have you set goals for yourself, and tracked your progress 28 (76%) 96 (79%) 79 (84%) 13 (81%) 99 (89%) 80 (82%) towards those goals, in the past year? PART 3: ATTITUDES Would you buy fresh vegetables from a shopkeeper or 35 (95%) 119 (98%) 93 (99%) 14 (88%) 106 (95%) 96 (99%) vendor who is HIV-positive? Do you think children living with HIV should be able to attend 36 (97%) 115 (94%) 94 (100%) 13 (81%) 104 (94%) 91 (94%) school with children who are HIV-negative? A husband or boyfriend is justified in hitting or beating his wife in at least one of the following circumstances: (1) she goes out without telling him, (2) she neglects the children, (3) 11 (30%) 14 (11%) 11 (12%) 5 (31%) 12 (11%) 12 (12%) she argues with him, (4) she refuses sex with him, (5) she burns the food. Should men and women have equal rights in society? 18 (49%) 83 (68%) 60 (64%) 9 (56%) 77 (69%) 56 (58%)

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Do you think that your current sexual behavior puts you (or 5 (14%) 22 (18%) 26 (28%) 0 (0%) 37 (33%) 25 (26%) your partner[s]) at risk of infection with HIV? Do you think that your current sexual behavior puts you (or 7 (19%) 34 (28%) 32 (34%) 2 (13%) 42 (38%) 36 (37%) your partner[s]) at risk of becoming pregnant? Do you think it is important to save money? 36 (97%) 117 (96%) 92 (98%) 15 (94%) 111 (100%) 97 (100%)

Has your life improved during the past year? 31 (84%) 88 (72%) 75 (80%) 15 (94%) 97 (87%) 82 (85%) Do you expect that your life will be better one year into the 35 (95%) 116 (95%) 89 (95%) 16 (100%) 104 (94%) 94 (97%) future? PART 4: ACCESS

Have you received an HIV test in the past year? 34 (92%) 112 (92%) 91 (97%) 14 (88%) 90 (81%) 81 (84%)

Have you received TB screening in the past year? 17 (46%) 66 (54%) 57 (61%) 10 (63%) 45 (41%) 53 (55%)

Have you received STI screening in the past year? 22 (59%) 71 (58%) 56 (60%) 7 (63%) 37 (33%) 40 (41%) Have you received family planning/contraceptive services in 18 (49%) 90 (74%) 71 (76%) 6 (44%) 61 (55%) 54 (56%) the past year? Have you received cancer screening in the past year (this 7 (19%) 32 (26%) 30 (32%) 2 (13%) 9 (8%) 12 (12%) can include a breast exam, pap smear or testicular exam)? If you accessed any of the above health services in the past 33 (89%) 107 (88%) 90 (96%) 13 (81%) 93 (84%) 78 (80%) one year, were they friendly? If you experienced sexual or gender-based violence in the 5 (14%) 17 (14%) 14 (15%) 1 (6%) 14 (13%) 14 (14%) past one year, did you receive post-violence care? If you experienced sexual or gender-based violence, did you 5 (14%) 12 (10%) 4 (4%) 0 (0%) 7 (6%) 4 (4%) report the experience to the police or other authorities? Have you accessed financial services in the past year (this 4 (11%) 27 (22%) 24 (26%) 4 (25%) 36 (32%) 33 (34%) can include services from a bank or insurance broker)? PART 5: ATTRIBUTION Did participating in the Stepping Stones program improve your knowledge about HIV, sexual and reproductive health, 37 (100%) 121 (99%) 94 (100%) 16 (100%) 111 (100%) 96 (99%) gender, relationships and saving money? Did participating in the Stepping Stones program help you to make better decisions about your behavior, to protect 34 (92%) 120 (98%) 94 (100%) 15 (94%) 111 (100%) 97 (100%) yourself against HIV, unintended pregnancy, violence and poverty? Did participating in the Stepping Stones program change your attitudes towards HIV stigma, relationships, gender, 36 (97%) 119 (98%) 92 (98%) 14 (88%) 110 (99%) 93 (96%) violence and saving money? Did participating in the Stepping Stones program facilitate your access to health services such as HIV testing, STI 37 (100%) 116 (95%) 88 (94%) 15 (94%) 102 (92%) 92 (95%) screening and family planning services?

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Annex 4. Stepping Stones Evaluation Participants Who Answered “Yes/True” to Survey Questions, By Inkhundla

Kukhanyeni Nkhaba Gege Mhlume Mahlangatja Nkwene Maphalaleni Ntondozi TOTAL (n=62) (n=48) (n=76) (n=94) (n=56) (n=49) (n=47) (n=45) (n=477) Survey Question Number (%)

PART 1: KNOWLEDGE

The risk of HIV transmission can be reduced by having sex with 55 (89%) 42 (88%) 61 (80%) 86 (91%) 50 (89%) 42 (86%) 46 (98%) 42 (93%) 424 (89%) only one uninfected partner who has no other partners A person can reduce the risk of getting HIV by using a condom 62 (100%) 46 (96%) 73 (96%) 93 (99%) 56 (100%) 47 (96%) 46 (98%) 43 (96%) 466 (98%) every time they have sex

A healthy-looking person can have HIV 55 (89%) 43 (90%) 69 (91%) 81 (86%) 50 (89%) 42 (86%) 44 (94%) 43 (96%) 427 (90%)

