Acceptability, Feasibility, and Preliminary Efficacy of a Resilience-Oriented Family Intervention to Prevent Adolescent HIV and Depression: A Pilot Randomized Controlled Trial

Family influences on oral PrEP use among adolescent girls and young women in Kenya and South Africa

INTRODUCTION

Effective use of oral HIV pre-exposure prophylaxis (PrEP) has been lower among African adolescent girls and young women (AGYW) than among older women, young men who have sex with men, and serodiscordant heterosexual couples in the region. Efforts to build PrEP support have centered around peers and male partners, but the family may also play an important role. This qualitative study aimed to describe family influence on PrEP use among AGYW in in three African cities.

METHODS

POWER (Prevention Options for Women Evaluation Research) was a PrEP demonstration project among 2550 AGYW (16-25 years old) in Johannesburg and Cape Town, South Africa and Kisumu, Kenya conducted from 2017 to 2020. In-depth interviews and focus group discussions were conducted with 136 AGYW participants to explore their PrEP views and experiences, including awareness and interest in PrEP; barriers and facilitators to uptake and use; the influence of family, peers, intimate partners, and community; and the key types of support for their PrEP use. Transcripts were coded and analysed thematically.

RESULTS

The decision to initiate PrEP was associated with fear and anxiety linked to anticipated stigma from family members, and with family's lived HIV experience. Family disclosure, especially to mothers, was important to participants, as most lived with their families and considered it essential for them to obtain their mother's approval to use PrEP. Most family members, particularly mothers, provided instrumental, emotional, informational and appraisal support to participants using PrEP, including reminders, encouragement, and problem-solving. Participants reported that family members with insufficient information about PrEP safety and efficacy and who voiced concerns were a substantial barrier to their use. However, they often became supportive after receiving more PrEP information.

CONCLUSION

Families, particularly mothers, can play an important role in supporting PrEP use. PrEP programmes should leverage family support to help with PrEP persistence by providing basic information to families about PrEP safety and efficacy. AGYW using PrEP should be encouraged to selectively disclose PrEP use to build support and counseled on how to disclose and address family concerns.

"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.

Primary-level and community worker interventions for the prevention of mental disorders and the promotion of well-being in low- and middle-income countries

BACKGROUND

There is a significant research gap in the field of universal, selective, and indicated prevention interventions for mental health promotion and the prevention of mental disorders. Barriers to closing the research gap include scarcity of skilled human resources, large inequities in resource distribution and utilization, and stigma.

OBJECTIVES

To assess the effectiveness of delivery by primary workers of interventions for the promotion of mental health and universal prevention, and for the selective and indicated prevention of mental disorders or symptoms of mental illness in low- and middle-income countries (LMICs). To examine the impact of intervention delivery by primary workers on resource use and costs.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, Global Index Medicus, PsycInfo, WHO ICTRP, and ClinicalTrials.gov from inception to 29 November 2021.

SELECTION CRITERIA

Randomized controlled trials (RCTs) of primary-level and/or community health worker interventions for promoting mental health and/or preventing mental disorders versus any control conditions in adults and children in LMICs.

DATA COLLECTION AND ANALYSIS

Standardized mean differences (SMD) or mean differences (MD) were used for continuous outcomes, and risk ratios (RR) for dichotomous data, using a random-effects model. We analyzed data at 0 to 1, 1 to 6, and 7 to 24 months post-intervention. For SMDs, 0.20 to 0.49 represented small, 0.50 to 0.79 moderate, and ≥ 0.80 large clinical effects. We evaluated the risk of bias (RoB) using Cochrane RoB2.

