Young people's experiences of sexual and reproductive health interventions in rural KwaZulu-Natal, South Africa

Incident pregnancy and mental health among adolescent girls and young women in rural KwaZulu-Natal, South Africa: an observational cohort study

Pregnancy can place adolescent girls and young women (AGYW) at risk of poor mental health. However, evidence linking youth pregnancy to mental health in resource-limited settings is limited, especially where HIV incidence is high. We analysed a population-representative cohort of AGYW aged 13-25 in rural KwaZulu-Natal to assess how adolescent pregnancy predicts subsequent mental health. Among 1851 respondents, incident pregnancy (self-reported past-12-month) rose from 0.7% at age 14 to 22.1% by 18. Probable common mental disorder (CMD; 14-item Shona Symptom Questionnaire) prevalence was 19.1%. In adjusted Poisson regression recent pregnancy was associated with slightly higher probable CMD (adjusted prevalence ratio [aPR] 1.19, 95%CI 0.96-1.49), and stronger association among 13-15 year-olds (aPR 3.25, 95%CI 1.50-7.03), but not with HIV serostatus. These findings suggest a possible incremental mental health impact of being pregnant earlier than peers, pointing to the need for age-appropriate mental health interventions for AGYW in resource-limited settings.

Gendered risks: access to and utilization of sexual and reproductive health services among young migrants in Southwestern Uganda: the role of the 'lending a hand' intervention

Introduction

Young migrants may engage in risky behaviours due to social, economic, and psychological challenges as they try to "get by" in their new host communities. This can result in unintended pregnancies, sexually transmitted infections including HIV, and poor mental health outcomes.During a study to test the feasibility and acceptability of an early intervention to reduce the harm of patterns of risk associated with migration, we assessed access to and utilization of sexual and reproductive health services (SRH) among recent migrants (14-24 years) in south-western Uganda.

Methods

The intervention conducted in 2022/23 involved training peer supporters to provide referral advice and support to young people. Between March-November 2022, 20 young migrants (11 males and 9 females) were purposively selected to participate in two in-depth interviews each to explore their experiences during the intervention. Data were analysed thematically.

Results

Women engaged in transactional sex to supplement their low pay while men got involved in risky behaviour once they had earned some money. Many suffered from sexually transmitted infections-related symptoms, were at risk for HIV infection and some women had fears of unwanted pregnancy. While some tried to seek for SRH services from public facilities, poor health service delivery such as long queues and shortages of drugs, discouraged them from going there. Young people tried to access treatment from private facilities but could not afford the costs. The intervention increased knowledge about SRH and supported young people to access services from the public health facilities at no cost thus increasing utilization.

Conclusion

Sexual health risks were experienced differently by women and men. The women were likely to experience symptoms related to sexually transmitted infections (including HIV) much earlier than men and this could increase their likelihood to engage with SRH services. The intervention served to increase men's readiness to access SRH services by providing them at a time and place that is convenient. Recognizing the different risk profiles of young people is important in tailoring appropriate interventions to promote equitable access and utilization of SRH services for both genders in this vulnerable population.

Factors influencing the uptake of a mono-PrEP implant for the prevention of HIV: Males' perspectives from three South African provinces

INTRODUCTION

Oral pre-exposure prophylaxis (PrEP) is an effective HIV prevention method; however, males over 15 years face challenges with its effective use. Long-acting prevention products could address barriers to effective PrEP use. This study aimed to estimate the potential uptake of a mono-PrEP implant and the factors influencing uptake among males in South Africa. The study also examined messaging and demand creation tactics that males perceive will improve HIV prevention uptake.

METHODS

We conducted a mixed methods study comprising participatory workshops and a self-administered survey among 142 PrEP-eligible males (18-40 years) in three provinces (Gauteng, Eastern Cape, and Kwa-Zulu Natal) in South Africa from July to November 2022. Logistic regression was used to assess the relationship between the potential uptake of a hypothetical, non-biodegradable mono-PrEP implant and socioeconomic and behavioural factors. Workshop data were analysed using content analysis.

