Trends and correlates of HIV prevalence among adolescents in South Africa: evidence from the 2008, 2012 and 2017 South African National HIV Prevalence, Incidence and Behaviour surveys

Prevalence and predictors of HIV testing among young men in Papua New Guinea: A cross-sectional analysis of a nationally representative sample

BACKGROUND

HIV testing is an important component of HIV prevention and serves as a gateway to other HIV-related services. However, the uptake remains suboptimal among young people, particularly in highly prevalent settings such as Papua New Guinea (PNG). This study aimed to assess the prevalence and determine the predictors of HIV testing uptake among young men aged 15-24 years in PNG.

METHODS

The 2016-2018 PNG Demographic and Health Survey (DHS) data was used. A total of 1,275 young men aged 15-24 years were included in the final analysis. Descriptive, bivariate, and multivariable logistic regression analyses were performed to determine independent predictors of HIV testing. Adjusted odds ratios (AORs) with 95% confidence intervals (CIs) were reported. All analyses were adjusted using survey weights to account for unequal sampling probabilities.

RESULTS

The overall prevalence of HIV testing among young men was 17.1% (95% CI: 15-19). Of those who were tested for HIV, about one-third (32.9%) had experienced a sexual debut at age <15 years, and 33.9% inconsistently used condoms during sex. In multivariable analysis, men aged 20-24 years (AOR 1.18, 95% CI: 1.00-2.31), who owned mobile phones (AOR 1.43, 95% CI: 1.00-2.55), who were aware that consistent condom use during sex can reduce HIV risk (AOR 2.18, 95% CI: 1.18-4.04), who had paid for sex (AOR 1.75, 95% CI: 1.01-5.83), and who had two or more sexual partners (AOR 1.37, 95% CI: 1.01-3.14) had increased odds of HIV testing. However, decreased odds of HIV testing were found among men who were never married (AOR 0.51, 95% CI: 0.29-0.88), lived in rural areas (AOR 0.54, 95% CI: 0.32-0.92), and consistently used condoms during sex (AOR 0.59, 95% CI: 0.34-1.01).

CONCLUSION

The findings show that HIV testing is low among young men in PNG. To increase HIV testing uptake among young men, it is crucial to implement comprehensive youth-friendly HIV/STI education and tailored sensitization programs and enable more accessible and affordable HIV testing services. Also, outreach and community-based testing programs for young men in rural and prioritized areas requiring urgent prevention interventions are feasible options in PNG.

Adolescents' risky sexual behaviours and practices: Implications for sexuality education implementation in Zambia

BACKGROUND

 Adolescents' risky sexual behaviours (RSB) are detrimental to their sexual and reproductive health (SRH) well-being and present a serious public health threat, particularly in low- and middle-income countries (LMICs).

AIM

 This study aims to assess RSB among Grade 12 school-going adolescents after exposure to comprehensive sexuality education (CSE).

SETTING

 This study was conducted in Kitwe district, Zambia.

METHODS

 This cross-sectional study included 807 Grade 12 pupils at 13 selected secondary schools. Data were collected using a structured questionnaire. Proportionate probability sampling involving 13 schools was employed. Risky sexual behaviours binary outcome variables were based on transactional sex, sex while drunk, multiple sexual partners, age-disparate sexual relationships, and condomless sex. We conducted univariate and bivariate analyses to summarise sociodemographic factors and fitted binary and multivariable logistic regression models.

RESULTS

 The prevalence of RSB was 40.4%. Drinking alcohol (adjusted odds ratio [AOR] = 20.825; 95% CI [6.7-64.489]); ever had sex (AOR = 9.024; 95% CI [1.953-41.704]); school location (AOR = 6.50; 95% CI [1.61-26.24]); living with mother only (AOR = 4.820; 95% CI [1.328-17.493]); sex (male) (AOR = 2.632; 95% CI [1.469-4.713]), watching pornography (AOR = 1.745; 95% CI [1008-3.021]); religion (AOR = 0.472; 95% CI [0.250-0.891]) and attending religious functions (AOR = 0.317; 95% CI [0.118-0.848]) were significantly associated with RSB. Of the sexually active pupils, 221 (67.7%), 64 (19.6%) and 41 (12.5%) were in the low, medium and high-risk categories, respectively.

