Supporting adolescents living with HIV within boarding schools in Kenya.

Adolescents and youth living with HIV (AYLHIV) are a uniquely vulnerable population facing challenges around adherence, disclosure of HIV status and stigma. Providing school-based support for AYLHIV offers an opportunity to optimize their health and wellbeing. The purpose of this study was to evaluate the feasibility of school-based supportive interventions for AYLHIV in Kenya. From 2016-2019, with funding from ViiV Healthcare, the Elizabeth Glaser Pediatric AIDS Foundation implemented the innovative Red Carpet Program (RCP) for AYLHIV in participating public healthcare facilities and boarding schools in Homa Bay and Turkana Counties in Kenya. In this analysis, we report the implementation of the school-based interventions for AYLHIV in schools, which included: a) capacity building for overall in-school HIV, stigma and sexual and reproductive health education; b) HIV care and treatment support; c) bi-directional linkages with healthcare facilities; and d) psychosocial support (PSS). Overall, 561 school staff and 476 school adolescent health advocates received training to facilitate supportive environments for AYLHIV and school-wide education on HIV, stigma, and sexual and reproductive health. All 87 boarding schools inter-linked to 66 regional healthcare facilities to support care and treatment of AYLHIV. Across all RCP schools, 546 AYLHIV had their HIV status disclosed to school staff and received supportive care within schools, including treatment literacy and adherence counselling, confidential storage and access to HIV medications. School-based interventions to optimize care and treatment support for AYLHIV are feasible and contribute to advancing sexual and reproductive health within schools.

Introduction

School attendance is a critical component in the lives and development of adolescents and youth, including those living with HIV [1-3]. School experience contributes to the emotional, social, cognitive, and behavioral development of children and adolescents [1], and provides a unique opportunity to reach adolescents and youth living with HIV (AYLHIV) beyond their homes to support their health, treatment, self-management and wellbeing [4, 5].

Public day and boarding schools are two of the most common forms of academic settings for children and youth in many countries, including Kenya [6]. Data from the Kenya Ministry of Education reports that there are approximately 4,300 secondary boarding schools nationally, which constitute 50% of all public secondary schools [7]. In Kenya, adolescents and youth spend 8–10 hours per week in a day school and 9 months of their daily lives in a boarding school during the school year, where they reside away from their homes [8]. For youth at boarding schools, their teachers, school staff, and peers become their main community and source of support as daily contact with families and caregivers is limited [9].

The boarding school environment poses specific challenges to AYLHIV [10-12]. Life at a boarding school affects access to HIV care and treatment compared to AYLHIV who attend day schools and have their families’ support and greater flexibility around healthcare facility access. Barriers and challenges to HIV care in boarding schools include restricted independence and increased controlled access to healthcare facilities (HCFs) and external providers, HIV status disclosure challenges, limited adherence support and difficulties with accessing daily antiretroviral treatment (ART), self and experienced stigma, and limited privacy and confidentiality [10, 13–17]. There is an unmet need to design and evaluate interventions to address these challenges and improve health outcomes among AYLHIV, especially those attending boarding schools [18, 19].

Kenya carries a high HIV burden among adolescents and youth with an estimated 91,634 adolescents aged 10–19 years and 145,471 youth aged 15–24 years living with HIV in 2019 [20]. In response to the needs of AYLHIV, the Elizabeth Glaser Pediatric AIDS Foundation’s (EGPAF) Red Carpet program (RCP), funded by ViiV Healthcare Positive Action, implemented, three packages of interventions including a healthcare facility intervention package, a meaningful youth engagement package and boarding school-based intervention package in Homa Bay and Turkana Counties, two high HIV epidemic burden regions in Kenya [21]. The main goal of the school-based RCP interventions was to provide care and treatment support for AYLHIV aged 10–24 years. Implemented in coordination with the Kenya Ministry of Education (MOE) and Ministry of Health (MOH), the RCP school interventions also included building of school capacity in sexual and reproductive health, HIV and stigma education and strengthening bi-directional coordination between RCP boarding schools and HCFs. The aim of this analysis is to evaluate the feasibility of the school-based RCP interventions for AYLHIV at participating boarding schools in Kenya.

Methods

Study design

This study analyzed programmatic data from implementation of the RCP boarding school-based intervention package in Homa Bay and Turkana Counties in Kenya over three project years from March 2016 through September 2019.

The RCP study protocol was approved by the Kenyatta National Hospital-University of Nairobi Ethical Review Board, Kenya, and Chesapeake Institutional Review Board, USA. The study obtained a waiver of informed consent, as it used programmatic de-identified data and posed no more than minimal risk to participants. No individual patient level data were collected during RCP evaluation.

