From late March 2020, in response to COVID-19, Kenya began a lockdown including shuttering schools. On 16th October, rising seniors could return to school to prepare for exams. In western Kenya, where among girls aged 15-19 HIV prevalence is 8.8% and HSV-2 prevalence is 28%, school closures likely have profound and lasting effects on HIV and sexually transmitted infection (STI) risk. Within a cohort of 436 secondary school girls, we are evaluating the effect of menstrual cups on the vaginal microbiome (VMB), Bacterial vaginosis (BV), and STIs. On October 1, we initiated the 30-month visit, having followed up 371 (85%) girls by December 18. The prevalence of BV was 21.8%, and 15.6% for chlamydia, gonorrhea, or trichomonas, representing a 55% increase in BV since last measure at the 18-month visit (14%), and 34% increase in STI since last measure at the 12-month evaluation (11.6%). Adjusted for socioeconomic factors, girls reporting high COVID- related stress and interpersonal violence had increased odds of BV and STI. Adolescents are especially sensitive to stress induced effects on the hypopituitary axis; increased stress and subsequent rise in cortisol leads to reduced estrogen, which is necessary to support the Lactobacillus crispatus dominant environment that helps prevent BV, STIs, and HIV. This study proposes to measure the socioeconomic, behavioral, and psychosocial impact of the COVID-19 crisis, how this relates to girls’ sexual exposures, and subsequent risk of BV, STI, and HIV. In Aim 1, we will quantify the economic, psychosocial, and behavioral impacts of COVID-19 and associated lockdowns and restrictions. Individual and village level assessments include changes in food security, water access, household income, violence, crime, and safety. Individual measures include extensive sexual practices, anxiety, depressive symptoms, interpersonal violence. In Aim 2, we will measure the association of COVID-19 stressors on risk for HIV and STIs. We will be able to estimate the hazard of STI and HIV outcomes under multiple conditions: pre-COVID (April 2018-October 2019), during COVID/school closures (since March 2020), during COVID/school reopening (anticipated), post-COVID (anticipated). In Aim 3, we will measure cortisol and estradiol and correlate this to reported stress, and quantify the influence of these biological measures of stress on VMB composition and subsequent BV, STI, and HIV. To understand girls’ own perceptions of and reasoning for behavioral and contextual changes, and to apply this to intervention development, we will employ a series of semi-structured focus group discussions. Implications: This study will provide detailed understanding of the financial, social, and behavioral impacts of COVID-19 and mitigation efforts on adolescent girls in rural areas of Africa as exemplified by this area of western Kenya. We will be able to examine this in relation to biological outcomes – VMB, BV, STI, HIV. The knowledge gained will directly contribute to intervention development, and support future policy and guidelines on school closures and the support adolescent girls need in the wake of similar future catastrophe.

Project Narrative We propose to study the impacts of socioeconomic, behavioral, and psychosocial impacts of COVID-19 pandemic and mitigation on adolescent girls in rural Kenya. We will examine these factors in relation to biological measures of stress, and how this relates to vaginal microbiome composition, Bacterial vaginosis, sexually transmitted infections, and HIV. This proposal advances global health and adolescent health, as the knowledge gained will support future policy and guidelines on school closures and the types of support adolescent girls need in the wake of similar future catastrophe.