The study was conducted in Kinshasa, the capital and administrative province of the Democratic Republic of the Congo (DRC). This large urban agglomeration is characterized by a high population density as well as significant social, economic, and health disparities that may influence access to HIV prevention services and the acquisition of preventive skills.

Participants were recruited from several health districts of Kinshasa, notably Funa, Lukunga, Mont Amba, and Tshangu. The selection of these areas aimed to ensure diverse geographical coverage and to take into account the different recruitment contexts of key populations.

This was a longitudinal analytical study with an explanatory and predictive purpose, conducted over a period of 36 months, from January 2022 to December 2024.

The longitudinal nature of the study aimed to assess changes in preventive skills over time and to analyze the relationships between didactic-pedagogical, psychological, behavioral, sociodemographic, and environmental factors and the level of acquisition of preventive skills.

The study followed an interdisciplinary approach combining educational sciences, epidemiology, and statistical modeling. This approach aimed to develop a contextualized explanatory and predictive model of the acquisition of preventive skills related to combined HIV prevention among key populations in Kinshasa.

The study population consisted of people belonging to the main key populations at increased risk of HIV infection in Kinshasa.

The groups concerned were:

female workers in high-risk occupations;men who have sex with men (MSM);trans. people (TG);people who inject drugs (PWID).

These groups were selected because of their importance in HIV prevention programs and the existence of individual, behavioral, social, and structural vulnerability factors likely to influence access to prevention services as well as the acquisition and implementation of preventive skills.

2.4.1. Inclusion Criteria

Participants were eligible if they:

were at least 15 years old;belonged to one of the predefined key population groups;had resided in Kinshasa for at least six months;voluntarily agreed to participate in the study;had provided informed consent in accordance with the established ethical procedures.

2.4.2. Exclusion Criteria

Participants were excluded if they:

were unable to answer the questionnaire because of severe communication or comprehension difficulties;refused to participate in the study or withdrew their consent;had insufficient data to allow assessment of the main study variables.

The minimum theoretical sample size was estimated using the Cochran formula applicable to the estimation of a proportion:

n₀ = Z² × p (1 − p)/d²

where Z = 1.96 for a 95% confidence level, p = 0.50 corresponding to the assumption of maximum variability, and d = 0.05 corresponding to a precision of 5%.

This formula resulted in a theoretical minimum sample size of 384 participants. To account for the sampling design and potential correlation between observations, a design effect of 2 was applied, increasing the theoretical minimum sample size to 768 participants.

The final sample consisted of 844 participants. This sample size was considered sufficient for the planned multivariate analyses and statistical modeling, while allowing for potential missing data and constraints related to longitudinal follow-up.

Participant recruitment was carried out using a strategy adapted to the characteristics of key populations, which are populations that are difficult to reach through conventional sampling methods.

A geographical organization of recruitment was implemented in the selected health districts, notably Funa, Lukunga, Mont Amba, and Tshangu. For populations without a comprehensive sampling frame, the Respondent-Driven Sampling (RDS) method was used.

The RDS procedure was based on the identification of initial participants, referred to as “seeds,” selected from the different key population groups. These initial participants received a controlled number of invitations intended to recruit eligible individuals from their social network. The process continued through successive recruitment waves.

This strategy aimed to improve access to populations that are difficult to identify through conventional survey systems and to reduce reliance on exclusively institutional or convenience-based recruitment. Information relating to recruitment chains was documented during data collection to allow description of the recruitment structure and assessment of its potential effects on sample composition.

Data were collected using a structured questionnaire comprising 64 items, developed based on the study objectives, the theoretical constructs involved, and the relevant dimensions of combined HIV prevention.

The questionnaire covered the following main dimensions:

1) sociodemographic characteristics;

2) knowledge related to combined HIV prevention;

3) didactic-pedagogical strategies;

4) motivation and self-efficacy;

5) environmental factors and access to services;

6) acquisition of preventive skills.

Knowledge related to combined prevention included, in particular, condom use, HIV testing, antiretroviral treatment, pre-exposure prophylaxis (PrEP), post-exposure prophylaxis (PEP), and treatment as a means of prevention.

The didactic-pedagogical strategies assessed included participatory discussions, practical demonstrations, role-playing activities, the use of audiovisual materials, individualized feedback, and learner involvement.

The motivational and psychological dimension included motivation to adopt preventive behaviors, self-efficacy, confidence in applying prevention measures, the ability to negotiate safer sexual practices, and perceived control over preventive decisions.

