Ending AIDS by 2030: the importance of an interlinked approach and meaningful youth leadership

"It's a 50/50 Thing You Know": Exploring the Multileveled Intersections of Gender and Power Within the Relationships of Young South African Men and Women

Efforts to advance sexual health globally require greater understandings of youth intimate relationship dynamics. Among 38 South African youth (21 women/17 men aged 21-30 from Durban and Soweto) we conducted qualitative cognitive interviews to explore how gender and power intersect to shape intimate relationship dynamics (October 2019-March 2021). Participants discussed perceptions and relevance of each of 13 items comprising the Sexual Relationship Power (SRP) scale, a widely used measure of gender equity, and the influence of SRP on youth sexual health. Data analysis was guided by constructivist grounded theory. The findings were organized using the socio-ecological model, revealing how gender and power intersected at multiple levels to influence youth intimate relationships. Key influencing factors included individual-level gender attitudes, male partner expectations, and women's resistance to dominance; intimate relationship-level power dynamics, consent, and intimacy; family-level household configurations and parental monitoring of daughters; and societal-level traditional gender norms. At all levels, women discussed resisting power inequities through communication and rejection of inequitable relationships. While men also displayed resistance to inequitable power structures, most upheld traditional gender norms through institutional affiliation (e.g. church) and deep-rooted socialized beliefs and attitudes. Efforts to improve youth sexual health require multileveled approaches that address inequitable power dynamics.

Improving Outcomes for Adolescents and Young Adults Living With HIV

Adolescents and young adults living with HIV (AYLHIV), ages 10-24, experience inferior outcomes across the HIV care continuum compared to adults. Inferior outcomes are caused by clinical systems that are not tailored to AYLHIV, structural barriers that prevent equitable care, and lack of engagement of AYLHIV by care teams. This position paper outlines three recommendations to bridge these gaps in care outcomes. The first advocates for offering differentiated and integrated health services. The second addresses structural changes that can improve outcomes for AYLHIV. The third calls for actively including input from AYLHIV about the care designed for them.

Correlates of condom use among male university students from eastern China who engage in casual sex

Consistent condom use with casual partners is critical for preventing the transmission of human immunodeficiency virus (HIV) among male university students. This study aimed to determine the level of consistent condom use and explore the correlates of condom use consistency in male university students in eastern China. A descriptive cross-sectional survey was conducted in 13 universities in Zhejiang Province, which involved the recruitment of 31,674 students by stratified random sampling. Among them, 545 male students who engaged in casual sex in the year prior to this study were included. Adjusted and unadjusted logistic regression models were used to examine the correlates associated with consistent condom use. Among the 545 male university students, only 205 (37.6%) consistently used condoms in the previous year. The following correlates were associated with higher rates of consistent condom use: 1) Knowledge, specifically, the number of correct answers to "HIV infection can be determined by appearance" (AOR: 2.06, 95% CI: 1.21-3.49); 2) never finding casual partners on the internet during the past over the prior year (AOR: 0.63; 95% CI: 0.40-0.99); 3) never drinking alcohol before casual sex during the last over the prior year (AOR: 0.30; 95% CI: 0.20-0.46); 4) never engaging in commercial sex (AOR: 0.57; 95% CI: 0.34-0.96); and 5) high condom self-efficacy score (AOR: 2.55; 95% CI: 1.44-4.49). The study found a low level of consistent condom use among male university students. Promoting condom self-efficacy, reducing web-based casual sex, drinking before sex, and commercial sex are essential to improving the level of consistent condom use among male university students to reduce the transmission of HIV.

Tracking adaptation strategies of an HIV prevention intervention among youth in Nigeria: a theoretically informed case study analysis of the 4 Youth by Youth Project

BACKGROUND

Although many behavioral interventions are adapted, little is known about the reasons for adaptations and the process and outcomes influencing adaptations. To address this gap, we explored the adaptations made to promote HIV prevention services, including HIV self-testing (HIVST), among Nigerian youth.