MAIN RESULTS

Description of studies We identified 113 studies with 32,992 participants (97 RCTs, 19,570 participants in meta-analyses) for inclusion. Nineteen RCTs were conducted in low-income countries, 27 in low-middle-income countries, 2 in middle-income countries, 58 in upper-middle-income countries and 7 in mixed settings. Eighty-three RCTs included adults and 30 RCTs included children. Cadres of primary-level workers employed primary care health workers (38 studies), community workers (71 studies), both (2 studies), and not reported (2 studies). Interventions were universal prevention/promotion in 22 studies, selective in 36, and indicated prevention in 55 RCTs. Risk of bias The most common concerns over risk of bias were performance bias, attrition bias, and reporting bias. Intervention effects 'Probably', 'may', or 'uncertain' indicates 'moderate-', 'low-', or 'very low-'certainty evidence. *Certainty of the evidence (using GRADE) was assessed at 0 to 1 month post-intervention as specified in the review protocol. In the abstract, we did not report results for outcomes for which evidence was missing or very uncertain. Adults Promotion/universal prevention, compared to usual care: - probably slightly reduced anxiety symptoms (MD -0.14, 95% confidence interval (CI) -0.27 to -0.01; 1 trial, 158 participants) - may slightly reduce distress/PTSD symptoms (SMD -0.24, 95% CI -0.41 to -0.08; 4 trials, 722 participants) Selective prevention, compared to usual care: - probably slightly reduced depressive symptoms (SMD -0.69, 95% CI -1.08 to -0.30; 4 trials, 223 participants) Indicated prevention, compared to usual care: - may reduce adverse events (1 trial, 547 participants) - probably slightly reduced functional impairment (SMD -0.12, 95% CI -0.39 to -0.15; 4 trials, 663 participants) Children Promotion/universal prevention, compared to usual care: - may improve the quality of life (SMD -0.25, 95% CI -0.39 to -0.11; 2 trials, 803 participants) - may reduce adverse events (1 trial, 694 participants) - may slightly reduce depressive symptoms (MD -3.04, 95% CI -6 to -0.08; 1 trial, 160 participants) - may slightly reduce anxiety symptoms (MD -2.27, 95% CI -3.13 to -1.41; 1 trial, 183 participants) Selective prevention, compared to usual care: - probably slightly reduced depressive symptoms (SMD 0, 95% CI -0.16 to -0.15; 2 trials, 638 participants) - may slightly reduce anxiety symptoms (MD 4.50, 95% CI -12.05 to 21.05; 1 trial, 28 participants) - probably slightly reduced distress/PTSD symptoms (MD -2.14, 95% CI -3.77 to -0.51; 1 trial, 159 participants) Indicated prevention, compared to usual care: - decreased slightly functional impairment (SMD -0.29, 95% CI -0.47 to -0.10; 2 trials, 448 participants) - decreased slightly depressive symptoms (SMD -0.18, 95% CI -0.32 to -0.04; 4 trials, 771 participants) - may slightly reduce distress/PTSD symptoms (SMD 0.24, 95% CI -1.28 to 1.76; 2 trials, 448 participants).

AUTHORS' CONCLUSIONS

The evidence indicated that prevention interventions delivered through primary workers - a form of task-shifting - may improve mental health outcomes. Certainty in the evidence was influenced by the risk of bias and by substantial levels of heterogeneity. A supportive network of infrastructure and research would enhance and reinforce this delivery modality across LMICs.

Evidence and gap map report: Social and Behavior Change Communication (SBCC) interventions for strengthening HIV prevention and research among adolescent girls and young women (AGYW) in low- and middle-income countries (LMICs)

Background

Adolescent girls and young women (AGYW), aged 15-24 years, are disproportionately affected by HIV and other sexual and reproductive health (SRH) risks due to varying social, cultural, and economic factors that affect their choices and shape their knowledge, understanding, and practices with regard to their health. Socio-Behavioral Change Communication (SBCC) interventions targeted at strengthening the capabilities of individuals and their networks have supported the demand and uptake of prevention services and participation in biomedical research. However, despite growing global recognition of the domain, high-quality evidence on the effectiveness of SBCC remains scattered. This evidence and gap map (EGM) report characterizes the evidence base on SBCC interventions for strengthening HIV Prevention and Research among AGYW in low- and middle-income countries (LMICs), identifying evidence gaps and outlining the scope of future research and program design.

Objectives

The objectives of the proposed EGM are to: (a) identify and map existing EGMs in the use of diverse SBCC strategies to strengthen the adoption of HIV prevention measures and participation in research among AGYW in LMICs and (b) identify areas where more interventions and evidence are needed to inform the design of future SBCC strategies and programs for AGYW engagement in HIV prevention and research.