RCP boarding school selection and engagement

The process of involving schools into RCP began with engaging and sensitizing the regional MOH and MOE on RCP to ensure project ownership and support. In collaboration with county MOH, MOE and the Teachers Service Commission (TSC), RCP conducted a joint mapping exercise to identify the boarding schools attended by AYLHIV in care and located within the catchment area of local HCFs. Following identification of schools to be engaged in the project, a joint MOH and MOE meeting was conducted to establish sub-county working groups to lobby for access to schools in addition to coordination, planning, and implementation of the RCP school-based project. RCP team and sub-county working groups led the series of meetings with key sub-county stakeholders (TSC, Parents Association (PA), Parent Teachers Associations (PTA), School Health Committees (SHC) and AYLHIV champions) and heads of school to discuss implementation of RCP and the needs of AYLHIV. With affirmed participation, RCP schools and their respective SHC were linked to the local RCP HCFs and sub-county RCP teams for project implementation.

The main criteria for RCP HIV responsive schools were established by the EGPAF RCP team and included a checklist of target characteristics which were reviewed and approved by county and sub-county stakeholders (S1 Appendix). Based on these criteria, within each individual school, head teacher or principle, SHC members, school-based peer educators, sub-county RCP Adolescent Youth Peer Advisory Group (AYPAG) and healthcare workers (HCWs) from interlinked RCP HCFs facilities, jointly designed and further implemented individual school RCP activities. AYPAGs are comprise of trained AYLHIV who participate on a voluntary basis to represent the interests of AYLHIV in advocacy and implementation activities at the facility, sub-county, and county level in discussions and working groups, along with supporting peers at the facility level.

School-based RCP package interventions included: a) capacity building for overall in-school HIV, stigma and sexual and reproductive health (SRH) education; b) HIV care and treatment support; c) bi-directional linkages with HCFs; and d) psychosocial support (PSS) (Fig 1). Each school-based intervention comprised of various activities involving AYLHIV, HCWs, school staff, SCH members, adolescent and youth peer volunteers and newly identified and trained adolescent health advocates (AHA).

Fig 1

Key interventions of RCP package in schools, Homa Bay and Turkana Counties, Kenya.

Capacity building for overall in-school HIV, stigma and SRH education included support for existing SHCs and AHA training, and school-wide SRH, HIV, and stigma education. In order to foster productive dialogues in schools, relevant, age appropriate, evidence-based information on HIV and SRH was provided and discussed in various venues including school health days and school gatherings. The school-wide provision of information and dialogues on HIV supported building understanding among school staff and adolescents and youth overall of discriminatory or stigmatizing behaviors towards people living with HIV.

SHCs already existed within the MOE policy framework regionally and nationwide; however, RCP aimed to ensure the integration of supportive elements for AYLHIV within SHC roles and responsibilities (Fig 2). SHCs at RCP schools required school staff members and/or representatives of the school to receive training on how to support AYLHIV in school settings. Training for teachers and school support personnel was conducted using an EGPAF developed curriculum adapted from the national Adolescent Package of Care (APOC) [22] training. RCP trainings were offered to various school staff including guidance counselling teachers, boarding masters/mistresses, school matrons, school nurses, and members of SHCs. RCP trainings emphasized privacy and confidentiality to assure trust and to prevent stigma and discrimination towards AYLHIV. In recognizing the significant challenge and barrier stigma and discrimination play in the school and treatment experience for AYLHIV [11, 16], RCP also engaged parents and students in education and practical skill building activities to empower the broader school community with the tools and knowledge to prevent and combat HIV stigma.

Fig 2

School Health Committee (SHC) composition and core functions in RCP schools.

Trained school staff (mostly teachers) were asked to volunteer for the role of adolescent health advocates (AHA) to directly support RCP coordination and implementation in schools and to lead the education efforts on the needs of AYLHIV with a focus on support for care and treatment. These more specific education and trainings focused on sensitizing school personnel, SHC members and AHA on the needs of AYLHIV, including support for disclosure of HIV status, dealing with internal and external stigma, gaining treatment literacy, assuring adherence support and ARVs storage, and providing PSS. These trainings employed skill-building practice sessions on counseling, communication skills, and strategies to support AYLHIV.

Several designated focal contacts at schools (school staff, SHC members and AHA) were created and advertised across the school community to facilitate AYLHIV approaching these individuals without fear of repercussion for their needs, including disclosure support, gaining confidential access to the medication in storage or planning attendance clinic appointments.

