Decriminalisation is another crucial step towards a more humane and effective drug policy – accompanied by support for social reintegration. We need to start treating the person, not punishing the drug use disorder.”
– Volker Türk, UN High Commissioner for Human Rights

This policy brief, commissioned by NACOSA with funding from the Global Fund, and developed by
Students for Sensible Drug Policy International (SSDPI), examines the current legal and policy frameworks, the barriers they create and makes recommendations for policy reform. Expanding harm reduction services for minors would support prevention of avoidable health harms, improve access to care and strengthen protection of children’s rights.

This policy brief incorporates the assessment findings, input from the feedback workshop and policy recommendations based on this process, written by Dr Wiseman Magasela.

The HERStory 3 study commissioned by the Global Fund principal recipients (NACOSA, AFSA and Beyond Zero), was conducted by the South African Medical Research Council to evaluate the impact of the My Journey Programme, investigating HIV prevalence andincidence, knowledge of HIV status, school retention and HIV prevention and care coverage. According to the SAMRC:

“It is rare to evaluate combination HIV prevention interventions on such a large scale and this evaluation is one of the few that have been conducted. Such large-scale evaluations are critical as they provide vital information on how well the combination HIV prevention intervention strategies might work for countries with large HIV epidemics.”

My Journey was a combination HIV prevention intervention for adolescent girls and young women implemented in 12 subdistricts across eight provinces of South Africa. It aimed to reduce HIV incidence, teenage pregnancy, and gender-based violence and increase retention in school and access to economic opportunities. It was funded by the Global Fund to Fight AIDS, Tuberculosis and Malaria and implemented by South African organisations, including NACOSA.

Mixed-methods evaluation

The evaluation was a non-randomised cluster controlled trial conducted in 12 intervention and 12 matching comparison subdistricts. Two sites per subdistrict were sampled with 100 young women aged 15-24 years enrolled per site, providing a sample size of 4,800 young women. Dried blood spot specimens were taken to measure HIV status (as the primary outcome of the evaluation) and exposure to  antiretrovirals, pre-exposure prophylaxis (PrEP) and viral load level. Participants self-completed an electronic questionnaire and an optional HIV rapid test was offered to participants after survey completion. A qualitative component of the study looked at the acceptability of the intervention with young women as well as the self-reported impact the programme had on their lives.

The young women that took part in the study faced a number of challenges. Rates of maternal orphanhood were high (over 15%) and the rates of paternal orphanhood were even higher (over 24%) in both the intervention and comparison communities. Approximately one third of all participants reported that they had ever been pregnant. Among participants under 20, 17% in the intervention arm and 15% in the comparison arm had ever been pregnant.

The My Journey experience

My Journey reached a large proportion of participants in the targeted sites – between 21% and 73% of participants reported being approached by one of the implementers and invited to participate in the programme. Most participants reported that the first time they were approached was at home (29%), at school (26%) or at a clinic (4%). Most participants reported to have received good quality service, were treated in a friendly and respectful manner, waited no longer than one hour, and were provided a confidential and comprehensive service. Over 78% in all subdistricts reported “good” or “wonderful” experiences of the programme.  

“I felt like that there are people out there that care, I felt cared for, that there are people that take effort for me.” – qualitative study participant

HIV testing and prevalence

HERStory3 found a statistically significant impact on increasing knowledge of HIV status – with 85% of young women in the intervention arm and 81% in the comparison arm knowing their HIV status. There was reliable evidence that HIV testing of all kinds was statistically significantly higher in the intervention arm. HIV self-testing was significantly higher in the intervention arm compared with the comparison arm.

My Journey made a small impact on reducing HIV prevalence. HIV prevalence was 9.5% in the intervention arm and 10.4% in the comparison arm with a risk difference of 0.9%, after adjusting for age, socio-economic status, education enrolment, sexual debut and maternal orphanhood. The study was powered to detect a decrease in HIV prevalence from 12% to 6%: four subdistricts (Klipfontein, Dihlabeng, Fetakgomo Tubatse and Rusternburg) met or exceeded the expected 6% difference, five subdistricts (Abaqulusi, Govan Mbeki, Setsoto, Tswane 1 and City of Uhlathuze) showed a decrease from the expected baseline prevalence of 12% but not reaching 6%, and three subdistrict (Nelson Mandela, Nyandeni and Mbombela) showed no positive intervention effect.

Choosing PrEP

The My Journey Programme substantially increased the coverage of PrEP among young women who were not living with HIV, doubling the uptake of PrEP in the intervention arm compared with the comparison arm. The HIV prevention cascades for PrEP show substantial and statistically significant differences in favour of the intervention arm in knowing what PrEP is, ever having been offered PrEP, and ever having used PrEP.

