Tracking adaptation strategies of an HIV prevention intervention among youth in Nigeria: a theoretically informed case study analysis of the 4 Youth by Youth Project
Authors: Iwelunmor Juliet , Ezechi Oliver , Obiezu-Umeh Chisom , Gbaja-Biamila Titilola , Musa Adesola Z. , Nwaozuru Ucheoma , Obasi Nnamdi , Ojo Victor , Xian Hong , Oladele David , Airhihenbuwa Collins O. , Muessig Kathryn , Rosenberg Nora , Conserve Donaldson F. , Ong Jason J. , Nkengasong Susan , Tahlil Kadija M. , BeLue Rhonda , Engelhart Alexis , Mason Stacey , Tang Weiming , Ogedegbe Gbenga , Tucker Joseph D. 
Published: April 2023

Abstract
Background
Although many behavioral interventions are adapted, little is known about the reasons for adaptations and the process and outcomes influencing adaptations. To address this gap, we explored the adaptations made to promote HIV prevention services, including HIV self-testing (HIVST), among Nigerian youth.

Methods
The main objective of this qualitative case study design was to document the adaptations made over time using the Framework for Reporting Adaptations and Modifications – Expanded (FRAME). Between 2018 and 2020, we organized four participatory activities as part of the 4 Youth by Youth project to increase the uptake of HIVST services in Nigeria—an open call, a designathon, a capacity-building bootcamp and a pilot feasibility trial. We also began the process of implementing a final intervention using a pragmatic randomized control trial (RCT). The open call solicited creative strategies to promote HIVST among Nigerian youth and then had experts evaluate them. The designathon brought together youth teams to further develop their HIVST service strategies into implementation protocols. Teams determined to be exceptional were invited to a four-week capacity-building bootcamp. The five teams that emerged from the bootcamp were supported to pilot their HIVST service strategies over a 6-month period. The adapted intervention is currently being evaluated in a pragmatic RCT. We transcribed meeting reports and conducted document reviews of study protocols and training manuals.

Results
Sixteen adaptations were identified and categorized into three domains: (1) modifications to the content of the intervention (i.e. photo verification system and/or Unstructured Supplementary Service Data (USSD) system to verify HIVST); (2) modifications to the delivery the intervention (i.e. implement participatory learning community sessions to provide supportive supervision and technical support); (3) modifications to the evaluation processes (i.e. economic evaluation to estimate the cost of implementing intervention on a larger scale). Frequent reasons for adaptation included increasing intervention reach, modifying interventions to enhance their appropriateness and fit with the recipient, and increasing the intervention’s feasibility and acceptability. Most adaptations were planned and reactive, and the need for modifications was determined by the youths, 4YBY program staff, and advisory group.

Conclusions
Findings suggest that the nature of adaptations made throughout the implementation process reflects the necessity of evaluating services in context while adjusting to specific challenges as they are identified. Further research is needed to understand the effect of these adaptations on the overall intervention effect as well as the quality of youth engagement.