METHODS

The main objective of this qualitative case study design was to document the adaptations made over time using the Framework for Reporting Adaptations and Modifications - Expanded (FRAME). Between 2018 and 2020, we organized four participatory activities as part of the 4 Youth by Youth project to increase the uptake of HIVST services in Nigeria-an open call, a designathon, a capacity-building bootcamp and a pilot feasibility trial. We also began the process of implementing a final intervention using a pragmatic randomized control trial (RCT). The open call solicited creative strategies to promote HIVST among Nigerian youth and then had experts evaluate them. The designathon brought together youth teams to further develop their HIVST service strategies into implementation protocols. Teams determined to be exceptional were invited to a four-week capacity-building bootcamp. The five teams that emerged from the bootcamp were supported to pilot their HIVST service strategies over a 6-month period. The adapted intervention is currently being evaluated in a pragmatic RCT. We transcribed meeting reports and conducted document reviews of study protocols and training manuals.

RESULTS

Sixteen adaptations were identified and categorized into three domains: (1) modifications to the content of the intervention (i.e. photo verification system and/or Unstructured Supplementary Service Data (USSD) system to verify HIVST); (2) modifications to the delivery the intervention (i.e. implement participatory learning community sessions to provide supportive supervision and technical support); (3) modifications to the evaluation processes (i.e. economic evaluation to estimate the cost of implementing intervention on a larger scale). Frequent reasons for adaptation included increasing intervention reach, modifying interventions to enhance their appropriateness and fit with the recipient, and increasing the intervention's feasibility and acceptability. Most adaptations were planned and reactive, and the need for modifications was determined by the youths, 4YBY program staff, and advisory group.

CONCLUSIONS

Findings suggest that the nature of adaptations made throughout the implementation process reflects the necessity of evaluating services in context while adjusting to specific challenges as they are identified. Further research is needed to understand the effect of these adaptations on the overall intervention effect as well as the quality of youth engagement.

Community Health Workers Improve HIV Disclosure Among HIV-Affected Sexual Partners in Rural Uganda: A Quasi-Experimental Study

BACKGROUND

We evaluated the efficacy of a community health worker (CHW)-led intervention in supporting disclosure among adults living with HIV in heterosexual relationships.

METHODS

We conducted a quasi-experimental study with 2 arms allocated by geographically determined clusters and adjusted for between-group differences among adults living with HIV in the greater Luwero region of Uganda who had never disclosed their status to their current primary sexual partners. Clusters were allocated to either a CHW-led intervention or a control arm. In both arms, participants were consecutively recruited. As opposed to receiving routine care for the control arm, participants in the intervention arm received additional CHW disclosure support. The overall follow-up was 6 months, and the primary outcome was disclosure to the sexual partner. Data were analyzed using a clustered modified Poisson regression model with robust standard errors to determine independent factors associated with disclosure.

RESULTS

Of the 245 participants who enrolled, 230 (93.9%) completed the study, and 112 (48.7%) of those were in the intervention arm. The median age was 30 (interquartile range=25-37) years, the majority were women (76.5%), and most (80%) did not know their partners' HIV status at study entry. At the end of follow-up, the overall disclosure prevalence was 74.4% (95% confidence interval [CI]=68.2, 79.9) and participants in the intervention arm were 51% more likely to disclose compared to those in the control (adjusted relative ratio [aRR]=1.51; 95% CI=1.28, 1.77). Men were 24% (aRR=1.24; 95% CI=1.07, 1.44) more likely to disclose compared to women, and membership in an HIV/AIDS association increased disclosure by 18% (aRR=1.18; 95% CI=1.01, 1.39).

CONCLUSION

CHW support improved disclosure among adults living with HIV in heterosexual relationships when compared to routine care. Therefore, CHW-led mechanisms may be utilized in increasing disclosure among adults living with HIV in heterosexual relationships in rural settings.