RESULTS

The top three HIV prevention products that males would consider using were the monthly pill (74.6%), the mono-PrEP implant (62.7%), and event-driven oral PrEP (59.2%). If one prevention option was available, 31.7% of participants stated that they would use the monthly oral pill, 28.2% would use the six-monthly injection, and 19.7% the mono-PrEP implant. Four key themes were noted as influential to potential mono-PrEP uptake: "Health Over Everything", "Mono-PrEP Implant Concerns", "Potential Disclosure of Mono-PrEP Use", and "Information Distribution Channels". Participants preferred social and mainstream media as information distribution channels to receive information on HIV prevention services, including the mono-PrEP implant.

CONCLUSION

In this study among predominantly heterosexual men in South Africa, there was interest in long-acting HIV prevention methods but concerns about the mono-PrEP implant. A comprehensive and participatory introduction will be needed for the implant, to improve acceptability and address potential concerns. Demand-creation strategies utilising social media and health campaigns should be considered to engage and reach males.

Thetha Nami ngithethe nawe (Let's Talk): a stepped-wedge cluster randomised trial of social mobilisation by peer navigators into community-based sexual health and HIV care, including pre-exposure prophylaxis (PrEP), to reduce sexually transmissible HIV amongst young people in rural KwaZulu-Natal, South Africa

BACKGROUND

Antiretroviral therapy (ART) through universal test and treat (UTT) and HIV pre-exposure prophylaxis (PrEP) substantially reduces HIV-related mortality and incidence. Effective ART based prevention has not translated into population-level impact in southern Africa due to sub-optimal coverage among youth. We aim to investigate the effectiveness, implementation and cost effectiveness of peer-led social mobilisation into decentralised integrated HIV and sexual reproductive health (SRH) services amongst adolescents and young adults in KwaZulu-Natal (KZN).

METHODS

We are conducting a type 1a hybrid effectiveness/implementation study, with a cluster randomized stepped-wedge trial (SWT) to assess effectiveness and a realist process evaluation to assess implementation outcomes. The SWT will be conducted in 40 clusters in rural KZN over 45 months. Clusters will be randomly allocated to receive the intervention in period 1 (early) or period 2 (delayed). 1) Intervention arm: Resident peer navigators in each cluster will approach young men and women aged 15-30 years living in their cluster to conduct health, social and educational needs assessment and tailor psychosocial support and health promotion, peer mentorship, and facilitate referrals into nurse led mobile clinics that visit each cluster regularly to deliver integrated SRH and differentiated HIV prevention (HIV testing, UTT for those positive, and PrEP for those eligible and negative). Standard of Care is UTT and PrEP delivered to 15-30 year olds from control clusters through primary health clinics. There are 3 co-primary outcomes measured amongst cross sectional surveys of 15-30 year olds: 1) effectiveness of the intervention in reducing the prevalence of sexually transmissible HIV; 2) uptake of universal risk informed HIV prevention intervention; 3) cost of transmissible HIV infection averted. We will use a realist process evaluation to interrogate the extent to which the intervention components support demand, uptake, and retention in risk-differentiated biomedical HIV prevention.

DISCUSSION

The findings of this trial will be used by policy makers to optimize delivery of universal differentiated HIV prevention, including HIV pre-exposure prophylaxis through peer-led mobilisation into community-based integrated adolescent and youth friendly HIV and sexual and reproductive health care.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier-NCT05405582. Registered: 6th June 2022.

"Words are too small": exploring artmaking as a tool to facilitate dialogues with young South African women about their sexual and reproductive health experiences

Background

Adolescents and young women are at high risk for sexually transmitted infections (STIs) and unintended pregnancies. However, conversations about sexual and reproductive health (S&RH) are difficult and stigmatised. Visual art-based approaches have been a useful adjunct to language-dependent interviews, encouraging embodied memory recall. Here, we explored a novel visual art-based methodology-"Stories from the Edge"-with a cohort of young women to understand how artmaking might facilitate dialogue of how S&RH experiences influenced behaviour, to enrich dialogues captured in the individual in-depth interviews (IDIs).

Methods

Seven isiXhosa-speaking young women (aged 21-25 years) were recruited into a six-session art-based engagement, painting the stories of their S&RH experiences. Large format artmaking and IDIs contributed to the data set. IDIs were audio recorded, transcribed, and translated and then analysed thematically.