CONCLUSION

 Close to half of the respondents engaged in RSB. This is a significant number that needs intervention. The CSE programme needs to be linked with structural programmes that address the social drivers of RSB among adolescents.Contribution: The study provides a backdrop for evaluating current CSE strategies in LMICs.

Process evaluation of comprehensive sexuality education programme in Zambia: a focus on contextual factors, mechanisms of impact, quality of development and implementation process

BACKGROUND

Comprehensive sexuality education (CSE) is critical in addressing negative sexual and reproductive health (SRH) outcomes among adolescents. Yet in many low- and middle-income countries (LMICs) including Zambia, little is known about the impact, realities of CSE implementation, the quality of teaching and the comprehensiveness of the content covered.

METHODS

Our approach was informed by a process evaluation incorporating recommendations by the European Expert Group guidance on evaluating sexuality education programmes and the Medical Research Council (MRC) guidelines on process evaluation. The development process and quality of CSE implementation were assessed using eight and six quality criteria respectively. In-depth interviews (IDIs), focus group discussions (FGDs), document analysis and classroom observation were employed to assess contextual factors, implementation process and mechanisms of impact of CSE. In-depth interviews (50) and focus group discussions (2) with seven pupils in each group were conducted among 64 purposefully selected participants. The sample comprised pupils (35), parents (4) and teachers (17) from nine secondary schools (four peri-urban, four urban and one rural), policymakers (4), and religious leaders (4). We employed deductive content analysis to analyse the data.

RESULTS

Contextual factors that influenced the implementation of CSE included: (1) piecemeal funding for the CSE programme; (2) lack of monitoring programmes in schools; (3) lack of community engagement; (4) religious and socio-cultural barriers; (5) lack of skills and competency to teach CSE; and (6) insufficient time allocation for CSE. The assessment of the quality of the development of CSE revealed: (1) a lack of sexual diversity; (2) no meaningful participation of pupils in programme implementation; (3) a lack of stakeholder engagement during programme implementation; (4)  lack of gender sensitivity; and (5) lack of human rights approach. Assessment of the quality of the implementation of CSE revealed: (1) no evidence of skill-based CSE teaching; (2) no linkage between CSE and SRH services in the communities; and (3) a lack of incorporation of multiple delivery methods during CSE teaching. The mechanisms of impact of CSE were related to the acceptability and positive changes in pupils' SRH practices.

CONCLUSION

The complex influences of contextual factors during CSE implementation highlight the need for contextual analysis during the interventional design. Co-creation of the CSE programme through stakeholder participation could reduce social opposition and enable a culturally sensitive CSE. Comprehensive teacher training, a guiding curriculum as well as setting of appropriate monitoring tools and indicators are likely to enhance the quality of CSE implementation.

HIV Stigma, Health, and Violence: A Longitudinal Study among Adolescent Boys with HIV in Soweto, South Africa

There are over 1.4 million adolescents living with HIV in sub-Saharan Africa, the majority of whom acquired the virus through perinatal transmission (PHIV). HIV stigma is particularly high among adolescents living with HIV and is associated with several outcomes that worsen health and increase the risk of onward HIV transmission. We tested associations between internalized HIV stigma and four of these outcomes over a one-year period among a sample of adolescent boys living with PHIV in Soweto, South Africa. Participants (N = 241) answered questions about internalized HIV stigma at baseline. They completed weekly mobile surveys over the following year to answer questions about their experiences with depression, binge drinking, medication adherence, and violence victimization. Using generalized linear mixed models, we found that baseline internalized HIV stigma was associated with increased odds of depression (OR 1.74), alcohol misuse (OR 2.09), and violence victimization (OR 1.44) and decreased odds of medication adherence (OR 0.60) over the course of a year. These outcomes negatively impact the health and wellbeing of adolescents living with PHIV and increase their risk of transmitting HIV to their partners in the future. Our findings provide novel, longitudinal evidence for the deleterious effects of HIV stigma. To improve health outcomes for adolescents with PHIV, it will be crucial to develop effective HIV stigma reduction interventions that address specific developmental, gendered, and cultural experiences.

