Introduction

Global progress in human immunodeficiency virus (HIV) prevention has accelerated in recent years, with the year 2024 recording a 40% reduction in incidence compared to 2010. However, an estimated 1.3 million people acquired HIV in 2024, nearly three times the global target of fewer than 370,000 new infections by 2025 [1]. Sub-Saharan Africa accounted for half of all new infections, even as the region experienced the steepest decline globally, a 56% decrease in incidence over the same period [1].

Adolescent girls and young women (AGYW) remain disproportionately affected. HIV incidence among AGYW is more than three times higher than that of their male peers [1]. Although global targets aimed to reduce new infections among AGYW to less than 50,000 by 2025, an estimated 210,000 AGYW acquired HIV in 2024 [1]. In eastern and southern Africa, the estimated number of new HIV infections among AGYW was 140,000, and in western and central Africa it was 31,000 [1]. This persistent vulnerability reflects deep-rooted gender inequalities, power imbalances, restrictive social norms, stigma, discrimination, criminalization, violence and socioeconomic inequalities across sub-Saharan Africa, which collectively limit AGYW’s ability to negotiate safer sex, access services, and exercise sexual autonomy [1,2].

Despite the availability of effective prevention tools, uptake is inadequate. Condom use, one of the most cost-effective HIV prevention strategies, remains suboptimal due to stigma, limited access, gendered power dynamics, and scarcity of youth-friendly service environments [3–5]. Likewise, biomedical HIV preventions options such as pre-exposure prophylaxis (PrEP), condom distribution and HIV testing, have expanded the prevention landscape, yet their uptake among AGYW is suboptimal, especially within traditional facility-based models [1].

Schools represent one of the most consistent and scalable contact points for reaching AGYW in sub-Saharan Africa. They offer access to large cohorts of adolescents in a structured setting and can serve as effective entry points for integrated sexual and reproductive health interventions. Evidence demonstrates that educational programmes can enhance HIV-related knowledge, build agency, and promote protective behaviours among adolescents [6,7]. However, curriculum-based HIV education alone has shown limited effectiveness in reducing HIV incidence or maintaining behaviour change without complementary access to prevention services [8,9].

Emerging research suggests that schools may also be promising delivery sites for biomedical HIV prevention interventions such as PrEP, condom distribution, and HIV testing. Studies have reported higher PrEP uptake in school-based or school-linked delivery models compared to community or clinic-based approaches [10]. Qualitative research further indicates that comfort, accessibility, trust, and peer support facilitate PrEP initiation among AGYW in school environments [11]. This suggests that integrating biomedical prevention within school settings may help overcome many of the barriers that limit AGYW’s access to facility-based services.

Existing reviews have focused largely on sexual and reproductive health education, abstinence-only, or broader behavioural interventions, with limited attention to school-based biomedical or service-oriented HIV prevention initiatives and their implementation outcomes [8,12–14].

This systematic review will address this gap by synthesizing quantitative and qualitative evidence to understand what works, what is feasible, and what barriers and facilitators influence the implementation of school-based HIV prevention initiatives, including PrEP, condom, and HIV testing for AGYW in sub-Saharan Africa. The findings will inform programme design, implementation, and scale-up of efforts aimed at reducing HIV incidence among AGYW.

Materials and methods

This protocol was developed using the Preferred Reporting Items for Systematic reviews and Meta-Analyses Protocols (PRISMA-P) checklist.

Eligibility criteria

For this review, biomedical HIV prevention interventions refer to school-based interventions that provide, deliver, or facilitate access to PrEP, condoms, or HIV testing services.

Selected studies will be based on the eligibility criteria outlined in Table 1:

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Table 1. Study eligibility criteria.

https://doi.org/10.1371/journal.pone.0352973.t001

Information sources

Search strategy.

We will search multiple online databases to identify peer-reviewed articles and grey literature. The following databases will be searched:

• PubMed through the PubMed interface using MeSH terms and keywords
• Embase via Elsevier using Emtree Terms and keywords
• PsycINFO via EBSCOhost using APA Thesaurus and keywords
• CINAHL via EBSCOhost using CINAHL Subject Headings and keywords
• African Index Medicus via WHO AIM portal using keywords
• Grey literature: WHO, UNAIDS, UNICEF, PEPFAR

The search will be restricted to studies published between January 2015 and December 2025. The year 2015 was selected because it coincides with major developments in global HIV prevention policy and programming. In 2015, the United Nations adopted the Sustainable Development Goals (SDGs), which included a commitment to end the AIDS epidemic as a public health threat by 2023. That same year, the World Health Organization (WHO) recommended the broader use of oral PrEP for populations with substantial risk of HIV infection [15,16]. Restricting the review to studies published between 2015 and 2025 ensures that the evidence reflects contemporary HIV prevention policies, service delivery models, and implementation approaches. Due to resource constraints and the absence of multilingual screening and data extraction capacity, the review will be limited to studies published in English. Table 2 presents an example of the search strategy to be used in PubMed.