Results

Young women felt that the visual art-based methodology eased barriers to communicating experiences of S&RH-seeking behaviours, with one woman commenting that "words are too small" to capture lived experiences. Artmaking provided the opportunity to express emotional complexities of the pleasures of intimate relationships and the heartbreak of betrayal for which they had no language. Significant social relationships (family, partners, peers) influenced sexual and reproduction attitudes and practices more than healthcare facilities and staff and more distal socio-cultural attitudes/practices. These influences shifted from adolescence to adulthood-from family to peer and partners.

Conclusion

Young women valued using the art-based methodology, which facilitated recall and verbalising their S&RH experiences more fully than language-only research. The process outlined here could provide a creative method that builds communication skills to negotiate the needs and desires of young women with partners and staff at S&RH services.

Ethical and methodological reflections: Digital storytelling of self-care with students during the COVID-19 pandemic at a South African University

The enforcement of the coronavirus disease 2019 (COVID-19) pandemic restrictions disrupted the traditional face-to-face qualitative data collection in public health. The pandemic forced qualitative researchers to transition to remote methods of data collection such as digital storytelling. Currently, there is a limited understanding of ethical and methodological challenges in digital storytelling. We, therefore, reflect on the challenges and solutions for implementing a digital storytelling project on self-care at a South African university during the COVID-19 pandemic. Guided by Salmon's Qualitative e-Research Framework, reflective journals were used in a digital storytelling project between March and June 2022. We documented the challenges of online recruitment, obtaining informed consent virtually, and collecting data using digital storytelling as well as the efforts of overcoming the challenges. Our reflections identified major challenges, namely online recruitment and informed consent compromised by asynchronous communication; participants' limited research knowledge; participants' privacy and confidentiality concerns; poor internet connectivity; quality of digital stories; devices with a shortage of storage space; participants' limited technological skills; and time commitment required to create digital stories. Strategies adopted to address these challenges included an ongoing informed consent process; flexible timelines for the creation of digital stories; one-on-one guidance on creating digital stories; and multiple online platforms to share digital stories. Our critical reflection offers practical guidance for the ethical conduct of digital storytelling in public health research and makes a significant contribution to methodological considerations for use in future pandemics. These ethical and methodological challenges should be recognized as features of the context of the research setting including restrictions imposed by the COVID-19 pandemic than disadvantages of digital storytelling.

"They will judge you more like a parent instead of like a health practitioner": Perceptions and preferences of young people regarding sexual and reproductive health services in Southwest Nigeria

Adolescents and young people (AYP) experience many barriers in the utilization of sexual and reproductive health (SRH) services. These barriers can be cultural, structural, personal or health worker-related. In this study, we explored the perceptions and preferences of AYP in receiving SRH services at public health facilities in a Nigerian setting. We conducted 16 focus group discussion (FGD) sessions with adolescents and young people allowing for maximum variation by sex (male, female), age (15-19 years and 20-24 years), and marital status (married and unmarried). We applied a thematic framework analysis to explore the data collected. Our findings included both positive and negative attitudes of health workers at public health facilities, non-involvement of AYP in activities relating to the planning, implementation, or evaluation of SRH programs for AYP, and non-awareness among AYP of some of the rights that AYP have with respect to SRH services in public health facilities. Many participants preferred younger health workers or those living within their neighborhood. Some older health workers were said to often act as (strict) parents, not health workers. We conclude that the role ascribed to 'neighborhood' nurses in this study is instructive and deserves more attention. Also, there is a need to increase the awareness of the young people about the type of SRH services they can obtain in the public health facilities, as well as, a need for health workers to be trained and retrained in providing SRH services to AYP.