"It's about making adolescents in charge of their health": policy-makers' perspectives on optimizing the health care transition among adolescents living with HIV in Kenya

ABSTRACTThe health care transition (HCT) from pediatric to adult care is a potential contributor to poor clinical outcomes among adolescents living with HIV (ALHIV). In sub-Saharan Africa (SSA), there is limited information on effective tools and processes to prepare and support ALHIV through this transition. This study elicited perspectives of policy-makers regarding barriers and facilitators to successful HCT among ALHIV in Kenya. Twenty in-depth interviews (IDIs) were conducted with policy-makers using a semi-structured guide. Using the socio-ecological model (SEM) as an organizing framework, directed content and thematic network analyses methods were used to characterize themes related to key influences on HCT processes and to describe actionable recommendations for improved tools and resources. Policy-makers identified multilevel support, including the development of a triadic relationship between the caregiver, healthcare worker (HCW) and adolescent, as an essential strategy for improved HCT success. Across the SEM, policy-makers described the importance of actively engaging adolescents in their care to promote increased ownership and autonomy over health decisions. At the structural level, the need for more comprehensive HCT guidelines and improved HCW training was highlighted. Expanded HCT tools and guidelines, that emphasize supportive relationships and intensified adolescent engagement, may improve HCT processes and outcomes.

A designathon to co-create community-driven HIV self-testing services for Nigerian youth: findings from a participatory event

BACKGROUND

Youth are at high risk for HIV, but are often left out of designing interventions, including those focused on adolescents. We organized a designathon for Nigerian youth to develop HIV self-testing (HIVST) strategies for potential implementation in their local communities. A designathon is a problem-focused event where participants work together over a short period to create and present solutions to a judging panel.

METHODS

We organized a 72-h designathon for youth (14-24 years old) in Nigeria to design strategies to increase youth HIVST uptake. Proposals included details about HIVST kit service delivery, method of distribution, promotional strategy, and youth audience. Teams pitched their proposals to a diverse seven-member judging panel who scored proposals based on desirability, feasibility, potential impact and teamwork. We examined participants' socio-demographic characteristics and summarized themes from their HIVST proposals.

RESULTS

Forty-two youth on 13 teams participated in the designathon. The median team size was 3 participants (IQR: 2-4). The median age was 22.5 years (IQR: 21-24), 66.7% were male, 47.4% completed tertiary education, and 50% lived in Lagos State. Themes from proposals included HIVST integration with other health services, digital marketing and distribution approaches, and engaging students. Judges identified seven teams with exceptional HIVST proposals and five teams were supported for further training.

CONCLUSIONS

The designathon provided a structured method for incorporating youth ideas into HIV service delivery. This approach could differentiate HIV services to be more youth-friendly in Nigeria and other settings.

Predictors of Poor Adherence to CART and Treatment Failure at Second-Line Regimens Among Adults in Public Hospitals of Amhara Region, North-Western Ethiopia: A Retrospective Cohort Study

BACKGROUND

Globally, HIV/AIDS has challenged the lives of 36.3 million people and resulted in 17 million orphans. The disease has neither a vaccine nor a cure and the only option currently is highly active antiretroviral therapy. This research was conducted to identify the predictors of poor adherence to CART and treatment failure at second-line regimen among adults living with HIV/AIDS in public hospitals of Amhara region, north-western Ethiopia.

METHODS

A retrospective cohort study design was conducted on 700 HIV-positive people who were receiving a second-line CART regimen. Participants on second-line regimens who followed their treatment between 2016 and 2019 were considered. Data were extracted from participants' clinical charts from June 18-July 7, 2020.

RESULTS

A multivariate regression analysis indicates that age of patients (OR = 1.025, 95% CI: 1.001-1.321; p = 0.005), follow-up visits (OR = 0.979, 95% CI: 0.873-0.998; p < 0.001), CD4 cell count change (OR = 0.9860; 95% CI: 0.835-0.998; p < 0.01), marital status (OR = 0.973, 95% CI: 0.789- 0.997; p = 0.006), female HIV-infected patients (OR = 0.990; 95% CI: 0.789-0.999; p <0.001), rural patients (OR = 1.151; 95% CI 1.065-1.398; p = 0.004), non-educated adult patients (OR = 1.026, 95% CI: 1.002-1.198; p = 0.003), existence of social violence (OR = 0.012, 95% CI: 0.008-0.134; p< 0.01), patients with opportunistic diseases (OR = 1.0345, 95% CI 1.002-1.142; p = 0.001), CD4 cell count (OR = 0.901, 95% CI: 0.843-0.995; p = 0.025) and malnutrition (OR = 0.883, 95% CI; 0.762-0.954; p = 0.001) significantly affected the two response variables.