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Table 2. Search strategy in PubMed.

https://doi.org/10.1371/journal.pone.0352973.t002

Study records

Data management.

All records identified through database searches will be imported into Zotero for reference management. Full-text articles will be downloaded and stored locally, organized by first author surname and year of publication. Extracted data, reviewer decisions, and synthesis outputs will be archived across platforms to ensure transparency and reproducibility.

Study selection and data extraction.

Title/abstract screening and full-text review will be conducted using Rayyan, a web-based tool designed to facilitate blinded and collaborative screening. Two reviewers will independently screen each record against the predefined eligibility criteria. Disagreements will be resolved through discussion or adjudication by a third reviewer. Full-text screening will follow the same dual-review process within Rayyan, with exclusion reasons documented systematically.

Studies meeting the eligibility criteria will undergo data extraction, which will be conducted independently by two reviewers using a structured template aligned with the review’s objectives. Conflicts will be discussed and resolved between the two reviewers, and where resolution cannot be reached, a third reviewer will be involved to decide. RevMan will be used to facilitate data extraction, risk of bias assessment and data synthesis.

The reference lists of all included studies will be screened to identify additional eligible studies not captured through the database search.

When relevant data are missing or unclear, the corresponding author of the article will be contacted to request additional information. The study selection process will be reported using the PRISMA flow diagram (Fig 1).

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Fig 1. PRISMA flow diagram.

https://doi.org/10.1371/journal.pone.0352973.g001

Data items.

Implementation outcomes will be assessed according to the implementation science frameworks by Proctor and colleagues [17] and adapted to the school-based HIV prevention context. For this review:

1. Feasibility refers to the extent to which the intervention can be delivered within school settings as intended, including logistics, staffing, training, fidelity, and integration into school routines.
2. Accessibility refers to the degree to which AGYW can access and use the intervention, including acceptability, uptake, privacy, confidentiality, perceived appropriateness, and equity of access.
3. Effectiveness (implementation-linked) refers to biomedical or behavioural outcomes directly related to intervention delivery, such as HIV testing uptake, PrEP initiation or continuation, and condom uptake or use. These outcomes reflect real-world effects of implementation rather than clinical efficacy.
4. Secondary implementation outcomes include cost and cost-effectiveness, sustainability or maintenance, engagement of school personnel or parents, and contextual barriers and facilitators such as gender norms, stigma, or school policies.

The list of variables to be extracted and their definitions are presented in Table 3.

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Table 3. List and definitions of all variables for which data will be sought.

https://doi.org/10.1371/journal.pone.0352973.t003

Status and timeline of the study

Table 4 summarizes the planned timeline for screening, data extraction, analysis and expected completion of the study.

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Table 4. Study timeline.

https://doi.org/10.1371/journal.pone.0352973.t004

Discussion

This systematic review will synthesize evidence on school-based HIV prevention interventions targeting AGYW in sub-Saharan Africa. Implementation of these interventions is often shaped by contextual factors, including stigma, policy constraints, and resource availability.

By focusing on studies conducted within educational institutions, this review aims to clarify what works in integrating biomedical HIV prevention into school settings and to clarify implementation bottlenecks and equity gaps. The inclusion of both quantitative and qualitative components will allow for a nuanced understanding of not only outcomes but also implementation processes, barriers and facilitators.

Potential limitations include variability in study design, outcome definitions, and measurement tools, which may limit the feasibility of meta-analysis. Restricting the review to English-language publications may introduce language bias and may result in the exclusion of relevant studies from francophone and lusophone countries in sub-Saharan Africa. This limitation reflects resource constraints, and the findings should be interpreted in light of this.

Ultimately, this review will contribute to the evidence base for equity-driven HIV prevention programming in schools, helping to inform future research, policy, and practice at reducing HIV vulnerability among AGYW in sub-Saharan Africa.

Supporting information