Cox proportional hazard-model application: time to cervical cancer screening among women living with HIV in South Africa

BACKGROUND

There is an increased risk of cervical cancer among women living with HIV. While studies have long examined the association between cervical cancer among women with HIV, no study has examined the time taken for women with HIV to undergo cervical cancer screening as well as the hazard thereof in South Africa.

METHODS

The study used cross-sectional data from the 2016 South Africa Demographic and Health Survey. To allow for longitudinal analysis and to address the issue of right-censoring, the data were reformatted to a person-data file. The selection criteria were limited to women living with HIV (WLHIV) who had also responded to the question on cervical cancer screening. Descriptive statistics were employed to show the levels of HIV among women aged 15 and older in South Africa. Additionally, Kaplan‒Meier curves were employed to investigate the time to CCS by WLHIV in South Africa. Thereafter, an unadjusted Cox hazards regression model was employed to examine the hazard of undergoing CCS among WLHIV. Finally, it employed an adjusted model to examine the hazard of CCS among WLHIV while adjusting for other factors.

RESULTS

Nineteen percent (n = 1,159) of the women who participated in the study tested positive for HIV. Herein, it was found that the risk of CCS among WLHIV began at the age of approximately 19 years. Thereafter, the hazard of undergoing CCS among WLHIV began to decrease at 58 years. There was a significant association between CCS and WLHIV. Additionally, several covariates were found to be significantly associated with HIV. These were race, province, area of residence, marriage, educational attainment, employment, alcohol consumption, perceived health perception, and health insurance.

CONCLUSION

The hazard of CCS was lower among WLHIV compared to WLHIV who did not undergo CCS in South Africa. This puts HIV-positive women at risk of increased morbidity and mortality from potential cervical cancer and HIV comorbidity due to CCS deficits within this group. This is because they are susceptible to HPV and subsequent cervical cancer due to a compromised immune system. HIV-positive women need to routinely undergo CCS every 12 months from baseline for 3 years. Thereafter, they should undergo CCS once every 3 years to reduce their risk of developing the disease.

Multi-modal analysis of inflammation as a potential mediator of depressive symptoms in young people with HIV: The GOLD depression study

People living with HIV are at three times greater risk for depressive symptoms. Inflammation is a notable predictor of depression, and people with HIV exhibit chronic inflammation despite antiretroviral therapy. We hypothesised that inflammatory biomarkers may mediate the association between HIV status and depressive symptoms. Participants (N = 60, 53% girls, median [interquartile range (IQR)] age 15.5 [15.0, 16.0] years, 70% living with HIV, of whom 90.5% were virally-suppressed) completed the nine-item Patient Health Questionnaire (PHQ-9). We measured choline and myo-inositol in basal ganglia, midfrontal gray matter, and peritrigonal white matter using magnetic resonance spectroscopy, and 16 inflammatory proteins in blood serum using ELISA and Luminex™ multiplex immunoassays. Using structural equation mediation modelling, we calculated standardised indirect effect estimates with 95% confidence intervals. Median [IQR] total PHQ-9 score was 3 [0, 7]. HIV status was significantly associated with total PHQ-9 score (B = 3.32, p = 0.022). Participants with HIV showed a higher choline-to-creatine ratio in the basal ganglia than those without HIV (β = 0.86, pFDR = 0.035). In blood serum, participants with HIV showed higher monocyte chemoattractant protein-1 (MCP-1, β = 0.59, pFDR = 0.040), higher chitinase-3 like-1 (YKL-40, β = 0.73, pFDR = 0.032), and lower interleukin-1beta (IL-1β, β = -0.67, pFDR = 0.047) than those without HIV. There were no significant associations of any biomarkers with total PHQ-9 score. None of the indirect effects were significant, mediating <13.1% of the association. Findings remained consistent when accounting for age, gender, and time between neuroimaging and PHQ-9 administration. Using a robust analytical approach in a community-based sample, we have shown that participants living with HIV reported greater depressive symptoms than those without HIV, but we did not find that neuroimaging and blood biomarkers of inflammation significantly mediated this association. Further studies with participants experiencing severe depression may help to elucidate the links between HIV, inflammation, and depression.