Environmental factors included, in particular, accessibility and availability of HIV prevention services, social support, stigma, and certain structural barriers.

Attitudinal items were mainly assessed using a five-point Likert scale ranging from “Strongly disagree” to “Strongly agree”.

The questionnaire was administered by previously trained interviewers according to a standardized procedure. Particular attention was paid to confidentiality, neutrality in administering the questions, and respect for participants’ rights.

Before being used in the main analysis, the data collection instrument underwent a validation procedure aimed at assessing its relevance to the constructs studied and the internal consistency of its different dimensions.

The relevance of the items was examined in relation to the study objectives and the theoretical concepts involved. The internal consistency of the questionnaire dimensions was assessed using appropriate reliability indicators.

This procedure aimed to verify that the items grouped within the same dimension measured the corresponding construct with sufficient consistency. Any adaptations made to the questionnaire were completed before the main data collection.

2.9.1. Dependent Variable: Acquisition of Preventive Skills

The acquisition of preventive skills related to combined HIV prevention constituted the main dependent variable.

It was measured using 10 items corresponding to questions 45 to 54 of the questionnaire. These items addressed, in particular, condom use, HIV testing, knowledge and access to PrEP and PEP, recognition of risk situations, participation in prevention activities, application of acquired knowledge, and decision-making favorable to HIV prevention.

Each item was assessed using a five-point Likert scale:

1 = “Strongly disagree”;

2 = “Disagree”;

3 = “Neither agree nor disagree”;

4 = “Agree”;

5 = “Strongly agree”.

A composite preventive skills acquisition score was calculated as the mean of the responses to the ten items. The score therefore ranged from 1 to 5, with higher values corresponding to a higher level of acquisition of preventive skills.

For analyses requiring a categorical variable, the score could be grouped into three levels: low (1.00 - 2.33), moderate (2.34 - 3.66), and high (3.67 - 5.00). When longitudinal or predictive analyses required a quantitative variable, the continuous score was retained in order to preserve, as much as possible, the information contained in the original responses.

2.9.2. Independent Variables

The independent variables included sociodemographic, educational, psychological, and environmental factors.

Sociodemographic variables included, in particular, age, sex, educational level, marital status, occupation, income, and residential district.

Didactic-pedagogical factors included, in particular, exposure to participatory strategies, practical demonstrations, educational materials, feedback, and activities promoting learner involvement.

Psychological factors mainly included motivation and self-efficacy.

Environmental factors included access to prevention services, service availability, social support, stigma, and structural barriers.

Within the longitudinal framework of the study, data relating to preventive skills and explanatory factors were collected according to the follow-up schedule defined in the protocol.

The initial measurement constituted the reference time point (M₀). Repeated measurements conducted during the follow-up period made it possible to establish a longitudinal data structure suitable for analyzing individual changes in the level of skills.

Available observations at several time points for the same participant were taken into account in the statistical analyses in order to account for dependence between repeated measurements.

Important methodological note: clinical visits, serological testing, and viral load measurements should only be mentioned in this section if they were actually performed as part of the present study protocol and if their data were incorporated into the analyzed database. Otherwise, these elements should be removed to avoid inconsistency between the protocol, the variables analyzed, and the results presented.

The interviewers were trained on the study objectives, standardized administration of the questionnaire, respect for confidentiality, and data collection procedures.

Participants were informed about the study objectives, participation procedures, and their right to refuse or discontinue their participation without consequence.

Completed questionnaires underwent quality control, after which the data were entered, cleaned, and verified before statistical analysis. Data allowing direct identification of participants were not used in the statistical analyses.

Data were entered, cleaned, and verified using Microsoft Excel, and then analyzed using SPSS version 27 and R software for advanced statistical analyses.

2.12.1. Descriptive Analysis

Descriptive analysis was used to characterize the study population. Categorical variables were presented as frequencies and percentages. Quantitative variables were described using the mean and standard deviation when their distribution allowed it, or using appropriate descriptive statistics otherwise.

2.12.2. Analysis between Explanatory Variables and Preventive Skills

Associations between explanatory variables and levels of acquisition of preventive skills were examined using statistical tests appropriate to the nature of the variables.

Pearson’s Chi-square test was used to analyze associations between categorical variables when its assumptions were met. Fisher’s exact test was used when the expected frequencies were insufficient.

The statistical significance threshold was set at p< 0.05.

2.12.3. Longitudinal Modeling Using GEE

Given the longitudinal structure of the data and the presence of repeated measurements among some participants, generalized estimating equations (GEE) were used to account for within-subject correlation of observations.