HIV care and treatment support started with the process of disclosure of HIV status at schools among AYLHIV. The support for the disclosure of HIV status was offered to AYLHIV and/or their caregivers. AHA, SHC and designated school staff were trained on supporting two types of disclosure of HIV status: a) AYLHIV who knew their status were supported to disclose their status to the school staff, caregivers and peers, where applicable; and b) caregivers were supported to disclose the AYLHIV status to the school staff and to the AYLHIV who were unaware of their HIV status. Both types of disclosure resulted in school staff knowing the HIV status of AYLHIV in order to support their needs. SHC, AHA and school staff made the wider school community (including PA and students) aware that disclosure support was available and emphasized the confidentiality and discretion of the process. RCP school staff, SHC and AHA regularly reached out to the school community reaffirming the availability of support for disclosure of HIV status. Every effort was made to provide disclosure support in a way that would minimize accidental disclosure and prevent internal and external stigma. Once disclosed, AYLHIV were supported with treatment literacy education and treatment counselling, confidential access to ART, and bi-directional support in coordination of refills and appointments with HCFs. For AYLHIV who had their HIV status disclosed, storage of their ARVs in designated drug cabinets in private spaces was offered. AYLHIV had the option of morning visits to this private space where the school matron or nurse would assure their access to their medication. In order to minimize the potential stigma among peers, the space for ART storage and administration was shared with other adolescents and youth accessing medical services within the school for other chronic health conditions. For AYLHIV experiencing significant adherence challenges, directly observed therapy (DOT) was administered daily with guidance and in coordination with HCWs from linked HCFs in confidential and private settings by a school matron, school nurse, or trained AHA.

Bi-directional linkages with HCFs included joint planning and coordination of ART refills, AYLHIV clinical visits, and referrals to additional services. HCFs RCP coordinators communicated with designated AHA and school staff on AYLHIV needs for clinical follow up and refills, while school staff tracked AYLHIV attendance to clinic visits for treatment and follow-up and equally assured prompt communication with interlinked HCFs for ARV refills and any other clinical needs. Those AYLHIV who received care at HCFs outside of the RCP project areas, received school-based care, treatment support and PSS support.

Psychosocial support services (PSS) for AYLHIV included peer counselling and support conducted by AHA with engagement of peer facilitators and AYPAG members, focusing on positive living with HIV and development and/or enhancement of self-management skills. Peer counselling and support was available on a regular basis (bi-weekly) in private, confidential spaces via individual and/or group (minimum of two AYLHIV) sessions. When feasible and applicable, caregivers were invited to engage in treatment literacy sessions to support AYLHIV. Caregivers received treatment literacy and adherence counselling through the PTA, which included sensitization on AYLHIV needs, RCP and skills building around child-caregiver communication.

Data analysis

Routine programmatic RCP data collected included: number of schools in the project; number of RCP HCFs linked to schools; number of school staff, AHA, and SHC staff trained; number of AYLHIV who had their HIV status disclosed at school; number of AYLHIV who accessed ART support and PSS at school; and estimated number of adolescents and youth in schools reached with HIV, SRH and stigma educational activities. The school-based care and treatment support and linkage between schools and HCFs were assessed through documenting the mutual referral/communication processes via point of contact staff assigned at HCFs and schools, documentation of the HCF within the school health records for the disclosed AYLHIV and documentation of school-based support (access to ART and PSS) within schools and HCF records. Programmatic monitoring and evaluation visits were used to verify the bi-directional connections between HCF and schools with random client reviews. The mean viral suppression rate among the AYLHIV (stratified by age) at RCP HCFs was calculated using viral suppression programmatic reports from the county HCFs. Descriptive statistics were used for data analysis. Since RCP was a programmatic intervention and not a prospective trial of new interventions, including a control group of non-intervention schools while being desirable was not feasible.

Results

RCP achievements throughout the overall period of study implementation of the school-based package is summarized in Table 1. Following the pilot of RCP school-based support in 25 high volume secondary boarding schools in Homa Bay County, the number of participating secondary boarding schools increased gradually in Homa Bay Country in the first two years of the project, with expansion to Turkana County in the third project year reaching a total of 87 schools (74 in Homa Bay County and 13 in Turkana County).

Table 1

Cumulative summary of the RCP achievements by project year, 2016–2019.

Project Year	Number of participating schools	Number of HCFs linked with schools	Number of AYLHIV supported	Number of AY in RCP schools	Number of school staff sensitized	Number of AHAs
1	67	50	264	986	420	140
2	80	66	362	1028	325	300
3	87	66	546	1774	361	476

A total of 561 school staff were trained over the project period. Overall, 476 AHA received capacity building training to support their roles in RCP participating schools. Based on school-wide engagement and documented school attendance, an estimated 1774 students were reached across participating schools with various educational events focusing on SRH, HIV and stigma through diverse platforms including school health days and school gatherings.

By the end of the third project year, all 87 RCP schools were inter-linked to 66 local HCFs to support the care and treatment of AYLHIV. Across the 87 schools, 546 AYLHIV (~ 6 AYLHIV per RCP school) had their HIV status disclosed at school and received care and treatment and PSS within schools; 536 AYLHIV received bi-directional coordination of their care with interlinked HCFs (10 AYLHIV had their care at non-RCP HCFs and received school-based support only).

While baseline data for the HIV treatment outcomes were not collected, the mean viral suppression rate among the AYLHIV at RCP HCFs was 82% during 2019, the third project year, with 87% among AYLHIV aged 10–14 years, 90% for AYLHIV aged 15–19 years and 93% for AYLHIV aged 20–24 years.