A person can get HIV by hugging or shaking hands with a person 2 (3%) 1 (2%) 0 (0%) 2 (2%) 2 (4%) 0 (0%) 1 (2%) 2 (4%) 10 (2%) who is infected A person can get HIV by sharing food with someone who is 7 (11%) 2 (4%) 1 (1%) 4 (4%) 3 (5%) 1 (2%) 2 (4%) 2 (4%) 22 (5%) infected. Voluntary medical male circumcision can reduce the risk of 59 (95%) 45 (94%) 69 (91%) 92 (98%) 55 (98%) 47 (96%) 43 (91%) 42 (93%) 452 (95%) acquiring HIV. There is a daily drug available called “PrEP” that can be taken by people who don't have HIV to prevent them from being infected 32 (52%) 22 (46%) 51 (67%) 62 (66%) 34 (61%) 26 (53%) 27 (57%) 31 (69%) 285 (60%) with the virus. Having many sexual partners at the same time can increase your 61 (98%) 46 (96%) 75 (99%) 89 (95%) 53 (95%) 42 (86%) 44 (95%) 43 (96%) 453 (95%) risk of acquiring HIV. Having a sexual partner (or partners) who is much older than you 38 (61%) 25 (52%) 44 (58%) 72 (77%) 40 (71%) 36 (73%) 30 (64%) 33 (73%) 318 (67%) can increase your risk of acquiring HIV. You can get sexually transmitted infections (STIs) from sitting on a 40 (65%) 22 (46%) 47 (62%) 59 (63%) 27 (48%) 25 (51%) 28 (60%) 28 (62%) 276 (58%) toilet seat It is legal to discriminate against a person on the grounds that they 7 (11%) 4 (8%) 7 (9%) 6 (6%) 2 (4%) 2 (4%) 1 (2%) 1 (2%) 30 (6%) have HIV.

It is legal to force a person to have an HIV test. 10 (16%) 15 (31%) 22 (29%) 19 (20%) 14 (25%) 15 (31%) 6 (13%) 12 (27%) 113 (24%)

A woman can’t get pregnant until she is 16. 8 (13%) 3 (6%) 9 (12%) 21 (22%) 6 (11%) 7 (14%) 11 (23%) 10 (22%) 75 (16%)

A woman can only get pregnant if she has sex often. 13 (21%) 15 (31%) 18 (24%) 30 (32%) 6 (11%) 12 (24%) 13 (28%) 11 (24%) 118 (25%)

Using the injection or the pill as contraception provides no 40 (65%) 32 (67%) 40 (53%) 68 (72%) 47 (84%) 37 (76%) 31 (66%) 34 (76%) 329 (69%) protection against HIV or STIs. Physical and sexual violence may include: slapping, beating, 55 (89%) 48 (100%) 72 (95%) 91 (97%) 56 (100%) 49 (100%) 47 (100%) 44 (98%) 462 (97%) pinching, hair pulling, threatening or attacking with a weapon,

Stepping up the Fight An evaluation of the Stepping Stones approach to HIV prevention 81 among adolescents and young people in Eswatini locking a partner in a room, or forcing a partner to have sex or do something sexual they do not want to do. It is abusive towards men if wives or girlfriends do not do domestic 23 (37%) 22 (46%) 38 (50%) 41 (44%) 33 (59%) 21 (43%) 25 (53%) 15 (33%) 218 (46%) work at home, such as cooking, ironing and cleaning.

PART 1: BEHAVOUR

Did you use a condom the last time you had sex with non-marital, 37 (60%) 34 (71%) 51 (67%) 67 (71%) 43 (77%) 34 (69%) 35 (74%) 27 (60%) 328 (69%) non-cohabiting partner?

Are you currently using a method of modern contraception? 46 (74%) 41 (85%) 65 (86%) 75 (80%) 44 (79%) 35 (71%) 42 (89%) 30 (67%) 378 (79%)

Have you or your partner fallen pregnant in the past year? 19 (31%) 13 (27%) 33 (43%) 25 (27%) 11 (20%) 15 (31%) 10 (21%) 8 (18%) 134 (28%)

Have you received money, goods or other favors in exchange for 5 (8%) 3 (6%) 1 (1%) 9 (10%) 4 (7%) 3 (6%) 1 (2%) 2 (4%) 28 (6%) sex in the past year? Have you had a sexual partner who was 10 or more years older 8 (13%) 3 (6%) 5 (7%) 22 (23%) 8 (14%) 11 (22%) 5 (11%) 3 (7%) 65 (14%) than you in the past year? Have you said “no” to an unwanted sexual situation in the past 31 (50%) 26 (54%) 28 (37%) 62 (66%) 20 (36%) 26 (53%) 20 (43%) 22 (49%) 235 (49%) year? Have you been able to identify risk or warning signs of sexual and gender-based violence among your family and/or friends and give 28 (45%) 19 (40%) 23 (30%) 51 (54%) 9 (16%) 11 (22%) 17 (36%) 15 (33%) 173 (36%) them information about where they can access services and support in the past year? Have you taken actions to save money in the past year? 39 (63%) 37 (77%) 47 (62%) 65 (69%) 49 (88%) 37 (76%) 32 (68%) 33 (73%) 339 (71%)

Have you set goals for yourself, and tracked your progress 54 (87%) 43 (90%) 55 (72%) 71 (76%) 52 (93%) 43 (88%) 37 (79%) 40 (89%) 395 (83%) towards those goals, in the past year?