Methods

This EGM is based on a comprehensive search of systematic reviews and impact evaluations corresponding to a range of interventions and outcomes-aimed at engaging AGYW in HIV prevention and research - that were published in LMICs from January 2000 to April 2021. Based on guidance for producing a Campbell Collaboration EGM, the intervention and outcome framework was designed in consultation with a group of experts. These interventions were categorized across four broad intervention themes: mass-media, community-based, interpersonal, and Information Communication and Technology (ICT)/Digital Media-based interventions. They were further sub-categorized into 15 intervention categories. Included studies looked at 23 unique behavioral and health outcomes such as knowledge attitude and skills, relationship dynamics, household dynamics, health care services, and health outcomes and research engagement. The EGM is presented as a matrix in which the rows are intervention categories/sub-categories, and the columns are outcome domains/subdomains. Each cell is mapped to an intervention targeted at outcomes. Additional filters like region, country, study design, age group, funding agency, influencers, population group, publication status, study confidence, setting, and year of publication have been added.

Selection Criteria

To be eligible, studies must have tested the effectiveness of SBCC interventions at engaging AGYW in LMICs in HIV prevention and research. The study sample must have consisted of AGYW between the ages of 15-24, as defined by UNAIDS. Both experimental (random assignment) and quasi-experimental studies that included a comparison group were eligible. Relevant outcomes included those at the individual, influencer, and institutional levels, along with those targeting research engagement and prevention-related outcomes.

Results

This EGM comprises 415 impact evaluations and 43 systematic reviews. Interventions like peer-led interactions, counseling, and community dialogues were the most dominant intervention sub-types. Despite increased digital penetration use of media and technology-driven interventions are relatively less studied. Most of the interventions were delivered by peers, health care providers, and educators, largely in school-based settings, and in many cases are part of sex-education curricula. Evidence across geographies was mostly concentrated in Sub-Saharan Africa (70%). Most measured outcomes focused on disease-related knowledge dissemination and enhancing awareness of available prevention options/strategies. These included messaging around consistent condom use, limiting sexual partners, routine testing, and awareness. Very few studies were able to include psychographic, social, and contextual factors influencing AGYW health behaviors and decisions, especially those measuring the impact of social and gender norms, relationship dynamics, and household dynamics-related outcomes. Outcomes related to engagement in the research were least studied.

Conclusion

This EGM highlights that evidence is heavily concentrated within the awareness-intent spectrum of behavior change and gets lean for outcomes situated within the intent-action and the action-habit formation spectrum of the behavior change continuum. Most of the evidence was concentrated on increasing awareness, knowledge, and building risk perception around SRH domains, however, fewer studies focused on strengthening the agency and self-efficacy of individuals. Similarly, evidence on extrinsic factors-such as strengthening social and community norms, relationships, and household dynamics-that determine individual thought and action such as negotiation and life skills were also found to be less populated. Few studies explore the effectiveness of these interventions across diverse AGYW identities, like pregnant women and new mothers, sex workers, and people living with HIV, leading to limited understanding of the use of these interventions across multiple user segments including key influencers such as young men, partners, families, religious leaders, and community elders was relatively low. There is a need for better quality evidence that accounts for the diversity of experiences within these populations to understand what interventions work, for whom, and toward what outcome. Further, the evidence for use of digital and mass-media tools remains poorly populated. Given the increasing penetration of these tools and growing media literacy on one end, with widening gender-based gaps on the other, it is imperative to gather more high-quality evidence on their effectiveness. Timely evidence generation can help leverage these platforms appropriately and enable intervention designs that are responsive to changing communication ecologies of AGYW. SBCC can play a critical role in helping researchers meaningfully engage and collaborate with communities as equal stakeholders, however, this remains poorly evidenced and calls for investigation and investment. A full list of abbreviations and acronyms are available in Supporting Information: Appendix F.