Discussion

The implementation of RCP demonstrated the feasibility of integrating support for AYLHIV within boarding schools in high HIV burden areas in Kenya. AYLHIV have been reported to face multiple challenges with adherence, disclosure of HIV status and stigma within school environments [4, 23, 24]. The WHO acknowledges the critical opportunity in linking schools and community services to support an integrated approach to health along with the need for capacitation and active engagement of teachers and school staff in school-based health programs [25]. To date, a limited number of studies have shown school’s capacity to reduce barriers to care among AYLHIV by providing ART support, linkages to HCFs, and improving overall outcomes of HIV disease, such as viral suppression and living positively [14, 26].

Schools can play a significant role in improving the management and outcomes of several chronic diseases affecting adolescent populations. For instance, school-based asthma programs have demonstrated significant improvements in self-management, responsibility, coping with negative feelings, and health outcomes among children and youth [27, 28]. School-based programs addressing mental health conditions have also demonstrated reduction in mental health symptoms and improved function among youth and support the feasibility and efficacy of school-based health interventions [29, 30].

Following capacity building in our RCP program, more than 500 AYLHIV had their HIV status disclosed at schools in two counties in Kenya with high HIV prevalence. Similarly, a school-based teacher led initiative in Uganda contributed to a more open, welcoming, stigma-free environment that promoted stronger HIV openness between teachers and pupils; and in combination with multi-faceted activities such as edutainment and dance/dramas at school assemblies, enabled AYLHIV to disclose their status at school [31]. A qualitative study from Kisumu, Kenya reported that fear of stigma prevented the disclosure of HIV status to school staff among AYLHIV and led to higher rates of disengagement from care [16]. Our school-based package, which provided capacity building to school personnel and SHC, contributed to creating an enabling environment for AYLHIV. Importantly, the rates of viral suppression among AYLHIV within the area of RCP implementation, were higher (87% for younger adolescents (10–14 years), 90% for older adolescents (15–19 years) compared to the overall rates of viral suppression among ALHIV (10–19 years) at 61% in Kenya nationally during the same time period [32].

In addition to supporting AYLHIV, the RCP school-based package also served as a platform to reaching wider school-based communities with HIV, stigma, and SRH education. Despite some controversy surrounding the significance of school-based support in preventing HIV and other STIs among adolescents [33, 34], school-based programs have been shown to successfully implement HIV education, prevention and testing activities in schools [35, 36]. Limited studies from sub-Saharan Africa and Asia highlight primarily qualitative insights into the anticipated positive role schools can play in contributing to the overall health, wellbeing and academic success of AYLHIV students through the provision of care and treatment support [37, 38]. Significant gaps remain in evidence regarding feasibility of effective school-based interventions to improve health outcomes among AYLHIV in resource-limited settings affected by the HIV epidemic [16, 23, 39]. Because of the dearth in literature on school-based support for AYLHIV, the potential and value of treatment and care support in school settings remain largely unrecognized.

The RCP model provides evidence to establishing and maintaining comprehensive support for care and treatment of AYLHIV in schools and forming bi-directional linkages with HCFs while enabling broader HIV supportive school environments. The high level of collaboration between partners and stakeholders was essential to the success of RCP at schools. MOH, MOE and TSC in Homa Bay and Turkana Counties were consistently engaged, along with other stakeholders including AYLHIV, and led the planning and implementation of the school-based HIV interventions. Their involvement and continued coordination and support assured the success of the program. Establishing and sustaining meaningful relationships between health and education sectors at local and regional levels is crucial to enabling the implementation of school-based activities to support AYLHIV and enhancing HIV and SRH education among staff and students.

Our study has several limitations. We evaluated programmatic implementation, did not conduct qualitative baseline assessments and did not have a control group for the prospective evaluation of the school interventions. Not all schools were able to implement all elements of the RCP school package (though the majority implemented ≥80% of the required activities), which makes it challenging to draw conclusions about the efficacy of the separate elements of our school-based package of interventions. We also did not collect individual patient level data to assess a change in the self-management skills among AYLHV; however, we did conduct focus groups discussions with AYLHIV as part of the RCP project with a separate qualitative analysis on self-reported barriers to care, which remains in progress. Our findings are specific to Kenya and might not be generalizable to other country contexts. Despite these limitations, our study provides important contributions to the gap in the literature reporting feasibility of implementing school-based HIV care and treatment support in schools located in high HIV epidemic burden resource-limited settings.

Conclusions

We report the feasibility of implementing a package of school-based interventions to support AYLHIV within boarding schools in two counties with high HIV prevalence in Kenya. We achieved strong collaboration between regional healthcare and education authorities and stakeholders including AYLHIV and their caregivers. Implementation of the RCP school-based package of interventions resulted in improved capacity to support AYLHIV and increased the number of AYLHIV with a disclosed HIV status, with access to ART and who were supported through coordination of care within boarding schools. This study addresses a gap in the literature around the feasibility, sustainability and outcomes of school-based HIV care and treatment support within boarding schools in resource-limited settings heavily affected by the HIV epidemic. Further research of effective evidence-based interventions is needed to strengthen approaches that optimize HIV care and treatment and supportive environments in school settings for millions of AYLHIV globally.