PART 3: ATTITUDES

Would you buy fresh vegetables from a shopkeeper or vendor who 61 (98%) 48 (100%) 73 (96%) 88 (94%) 55 (98%) 47 (96%) 47 (100%) 44 (98%) 463 (97%) is HIV-positive? Do you think children living with HIV should be able to attend 59 (95%) 46 (96%) 73 (96%) 87 (93%) 55 (98%) 44 (90%) 44 (94%) 45 (100%) 453 (95%) school with children who are HIV-negative? A husband or boyfriend is justified in hitting or beating his wife in at least one of the following circumstances: (1) she goes out without 5 (8%) 9 (19%) 7 (9%) 14 (15%) 9 (16%) 8 (16%) 10 (21%) 3 (7%) 65 (14%) telling him, (2) she neglects the children, (3) she argues with him, (4) she refuses sex with him, (5) she burns the food. Should men and women have equal rights in society? 46 (74%) 26 (54%) 50 (66%) 60 (64%) 31 (55%) 31 (63%) 27 (57%) 32 (71%) 303 (64%)

Do you think that your current sexual behavior puts you (or your 17 (27%) 11 (23%) 16 (21%) 24 (26%) 13 (23%) 11 (22%) 10 (21%) 13 (29%) 115 (24%) partner[s]) at risk of infection with HIV? Do you think that your current sexual behavior puts you (or your 18 (29%) 13 (27%) 26 (34%) 34 (36%) 15 (27%) 19 (39%) 15 (32%) 13 (29%) 153 (32%) partner[s]) at risk of becoming pregnant?

Do you think it is important to save money? 60 (97%) 48 (100%) 74 (97%) 93 (99%) 55 (98%) 49 (100%) 45 (96%) 44 (98%) 468 (98%)

Stepping up the Fight An evaluation of the Stepping Stones approach to HIV prevention 82 among adolescents and young people in Eswatini

Has your life improved during the past year? 50 (81%) 39 (81%) 51 (67%) 72 (77%) 50 (89%) 41 (84%) 42 (89%) 43 (96%) 388 (81%)

Do you expect that your life will be better one year into the future? 59 (95%) 46 (96%) 73 (96%) 85 (90%) 55 (98%) 48 (98%) 43 (91%) 45 (100%) 454 (95%)

PART 4: ACCESS

Have you received an HIV test in the past year? 52 (84%) 43 (90%) 71 (93%) 82 (87%) 47 (84%) 43 (88%) 42 (89%) 42 (93%) 422 (88%)

Have you received TB screening in the past year? 33 (53%) 23 (48%) 43 (57%) 48 (51%) 30 (54%) 27 (55%) 26 (55%) 27 (60%) 257 (54%)

Have you received STI screening in the past year? 28 (45%) 22 (46%) 40 (53%) 48 (51%) 27 (48%) 26 (53%) 17 (36%) 25 (56%) 233 (49%)

Have you received family planning/contraceptive services in the 42 (68%) 34 (71%) 59 (78%) 58 (62%) 34 (61%) 28 (57%) 24 (61%) 21 (47%) 300 (63%) past year? Have you received cancer screening in the past year (this can 15 (24%) 13 (27%) 20 (26%) 22 (23%) 2 (4%) 11 (22%) 7 (15%) 2 (4%) 92 (19%) include a breast exam, pap smear or testicular exam)? If you accessed any of the above health services in the past one 50 (81%) 39 (81%) 66 (87%) 85 (90%) 49 (88%) 45 (92%) 42 (89%) 38 (84%) 414 (87%) year, were they friendly? If you experienced sexual or gender-based violence in the past 9 (15%) 11 (23%) 6 (8%) 17 (18%) 6 (11%) 7 (14%) 4 (9%) 5 (11%) 65 (14%) one year, did you receive post-violence care? If you experienced sexual or gender-based violence, did you report 7 (11%) 4 (8%) 2 (3%) 9 (10%) 3 (5%) 3 (6%) 2 (4%) 2 (4%) 32 (7%) the experience to the police or other authorities? Have you accessed financial services in the past year (this can 18 (29%) 10 (21%) 13 (17%) 28 (30%) 24 (43%) 13 (27%) 15 (32%) 7 (16%) 128 (27%) include services from a bank or insurance broker)?

PART 5: ATTRIBUTION Did participating in the Stepping Stones program improve your knowledge about HIV, sexual and reproductive health, gender, 62 (100%) 48 (100%) 76 (100%) 93 (99%) 56 (100%) 48 (98%) 47 (100%) 45 (100%) 475 (100%) relationships and saving money? Did participating in the Stepping Stones program help you to make better decisions about your behavior, to protect yourself against 62 (100%) 46 (96%) 75 (99%) 94 (100%) 56 (100%) 47 (96%) 46 (98%) 45 (100%) 471 (99%) HIV, unintended pregnancy, violence and poverty? Did participating in the Stepping Stones program change your attitudes towards HIV stigma, relationships, gender, violence and 60 (97%) 47 (98%) 74 (97%) 88 (94%) 55 (98%) 49 (100%) 46 (98%) 45 (100%) 464 (97%) saving money? Did participating in the Stepping Stones program facilitate your access to health services such as HIV testing, STI screening and 61 (98%) 47 (98%) 71 (93%) 85 (90%) 54 (96%) 45 (92%) 43 (91%) 44 (100%) 450 (94%) family planning services?