A qualitative exploration of the salience of MTV-Shuga, an edutainment programme, and adolescents' engagement with sexual and reproductive health information in rural KwaZulu-Natal, South Africa

Young people, particularly adolescent girls and young women, represent a growing proportion of those living with HIV. Edutainment programmes have been widely used throughout the world to "educate" and "entertain" audiences and tackle serious social issues in bold and engaging ways. This paper examines the extent to which an edutainment programme, MTV-Shuga, was reported to influence young people's engagement with sexual and reproductive health (SRH) information in rural KwaZulu-Natal, South Africa. In 2019 we conducted eight community-based screenings of MTV-Shuga episodes followed by 25 individual in-depth interviews and 13 focus group discussions with young people aged between 15 and 30. Interviews were audio recorded and transcribed verbatim. Data analysis was thematic and complemented by constant comparison and deviant case analysis techniques. In this rural and poor setting with a high burden of HIV, young people exhibited high levels of awareness of SRH and HIV but had constrained access to services, and limited ability to engage with parents or guardians on SRH matters. MTV Shuga provided an entertaining guide of ways to navigate the risks that they faced in a way that resonated with them. The findings highlight the importance of enabling young people in rural areas to watch MTV Shuga with peers in a safe space in which discussion of the content is facilitated. There is also value in encouraging parents to watch MTV Shuga as a means of enabling discussions between children and adults in their lives about SRH matters.

Adolescent Girls and Young Women's Experiences of Living with HIV in the Context of Patriarchal Culture in Sub-Saharan Africa: A Scoping Review

Adolescent girls and young women (AGYW) in sub-Saharan Africa are disproportionately affected by the human immunodeficiency virus (HIV) due to socio-cultural gender, power, and economic disparities. This scoping review examined the literature to explore what is known about AGYW's everyday personal, relational, and social experiences of HIV to help shape future protective HIV policy and practice. Six databases were searched: Medline, CINAHL, Scopus, ASSIA, Google Scholar, and ProQuest, resulting in a total of 12,581 articles. Of these, 40 articles were included in the review. Key themes generated from the thematic analysis were relational and psychosocial challenges, inhibiting sexual expression, poverty, stigma, and discrimination; managing health in everyday life; agency and resilience; and personal space and social support. In conclusion, the review found a lack of understanding of AGYW's everyday experiences of living with HIV from their own perspectives. There was also little consideration of the role of patriarchal culture and how this constrains AGYW's ability to negotiate their relationships. Further research is needed to reveal AGYW's perspectives on living with HIV in sub-Saharan Africa.

A qualitative investigation of facilitators and barriers to DREAMS uptake among adolescents with grandparent caregivers in rural KwaZulu-Natal, South Africa

Adolescents with grandparent caregivers have experienced challenges including the death of one or both parents due to HIV in sub-Saharan Africa. They may be left out of existing HIV prevention interventions targeting parents and children. We investigated the facilitators and barriers to DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored and Safe) programme uptake among adolescents with grandparent caregivers across different levels of the socio-ecological model in rural South Africa. Data were collected in three phases (October 2017 to September 2018). Adolescents (13-19 years old) and their grandparent caregivers (≥50 years old) (n = 12) contributed to repeat in-depth interviews to share their perceptions and experiences regarding adolescents' participation in DREAMS. Data were triangulated using key informant interviews with DREAMS intervention facilitators (n = 2) to give insights into their experiences of delivering DREAMS interventions. Written informed consent or child assent was obtained from all individuals before participation. All data were collected in isiZulu and audio-recorded, transcribed verbatim and translated into English. Thematic and dyadic analysis approaches were conducted guided by the socio-ecological model. Participation in DREAMS was most effective when DREAMS messaging reinforced existing norms around sex and sexuality and when the interventions improved care relationships between the adolescents and their older caregivers. DREAMS was less acceptable when it deviated from the norms, raised SRH information that conflicts with abstinence and virginity, and when youth empowerment was perceived as a potential threat to intergenerational power dynamics. While DREAMS was able to engage these complex families, there were failures, about factors uniquely critical to these families, such as in engaging children and carers with disabilities and failure to include adolescent boys in some interventions. There is a need to adapt HIV prevention interventions to tackle care relationships specific to adolescent-grandparent caregiver communication.