Components of RCP activities within the SHC.

This file outlines components of RCP activities coordinated through the SHC concerning identification of LLHIV, linkages to, and retention in care within schools. The HIV-responsive school checklist outlines criteria consistent with characteristics of an HIV-responsive school.

(DOCX)

Click here for additional data file.

25 Jun 2021

PONE-D-21-12670

Engaging boarding schools to support adolescents living with HIV in Kenya

PLOS ONE

Dear Judith Kose,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

ACADEMIC EDITOR: Dear Judith Kose,

Your manuscript covers an important topic and therefore requires to be read wide and large. However, the current version requires some attention and they are well highlighted by reviewers.

1. Ensure your study title, goal, and specific objectives of this submission align across the manuscript.

2. Provide more information on the consent, disclosure of HIV, and potential for stigma among the participants through getting involved in this project

3. Revisit the methodology section and add missing details on assessments done and analyses. Furthermore your reporting style should ensure flow and easy communication of findings to the reader

4. Your discussion and conclusion must only address that which is provided in the results

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'This work was supported with funding by a grant from the Positive Action for Adolescents Programme by ViiV Healthcare UK Ltd, London, UK under the Positive Action for Adolescents Program. EGPAF’s adolescent and youth-focused programs in Kenya are supported by funding from United States Government (USG), ELMA Philanthropies, and ViiV Healthcare UK Ltd, London, UK. The funder did not participate in the implementation of the program or interpretation of the results as presented in this manuscript. The results do not necessarily represent the views of the funder.'

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Dear Judith Kose,

Your manuscript covers an important topic and therefore requires to be read wide and large. However, the current version requires some attention and they are well highlighted by reviewers.

1. Ensure your study title, goal and specific objectives of this submission align across the manuscript.

2. Provide more information the consent, disclosure and potential for stigma among the participants through getting involved in this project

3. Revisit the methodology section and add missing details on assessments done and analyses. Furthermore your reporting style should ensure flow and easy communication of findings to the reader

4. Your discussion and conclusion must only address that which is provided in the results

5. Ensure you bring out the special gap in knowledge that your manuscript addresses - apart from telling us about this great project, why should anyone care? Who should care? What's the special significance?

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Reviewer #1: Partly

Reviewer #2: Yes

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Reviewer #1: KEY MESSAGE:

- The study is an important one and will contribute to the knowledge gap regarding adolescents living with HIV in the boarding school environment.

- The initial impression is that the authors wished to evaluate the impact of the RCP intervention on retention in care and treatment. However, on further reading, the real question being asked is whether one can implement an intervention to improve student-school-HCF interactions in boarding secondary schools.

- The initial aim is therefore not addressed by the study findings

- I highlight what needs to be done in the various sections of the manuscript to improve its message and contribution to the scientific community.

A. Introduction:

- The question the authors sought to answer has changed from the introduction through the results and conclusions.

- On page 3 of the manuscript:

“The overarching goal of RCP is to increase linkages to and retention in care and treatment among AYLHIV aged 10-24 years. Implemented in coordination with the Kenya Ministry of Education (MOE) and Ministry of Health (MOH), the RCP school interventions included enhancing partnerships between boarding schools and RCP healthcare facilities (HCFs) while building capacity of schools to support AYLHIV.”

This does not seem to be captured in the results and conclusions of the manuscript. It however appears the main question was whether the intervention can be implemented.

Suggestion for improvement: Focus your introduction and aim both in abstract and main text on the intervention in the two counties and that is an offshoot of the main RCP school interventions.

- The context of the study in the introduction is clear.

B. Methods/Study design/Statistics:

- Well done.

- Few concerns that if addressed will make it more readable.

- Waiver for consent was requested and granted because of the minimal risk intervention. Did you consider the psychological consequences of inadvertent disclosure for those in school without complete disclosure about their HIV status?

- If so, it is not clear from the description how that was addressed during the study implementation.

- What of the stigma related to classmates realizing their HIV status?

- How was this mitigated against because it could have far reaching effects on the adolescent? If this was addressed, please outline how?

- Also, it would help to know if all schools were selected or if not, the method used in identifying the intervention schools.

- You mention as a limitation that you did not have non-intervention schools to compare with. Any reason why you did not consider intervention and non-intervention schools.

- It is not clear how improved linkage between Schools and HCT was assessed. In other words, if a child has a primary HCF from outside the catchment of the study, were they transferred to the county HCF?

- DOT: How was the improvement in this assessed? And how was it practically done?

- Counselors: How was their improved skill/improved psychosocial support assessed?

- Training curriculum for teachers: You used the HCP APOC curriculum. This is not been purposed for secondary school teachers. How did you modify it to enable the education given to the schools to be dependable?

Suggested improvements: Explain each item above, if considered how it was addressed?