Implementing Task-Shared Child and Adolescent Psychological Interventions in Low- and Middle-Income Countries: A Scoping Review

OBJECTIVE

Effective "task shared," or nonspecialist delivered, psychological interventions for children and adolescents have been developed or adapted in low- and middle-income countries with the aim of closing the global treatment gap for youth mental health care. Yet, delivery remains limited, in part due to the lack of knowledge of associated implementation, or process, outcomes. This scoping review aims to describe, examine the quality of, and synthesize findings on implementation outcomes of child and adolescent psychological interventions in low-and middle-income countries.

METHODS

PubMed, Web of Science, and PsycInfo were searched for studies on child and adolescent psychological interventions in low- and middle-income countries reporting on implementation outcomes. After abstract and full-text review, data were extracted and summarized on implementation outcomes and quality of implementation outcomes reporting. Implementation barriers and recommendations for addressing barriers were also charted and narratively synthesized.

RESULTS

Out of 5,207 manuscripts, 86 met inclusion criteria. Younger children were underrepresented. Studies largely reported feasibility and acceptability and did not state hypotheses or use conceptual models. Barriers primarily related to interventions being too complex, not an acceptable fit with participant cultures, and facilitators lacking time for or experiencing distress delivering interventions. Recommendations focused on increasing intervention fit and flexibility, training and support for facilitators, and linkages with existing systems.

CONCLUSIONS

Rigorous, broader implementation outcomes research is needed within child and adolescent psychological intervention research in low-and middle-income countries. Current evidence suggests the importance of the further developing strategies to increase acceptability to participants and better support facilitators.

Understanding Oral Prep Interest Among South African Adolescents: The Role of Perceived Parental Support and PrEP Stigma

We examined oral PrEP interest among adolescents and its association with perceived parental support and PrEP stigma. Cross-sectional data were collected during baseline procedures of the "Our Family Our Future" intervention trial in South Africa. Adolescents (14-16 years) at elevated risk for acquiring HIV and their parents or caregivers were dyadically enrolled from 2018 to 2021. There were 879 complete adolescent-parent dyads. Among adolescents, 27% had heard about PrEP, 67% reported they would want to use PrEP, and 58% thought their parent would want them to use PrEP. Among parents, 33% had heard about PrEP and 85% reported they would want their adolescent to use PrEP. Adolescents who thought their parent would want them to use PrEP were more likely to be interested in PrEP than adolescents who thought their parent would not want them to use PrEP (adjusted prevalence ratio (aPR) = 2.11, 95% CI 1.82, 2.44). Further, adolescents with higher average PrEP stigma scores above the adolescent sample median were less likely to be interested in PrEP than adolescents with lower average PrEP stigma scores (aPR = 0.81, 95% CI 0.72, 0.91). In conclusion, parents were more supportive of their adolescent taking PrEP than adolescents perceived they would be, and perceptions of low parental support and greater PrEP stigma were associated with reduced PrEP interest among adolescents. Interventions should aim to improve adolescent-parent communication around sexual health and effective HIV prevention tools.

Implementation Science for the Prevention and Treatment of HIV among Adolescents and Young Adults in Sub-Saharan Africa: A Scoping Review

Despite many evidence-based adolescent and young adult (AYA) HIV interventions, few are implemented at scale in sub-Saharan Africa (SSA). A growing implementation science literature provides important context for scaling up AYA HIV interventions in this high HIV-burden region. This scoping review examined the use of implementation research in AYA HIV studies conducted in SSA. We searched five databases and included articles which focused on AYA (10-24 years old), addressed HIV prevention or treatment, were conducted exclusively in SSA countries, and included an implementation science outcome. We included 44 articles in 13 SSA countries. Most were in East (52.3%) and South Africa (27.3%), and half focused exclusively on HIV prevention components of the care continuum. Acceptability and feasibility were the most cited implementation science outcomes. Only four articles used an established implementation science framework. The findings informed our recommendations to guide the design, implementation, and dissemination of further studies and health policymaking.