Stepping up the Fight An evaluation of the Stepping Stones approach to HIV prevention 83 among adolescents and young people in Eswatini

Annex 5. Stepping Stones Evaluation Participants Who Answered “Yes/True” to Survey Questions, By Level of Program Completion

Participants who completed fewer than 9 Participants who completed 9 sessions Difference between graduates session (non-graduates) or more (graduates) and non-graduates

Survey Question Number (%) % Girls Boys All Girls Boys All Girls Boys All (n=124) (n=100) (n=223) (n=131) (n=124) (n=254)

PART 1: KNOWLEDGE

The risk of HIV transmission can be reduced by having sex 103 (83%) 96 (96%) 199 (89%) 113 (86%) 112 (90%) 225 (89%) +3% -6% -1% with only one uninfected partner who has no other partners A person can reduce the risk of getting HIV by using a 118 (95%) 99 (99%) 217 (97%) 126 (96%) 123 (99%) 249 (98%) +1% 0% +1% condom every time they have sex

A healthy-looking person can have HIV 108 (87%) 93 (93%) 201 (90%) 114 (87%) 112 (90%) 226 (89%) 0% -3% -1%

A person can get HIV by hugging or shaking hands with a 3 (2%) 1 (1%) 4 (2%) 3 (2%) 3 (2%) 5 (2%) 0% +1% 0% person who is infected A person can get HIV by sharing food with someone who is 2 (2%) 4 (4%) 6 (3%) 8 (6%) 8 (6%) 15 (6%) +4% +2% +3% infected. Voluntary medical male circumcision can reduce the risk of 117 (94%) 96 (96%) 213 (96%) 119 (91%) 120 (97%) 239 (94%) -4% +1% -1% acquiring HIV. There is a daily drug available called “PrEP” that can be taken by people who don't have HIV to prevent them from 69 (56%) 53 (53%) 122 (55%) 91 (69%) 72 (58%) 163 (64%) +14% +5% +9% being infected with the virus. Having many sexual partners at the same time can increase 112 (90%) 96 (96%) 208 (93%) 126 (96%) 119 (96%) 245 (96%) +6% 0% +3% your risk of acquiring HIV. Having a sexual partner (or partners) who is much older than 88 (71%) 71 (71%) 159 (71%) 80 (61%) 79 (64%) 159 (63%) -10% -7% -9% you can increase your risk of acquiring HIV. You can get sexually transmitted infections (STIs) from 74 (60%) 50 (50%) 124 (56%) 85 (65%) 67 (54%) 152 (60%) +5% +4% +4% sitting on a toilet seat It is legal to discriminate against a person on the grounds 10 (8%) 3 (3%) 13 (6%) 11 (8%) 6 (5%) 17 (7%) 0% +2% +1% that they have HIV.

It is legal to force a person to have an HIV test. 32 (26%) 19 (19%) 51 (23%) 46 (35%) 16 (13%) 62 (24%) +9% -6% +2%

A woman can’t get pregnant until she is 16. 14 (11%) 16 (16%) 30 (13%) 26 (20%) 19 (15%) 45 (18%) +9% -1% +4%

A woman can only get pregnant if she has sex often. 29 (23%) 24 (24%) 53 (24%) 33 (25%) 32 (26%) 65 (26%) +2% +2% +2%

Using the injection or the pill as contraception provides no 93 (75%) 71 (71%) 164 (74%) 77 (59%) 88 (71%) 165 (65%) -16% 0% -9% protection against HIV or STIs. Physical and sexual violence may include: slapping, beating, 119 (96%) 95 (95%) 214 (96%) 126 (96%) 122 (98%) 248 (98%) 0% +3% +2% pinching, hair pulling, threatening or attacking with a

Stepping up the Fight An evaluation of the Stepping Stones approach to HIV prevention 84 among adolescents and young people in Eswatini

weapon, locking a partner in a room, or forcing a partner to have sex or do something sexual they do not want to do. It is abusive towards men if wives or girlfriends do not do domestic work at home, such as cooking, ironing and 44 (35%) 44 (44%) 88 (39%) 64 (49%) 66 (53%) 120 (47%) +13% +9% +8% cleaning. PART 1: BEHAVOUR Did you use a condom the last time you had sex with non- 76 (61%) 71 (71%) 147 (66%) 91 (69%) 90 (73%) 175 (69%) +8% +2% +3% marital, non-cohabiting partner? Are you currently using a method of modern contraception? 93 (75%) 80 (80%) 173 (78%) 105 (80%) 100 (81%) 205 (81%) +5% +1% +3%

Have you or your partner fallen pregnant in the past year? 54 (44%) 18 (18%) 72 (32%) 50 (38%) 12 (10%) 62 (24%) -6% -8% -8% Have you received money, goods or other favors in 7 (6%) 10 (10%) 17 (8%) 6 (5%) 5 (4%) 11 (4%) -1% -6% -3% exchange for sex in the past year? Have you had a sexual partner who was 10 or more years 18 (15%) 11 (11%) 29 (13%) 26 (20%) 10 (8%) 35 (14%) +5% -3% +1% older than you in the past year? Have you said “no” to an unwanted sexual situation in the 68 (55%) 31 (31%) 99 (44%) 74 (56%) 62 (50%) 128 (50%) +2% +19% +6% past year? Have you been able to identify risk or warning signs of sexual and gender-based violence among your family and/or 38 (31%) 41 (41%) 79 (35%) 43 (33%) 51 (41%) 89 (35%) +2% 0% +0% friends and give them information about where they can access services and support in the past year? Have you taken actions to save money in the past year? 82 (66%) 73 (73%) 155 (70%) 85 (65%) 99 (80%) 174 (69%) -1% 7% -1% Have you set goals for yourself, and tracked your progress 100 (81%) 81 (81%) 181 (81%) 103 (79%) 111 (90%) 207 (81%) -2% +9% 0% towards those goals, in the past year? PART 3: ATTITUDES Would you buy fresh vegetables from a shopkeeper or 122 (98%) 95 (95%) 217 (97%) 125 (95%) 121 (98%) 235 (93%) -3% +3% -5% vendor who is HIV-positive? Do you think children living with HIV should be able to attend 118 (95%) 94 (94%) 212 (95%) 127 (97%) 114 (92%) 232 (91%) +2% -2% -4% school with children who are HIV-negative? A husband or boyfriend is justified in hitting or beating his wife in at least one of the following circumstances: (1) she goes out without telling him, (2) she neglects the children, (3) 17 (14%) 13 (13%) 29 (13%) 19 (15%) 17 (14%) 34 (13%) +1% +1% 0% she argues with him, (4) she refuses sex with him, (5) she burns the food. Should men and women have equal rights in society? 75 (60%) 59 (59%) 134 (60%) 86 (66%) 83 (67%) 161 (63%) +5% +8% +3% Do you think that your current sexual behavior puts you (or 31 (25%) 33 (33%) 64 (29%) 22 (17%) 29 (23%) 48 (19%) -8% -10% -10% your partner[s]) at risk of infection with HIV? Do you think that your current sexual behavior puts you (or 41 (33%) 41 (41%) 82 (37%) 32 (24%) 39 (31%) 71 (28%) -9% -10% -9% your partner[s]) at risk of becoming pregnant? Do you think it is important to save money? 120 (97%) 100 (100%) 220 (99%) 125 (95%) 123 (99%) 236 (93%) -1% -1% -6%

