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.
