Effects of a Multimedia Campaign on HIV Self-Testing and PrEP Outcomes among Young People in South Africa: A Mixed-Methods Impact Evaluation of 'MTV Shuga Down South'

"The findings suggest ways in which a popular, immersive multimedia campaign like MTV Shuga can accelerate achievement of HIV prevention goals for young people."

Young people aged 15-24 years, an important demographic group for the global goal to end AIDS as a public health threat by 2030, are less likely than older adults to know their HIV status. Tools such as HIV self-testing (HIVST) enable people to test in private, without the judgment, stigma or discrimination they may face in facility-based services. Armed with knowledge, they might be more likely to access prevention in the form of pre-exposure prophylaxis (PrEP). To create awareness and demand among adolescents and young adults, a campaign of the pan-African MTV Shuga series Down South 2 (DS2) featured storylines and messages about HIVST and PrEP through television, radio, and accompanying multimedia activities. This paper reports on a mixed-methods evaluation that was conducted in 2020 to determine whether and how DS2 impacted HIV prevention outcomes among 15- to 24-year olds in Eastern Cape, South Africa.

MTV Shuga (see Related Summaries, below) is a multimedia campaign based around a popular dramatic series that promotes HIV prevention and positive sexual health messaging with entertaining storylines and characters. In 2019-2020, a new MTV Shuga series, DS2 was produced and televised in South Africa. It was based on formative work to develop and validate storylines and scripts with young people. The show was complemented by wrap-around, "360-media" activities, including a radio series, documentary films, and online resources. In the town of Mthatha in Eastern Cape, South Africa, peer education, community events, and a graphic novel distributed through schools enabled opportunities for offline engagement among those underserved by television and internet.

Quantitative and qualitative methods were used for the study. A web-based survey, promoted via social media platforms of schools, universities, and communities, assessed exposure to MTV Shuga/DS2 and knowledge of HIV status; secondary outcomes included awareness and uptake of HIVST and PrEP. The researchers used multivariable logistic regression to estimate associations between exposure to DS2 and each outcome, adjusting for sociodemographic factors, media assets, and exposure to other media campaigns. An embedded qualitative evaluation explored mechanisms of DS2's impact through deductive and inductive thematic analysis of in-depth individual and group interviews.

Among 3,431 online survey participants, 43% had engaged with MTV Shuga and 24% with DS2 specifically. Engagement most often involved attending a peer educator-led group discussion about DS2 (15%), followed by watching the affiliated "In Real Life" documentary (11%), reading the DS2 graphic novel (10%), attending a DS2 community event (9%), and watching DS2 on TV or the internet and identifying it as season 2 (7%). Only a small proportion reported listening to DS2 on the radio (2%).

About 47% of respondents said they were aware of their HIV status. Knowledge of HIV status was higher among those exposed to DS2 (71%) vs those who were not (39%; adjusted odds ratio (OR)=2.26 (95% confidence interval (CI) 1.78-2.87)). Exposure was also associated with increased awareness of HIVST (60% vs 28%; aOR=1.99 (1.61-2.47)) and use of HIVST (29% vs 10%; aOR=2.49 (1.95-3.19)). One-third of respondents were aware of PrEP, with higher proportions among those exposed versus non-exposed to DS2 (52% vs 27%; aOR=1.90 (1.53-2.35)). Demand for PrEP (i.e., willingness to take PrEP every day) was high overall, with weak evidence of higher demand among those exposed to DS2 (85% vs 80% among non-exposed; aOR=1.31 (0.97-1.76)).

In analysis of qualitative data, themes emerged about the behavioural mechanisms through which MTV Shuga DS2 influenced participants' awareness, confidence, and motivation related to HIVST and PrEP outcomes. For example, awareness (an aspect of capability) of HIVST and PrEP was enhanced by watching the show, with some learning about these resources for the first time from DS2. Young people described how scenes and storylines from DS2 helped them feel more confident to learn more (e.g., from internet searches) and prepared to access HIV services. However, the show had less influence on opportunity to access services like HIVST and PrEP. While viewers saw ways in which they could get such resources, from the show, many doubted the availability in their own setting, especially during closures related to COVID-19 lockdowns. Thus, an important limitation to a multimedia campaign like MTV Shuga is its lack of influence on supply of services, either actual or perceived.

The qualitative data also illustrate ways in which DS2 had a broader influence beyond its immediate audience. For example, it helped some viewers initiate conversations and discussion with partners and parents, with whom they said conversations about sex are often avoided or awkward, although some remained hesitant to engage in such discussions. Many saw the role they themselves could play as educators and advocates for HIV testing and prevention, in their community and their own family.

Reflecting on the findings, the researchers note that "MTV Shuga's influence is consistent with a person-centred approach to HIV prevention: through engaging storylines and characters, young people are offered accurate and relevant information on HIV prevention options and enabled to make their own choices (in contrast to assuming that young people are 'passive beneficiaries')....Positive effects were equally strong for females and males, and the diverse characters and storylines enabled MTV Shuga viewers to reflect on their personal needs and HIV prevention choices."

In conclusion: "With stronger, more direct links to the supply and distribution of prevention tools like self-test kits and PrEP, growing use of digital media among young people, and the potential for early adopters to diffuse innovation, a popular edutainment campaign like MTV Shuga has an important role to play in closing age and gender gaps in HIV testing and prevention goals."

Editor's note: Click on the links below to watch two 1-minute video summaries of the study, presented by Sarah Mulwa and Venetia Baker:

• Video 1
• Video 2