Stepping up the Fight An evaluation of the Stepping Stones approach to HIV prevention 85 among adolescents and young people in Eswatini

Has your life improved during the past year? 94 (76%) 85 (85%) 179 (80%) 100 (76%) 109 (88%) 209 (82%) +1% +3% +2% Do you expect that your life will be better one year into the 117 (94%) 95 (95%) 212 (95%) 123 (94%) 119 (96%) 242 (95%) 0% +1% 0% future? PART 4: ACCESS

Have you received an HIV test in the past year? 115 (93%) 85 (85%) 200 (90%) 122 (93%) 100 (81%) 222 (87%) 0% -4% -2%

Have you received TB screening in the past year? 74 (60%) 49 (49%) 123 (55%) 66 (50%) 59 (48%) 125 (49%) -9% -1% -6%

Have you received STI screening in the past year? 81 (65%) 41 (41%) 122 (55%) 68 (52%) 43 (35%) 111 (44%) -13% -6% -11% Have you received family planning/contraceptive services in 82 (66%) 52 (52%) 134 (60%) 97 (74%) 69 (56%) 166 (65%) +8% +4% +5% the past year? Have you received cancer screening in the past year (this 28 (23%) 16 (16%) 44 (20%) 41 (31%) 7 (6%) 48 (19%) +9% -10% -1% can include a breast exam, pap smear or testicular exam)? If you accessed any of the above health services in the past 112 (90%) 84 (84%) 196 (88%) 118 (90%) 100 (81%) 218 (86%) 0% -3% -2% one year, were they friendly? If you experienced sexual or gender-based violence in the 15 (12%) 10 (10%) 25 (11%) 21 (16%) 19 (15%) 40 (16%) +4% +5% +5% past one year, did you receive post-violence care? If you experienced sexual or gender-based violence, did you 8 (6%) 2 (2%) 11 (5%) 13 (10%) 9 (7%) 21 (8%) +4% +5% +3% report the experience to the police or other authorities? Have you accessed financial services in the past year (this 28 (23%) 33 (33%) 61 (27%) 27 (21%) 40 (32%) 67 (26%) -2% -1% -1% can include services from a bank or insurance broker)? PART 5: ATTRIBUTION Did participating in the Stepping Stones program improve 124 254 your knowledge about HIV, sexual and reproductive health, 122 (98%) 99 (99%) 221 (99%) 130 (99%) +1% +1% 1% (100%) (100%) gender, relationships and saving money? Did participating in the Stepping Stones program help you to make better decisions about your behavior, to protect 124 253 119 (96%) 99 (99%) 218 (98%) 129 (98%) +3% +1% +2% yourself against HIV, unintended pregnancy, violence and (100%) (100%) poverty? Did participating in the Stepping Stones program change your attitudes towards HIV stigma, relationships, gender, 120 (97%) 97 (97%) 217 (97%) 127 (97%) 120 (97%) 247 (97%) 0% 0% 0% violence and saving money? Did participating in the Stepping Stones program facilitate your access to health services such as HIV testing, STI 117 (94%) 96 (96%) 213 (96%) 124 (95%) 111 (90%) 237 (93%) 0% -6% -3% screening and family planning services?

Stepping up the Fight An evaluation of the Stepping Stones approach to HIV prevention 86 among adolescents and young people in Eswatini

Annex 6. Stepping Stones Evaluation Participants Who Answered “Yes/True” to Survey Questions, By Year of Program Enrollment