The sexual and reproductive health needs of school-going young people in the context of COVID-19 in rural KwaZulu-Natal, South Africa

Background: The impact of school closures due to COVID-19 raised widespread concerns about children's health and well-being. We examine the impact on the sexual health needs of learners in the context of COVID-19 related lockdowns in rural KwaZulu-Natal, South Africa.Methods: In july-November 2020 and August-November 2021 we conducted 24 in-depth interviews and 8 group discussions with teachers and learners from 4 schools, community members and key education stakeholders. All interviews were conducted by telephone. We used a thematic analysis approach and Nvivo 12 software to manage the data.Results: Four main themes related to the COVID-19 pandemic emerged from the data: the sexual and reproductive health (SRH) of learners in the lead-up to the pandemic; the impact of COVID-19 on learners' SRH and wellbeing; the opportunities schools provided to support sexual well-being of learners during the pandemic; and the role of schools in supporting SRH for learners during the pandemic. Learners and stakeholders reported that the SRH of young people was affected by alcohol misuse, poor SRH knowledge and few pathways to link learners with services. Stakeholders working with schools reported that a lack of access to biomedical interventions (e.g., contraception) increased learner pregnancies. Gender-based violence in learners' households was reported to have increased during the COVID-19 pandemic related to loss of income. School closures disrupted the provision of a safe space to provide SRH and HIV-education through Life Orientation lessons and school nurse talks. This loss of a safe space also left learners vulnerable to sexual and physical violence. However, once schools re-opened, daily COVID-19 screening in schools provided the opportunity to identify and support vulnerable children who had other social needs (food and uniforms).Conclusion: The COVID-19 pandemic may have increased SRH needs and vulnerability of school-going children in a high HIV-burden rural setting. School shutdowns reduced the opportunity for schools to provide a vital safe space and information to enhance SRH for adolescents. Schools play a vital health promotion and social protection role.

The association of exposure to DREAMS on sexually acquiring or transmitting HIV amongst adolescent girls and young women living in rural South Africa

OBJECTIVE

We investigate how risk of sexually acquiring or transmitting HIV in adolescent girls and young women (AGYW) changed following the real-world implementation of DREAMS (Determined, Resilient, Empowered, AIDS free, Mentored and Safe) HIV prevention programme.

DESIGN

A representative population-based prospective cohort study of AGYW living in rural KwaZulu-Natal.

METHODS

Between 2017 and 2019, we interviewed a random sample of AGYW aged 13-22 years annually. We measured exposure to DREAMS as self-reported receipt of an invitation to participate and/or participation in DREAMS activities that were provided by DREAMS implementing organizations. HIV and herpes simplex virus type 2 (HSV-2) statuses were ascertained through blood tests on Dried Blood Spot (DBS). We used multivariable regression analysis to assess the association between exposure to DREAMS and risk of acquiring HIV: measured as incident HSV-2 (a proxy of sexual risk) and incident HIV;and the risk of sexually transmitting HIV: measured as being HIV positive with a detectable HIV viral load (≥50 copie/ml) on the last available DBS. We adjusted for sociodemographic, sexual relationship, and migration.

RESULTS

Two thousand one hundred and eighty-four (86.4%) of those eligible agreed to participate and 2016 (92.3%) provided data for at least one follow-up time-point. One thousand and thirty (54%) were exposed to DREAMS;HIV and HSV-2 incidence were 2.2/100 person-years [95% confidence interval (CI) 1.66-2.86] and 17.3/100 person-years (95% CI 15.5-19.4), respectively. There was no evidence that HSV-2 and HIV incidence were lower in those exposed to DREAMS: adjusted rate ratio (aRR) 0.96 (95% CI 0.76-1.23 and 0.83 (95% CI 0.46-1.52), respectively. HIV viral load was detectable for 169 (8.9%) respondents;there was no evidence this was lower in those exposed to DREAMS with an adjusted risk difference, compared with those not exposed to DREAMS, of 0.99% (95% CI-1.52 to 3.82]. Participants who lived in peri-urban/ urban setting were more likely to have incident HIV and transmissible HIV. Both HSV-2 incidence and the transmissible HIV were associated with older age and ever having sex. Findings did not differ substantively by respondent age group.

CONCLUSION

DREAMS exposure was not associated with measurable reductions in risk of sexually acquiring or transmitting HIV amongst a representative cohort of AGYW in rural South Africa.

Family Planning Experiences and Needs of Young Women Living With and Without HIV Accessing an Integrated HIV and SRH Intervention in Zimbabwe-An Exploratory Qualitative Study

Background

People living with HIV have higher unmet family planning needs compared to those without HIV. This is heightened for young people. However, the provision of family planning for young people within HIV programmes is uncommon. We investigated family planning uptake, acceptability of, and engagement with a service offering integrated HIV and sexual and reproductive health services for youth in a community-based setting in Zimbabwe.

