Identification of adolescent girls and young women for targeted HIV prevention: a new risk scoring tool in KwaZulu Natal, South Africa

Sarah Gabrielle Ayton, Martina Pavlicova, Quarraisha Abdool Karim, Sarah Gabrielle Ayton, Martina Pavlicova, Quarraisha Abdool Karim

Abstract

The ongoing spread of human immunodeficiency virus (HIV) has driven novel interventions, such as antiretrovirals, for pre-exposure prophylaxis. Interventions have overlooked a high-risk Sub-Saharan African population: adolescent girls and young women (AGYW), particularly those under 18. We apply the Balkus risk tool among rural South African AGYW (n = 971) in a hyper-endemic setting, identify limitations, and assess deficiencies with modern statistical techniques. We apply the "Ayton" tool, the first risk tool applicable to sub-Saharan African AGYW, and compare performance of Balkus and Ayton tools under varying conditions. The Ayton tool more effectively predicted HIV acquisition. In low and high-risk AGYW, the Ayton tool out-performed the Balkus tool, which did not distinguish between risk classes. The Ayton tool better captured HIV acquisition risk and risk heterogeneities due to its AGYW-focused design. Findings support use of the Ayton tool for AGYW and underscore the need for diverse prognostic tools considering epidemic severity, age, sex and transmission.Clinical Trial Number ClinicalTrials.gov (NCT01187979) and the South African National Clinical Trials Registry (SANCTR) (DOH-27-0812-3345).

Conflict of interest statement

The authors declare no competing interests.

Figures

Figure 1
Figure 1
Evaluation of raw and simulated Balkus scores in AGYW. Distribution of (a) raw, (b) generic simulated (median [IQR]), and (c) reality-based simulated (median [IQR]) Balkus risk scores in AGYW who remained HIV seronegative and those who became seropositive at 1 year (left, Supplementary Table S1). Balkus scores were evaluated for sensitivity, specificity, PPV, and NPV against 1-year HIV status (right, Supplementary Table S2).
Figure 2
Figure 2
Comparison of risk classes from the Ayton with raw Balkus scores. Distribution of raw Balkus risk scores in AGYW who were classified by the Ayton tool as almost no, low, and high risk of HIV acquisition at 1 year (above). Raw Balkus scores were evaluated for sensitivity, specificity, positive predictive value, and negative predictive value against risk class determined by the Ayton tool (below).
Figure 3
Figure 3
Performance of Ayton tool risk classes as well as all Balkus evaluations compared with optimal performance, defined by 100% sensitivity and 100% specificity. Distances to the optimal performance point are displayed in parentheses.

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