2016 2017 2018 (n=106) (n=207) (n=164) Survey Question

PART 1: KNOWLEDGE The risk of HIV transmission can be reduced by having sex with only one uninfected partner who 89 (84%) 188 (91%) 147 (90%) has no other partners A person can reduce the risk of getting HIV by using a condom every time they have sex 104 (98%) 201 (97%) 161 (98%) A healthy-looking person can have HIV 93 (88%) 188 (91%) 146 (89%) A person can get HIV by hugging or shaking hands with a person who is infected 1 (1%) 5 (2%) 4 (2%) A person can get HIV by sharing food with someone who is infected. 7 (7%) 8 (4%) 7 (4%) Voluntary medical male circumcision can reduce the risk of acquiring HIV. 104 (98%) 196 (95%) 152 (93%) There is a daily drug available called “PrEP” that can be taken by people who don't have HIV to 66 (62%) 123 (59%) 96 (59%) prevent them from being infected with the virus. Having many sexual partners at the same time can increase your risk of acquiring HIV. 102 (96%) 193 (93%) 158 (96%) Having a sexual partner (or partners) who is much older than you can increase your risk of 68 (64%) 136 (66%) 114 (70%) acquiring HIV. You can get sexually transmitted infections (STIs) from sitting on a toilet seat 63 (59%) 115 (56%) 98 (60%) It is legal to discriminate against a person on the grounds that they have HIV. 7 (7%) 11 (5%) 12 (7%) It is legal to force a person to have an HIV test. 30 (28%) 43 (21%) 40 (24%) A woman can’t get pregnant until she is 16. 17 (16%) 27 (13%) 31 (19%) A woman can only get pregnant if she has sex often. 32 (30%) 41 (20%) 45 (27%) Using the injection or the pill as contraception provides no protection against HIV or STIs. 64 (60%) 155 (75%) 110 (67%) Physical and sexual violence may include: slapping, beating, pinching, hair pulling, threatening or attacking with a weapon, locking a partner in a room, or forcing a partner to have sex or do 100 (94%) 203 (98%) 159 (97%) something sexual they do not want to do. It is abusive towards men if wives or girlfriends do not do domestic work at home, such as 50 (47%) 95 (46%) 73 (45%) cooking, ironing and cleaning. PART 1: BEHAVOUR Did you use a condom the last time you had sex with non-marital, non-cohabiting partner? 74 (70%) 140 (68%) 114 (70%) Are you currently using a method of modern contraception? 92 (87%) 155 (75%) 131 (80%) Have you or your partner fallen pregnant in the past year? 28 (26%) 62 (30%) 44 (27%) Have you received money, goods or other favors in exchange for sex in the past year? 2 (2%) 22 (11%) 4 (2%) Have you had a sexual partner who was 10 or more years older than you in the past year? 16 (15%) 28 (14%) 21 (13%) Have you said “no” to an unwanted sexual situation in the past year? 58 (55%) 100 (48%) 77 (47%) Have you been able to identify risk or warning signs of sexual and gender-based violence among your family and/or friends and give them information about where they can access services and 33 (31%) 78 (38%) 62 (38%) support in the past year? Have you taken actions to save money in the past year? 76 (72%) 148 (71%) 115 (70%)

Stepping up the Fight An evaluation of the Stepping Stones approach to HIV prevention 87 among adolescents and young people in Eswatini

Have you set goals for yourself, and tracked your progress towards those goals, in the past 84 (79%) 177 (86%) 134 (82%) year? PART 3: ATTITUDES Would you buy fresh vegetables from a shopkeeper or vendor who is HIV-positive? 105 (99%) 201 (97%) 157 (96%) Do you think children living with HIV should be able to attend school with children who are HIV- 99 (93%) 198 (96%) 156 (95%) negative? A husband or boyfriend is justified in hitting or beating his wife in at least one of the following circumstances: (1) she goes out without telling him, (2) she neglects the children, (3) she argues 15 (14%) 28 (14%) 22 (13%) with him, (4) she refuses sex with him, (5) she burns the food. Should men and women have equal rights in society? 72 (68%) 129 (62%) 102 (62%) Do you think that your current sexual behavior puts you (or your partner[s]) at risk of infection 27 (25%) 53 (26%) 35 (21%) with HIV? Do you think that your current sexual behavior puts you (or your partner[s]) at risk of becoming 26 (25%) 67 (31%) 60 (37%) pregnant? Do you think it is important to save money? 104 (98%) 204 (99%) 160 (98%) Has your life improved during the past year? 89 (84%) 170 (82%) 129 (79%) Do you expect that your life will be better one year into the future? 100 (94%) 199 (96%) 155 (95%) PART 4: ACCESS Have you received an HIV test in the past year? 96 (91%) 181 (87%) 145 (88%) Have you received TB screening in the past year? 48 (45%) 110 (53%) 90 (55%) Have you received STI screening in the past year? 51 (48%) 100 (53%) 82 (50%) Have you received family planning/contraceptive services in the past year? 72 (68%) 117 (57%) 111 (68%) Have you received cancer screening in the past year (this can include a breast exam, pap smear 24 (23%) 35 (17%) 33 (20%) or testicular exam)? If you accessed any of the above health services in the past one year, were they friendly? 91 (86%) 175 (85%) 148 (90%) If you experienced sexual or gender-based violence in the past one year, did you receive post- 13 (12%) 26 (13%) 26 (16%) violence care? If you experienced sexual or gender-based violence, did you report the experience to the police 9 (8%) 10 (5%) 13 (8%) or other authorities? Have you accessed financial services in the past year (this can include services from a bank or 38 (36%) 43 (21%) 47 (29%) insurance broker)? PART 5: ATTRIBUTION Did participating in the Stepping Stones program improve your knowledge about HIV, sexual and 105 (99%) 206 (100%) 164 (100%) reproductive health, gender, relationships and saving money? Did participating in the Stepping Stones program help you to make better decisions about your 105 (99%) 206 (100%) 160 (98%) behavior, to protect yourself against HIV, unintended pregnancy, violence and poverty? Did participating in the Stepping Stones program change your attitudes towards HIV stigma, 104 (98%) 200 (97%) 160 (98%) relationships, gender, violence and saving money? Did participating in the Stepping Stones program facilitate your access to health services such as 97 (92%) 194 (94%) 159 (97%) HIV testing, STI screening and family planning services?