- Outcomes: Your main outcomes seem to increased numbers of Secondary school-HCF units, increased AYLWH who were paired to HCF, number of teachers and counsellors trained on HIV care.

- I would have expected additional outcomes which were readily available to you to be presented in methods and results. These include adherence to medications, viral suppression (which comes in the discussion although missing in results), and psychological well-being using standard tools for assessment.

Suggested improvement: If you have contact of the individual AYLWH you can improve the manuscript by looking at baseline data on adherence to medications, viral suppression, and psychological well-being on these participants and including it.

- Outcome changes: The increased numbers from school-HCF units, teachers, counselors etc were never subjected to inferential statistics.

Suggested improvement: If you have pre and post-intervention numbers, you some inferential statistics can be done. However, the best approach would have been using a non-intervention group.

C. Results, Tables and Figures:

- -Overall impression: This is fairly well done. However some data is mentioned as percentages in the text but no raw number accompany that data.

- Examples:

“Overall, throughout RCP implementation, the number of schools with competent guidance and counselling teachers increased by 19.4%, the number of schools with teachers trained on caring and supporting AYLHIV increased by 99%, and the number of schools linked to a HCFs increased by 62%, compared to baseline”.

Suggestion for improvement: The bolded numbers need to have raw number –for example from xx to xx (19.4%). Having some of the data in the tables and referring to them will improve readability.

D. Conclusions:

- Indicates there is potential to improve retention in care and reduction of stigma. However, the results do not have any outcomes for any of the potential heath indicators.

Suggested change: Indicate the specific parameters that improved although the improvements were not tested statistically to confirm significance.

E. References and Appendices:

- Fairly well done

Thank you.

Reviewer #2: The paper is well written and has reviewed the latest literature in the area area related to the study. The methodology for implementing the intervention, as well as the methods of data analysis have been presented in a logical manner. However, while the paper has demonstrated the relevance of its findings in interventions that address HIV/AIDS and related challenges especially among the school-going youths, there has been little effort to demonstrate the scholarly contributions of the study. How does this study contribute to the field of sociology or related broad subject areas? What scholarly (academic) gaps was it designed to address and what new knowledge has the study contributed?

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Reviewer #1: Yes: Winstone Nyandiko

Reviewer #2: Yes: Abraham Kiprop Mulwo

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Submitted filename: ENGAGING BOARDING SCHOOLS TO SUPPORT ADOLESCENTSLIVING WITH HIV IN KENYA.docx

Click here for additional data file.

10 Aug 2021

Reviewers’ Comments

Your manuscript covers an important topic and therefore requires to be read wide and large. However, the current version requires some attention, and they are well highlighted by reviewers.

1. Ensure your study title, goal, and specific objectives of this submission align across the manuscript.

Thank you for this comment. We have aligned study title, goal, and specific objectives across the manuscript.

2. Provide more information on the consent, disclosure of HIV, and potential for stigma among the participants through getting involved in this project

We have added details on the consent, disclosure of HIV status and on the stigma considerations and measures to address it among the participants to the manuscript under Methods [lines 170-185; 166-190] and Discussion [lines 271-280].

3. Revisit the methodology section and add missing details on assessments done and analyses. Furthermore, your reporting style should ensure flow and easy communication of findings to the reader

As suggested, we revised methodology section and added more details on the assessments and data analysis [lines 218-228]. We have also adjusted our reporting style to ensure better flow and easy communication of the findings to the reader. As part of this revision, we have removed Figure 3 to be able to focus on the results of the whole project during the implementation period.

4. Your discussion and conclusion must only address that which is provided in the results

As suggested, we revised the manuscript to make sure that the Discussion and Conclusion sessions only address our results.

5. Ensure you bring out the special gap in knowledge that your manuscript addresses - apart from telling us about this great project, why should anyone care? Who should care? What's the special significance?

As suggested, we provided the evidence and highlighted the gaps and significance of our findings for the readers [lines 258-270; 289-300].

Reviewer #1

KEY MESSAGE:

- The study is an important one and will contribute to the knowledge gap regarding adolescents living with HIV in the boarding school environment.

- The initial impression is that the authors wished to evaluate the impact of the RCP intervention on retention in care and treatment. However, on further reading, the real question being asked is whether one can implement an intervention to improve student-school-HCF interactions in boarding secondary schools.

- The initial aim is therefore not addressed by the study findings

- I highlight what needs to be done in the various sections of the manuscript to improve its message and contribution to the scientific community.

We thank Reviewer 1 for these comments. Indeed, we describe the program with multiple components, some of them have been published already and are cited. We did focus this analysis on the school interventions only and have clarified that the initial aim of this analysis was for the analysis of the feasibility of school interventions [lines 76-87]; the healthcare facility interventions have been described in a separate published manuscript. We made sure to reflect this focus in various sections of the manuscript as suggested by the reviewer.

A. Introduction:

- The question the authors sought to answer has changed from the introduction through the results and conclusions.