Binge drinking and condom negotiation behaviours among adolescent girls and young women living in Cape Town, South Africa: sexual control and perceived personal power

BACKGROUND

Condom use among young people in South Africa has declined in recent years and adolescent girls and young women continue to bear the highest incidence of HIV in the country. Young women who have dropped out of school may be more at risk because of traditional gender norms that create substantial power imbalances and a lack of power to negotiate condom use with their male partners, especially when using alcohol and other drugs.

METHODS

This study presents an analysis of baseline data provided by 500 adolescent girls and young women (AGYW) from Cape Town communities between November 2016 and November 2018 who were reached for a cluster-randomised trial conducted to assess the efficacy of an evidence-based, young woman-focused intervention seeking to reduce HIV risk and substance use behaviours. The analysis focuses on associations between binge drinking, condom use, and sexual negotiation, including impaired sex (any substance use at last sex).

RESULTS

AGYW who reported frequent condom negotiation with their partners were 8.92 times (95% CI: [4.36, 18.24]) as likely to use a condom when alcohol or other drugs were not used at last sex and 5.50 times (95% CI: [2.06, 14.72]) as likely when alcohol or other drugs were used at last sex (p < 0.05). AGYW who reported frequent binge drinking in the past month (n = 177) had significantly reduced odds of condom use at last sex, irrespective of whether the sex was impaired (OR 0.60, 95% CI: [0.49, 0.73]) or not impaired (OR 0.69, 95% CI: [0.60, 0.81]).

DISCUSSION

The findings highlight the need for interventions that reach AGYW in South Africa by specifically aiming to educate AGYW about the effect of binge drinking on negotiating power in their relationships, thus providing them with the knowledge and skills to increase agency regarding condom use.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02974998 (recruitment completed). 29/11/2016.

'I feel that I should decide on my own….': who should be involved in the decision-making process for adolescent involvement in HIV research?

INTRODUCTION

Efforts to improve health outcomes among adolescents and young adults living with HIV (ALHs) are hampered by limited adolescent engagement in HIV-related research. We sought to understand the views of adolescents, caregivers and healthcare workers (HCWs) about who should make decisions regarding ALHs' research participation.

METHODS

We conducted focus group discussions (FGDs) and in-depth interviews (IDIs) with ALHs (aged 14-24 years), caregivers of ALHs and HCWs from six HIV care clinics in Western Kenya. We used semi-structured guides to explore ALHs' involvement in research decisions. Transcripts were analysed using thematic analysis; perspectives were triangulated between groups.

RESULTS

We conducted 24 FGDs and 44 IDIs: 12 FGDs with ALHs, 12 with caregivers, and 44 IDIs with HCWs, involving 216 participants. HCWs often suggested that HIV research decision-making should involve caregivers and ALHs deciding together. In contrast, ALHs and parents generally thought decisions should be made individually, whether by HCWs/research teams (although this is likely ethically problematic), adolescents or caregivers. Caregiver and ALH preferences depended on ALHs' age, with younger ALHs requiring more support. A few caregivers felt that ALHs should consult with the research team/HCWs due to their greater knowledge of clinical care. ALHs emphasised that they should independently decide because they thought they had the right to do so and the capacity to consent. Poor communication and parental non-disclosure of HIV status influenced ALHs' views to exclude caregivers from decision-making. Regarding influences on research decision-making, ALHs were more willing to participate based on perceived contribution to science and less interested in participating in studies with potential risks, including loss of confidentiality.