Stepping up the Fight An evaluation of the Stepping Stones approach to HIV prevention 88 among adolescents and young people in Eswatini

Annexes on evaluation tools

Annex 7. Survey Tool Used for Stepping Stones Evaluation

OPENING SCRIPT AND CONSENT PROCESS Hi, my name is [data collector’s name]. I am part of a team that is evaluating the Stepping Stones program in Eswatini. I am going to start by explaining this research study and making sure you are comfortable participating.

DESCRIPTION OF THE RESEARCH • You are invited to participate in a research study about the Stepping Stones program. • You have been asked to participate because you were part of the Stepping Stones program. • The purpose of the research is to assess the effectiveness of the Stepping Stones program, and improve HIV prevention for young people in Eswatini. • This study will include a purposeful sample of about 400 Stepping Stones participants from eight Tinkhundla.

WHAT WILL YOUR PARTICIPATION INVOLVE? • If you decide to participate in this study you will be asked to answer forty-five (45) yes/no questions. This part will take about 10-15 minutes. • You will then be asked to participate in a group discussion, where you will be asked to share more about your experience in the Stepping Stones program. This part will take bout 30-45 minutes.

ARE THERE ANY RISKS TO ME? • This study is anonymous. Neither your name nor any other identifiable information will be recorded. • Due to the nature of HIV and sexual and reproductive health, there are several questions that are personal in nature, and others that include topics like sex and violence. • If at any time you are uncomfortable with the content of this survey, you may choose to skip a question or stop participating completely. Completion of this survey is not required, and you may withdraw at any time.

ARE THERE ANY BENEFITS TO ME? • After completion of this survey, you will be given information about HIV and sexual and reproductive health and rights, including the correct answers to some of the questions in this survey. This may benefit your own awareness and access to services. • You will be given a transport allowance of E100 for your participant in this study. • Your participation will help to improve HIV prevention programming for young people in Eswatini, helping to ensure that Swazi youth live healthy and productive lives.

Can I ask you to sign this consent form, stating that you agree to take part in this study? Data collector to get participant’s signature on consent form.

YES NO

Has the person agreed to participate, and signed the consent form?

Stepping up the Fight An evaluation of the Stepping Stones approach to HIV prevention among adolescents and young people in Eswatini

CHARACTERISTICS OF PARTICIPANT

Region: Hhohho Manzini Shiselweni Lubombo

Inkhundla: Ekukhanyeni Nkhaba Gege Mhlume

Maphalaleni Ntontozi Nkwene Mahlangatja Other ______

Gender: Male Female

Marital status: Married Unmarried

Did not Education: Primary Secondary Tertiary attend

______Age:

Number of Stepping Stones Sessions Completed

______

PART 1: KNOWLEDGE

TRUE FALSE 1. The risk of HIV transmission can be reduced by having sex with only one uninfected partner who has no other partners. 2. A person can reduce the risk of getting HIV by using a condom every time they have sex.

3. A healthy-looking person can have HIV.

4. A person can get HIV by hugging or shaking hands with a person who is infected. 5. A person can get HIV by sharing food with someone who is infected. 6. Voluntary medical male circumcision can reduce the risk of acquiring HIV. 7. There is a daily drug available called “PrEP” that can be taken by people who don't have HIV to prevent them from being infected with the virus. 8. Having many sexual partners at the same time can increase your risk of acquiring HIV.

Stepping up the Fight An evaluation of the Stepping Stones approach to HIV prevention among adolescents and young people in Eswatini

9. Having a sexual partner (or partners) who is much older than you can increase your risk of acquiring HIV. 10. You can get sexually transmitted infections (STIs) from sitting on a toilet seat 11. It is legal to discriminate against a person on the grounds that they have HIV.

12. It is legal to force a person to have an HIV test.

13. A woman can’t get pregnant until she is 16.

14. A woman can only get pregnant if she has sex often.

15. Using the injection or the pill as contraception provides no protection against HIV or STIs. 16. Physical and sexual violence may include: slapping, beating, pinching, hair pulling, threatening or attacking with a weapon, locking a partner in a room, or forcing a partner to have sex or do something sexual they do not want to do. 17. It is abusive towards men if wives or girlfriends do not do domestic work at home, such as cooking, ironing and cleaning.

PART 2: BEHAVIOR

YES NO 18. Did you use a condom the last time you had sex with non- marital, non-cohabiting partner? 19. If not, what was the reason for not using a condom?

I did not My partner did I do not like have not want to use condoms one one

I was too I am not I am not afraid to worried about worried suggest it getting about HIV pregnant

YES NO 20. Are you currently using a method of modern contraception?

This includes any of the following: The pill (oral contraceptives) Intrauterine device (IUD) Injectables, Female sterilization, Male sterilization, Female condoms, Male condoms, Implants, Emergency contraception, Standard days method, Lactational amenorrhoea method (LAM), The diaphragm, Foam or jelly).

Stepping up the Fight An evaluation of the Stepping Stones approach to HIV prevention among adolescents and young people in Eswatini

21. Have you or your partner fallen pregnant in the past year?

22. Have you received money, goods or other favors in exchange for sex in the past year?

23. Have you had a sexual partner who was 10 or more years older than you in the past year?

24. Have you said “no” to an unwanted sexual situation in the past year?

25. Have you been able to identify risk or warning signs of sexual and gender-based violence among your family and/or friends and give them information about where they can access services and support in the past year?

26. Have you taken actions to save money in the past year?

This can include joining stokvels, getting bank accounts, avoiding bank charges, registering for funeral cover, etc.