CONCLUSION

Several variables affected both poor adherence to HAART and treatment failure at second-line regimens in the current investigation. Due attention should be given to aged patients, rural residents, non-educated patients, and patients with other morbidities to be successful with second-line treatment regimens.

Is HIV index testing and partner notification safe for adolescent girls and young women in low- and middle-income countries?

INTRODUCTION

While HIV index testing and partner notification (PN) services have the potential to reach adolescent girls and young women (AGYW) aged 15 to 24 and their sexual partners in need of HIV testing services, the potential social harms have not yet been studied. This commentary highlights the risks of this approach, including intimate partner violence (IPV), stigma and discrimination, and outlines an urgent research agenda to fully understand the potential harms of PN for AGYW, calling for the development of mitigation strategies.

DISCUSSION

A substantial evidence base exists demonstrating the feasibility, acceptability and effectiveness of index testing and partner notification for adults aged 18 years and older in low- and middle-income countries (LMICs), particularly for men, and for adults who are married/cohabiting and referring a current sexual partner. AGYW who are most vulnerable to HIV infection in LMICs do not reflect these demographics. Instead, they are often in age-disparate partnerships, have limited negotiating power within relationships, experience high rates of violence and face economic challenges that necessitate transactional sex. PN services may be particularly difficult for adolescent girls under 18 who face restrictions on their decision making and are at increased risk of rape. Adolescent girls may also face coercion to notify partners due to unequal power dynamics in the provider-adolescent client relationship, as well as judgemental attitudes towards adolescent sexual activity among providers.

CONCLUSIONS

As index testing and PN with AGYW is already being rolled out in some LMICs, research is urgently needed to assess its feasibility and acceptability. Implementation science studies should assess the availability, accessibility, acceptability and quality of HIV PN services for AGYW. Qualitative studies and routine monitoring with age-disaggregated data are critical to capture potential social harms, PN preferences and support needs for AGYW aged 15 to 17, 18 to 20 and 21 to 24. To mitigate potential harms, PN methods should prioritize confidentiality and avoidance of adverse outcomes. Healthcare providers should be trained to conduct routine enquiry for IPV and provide first-line support. Support services for AGYW living with HIV and survivors of violence should be implemented alongside HIV PN.

Ending AIDS by 2030: the importance of an interlinked approach and meaningful youth leadership

Introduction

This commentary by authors from the Adolescent HIV Treatment Coalition calls for action to improve advocacy and service delivery for young people by leveraging the interlinkages between HIV and the broader development agenda. The 2030 Agenda for Sustainable Development includes target 3.3 on ending the AIDS epidemic by 2030, and along with the 2016 Political Declaration on HIV and AIDS, this has led to a global renewal of political commitment to the HIV response. However, young people are still being left behind, and to provide an equitable and sustainable response to HIV we must ensure that we are meeting the needs of the 3.9 million young people living with HIV, and the millions more at risk.

Discussion

While HIV has its own target within the 2030 Agenda, efforts to end AIDS are inextricable from other goals and targets, such as on poverty eradication, education, gender equality and peace. To tackle HIV we must work beyond target 3.3 and provide a comprehensive response that addresses the underlying structural inequalities that impact adolescents and young people, ensuring that we enable the meaningful engagement of youth and adolescents as partners and leaders of sustainable development and the HIV response. Finally, it is necessary to collect better disaggregated data and evidence on the HIV epidemic among adolescents, as well as on best practices for supporting them.

Conclusions

Ending the AIDS epidemic among adolescents and young people (aged 10 to 24) by 2030 is possible. However, it requires an integrated, multi‐sectoral response to HIV which pays attention to the social determinants that put adolescents at risk and fuel the epidemic. Positioning efforts to end AIDS among young people within the broader 2030 Agenda and building youth leadership will contribute to building a more healthy, equitable and sustainable society for all.