- On page 3 of the manuscript:

“The overarching goal of RCP is to increase linkages to and retention in care and treatment among AYLHIV aged 10-24 years. Implemented in coordination with the Kenya Ministry of Education (MOE) and Ministry of Health (MOH), the RCP school interventions included enhancing partnerships between boarding schools and RCP healthcare facilities (HCFs) while building capacity of schools to support AYLHIV.”

This does not seem to be captured in the results and conclusions of the manuscript. It however appears the main question was whether the intervention can be implemented.

Suggestion for improvement: Focus your introduction and aim both in abstract and main text on the intervention in the two counties and that is an offshoot of the main RCP school interventions.

- The context of the study in the introduction is clear.

As pointed out by the reviewer, we describe the program with multiple components, some of them have been published already and we focus this analysis on the school interventions only. We have clarified that initial aim of this analysis was to focus on school interventions [lines 85-87; 91-93]. We made sure to reflect this focus in the Introduction and clarified that the separate analysis was conducted for all components of the RCP package.

B. Methods/Study design/Statistics:

- Well done.

- Few concerns that if addressed will make it more readable.

- Waiver for consent was requested and granted because of the minimal risk intervention. Did you consider the psychological consequences of inadvertent disclosure for those in school without complete disclosure about their HIV status?

- If so, it is not clear from the description how that was addressed during the study implementation.

- What of the stigma related to classmates realizing their HIV status?

- How was this mitigated against because it could have far reaching effects on the adolescent? If this was addressed, please outline how?

We thank the reviewer for pointing out this important area for clarification. We have clarified further our disclosure interventions. The disclosure of HIV status was offered to AYLHIV and/or their disclosed caregivers. AHA, SHC and selected school staff were trained on supporting two types of disclosure of HIV status: a) by AYLHIV to the school staff, caregivers and peers where applicable; and b) by caregivers to the school staff and AHA and undisclosed AYLHIV where applicable. AHA, SHC and school staff made the wider school community (including PA and learners) aware that disclosure support was available and emphasized the confidentiality and discretion of the process. RCP school staff, SCH and AHA regularly reached out to the school community reaffirming the available support for disclosure of HIV status. Every effort was made to provide disclosure support in a way that would minimize accidental disclosure and prevent internal and external stigma. Accidental or inadvertent disclosure was not reported in our study. Within the wider school community messaging about stigma, its harms and messaging about living positive with HIV were disseminated as part of RCP implementation. We clarified all the disclosure process, measures, and stigma mitigation in the manuscript [lines 171-190].

- Also, it would help to know if all schools were selected or if not, the method used in identifying the intervention schools.

To address this point, we have clarified the process of school selection in Methods [lines 101-113].

- You mention as a limitation that you did not have non-intervention schools to compare with. Any reason why you did not consider intervention and non-intervention schools.

The reviewer is correct, we did not have control group of non-intervention schools and did describe this as a limitation of our study. RCP was a programmatic intervention and not a prospective trial of new interventions, therefore including control group of non-intervention schools while being desirable, was not feasible.

- It is not clear how improved linkage between Schools and HCT was assessed. In other words, if a child has a primary HCF from outside the catchment of the study, were they transferred to the county HCF?

Thank you for this comment. We had only few AYLHIV (10) who had their HCF outside of the catchment areas. Those were not transferred to RCP HCF, but they received school-based care and treatment support and PSS support. The linkage between the schools and HCF was assessed through documenting the mutual referral/communication processes, point of contact staff assigned at healthcare facilities and schools, documentation of the HCF within the school health records for the disclosed AYLHIV and documentation of school-based support (access to ART, DOT and PSS) within HCF records. Programmatic monitoring and evaluation visits were used to verify the bi-directional connections between HCF and schools with random client reviews. We included all these clarifications in the manuscript. [lines 200-201; 218-223; 248-249]

- DOT: How was the improvement in this assessed? And how was it practically done?

We have clarified our DOT process in detail including practical aspects under the Methods [lines 190-193].

- Counselors: How was their improved skill/improved psychosocial support assessed?

We did not conduct a systematic assessment of the skills among AYLHV. We report on the strengthening of the PSS service and clarified this in the manuscript [lines 160-163; 205-211; 245-247].

- Training curriculum for teachers: You used the HCP APOC curriculum. This is not been purposed for secondary school teachers. How did you modify it to enable the education given to the schools to be dependable?

Suggested improvements: Explain each item above, if considered how it was addressed?

We have clarified in the Methods that the training for teachers and school support personnel was conducted using an EGPAF developed curriculum adapted using language from the national Adolescent Package of Care (APOC) training. Our training curricula focused on enhancing school personnel understanding of the current management of HIV care, antiretroviral treatment (ART) and support needs for AYLHIV with a focus on disclosure of HIV, stigma, treatment adherence support, ART storage, psychosocial support and coordination of care [lines 145-150; 160-163].