DISCUSSION

While research teams and HCWs felt that adolescents and caregivers should jointly make research decisions, ALHs and caregivers generally felt individuals should make decisions. As ALHs sometimes find caregiver support lacking, improving family dynamics might enhance research engagement.

"A spade was called a spade … ": Youth and intervention implementers' perceptions of a resilience-based HIV-prevention intervention for youth in South Africa

The youth (15-24 years old) in South Africa remain at high risk of HIV infection despite varied efforts to control the disease. An understanding of the perspectives of relevant stakeholders of HIV-prevention interventions targeting the youth is important to guide research, policy and practice aimed at improving these interventions. This study explores youth and intervention implementers' perceptions of a resilience-based HIV-prevention intervention (You Only Live Once) aimed at reducing risky sexual behaviours among the youth in South Africa. Semi-structured interviews were conducted with 10 young people who participated in the intervention, and four intervention implementers at a not-for-profit organisation in Maluti-a-Phofung Local Municipality, South Africa. Data were analysed using thematic analysis. Three main themes emerged from the data: (1) Acceptability and impact of the intervention; (2) Factors influencing intervention implementation; and (3) Recommendations to improve intervention implementation. These findings provide insights into the acceptability, impact, barriers and facilitators of resilience-based HIV-prevention interventions for the youth in South Africa and similar contexts, and how implementation of these interventions could be enhanced. The findings can help researchers, policy makers and health care practitioners in the field of HIV prevention to improve interventions targeting young people.

School-based healthcare services in Cape Town, South Africa: When there's a will, there's a way

South African secondary schools do not deliver school-based healthcare services despite high rates of human immunodeficiency virus (HIV) infection, sexually transmitted infections, and unplanned pregnancies among adolescents, ongoing sub-optimal uptake of healthcare services from public healthcare facilities by adolescents, and national policy support for such services. A pilot school health nursing programme (SHNP) was offered to 44 secondary schools in a single health sub-district within the Western Cape, South Africa. The programme included fortnightly nurse visits that offered a standard package of healthcare services, including sexual and reproductive health services tailored according to school preference.Of the 44 schools, 42 gave permission for the SHNP to operate, with the majority of schools selecting the full comprehensive package of services. Programme implementation was truncated such that delivery only occurred over two school terms (20 weeks); however, 344 students attended the service. The majority of service users were female with a median age of 16 years, and over a half attended the service for sexual and reproductive health services.Contribution: A key challenge to school-based health service delivery arose from inadequate stakeholder support and differential views of adolescent healthcare needs among government officials, parents, guardians, school staff and governing bodies. These findings motivate for ongoing multi-level stakeholder engagement around the reality of adolescent healthcare needs and further opportunities to deliver school health services for longer time periods such that their feasibility, acceptability, and potential to impact healthcare outcomes can be assessed in this setting.

Gender differences in HIV knowledge among adolescents and young people in low-and middle-income countries: a systematic review

Objectives

This review seeks to critically analyze studies assessing gender differences in HIV-related knowledge among adolescents and young people in low- and middle-income countries.

Methods

Using PRISMA guidelines and searching Pubmed and Scopus online databases, the search strategy combined search keywords with Boolean operators: (HIV OR AIDS) AND (knowledge) AND (gender) AND (adolescents). AC and EG conducted the search and independently reviewed all articles in Covidence software; conflicts were resolved by GC. Articles were included if they evaluated differences in HIV knowledge in at least two groups ages 10-24 and were implemented in a low or middle-income country.

Results

The search resulted in 4,901 articles, of which fifteen studies, implemented in 15 countries, met selection criteria. Twelve evaluated differences in HIV knowledge in school settings; three evaluated participants in clinic settings. Adolescent males consistently scored higher in composite knowledge scores, as well as knowledge of HIV transmission, prevention, attitudes and sexual decision-making.