Key recommendations on increasing the uptake and sustained use of PrEP included:

• Develop ongoing support systems that address emotional and contextual factors affecting PrEP decision-making.
• Enhance communication strategies to reduce stigma and misconceptions about PrEP.
• Invest in community engagement to shift social norms and support young women’s sustained PrEP use.

In the qualitative study, those young women who were using PrEP, reported a sense of feeling happy, protected and safe – in a context of high HIV prevalence and sexual violence – leading to a strong motivation to continue using it.

Work to do

A concerning finding from the study was that under 75% of HIV positive girls and young women in both arms were virally suppressed. Maintaining an undetectable viral load is important for the health of people living with HIV and is one of the most effective ways of preventing onward HIV transmission as an undetectable viral load means that the virus cannot be transmitted (undetectable equals untransmissible or U=U). These findings will inform My Journey Programme strategies to ensure better care and support for young women living with HIV.

The study results suggest a positive intervention impact on some of the perceived access barriers to condoms and young women in the intervention arm were more likely to have accessed information and counselling about condoms. However, the evaluation produced no evidence to show that the My Journey Programme impacted the coverage of condoms overall.

“If you are using a condom they do not want you, they want people who are not using a condom.” – qualitative study participant

Privacy, quality, respect

What seems to be most important to young women is quality of care, specifically the feeling of being respected and treated well by staff offering services. To ensure acceptability of services for young women, comprehensive services need to be provided in youth-friendly accessible spaces, by youth-friendly staff.

Key recommendations flowing from the research included:

• Expand programme outreach to out-of-school and high-risk adolescent girls and young women
• Strengthen HIV testing coverage by employing diverse testing modalities such as HIV self testing, mobile testing and community-based testing.
• Strengthen and enhance antiretroviral adherence support services and groups and embed education and information on U=U across the programme.
• Improve the quality of sexual reproductive health services and improve accessibility through decentralising services to where people are, in diverse settings.
• Enhance contraceptive counselling and include strong dual protection messaging – prevention of HIV and STIs, as well as prevention of pregnancy.
• Strengthen cost-effective HIV prevention efforts by making condoms more available and accessible and include boys and men as partners in condom programming.
• Enhance agency and informed decision making with messaging and communication and work to increase community and parental support for youth sexual and reproductive health services.

The HERStory3 study – as well as programme data – provided a rich source of learning that influenced the development of the next phase of the My Journey programme which runs from 2025 to 2028 and will reach over 380,000 girls and young women. It will be the largest youth programme in South Africa, funded by the Global Fund through NACOSA and implemented in communities by local organisations.

Young women will receive services in a range of community locations including safe spaces, hot spots, secondary schools and institutions of higher learning and community spaces. Health services will be provided according to a young woman’s needs, prioritising HIV testing, consistent condom use, prevention choices and continuity of care. Services for young women are grouped into three themes of My Journey which covers assessment and enrolment, My Choice for core health services, and My Voice for human rights issues and referrals.

“For so many young women, we need that hope. We need someone to hold our hand and tell us that it’s going to be okay.” – Tsakane Maluleke

Published in Frontiers in Public Health, the research paper analyses data from the HERStory3 study – a mixed methods impact evaluation of the My Journey Programme. Researchers analysed survey data from 2,608 adolescent girls and young women living in the intervention districts. A multilevel model was used to determine the association between spending time at a Safe Space in the past year and uptake of sexual and reproductive health services, educational enrolment and wellbeing. 

Even the health workers there (at the Safe Space). They are not so harsh, everything is nice… I prefer the Safe Space with the health workers and social workers rather than the clinic health workers. They very much want to help, it’s nice… without judging you, without being rude. (18-24 years, Gauteng)

The young women interviewed for the qualitative component of the study showed high levels of acceptability of Safe Spaces because of the welcoming and non-judgemental demeanour of the staff, the quality of services received and the openness of Safe Spaces that responded to their needs.

My aim… was to learn about things happening to us girls that our parents could not notice. If you do not have anyone that you can talk to at home, you also get a Safe Space there… every Thursday, there is a Safe Space for girls where you can share your story, maybe you were sexually assaulted, you can speak there. (18-24 years, Eastern Cape)

The quantitative survey data suggest that exposure to Safe Spaces was fairly high, as almost half of the survey participants had spent time at a Safe Space in the past year (46%). Furthermore, services were highly acceptable to participants, with 81% of participants reporting that they were satisfied or very satisfied with the services that they received.

The paper concludes that, given the high levels of acceptability, and positive health and health-related outcomes, Safe Spaces should be included as an important component of youth-friendly sexual and reproductive health programs.