27. Have you set goals for yourself, and tracked your progress towards those goals, in the past year?

PART 3: ATTITUDES

YES NO 28. Would you buy fresh vegetables from a shopkeeper or vendor who is HIV-positive? 29. Do you think children living with HIV should be able to attend school with children who are HIV-negative? 30. A husband or boyfriend is justified in hitting or beating his wife in at least one of the following circumstances: (1) she goes out without telling him, (2) she neglects the children, (3) she argues with him, (4) she refuses sex with him, (5) she burns the food.

31. Should men and women have equal rights in society? 32. Do you think that your current sexual behavior puts you (or your partner[s]) at risk of infection with HIV? 33. Do you think that your current sexual behavior puts you (or your partner[s]) at risk of becoming pregnant?

34. Do you think it is important to save money?

35. Has your life improved during the past year? 36. Do you expect that your life will be better one year into the future?

Stepping up the Fight An evaluation of the Stepping Stones approach to HIV prevention among adolescents and young people in Eswatini

PART 4: ACCESS

YES NO

37. Have you received an HIV test in the past year?

38. Have you received TB screening in the past year?

39. Have you received STI screening in the past year?

40. Have you received family planning/contraceptive services in the past year?

41. Have you received cancer screening in the past year (this can include a breast exam, pap smear or testicular exam)?

42. If you accessed any of the above health services in the past one year, were they friendly?

43. If you experienced sexual or gender-based violence in the past one year, did you receive post-violence care?

44. If you experienced sexual or gender-based violence, did you report the experience to the police or other authorities?

45. Have you accessed financial services in the past year (this can include services from a bank or insurance broker)?

PART 5: STEPPING STONES ATTRIBTION

46. Did participating in the Stepping Stones program: YES NO a) Improve your knowledge about HIV, sexual and reproductive health, gender, relationships and saving money?

b) Help you to make better decisions about your behavior, to protect yourself against HIV, unintended pregnancy, violence and poverty?

c) Change your attitudes towards HIV stigma, relationships, gender, violence and saving money?

d) Facilitate your access to health services such as HIV testing, STI screening and family planning services?

Stepping up the Fight An evaluation of the Stepping Stones approach to HIV prevention among adolescents and young people in Eswatini

CLOSING AND NEXT STEPS

Thank you for taking the time to participate in the Stepping Stones evaluation. Your answers will help the country to improve HIV prevention programs for young people in the future.

A report will be written which summarizes the overall impact of the Stepping Stones approach and makes recommendations for how it can be improved. A copy of this report, or a summary of it, can be made available to you if you, would like it.

Please enjoy some refreshments while we complete the surveys with the other participants. Next, we will have small group discussions where you will get an opportunity to share more of your opinions about the Stepping Stones program and how it can be improved.

When we are finished the surveys and the group discussions, you will receive your transport allowance and the process will come to an end.

THANK YOU!

Stepping up the Fight An evaluation of the Stepping Stones approach to HIV prevention among adolescents and young people in Eswatini

Annex 8. Focus Group Discussion Guide Used for Stepping Stones Evaluation

OPENING SCRIPT AND CONSENT PROCESS

Hi, my name is [data collector’s name]. I am part of a team that is evaluating the Stepping Stones program in Eswatini.

During the survey portion of this research you heard about why we are doing this study and you agreed to participate by signing a consent form. Are you happy to continue participating in the study? [wait for group to nod in agreement]

Now it is time for the focus group discussion. This is a relaxed discussion where you can share your views and opinions about the Stepping Stones program and how to improve it.

This is a safe space. You can feel free to share your perspectives without any consequences.

This part of the research remains anonymous. Your name will not be linked to anything to say or do during this discussion.

Our discussion will be guided by some questions, which I will read out. However, if there are other things you want to discuss, you can feel free. This is a flexible and open discussion.

CHARACTERISTICS OF FGD

Hhohho Manzini Shiselweni :

Inkhundla: Ekukhanyeni Nkhaba Gege Mhlume

Maphalaleni Ntontozi Nkwene Mahlangatja Other ______

Type of FGD: Adolescent Young women Stepping Stones girls age < age > 20 years mentors 20 years Adolescent Young men age boys age < > 20 years 20 years

Other: ______

Number of participants in ______FGD:

Stepping up the Fight An evaluation of the Stepping Stones approach to HIV prevention among adolescents and young people in Eswatini

FGD GUIDE

1. What was your experience like in the Stepping Stones program?

2. What was the best thing about the Stepping Stones program? What part was most important to you? What was your favorite Stepping Stones session and why?

3. Can you share something new that you learned from the Stepping Stones program, that you did not know before you enrolled?

4. Do you think that the knowledge you gained during Stepping Stones adequate to protect yourself against HIV, unintended pregnancy and sexual and gender-based violence, or is there additional support that you would like or need?

5. Do you feel that the Stepping Stones program empowered you, economically? What other economic empowerment activities would you like to be offered, either through Stepping Stones or through other programs?

6. If there was one thing you would change about the Stepping Stones program, what would it be?

7. Do you think the length of the program is the right number of weeks?

8. Would you like to add something to the topic of today’s discussion?

CLOSING AND NEXT STEPS

Thank you for taking the time to participate in the Stepping Stones evaluation. Your answers will help the country to improve HIV prevention programs for young people in the future.

A report will be written which summarizes the overall impact of the Stepping Stones approach and makes recommendations for how it can be improved. A copy of this report, or a summary of it, can be made available to you if you, would like it.

We have now completed the research activities for today. You can collect your transport allowance from [name of admin support issuing the transport allowances].

THANK YOU!

Stepping up the Fight An evaluation of the Stepping Stones approach to HIV prevention among adolescents and young people in Eswatini