Methods

CHIEDZA, a community-based intervention offering integrated HIV and sexual and reproductive health services to young people aged 16-24 years, is being trialed in Zimbabwe. This exploratory qualitative study was nested within an ongoing study process evaluation. Data was collected between March-May 2021 with two sets of interviews conducted: I) twelve semi-structured interviews with young women living with HIV aged 17-25 years and II) fifteen interviews conducted with young women without HIV aged between 20 and 25 years who used a contraceptive method. A thematic analysis approach was used.

Results

Before engaging with CHIEDZA, young women had experienced judgmental providers, on account of their age, and received misinformation about contraceptive use and inadequate information about ART-contraceptive interactions. These presented as barriers to uptake and engagement. Upon attending CHIEDZA, all the young women reported receiving non-judgmental care. For those living with HIV, they were able to access integrated HIV and family planning services that supported them having broader sexual and reproductive needs beyond their HIV diagnosis. The family planning preference of young women living with HIV included medium to long-acting contraceptives to minimize adherence challenges, and desired partner involvement in dual protection to prevent HIV transmission. CHIEDZA's ability to meet these preferences shaped uptake, acceptability, and engagement with integrated HIV and family services.

Conclusions

Recommendations for an HIV and family planning integrated service for young people living with HIV include: offering a range of services (including method-mix contraceptives) to choose from; supporting their agency to engage with the services which are most acceptable to them; and providing trained, supportive, knowledgeable, and non-judgmental health providers who can provide accurate information and counsel. We recommend youth-friendly, differentiated, person-centered care that recognize the multiple and intersecting needs of young people living with HIV.

A Mixed-Method Analysis of Inequalities Associated With Adverse Sexual and Reproductive Health Outcomes and the Requisite Interventions Among Young Women in Durban Informal Settlements, South Africa

Background

Over the years, positive sexual and reproductive health (SRH) outcomes have been made possible by a series of policies such as the Sustainable Development Goals, targeted toward different aspects of young women's SRH needs. Nevertheless, inequalities in the levels and trends of adverse SRH outcomes still exist in sub-Saharan Africa (SSA), including South Africa. Thus, this study examines the inequalities associated with adverse SRH outcomes among young women in Durban informal settlements, South Africa, using a mixed-method analysis and suggested requisite interventions to reduce or eliminate the disparity.

Methods

A mixed-method sequential explanatory design was used to address the research question. First, a quantitative cross-sectional survey was conducted among 547 young women aged 18 to 24 years in four informal settlements in Durban, South Africa, between April and July 2021. Thereafter, twenty (20) key informant interviews were conducted among different participants but with the same study characteristics. The study's outcome variable was adverse SRH outcomes, including HIV, STIs and unintended pregnancy, while the independent variable was inequality. The quantitative analysis employed binary and multivariable analysis to determine the association between the outcome and explanatory variables, using an alpha level of p < 0.05 to determine significance, while the qualitative analysis was done thematically.

Results

At the quantitative level, the prevalence of adverse SRH outcomes among young women dwelling in Durban informal settlements was 82.45%, 90.86% and 81.90% for STIs, HIV and unintended pregnancy, respectively. The adjusted odds ratio showed that young women who ever discussed sexual matters with their parents had a lower likelihood of reporting having STIs [aOR = 0.20; 95% (CI = 0.15-1.01)], HIV [aOR = 0.20; 95% (CI = 0.15-1.01)] and unintended pregnancy [aOR = 0.20; 95% (CI = 0.15-1.01)] compared to young women who never had a sexual discussion with their parents. Almost all the key informant interview participants shared the same perspective and proffered possible solutions in the qualitative results.

Conclusion

There are disparities in the factors associated with adverse SRH outcomes in Durban's informal settlements. Healthcare proximity, child support grants, cigarette smoking, alcohol consumption, polygamous family structures and gender based violence were associated with higher odds of reporting adverse SRH outcomes.