Conclusion

We found gender-based discrepancies between knowledge, perception of risk and HIV prevalence among youth globally, with boys consistently scoring higher in HIV knowledge. However, there is significant evidence that social and cultural contexts render girls at high risk of HIV infection, and the gaps in girls' knowledge and boys' roles in HIV risk must be addressed urgently. Future research should consider interventions that facilitate discussion and HIV knowledge building across genders.

Hepatitis B Virus Immunity Gap: A Six-Year Laboratory Data Review of Hepatitis B Serological Profiles in Gauteng Province, South Africa

Background

In 1995, the hepatitis B vaccine in South Africa was incorporated into the childhood expanded programme of immunization. We report on immunity gaps of laboratory-based hepatitis B virus (HBV) among patients in public facilities in Gauteng Province from 1st January 2014 to 31st December 2019. Methodology. We analyzed HBV serological data extracted from the National Health Laboratory Services Central Data Warehouse (NHLS CDW). A descriptive analysis was performed for hepatitis B surface antigen (HBsAg), antibodies to HBV core (anti-HBc) total, anti-HBc IgM, and antibodies to HBV surface antigen (anti-HBs) according to annual distribution, age groups, and sex.

Results

The HBsAg positivity rate was 7.0% (75,596/1,095,561; p=0.001): 7.4% (96,532/944,077) in the 25 years and over age group and 4.0% (358/9,268 and 325/10,864) in the under 5 and 13-24 year age groups. The positivity rates of the other HBV serological markers were as follows: anti-HBc total was 37.0% (34,377/93,711; p  <  0.001), anti-HBc IgM was 2.4% (5,661/239,237; p=0.05), and anti-HBs was 37.0% (76,302/206,138; p ≤ 0.001). Naturally acquired HBV immunity was detected in 25.7% (11,188/43,536) of patients in the 25 years and over age group, and 9.7% and 8.2% (113/1,158 and 541/6,522) among those under 5 years and 13-24 year age group, respectively (p  <  0.001). Vaccine-induced immunity was 56.6% (656/1,158) in children under 5 years and 10.2% (4,425/43,536) among those 25 years and above (p  <  0.001). Fifty-six percent (29,404/52,581) of patients were HBV seronegative; predominantly among patients in the 13-24 year age group (60.6%; (3,952/6,522)) and 25 years and over (56.3% (24,524/43,536)) (p=<0.001).

Conclusion

The HBV infection seroprevalence remains high in South Africa, with Gauteng province having high intermediate endemicity. However, the HBV immunity gap has shifted from younger children to older children and adults.

HIV Treatment and Care of Adolescents: Perspectives of Adolescents on Community-Based Models in Northern Uganda

Background

Differentiated service delivery models for people living with HIV continue to be scaled up to expand access to HIV services and treatment continuity. However, there is a gap in information on adolescents' perspectives on community-based models. We aimed to explore the perspectives of adolescents living with HIV on community-based models in northern Uganda.

Materials and Methods

Between February and March 2022, we conducted a descriptive qualitative study at two health centres IV in Northern Uganda. Data was collected using an interview guide. The study had 25 purposively selected adolescents enrolled in community-based models for HIV care and treatment. The interviews were audio-recorded, transcribed verbatim, and translated. We analyzed data using a thematic approach.

Results

A total of 25 in-depth interviews with HIV-positive adolescents were conducted. More than half (52.0%) of the participants were females, 84.0% were not married, and 44.0% had no formal education. The mean age of the respondents was 15.6 (±1.9) years. The major themes were: community-based models currently accessed by adolescents, benefits, and challenges of the models. Although there are other community-based models (community pharmacies, home ART deliveries) our exploration only discovered two models used by these adolescents to access care, namely, Community Drug Distribution Point (CDDP) and Community Client-Led ART Delivery Groups (CCLADs). The benefits included reduced transportation costs, convenient service access, ART adherence, peer support, a comfortable environment and less stress. However, our results indicate that these models had some challenges, including lack of confidentiality and privacy, perceived stigma, and a lack of face-to-face interaction.