GEE models were used to estimate the association between explanatory factors and changes in the level of acquisition of preventive skills while accounting for the dependence between repeated measurements.

The results were presented as adjusted coefficients or measures of association, together with their 95% confidence intervals and p-values, according to the model specification.

2.12.4. Generalized Additive Models

Generalized additive models (GAM) were used to examine the possibility of nonlinear relationships between certain explanatory variables and the level of acquisition of preventive skills.

This approach made it possible not to impose a priori a strictly linear relationship between continuous explanatory variables and the dependent variable.

2.12.5. Linear Mixed Models

Linear mixed models (LMM) were also explored to account for the longitudinal structure of observations and, where appropriate, inter-individual variability.

Fixed effects represented the explanatory factors of interest, while random effects made it possible to account for the dependence between observations originating from the same participant.

2.12.6. Model Validation and Comparison

Model performance was assessed using indicators appropriate to their objective and the nature of the dependent variable.

When discrimination analysis was applicable, predictive performance was assessed in particular using the area under the ROC curve (AUC).

The AUC values obtained were 0.81 for the GEE model, 0.87 for the GAM, and 0.79 for the LMM. These results indicated high discriminative ability for the GAM, which showed the best performance among the models compared.

Model comparison was interpreted jointly with the available fit indicators and considerations regarding their suitability for the data structure.

The statistical significance threshold was set at 5%, with 95% confidence intervals when appropriate.

The study was conducted in accordance with the ethical principles applicable to research involving human subjects and the principles of the Declaration of Helsinki.

The required ethical approval was sought from the competent ethics committee of the National AIDS and STI Control Program (PNLS) as well as from the relevant institutional authorities before the beginning of data collection.

Before inclusion, participants were informed about the study objectives, data collection procedures, the voluntary nature of their participation, potential benefits and risks, and the measures taken to ensure the confidentiality of the information collected.

Informed consent was obtained before participation in the study, in accordance with applicable ethical procedures.

The data were anonymized or coded and handled confidentially. No information allowing the direct identification of participants was included in the analytical database or presented in the results. The data were used exclusively for scientific purposes.

A total of 844 participants were included in the study.

Participants aged 15 to 24 years constituted the largest age group, with 564 participants (66.8%). Men accounted for 508 participants (60.2%), while women accounted for 336 (39.8%).

Regarding educational level, 102 participants (12.1%) had no formal education, 50 (5.9%) had primary education, 346 (41.0%) had secondary education, and 346 (41.0%) had university or higher education.

The largest proportion of participants came from Tshangu (40.4%), followed by Mont Amba (31.3%), Funa (14.7%), and Lukunga (13.6%). See Table 1.

Table 1. Sociodemographic characteristics of participants (N = 844).

The majority of participants (87.4%) had already heard about combined HIV prevention.

Knowledge of correct condom use was reported by 81.9% of participants, while 78.7% knew the importance of regular HIV testing.

Knowledge of new biomedical prevention approaches was lower. PrEP was known by 52.5% of participants, and 58.1% knew about the preventive effect of antiretroviral treatment. See Table 2.

Table 2. Knowledge indicators of combined HIV prevention.

Practical demonstrations were the most appreciated strategy (87.0%), followed by participatory discussions (83.2%), audiovisual materials (81.6%), individualized feedback (78.0%), and role-playing activities (72.9%). See Table 3.

Table 3. Perceived didactic-pedagogical strategies.

A large proportion of participants reported confidence in their ability to adopt preventive behaviors.

Self-efficacy regarding correct condom use was reported by 85.4% of participants, while 71.4% reported being able to negotiate safer sexual practices See Table 4.

Table 4. Motivation and self-efficacy indicators.

Based on the composite preventive skills score, 618 participants (73.2%) demonstrated satisfactory acquisition of preventive skills, while 226 (26.8%) demonstrated insufficient acquisition. See Table 5.

Table 5. Level of acquisition of preventive skills.

Several factors were significantly associated with the acquisition of preventive skills, including educational level, marital status, residential district, knowledge of PrEP, participatory discussions, practical demonstrations, educational feedback, and self-efficacy. See Table 6.

Table 6. Bivariate associations with the acquisition of preventive skills.

The GEE model identified several independent predictors of the acquisition of preventive skills. See Table 7.

Table 7. Sociodemographic predictors of the acquisition of preventive skills.