This Know Your Rights guide was created by NACOSA based on research by Covington & Burlington as part of the Thomson Reuters Foundation’s TrustLaw programme.

The study involved 68 adolescent girls and young women from seven regions, chosen from the HERStory3 impact evaluation of the My Journey Programme, funded by the Global Fund. Participants shared personal stories of support and stigma, their experiences of health services and the social pressures that influence pregnancy choices.   

For many participants, family support was key in their pregnancy journeys. Some described their mothers as anchors in uncertain times. 

Yes. There is someone I was talking with at home… My mother used to help me with everything, I got everything I needed from her.” (Gert Sibande, 18–24 years)   

This kind of support can make a big difference for a young woman navigating pregnancy. But it was not the story for everyone.  

Most of the girls say they are afraid to talk to their parents… They might feel scared because they feel that they have disappointed their parents…” (Zululand, 18–24 years).   

Others highlighted the impacts of absent or unsupportive partners, including financial uncertainty at a time when care and preparation are essential. Some young women described depression, isolation and traumatic birth experiences.   

One participant shared their experience with a difficult birth, stating, “It was depressing at the time…you don’t know what will happen during or after your pregnancy.” (Cape Town, 18–24 years)   

It’s been a hard year for me, so my health deteriorated, but I’ve managed to cope with it … a social worker was helping me actually at my school.” (Cape Town, 18–24 years). Another participant reflected on support she received from a school social worker. 

However, support for young women significantly reduced the emotional burden of stressful pregnancy experiences, and social workers emerged as important sources of emotional validation and guidance.  

Some young women delayed seeking care because they feared community stigma or did not recognise early pregnancy signs. Others struggled to navigate the health system or felt unwelcome:  

Some get the help and others don’t… they hide their pregnancy with jerseys because people tend to judge them.” (Ehlanzeni, 18–24 years)  

It was not easy because I was too young to have a baby… It depended on the people that were giving me help, some were shouting at me, (asking) why I got pregnant at this age and I felt bad. (Ehlanzeni, MP—15–17 years)  

Delays in starting antenatal care can have major health implications for both mother and baby, from life threatening problems to missed HIV testing and treatment, leading to the transmission of HIV in pregnancy or during breastfeeding.    

Rights-centred care   

South Africa’s legal and policy framework addressing the rights of pregnant and breastfeeding women is underpinned by the country’s Constitution, which guarantees fundamental human rights, including access to healthcare, education, and protection from discrimination. However, young women who become pregnant often face stigma in their families or communities which can prevent them from fully exercising these rights. 

As NACOSA’s policy brief on the rights of pregnant and breastfeeding women emphasises, legal protection alone is not enough. Turning rights into reality requires awareness, implementation, community engagement and supportive health systems that respond to the lived experiences of young women.   

These observations highlight the importance of comprehensive, rights-centred support for young mothers, including accessible and dignified healthcare, strong social and family support, and mental health care throughout pregnancy and the postpartum period.  

Over a third of organisations surveyed report having less than two months of funding to continue operations. Almost a quarter have already lost more than half of their funding, while nearly a half are feeling indirect impacts through reduced or delayed partner disbursements. A quarter of organisations have been forced to restructure or lay off staff – with some cutting up to 75% of their workforce.

“The message from our network organisations is loud and clear: unless community based organisations, who are the last line of defence in poorer communities, are urgently resourced, the health outcomes for poorer South Africans are going to be catastrophic,” said Mohamed Motala, NACOSA’s executive director.

These organisations are the connective tissue in the HIV and gender-based violence responses – impacting the lives of millions of people. If they collapse, essential services and jobs, which are in themselves injecting incomes into poorer households, will be lost and vulnerable communities’ suffering will deepen.”

With foreign aid declining and government budgets shrinking, organisations are struggling to sustain programmes and retain skilled staff. While many recognise the need for sustainability planning, only 41% currently have an up-to-date plan. Fundraising remains the most significant challenge, with 88% of organisations finding it difficult.

Despite the challenges, organisations continue to value networking, with increasing engagement in national and sector-specific forums reported. As one survey respondent says:

Prioritize networking spaces that connect NPOs with donors offering structural funding (most of which was lost when USAID was terminated), as sustainability remains a key challenge. Long-term support for core operations is essential to maintain quality services and retain skilled staff.”

NACOSA is calling for urgent action to strengthen the sector’s financial resilience. This includes mobilising local, home-grown funding solutions and advocating for sustainable, flexible financing for independent civil society in South Africa. “This survey shows that organisations are facing unprecedented headwinds,” says Motala. “As a society, we must pull all the levers at our disposal to ensure that community organisations can continue to provide locally-appropriate services in communities.”