Lives Interrupted: Navigating Hardship During COVID-19 Provides Lessons in Solidarity and Visibility for Mobile Young People in South Africa and Uganda

We examine data from young women and men in South Africa and young female sex workers in Uganda to explore the inequalities and hardships experienced during the COVID-19 pandemic and investigate the opportunities and ability presented to navigate in a virtual world to build an inclusive supportive future for young people on the move. We argue that against the backdrop of a fragile past, young people who see their today disturbed, tomorrow reshaped and their futures interrupted, need support to interact with their social environment and adjust their lives and expectations amidst the changing influences of social forces.

Thetha Nami: participatory development of a peer-navigator intervention to deliver biosocial HIV prevention for adolescents and youth in rural South Africa

BACKGROUND

Despite effective biomedical tools, HIV remains the largest cause of morbidity/mortality in South Africa - especially among adolescents and young people. We used community-based participatory research (CBPR), informed by principles of social justice, to develop a peer-led biosocial intervention for HIV prevention in KwaZulu-Natal (KZN).

METHODS

Between March 2018 and September 2019 we used CBPR to iteratively co-create and contextually adapt a biosocial peer-led intervention to support HIV prevention. Men and women aged 18-30 years were selected by community leaders of 21 intervention implementation areas (izigodi) and underwent 20 weeks of training as peer-navigators. We synthesised quantitative and qualitative data collected during a 2016-2018 study into 17 vignettes illustrating the local drivers of HIV. During three participatory intervention development workshops and community mapping sessions, the peer-navigators critically engaged with vignettes, brainstormed solutions and mapped the components to their own izigodi. The intervention components were plotted to a Theory of Change which, following a six-month pilot and process evaluation, the peer-navigators refined. The intervention will be evaluated in a randomised controlled trial ( NCT04532307 ).

RESULTS

Following written and oral assessments, 57 of the 108 initially selected participated in two workshops to discuss the vignettes and co-create the Thetha Nami (`talk to me'). The intervention included peer-led health promotion to improve self-efficacy and demand for HIV prevention, referrals to social and educational resources, and aaccessible youth-friendly clinical services to improve uptake of HIV prevention. During the pilot the peer-navigators approached 6871 young people, of whom 6141 (89%) accepted health promotion and 438 were linked to care. During semi-structured interviews peer-navigators described the appeal of providing sexual health information to peers of a similar age and background but wanted to provide more than just "onward referral". In the third participatory workshop 54 peer-navigators refined the Thetha Nami intervention to add three components: structured assessment tool to tailor health promotion and referrals, safe spaces and community advocacy to create an enabling environment, and peer-mentorship and navigation of resources to improve retention in HIV prevention.

CONCLUSION

Local youth were able to use evidence to develop a contextually adapted peer-led intervention to deliver biosocial HIV prevention.

Clinic and care: associations with adolescent antiretroviral therapy adherence in a prospective cohort in South Africa

OBJECTIVE

Adolescent antiretroviral treatment (ART) adherence remains critically low. We lack research testing protective factors across both clinic and care environments.

DESIGN

A prospective cohort of adolescents living with HIV (sample n = 969, 55% girls, baseline mean age 13.6) in the Eastern Cape Province in South Africa were interviewed at baseline and 18-month follow-up (2014-2015, 2015-2016). We traced all adolescents ever initiated on treatment in 52 government health facilities (90% uptake, 93% 18-month retention, 1.2% mortality).

METHODS

Clinical records were collected; standardized questionnaires were administered by trained data collectors in adolescents' language of choice. Probit within-between regressions and average adjusted probability calculations were used to examine associations of caregiving and clinic factors with adherence, controlling for household structure, socioeconomic and HIV factors.

RESULTS

Past-week ART adherence was 66% (baseline), 65% (follow-up), validated against viral load in subsample. Within-individual changes in three factors were associated with improved adherence: no physical and emotional violence (12.1 percentage points increase in adjusted probability of adherence, P < 0.001), improvement in perceived healthcare confidentiality (7.1 percentage points, P < 0.04) and shorter travel time to the clinic (13.7 percentage points, P < 0.02). In combination, improvement in violence prevention, travel time and confidentiality were associated with 81% probability of ART adherence, compared with 47% with a worsening in all three.

CONCLUSION

Adolescents living with HIV need to be safe at home and feel safe from stigma in an accessible clinic. This will require active collaboration between health and child protection systems, and utilization of effective violence prevention interventions.