Participatory discussions, practical demonstrations, audiovisual materials, individualized feedback, self-efficacy, and intrinsic motivation were significantly associated with the acquisition of preventive skills. See Table 8.

Table 8. Didactic-pedagogical predictors of the acquisition of preventive skills.

The reported predictive performance was highest for the GAM, followed by the GEE and the LMM. See Table 9.

Table 9. Predictive performance of statistical models.

The GAM had the highest AUC (0.87), suggesting better predictive performance within the modeling framework used.

The main findings can be summarized as follows:

73.2% of participants demonstrated satisfactory preventive skills;knowledge regarding biomedical prevention methods, particularly PrEP, remained limited;active educational strategies were significantly associated with the acquisition of preventive skills;self-efficacy was the most important predictor among the educational and psychological variables studied;intrinsic motivation was also strongly associated with the acquisition of preventive skills;the GAM demonstrated the best reported predictive performance.

These results support the hypothesis that the quality of didactic-pedagogical interventions contributes significantly to the acquisition of preventive skills related to combined HIV prevention.

This study aimed to develop a didactic-pedagogical model explaining the determinants associated with the acquisition of preventive skills related to combined HIV prevention among key populations in Kinshasa.

Overall, 73.2% of participants demonstrated satisfactory acquisition of preventive skills, compared with 26.8% who demonstrated insufficient acquisition. This finding suggests that a substantial proportion of key populations possess the capacities needed to mobilize prevention knowledge and resources, but that a considerable proportion remains vulnerable in terms of education and behavior. This situation is particularly important in the context of key populations, among whom social, structural, economic, and service-access barriers may limit the translation of knowledge into effective preventive practices [1][2].

The fact that more than one quarter of participants demonstrated insufficient acquisition shows that exposure to information alone does not guarantee operational mastery of preventive skills. Combined prevention relies on the integration of several components, including biomedical, behavioral, and structural measures, as well as individuals’ ability to access services and effectively use available tools [1]. Thus, knowledge of condoms, HIV testing, PrEP, or PEP must be accompanied by skills that enable their appropriate use in concrete situations.

This finding reinforces the importance of competency-based educational approaches that go beyond the simple transmission of knowledge and prioritize active learning, practice, interaction, feedback, empowerment, and the learner’s ability to address real-life situations. Peer education interventions have notably shown favorable effects on knowledge and certain preventive behaviors among populations at risk of HIV [3][4].

From this perspective, the acquisition of preventive skills should be considered a dynamic process in which the learner progressively transforms information into know-how and then into autonomous capacity for action. This conception is consistent with current WHO recommendations, which call for interventions adapted to key populations that are accessible, acceptable, and incorporate the community and structural dimensions of prevention [1].

General knowledge regarding HIV prevention was relatively high, particularly concerning condoms and HIV testing. However, knowledge of PrEP was considerably lower.

This situation is important because PrEP is now a recognized component of combined HIV prevention for people at substantial risk of acquiring HIV [5]. WHO recommendations emphasize the need to diversify and simplify access to PrEP in order to improve its initiation, persistence, and effective use [5]. Limited knowledge of this method may therefore represent an early stage in an incomplete prevention cascade.

Our findings are consistent with the international literature showing that, despite the demonstrated effectiveness of PrEP, awareness and particularly use remain uneven among vulnerable populations. A systematic review and meta-analysis notably showed that PrEP use remained relatively low in several subgroups of key populations and that culturally appropriate approaches were needed to reduce these disparities [6]. Other studies have highlighted that lack of knowledge, stigma, risk perception, mistrust, and difficulties accessing services constitute important barriers to PrEP use [7].

Understanding of the preventive effect of antiretroviral treatment was also insufficient among a substantial proportion of participants. Strengthening communication about treatment as a means of prevention and the principle of “Undetectable = Untransmittable” therefore appears particularly relevant. Education on this dimension may simultaneously contribute to improving knowledge, promoting the use of services, and reducing certain misconceptions about HIV.

These findings indicate that prevention education programs should progressively move from an approach centered on traditional prevention methods toward an integrated approach presenting the entire prevention continuum: condoms, testing, PrEP, PEP, antiretroviral treatment, prevention of injection-related risks, vaccination when relevant, and prompt use of health services. This orientation is consistent with international recommendations promoting combined prevention centered on the needs of key populations [1][5].

One of the main findings of this study was the strong association between active educational strategies and the acquisition of preventive skills.