- Outcomes: Your main outcomes seem to increased numbers of Secondary school-HCF units, increased AYLWH who were paired to HCF, number of teachers and counsellors trained on HIV care.

- I would have expected additional outcomes which were readily available to you to be presented in methods and results. These include adherence to medications, viral suppression (which comes in the discussion although missing in results), and psychological well-being using standard tools for assessment.

Suggested improvement: If you have contact of the individual AYLWH you can improve the manuscript by looking at baseline data on adherence to medications, viral suppression, and psychological well-being on these participants and including it.

Thank you for these comments. Collecting data on adherence and psychological well-being among AYLHIV requires additional resources and was not included in the scope of our evaluation. For viral suppression, we have reported rates of viral suppression from our programmatic data under the Discussion [lines 280-284] and now extended it under Results [lines 250-253].

- Outcome changes: The increased numbers from school-HCF units, teachers, counselors etc were never subjected to inferential statistics.

Suggested improvement: If you have pre- and post-intervention numbers, you some inferential statistics can be done. However, the best approach would have been using a non-intervention group.

As noted by the reviewer, we report post-intervention numbers. For the baseline assessment, we conducted a mapping analysis prior to the start of the project but did not include the qualitative evaluation. As clarified above, we did not have a control non-intervention group for this program implementation project.

C. Results, Tables and Figures:

- -Overall impression: This is fairly well done. However, some data is mentioned as percentages in the text, but no raw number accompany that data.

- Examples:

“Overall, throughout RCP implementation, the number of schools with competent guidance and counselling teachers increased by 19.4%, the number of schools with teachers trained on caring and supporting AYLHIV increased by 99%, and the number of schools linked to a HCFs increased by 62%, compared to baseline”.

Suggestion for improvement: The bolded numbers need to have raw number –for example from xx to xx (19.4%). Having some of the data in the tables and referring to them will improve readability.

Thank you for this suggestion. The referenced text was related to Figure 3 which reported data from project year two only. To avoid confusion and to better focus on the results of the project overall, we have removed Figure 3 and relevant text from the manuscript.

D. Conclusions:

- Indicates there is potential to improve retention in care and reduction of stigma. However, the results do not have any outcomes for any of the potential heath indicators.

Suggested change: Indicate the specific parameters that improved although the improvements were not tested statistically to confirm significance.

We have realigned our Conclusions [lines 323-329] to reflect the descriptive statistical findings of our evaluation study and also clarified this within the Discussion.

E. References and Appendices:

- Fairly well done

Thank you, based on our revisions we have slightly expanded and also updated the references [lines 431-433; 587-590; 591-594].

Reviewer #2

The paper is well written and has reviewed the latest literature in the area related to the study. The methodology for implementing the intervention, as well as the methods of data analysis have been presented in a logical manner. However, while the paper has demonstrated the relevance of its findings in interventions that address HIV/AIDS and related challenges especially among the school-going youths, there has been little effort to demonstrate the scholarly contributions of the study. How does this study contribute to the field of sociology or related broad subject areas? What scholarly (academic) gaps was it designed to address and what new knowledge has the study contributed?

We have clarified the major gap in the subject area, as very limited data on the effective school interventions to support AYLHIV. Specifically, we added the citation from WHO: “The WHO acknowledges the critical opportunity in linking schools and community services to support an integrated approach to health along with the need for capacitation and active engagement of teachers and school staff in school-based health programs.[26]” [lines 258-2610

We clarified further that our project was designed to improve disclosure of HIV status at schools to enable care and treatment support. Considering the dearth in literature exploring evidence-based school-based support for AYLHIV, the potential and value of care and treatment support in school environments needs to be recognized. [lines 271-280]

We also emphasized that our study contributes to the gap in the literature addressing the feasibility of implementing school-based HIV care and treatment support in high HIV epidemic burden, resource-limited settings. In our study, building capacity of school staff, parents, adolescents, and youth improved availability and provision of coordinated care within schools including adherence support, counselling, access, and storage of medication for AYLHIV, while expanding the HIV prevention and SRH education platform for the broader school community. [lines 286-300]

We have also added one more co-author who participated in the data analysis and contributed to the critical review of manuscript with reviewers’ feedback. Please, let us know if any additional information or clarifications are required.

Thank you for your consideration of our revised manuscript.

Submitted filename: Author response_ Supporting ALHIV in schools in Kenya.pdf

Click here for additional data file.

8 Nov 2021

Supporting adolescents living with HIV within boarding schools in Kenya

PONE-D-21-12670R1

Dear Dr. Judith Kose,

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Academic Editor

PLOS ONE

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

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Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

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Reviewer #2: Concerns that I had raised have been sufficiently addressed. the article may now be processed for publication

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Reviewer #1: Yes: Winstone Nyandiko, Professor of Pediatrics, Moi University

Reviewer #2: Yes: DR. Abraham Kiprop Mulwo

22 Nov 2021

PONE-D-21-12670R1

Supporting adolescents living with HIV within boarding schools in Kenya

Dear Dr. Kose:

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