Measuring sexual relationship power equity among young women and young men South Africa: Implications for gender-transformative programming

INTRODUCTION

Measures used to assess equitable relationship dynamics, including the sexual relationship power scale (SRPS) have previously been associated with lower HIV-risk among young women, and reduced perpetration of intimate partner violence among men. However, few studies describe how the SRPS has been adapted and validated for use within global youth sexual health studies. We examined gender-specific psychometric properties, reliability, and validity of a SRPS used within a South African youth-engaged cohort study.

METHODS

Young men and women (16-24 years) enrolled in community-based cohorts in Durban and Soweto (2014-2016) reporting a primary partner at 6-month follow-up completed a 13-item (strongly agree/agree/disagree/strongly disagree) South African adaptation of Pulerwitz's SRPS (range 13-52, higher scores indicating greater sexual relationship power [SRP] equity). SRPS modifications were made using gender-specific exploratory factor analyses (EFAs), removing items with factor loadings <0.3. Cronbach alphas were conducted for full and modified scales by gender. Using modified scales, unadjusted and adjusted regression models examined associations between 1. relevant socio-demographic and relationship determinants and SRP equity, and 2. SRP equity and sexual relationship related outcomes. All models adjusted for education, age, site, and current employment.

RESULTS

235 sexually-active youth (66% women, median age = 20) were included. Mean scores across all 13 scale items were 2.71 (SD 0.30) for women and 2.70 (SD 0.4) for men. Scale Cronbach's alphas were 0.63 for women and 0.64 for men. EFAs resulted in two gender-specific single-factor SRPS. Modified SRPS Cronbach alphas increased to 0.67 for women (8-items) and 0.70 for men (9-items). After adjusting for age, site and current employment, higher education remained associated with SRP equity across genders. In adjusted models, correlates of SRP equity included primary partnerships that were age-similar (<5 years older) and <2 years in length for women and living in Soweto and younger age for men. Greater SRP equity among women was also independently associated with no recent partner violence.

CONCLUSIONS

Results highlight important gender differences in SRP equity measures and associations, highlighting the critically need for future research to examine gendered constructions of SRP equity in order to accurately develop, validate and use appropriate measures within quantitative surveys.

STACKing the odds for adolescent survival: health service factors associated with full retention in care and adherence amongst adolescents living with HIV in South Africa

INTRODUCTION

There are two million HIV-positive adolescents in southern Africa, and this group has low retention in care and high mortality. There is almost no evidence to identify which healthcare factors can improve adolescent self-reported retention. This study examines factors associated with retention amongst antiretroviral therapy (ART)-initiated adolescents in South Africa.

METHODS

We collected clinical records and detailed standardized interviews (n = 1059) with all 10- to 19 year-olds ever initiated on ART in all 53 government clinics of a health subdistrict, and community traced to include lost-to-follow-up (90.1% of eligible adolescents interviewed). Associations between full self-reported retention in care (no past-year missed appointments and 85% past-week adherence) and health service factors were tested simultaneously in sequential multivariate regression and marginal effects modelling, controlling for covariates of age, gender, urban/rural location, formal/informal housing, maternal and paternal orphanhood, vertical/horizontal HIV infection, overall health, length of time on ART and type of healthcare facility.

RESULTS

About 56% of adolescents had self-reported retention in care, validated against lower detectable viral load (AOR: 0.63, CI: 0.45 to 0.87, p = 0.005). Independent of covariates, five factors (STACK) were associated with improved retention: clinics Stocked with medication (OR: 3.0, CI: 1.6 to 5.5); staff with Time for adolescents (OR: 2.7, CI: 1.8 to 4.1); adolescents Accompanied to the clinic (OR: 2.3, CI: 1.5 to 3.6); enough Cash to get to clinic safely (OR: 1.4, CI: 1.1 to 1.9); and staff who are Kind (OR: 2.6, CI: 1.8 to 3.6). With none of these factors, 3.3% of adolescents reported retention. With all five factors, 69.5% reported retention.

CONCLUSIONS

This study identifies key intervention points for adolescent retention in HIV care. A basic package of clinic and community services has the potential to STACK the odds for health and survival for HIV-positive adolescents.