Practical demonstrations showed a strong association with the outcome (adjusted β = 0.1489; p < 0.001). This finding suggests that learning preventive skills does not rely solely on exposure to educational messages, but also on the opportunity for learners to observe, experiment, reproduce, and correct a practice.

This observation is particularly relevant for skills related to condom use, access to PrEP or PEP, HIV testing, and the prompt seeking of care following exposure to risk. Interactive teaching methods may facilitate the transformation of declarative knowledge into operational skills.

Available evidence on peer education reinforces this interpretation. A meta-analysis involving 60 studies and 96,484 participants showed that peer education was associated with a reduction in HIV risk among high-risk groups [3]. Another meta-analysis conducted in developing countries observed an association between peer education, better HIV knowledge, and increased condom use [4]. These findings support the value of educational approaches that place the learner and their community at the center of the process.

Chevallard’s concept of didactic transposition provides a relevant framework for interpreting this finding. Biomedical and scientific knowledge must be transformed into knowledge that is teachable, understandable, and applicable within the learner’s social and cultural context. In HIV prevention, this transformation involves moving from abstract scientific content to concrete situations: how to correctly use a prevention method, where to obtain PrEP, when to seek PEP, how to get tested, and how to make a preventive decision in a real-life situation.

Houssaye’s pedagogical triangle also makes it possible to interpret these findings through the relationships between the learner, educator, and knowledge. Preventive education appears more likely to produce skills when the learner is actively involved in the educational process rather than being considered solely as a recipient of information.

Freire’s critical pedagogy complements this interpretation by emphasizing dialogue, participation, conscientization, and empowerment. In the context of key populations, this approach is particularly relevant because interventions must take into account lived experiences, power relations, stigma, and barriers to accessing services.

The significant association observed for participatory discussions and individualized feedback is consistent with the same perspective. It suggests that educational effectiveness may depend not only on the content delivered, but also on how this content is constructed, discussed, practiced, and adapted to the needs of each participant.

However, this interpretation should be qualified. A recent systematic review of behavioral counseling interventions among key populations did not find a statistically significant effect on HIV or STI incidence, despite participants’ expressed interest in certain interventions [8]. This observation shows that improving knowledge and skills is an important intermediate objective, but it should not automatically be equated with a demonstrated reduction in HIV incidence. Educational effects should therefore be assessed at several levels: knowledge, skills, self-efficacy, behaviors, use of services, and, where possible, biological indicators.

Self-efficacy was the most important predictor among the educational and psychological variables studied (adjusted β = 0.1715; p < 0.001).

This finding is consistent with Bandura’s social cognitive theory, according to which the beliefs a person holds regarding their ability to perform a behavior influence their engagement, persistence, and maintenance of action. In the field of HIV prevention, self-efficacy may particularly concern the ability to negotiate condom use, request HIV testing, seek PrEP or PEP, and maintain preventive practices despite social barriers.

This interpretation is supported by previous research on condom use, which has shown that self-efficacy may constitute an important determinant of preventive behaviors, whereas HIV knowledge alone may not necessarily predict condom use [9].

Thus, a person may have sufficient knowledge about HIV while experiencing difficulties translating this knowledge into action when they lack confidence in their ability to negotiate safer sexual practices or access prevention services. Developing self-efficacy should therefore be considered a central component of prevention education programs.

Intrinsic motivation was also significantly associated with the acquisition of preventive skills (adjusted β = 0.1398; p < 0.001). This finding suggests that effective HIV prevention education should address not only knowledge and technical skills, but also personal motivation to adopt and maintain preventive behaviors.

Motivational approaches may be useful from this perspective. Literature reviews show that motivational interviewing may promote certain behavioral changes in the context of HIV, although effects are not consistent across populations and behaviors studied [10][11]. More recently, a review focusing on the use of motivational interviewing to increase PrEP initiation and adherence highlighted its potential, while also emphasizing that the evidence remains limited [12].

Thus, the findings of our study support an educational conception in which the learner is not merely informed about what they should do, but is supported in understanding why they should do it, assessing their own capacities, overcoming barriers, and progressively developing autonomy.

Marital status, residential district, and occupation were independently associated with the acquisition of preventive skills in the GEE model.

The association with residential district could reflect geographical differences in the availability, accessibility, quality, and intensity of HIV prevention interventions. In Kinshasa, access to services may vary according to residential areas, community networks, distance to health facilities, and the availability of services adapted to key populations.

This interpretation is consistent with WHO recommendations, which emphasize that key populations continue to face social, legal, structural, and contextual barriers limiting their access to health services [1]. A recent review focusing on structural and sociocultural barriers also showed that the availability of prevention tools does not guarantee their use when stigma, social barriers, and difficulties accessing care persist [2].