Conclusion

Our findings show that CDDP and CCLADs are the two CBMs used by adolescents in Lira District to access treatment and care. Adolescents benefited from these models through reduced transport costs, the convenience of accessing HIV care and treatment, and social support. The challenges associated with these models are lack of confidentiality and privacy, perceived stigma, and a lack of face-to-face interaction. The Ministry of Health should work with other implementing partners to strengthen the implementation of these models to improve HIV/AIDS service delivery for adolescents.

"I am not shy anymore": A qualitative study of the role of an interactive mHealth intervention on sexual health knowledge, attitudes, and behaviors of South African adolescents with perinatal HIV

BACKGROUND

South Africa has one of the highest burdens of adolescents with perinatally-acquired HIV (APHIV) in the world. APHIV in South Africa have limited access to sexual and reproductive health (SRH) education and services specific to their HIV status. When lacking comprehensive SRH education, APHIV are prone to sexual risk behaviors that can lead to unintended pregnancy, sexually transmitted infections, and HIV transmission. The use of mHealth interventions has been shown to deliver information, foster social support, and improve decision-making skills. In this study, we evaluate how an mHealth intervention influences sexual health knowledge and behaviors in APHIV.

METHODS

We purposively enrolled adolescents from the intervention arm of a randomized clinical trial assessing a multi-module, moderated WhatsApp-based intervention-Interactive Transition Support for Adolescents Living with HIV (InTSHA)-within a government supported clinic in KwaMashu, an urban township of KwaZulu-Natal, South Africa. We conducted in-depth interviews based on World Health Organization guidelines for asking adolescents about SRH. We thematically analyzed data through an iterative, team-based coding approach combining deductive and inductive elements to contextualize SRH attitudes, knowledge, and behaviors before and after receiving the InTSHA intervention.

RESULTS

Of the 21 participants, 13 (61.9%) were female and the mean age was 16.6 years. Most participants reported first learning about SRH as young teenagers in school through non-targeted and negative ways, seeking clarification through peers and the internet rather than clinicians or caregivers. Participants reported that InTSHA provided a holistic perspective on relationships, gender, and sexuality specific to growing up with HIV in South Africa. They praised the ability to give and receive information from peers in a moderated setting through the mHealth intervention, building their confidence, decision-making skills, and communication with partners and caregivers throughout their everyday lives. Despite reporting some technological challenges, adolescents agreed that InTSHA was convenient, confidential, and user-friendly.

CONCLUSIONS

South African APHIV receive incomplete and conflicting sexual education from peers, caregivers, teachers, and technology that can be supplemented by mHealth curricula targeted for the unique needs of APHIV. Future, scaled-up mHealth interventions can lower SRH stigma by expanding access to sexual education and peer support, supplementing adolescents' existing SRH education.

Emotive Media as a Counterbalance to AIDS Messaging Fatigue in South Africa: Responses to an HIV/AIDS Awareness Music Video

South Africa recorded and estimated 230,000 new infections in 2020, and low levels of AIDS risk awareness remain prevalent among the nation's youth. While public health awareness initiatives continue to be necessary, the large quantity of AIDS-related content that has permeated the media landscape since the start of the epidemic has resulted in increasing indifference to health messaging. Drawing from the concept of referent emotional responses, this article analyzes the reception of "Sing," an HIV/AIDS awareness music video characterized by emotive visual representations of AIDS. The data highlight ongoing fatigue towards HIV/AIDS messaging and the potential of highly emotive media to engage target audiences in a climate of indifference to AIDS awareness. The article recommends that future awareness and prevention campaigns consider the role of emotive content in effective AIDS-related health promotion in South Africa.