Occupation may also influence access to information, social networks, opportunities for interaction with health services, and the economic resources needed to access prevention methods. These differences could explain why occupation remained associated with skills acquisition after adjustment for other individual characteristics.

In contrast, age, sex, educational level, and monthly income were not statistically significant after adjustment in the model presented. This finding suggests that general demographic characteristics are not necessarily sufficient to explain differences in skills acquisition when educational, motivational, psychosocial, and contextual factors are considered simultaneously.

This observation is an important finding for the MIDCAP-HIV model. It suggests that a prevention strategy based solely on sociodemographic segmentation may be insufficient and that it would be preferable to consider educational and psychosocial mechanisms that may directly modify preventive skills.

The GAM showed the best reported predictive performance (AUC = 0.87), compared with the GEE (AUC = 0.81) and the LMM (AUC = 0.79).

The discriminative performance of the models was assessed using the area under the ROC curve (AUC). The observed AUC values were 0.81 for the GEE, 0.87 for the GAM, and 0.79 for the LMM. These values indicate overall good discriminative ability, particularly for the GAM.

The relatively superior performance of the GAM may be explained by its ability to account for nonlinear relationships between explanatory variables and the outcome. The acquisition of preventive skills is indeed a complex process in which the effect of a variable may not be strictly linear. For example, the effect of exposure to educational interventions may vary according to the initial level of knowledge, motivation, or self-efficacy.

However, the AUCs reported in this study correspond to an assessment of performance in the study sample and should not be interpreted as external validation of the model. They reflect the discriminative ability observed in the data used for the analysis. Rigorous internal validation, using bootstrap or cross-validation, as well as external validation in an independent cohort, will be necessary to assess the reproducibility and transportability of the model.

This caution is particularly important for a model intended for possible application in other districts or provinces of the Democratic Republic of the Congo. A predictive model may demonstrate excellent discrimination in the population used for its development while showing different performance in an external population.

Based on the conceptual and empirical findings, this study proposes the MIDCAP-HIV model, defined as the Integrated Didactic-Pedagogical Model for the Acquisition of HIV-Related Preventive Skills.

The model integrates five complementary dimensions:

1) knowledge related to combined HIV prevention;

2) active didactic-pedagogical strategies;

3) intrinsic motivation;

4) self-efficacy;

5) a supportive social and health environment.

The model therefore proposes considering the acquisition of preventive skills as a multidimensional process rather than simply as a consequence of receiving information about HIV prevention.

This conception is consistent with current recommendations for an HIV response centered on key populations, combining biomedical, behavioral, and structural interventions [1]. It is also consistent with evidence demonstrating the importance of community-based interventions, peer education, and strategies aimed at reducing barriers to accessing services [2]-[4].

The MIDCAP-HIV model thus provides an additional contribution by explicitly placing didactic-pedagogical mechanisms at the center of the acquisition of preventive skills. It does not claim to replace existing behavioral models, but rather proposes their integration with principles from educational sciences and with contextual determinants of access to services.

Integrate competency-based health education into HIV prevention programs;strengthen communication on PrEP, PEP, treatment as a means of prevention, and the principle of “Undetectable = Untransmittable”;develop standardized tools for assessing preventive skills;improve equitable access to HIV prevention services across different health districts;strengthen strategies aimed at reducing the structural and sociocultural barriers faced by key populations [1][2].

promote participatory educational methods;increase the use of practical demonstrations and role-playing activities;provide individualized counseling and continuous feedback;strengthen peer education;develop community navigation and support strategies;combat stigma and structural barriers to accessing prevention services.

These recommendations are consistent with available evidence on peer education and community-based interventions among key populations [3][4][13].

integrate health education pedagogy into relevant training curricula;train educators involved in HIV prevention in active and competency-based learning methods;develop educational situations that allow practical training;promote the integration of the MIDCAP-HIV model into the planning of HIV prevention interventions.

validate the MIDCAP-HIV model in other provinces of the Democratic Republic of the Congo;conduct intervention studies comparing different educational strategies;perform internal validation using bootstrap or cross-validation of predictive models;conduct external validation in independent cohorts;evaluate digital and community-based educational tools designed to develop preventive skills;investigate longitudinal pathways linking educational interventions, self-efficacy, motivation, and preventive behaviors;where possible, incorporate objective and biological indicators to complement self-reported measures.