Decade of research into the acceptability of interventions aimed at improving adolescent and youth health and social outcomes in Africa: a systematic review and evidence map

OBJECTIVE

Interventions aimed at improving adolescent health and social outcomes are more likely to be successful if the young people they target find them acceptable. However, no standard definitions or indicators exist to assess acceptability. Acceptability research with adolescents in low-and-middle-income countries (LMICs) is still limited and no known reviews systhesise the evidence from Africa. This paper maps and qualitatively synthesises the scope, characteristics and findings of these studies, including definitions of acceptability, methods used, the type and objectives of interventions assessed, and overall findings on adolescent acceptability.

DESIGN

We conducted a systematic review of peer-reviewed studies assessing intervention acceptability with young adults (aged 10-24) in Africa, published between January 2010 and June 2020.

DATA SOURCES

Web of Science, Medline, PsycINFO, SociIndex, CINAHL, Africa-wide, Academic Search Complete and PubMed were searched through July 2020.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Papers were selected based on the following inclusion criteria: if they (1) reported primary research assessing acceptability (based on the authors' definition of the study or findings) of one or more intervention(s) with adolescents and young adults 10-24; (2) assessed acceptability of intervention(s) aimed at positively influencing one or more development outcome(s), as defined by sustainable development goal (SDG) indicators; (3) reported on research conducted in Africa; (4) were in the English Language; (5) were peer-reviewed and and (6) were published between 1 January 2010 and 30 June 2020.

DATA EXTRACTION AND SYNTHESIS

Abstracts were reviewed independently by the two first authors to determine relevance. Full text of potentially eligible studies were retrieved and independently examined by the same two authors; areas of disagreement or lack of clarity were resolved through discussion by the two authors and-where necessary-the assessment of a third author.

RESULTS

55 studies were considered eligible for inclusion in the review. Most studies were conducted in Southern Africa, of which 32 jointly in South Africa and Uganda. The majority of interventions assessed for acceptability could be classified as HIV or HPV vaccine interventions (10), E-health (10), HIV testing interventions (8), support group interventions (7) and contraceptive interventions (6). The objectives of most interventions were linked to SDG3, specifically to HIV and sexual and reproductive health. Acceptability was overall high among these published studies. 22 studies provided reasons for acceptability or lack thereof, some specific to particular types of interventions and others common across intervention types.

CONCLUSIONS

Our review exposes considerable scope for future acceptability research and review work. This should include extending acceptability research beyond the health (and particularly HIV) sector and to regions in Africa where this type of research is still scarce; including adolescents earlier, and potentially throughout the intervention process; further conceptualising the construct of acceptability among adolescents and beyond; and examining the relationship between acceptability and uptake.

Advancing a cascading train-the-trainer model of frontline HIV service providers in South Africa: protocol of an implementation trial

BACKGROUND

South Africa is marked by high rates of both HIV and alcohol use, and there is a detrimental synergistic relationship between these two epidemics. The Institute of Medicine recommends integrated care for alcohol use treatment and HIV, but implementation of integrated services remains a challenge in South Africa. This protocol describes a study designed to evaluate trainer, provider-, and patient encounter-level outcomes relating to the national rollout of a cascade train-the-trainer model of task-sharing to build capacity of the HIV workforce to deliver Screening, Brief Intervention, and Referral to Treatment (SBIRT) to address risky alcohol use.

METHODS

This 5 year protocol consists of two phases. First, we will finalize development of a robust SBIRT train-the-trainer model, which will include an SBIRT Trainer Manual, Provider Resource Guide, fidelity observational coding system, case vignettes, and a curriculum for ongoing consultation sessions. Materials will be designed to build the capacity of novice trainers to train lay workers to deliver SBIRT with fidelity. Second, we will recruit 24-36 trainers and 900 providers in order to evaluate the effects of the SBIRT train-the-trainer model on trainer- (e.g., fidelity, knowledge), provider- (e.g., SBIRT attitudes, confidence, acceptability), and patient encounter- (e.g., proportion receiving screening, brief intervention, referral to treatment) level variables. Data on patient encounters will be tracked by providers on programmed tablets or scannable paper forms in real-time. Providers will report on SBIRT delivery on an ongoing basis over a 6-months period. Additionally, we will test the hypothesis that trainer-level factors will account for a substantial proportion of variability in provider-level factors which will, in turn, account for a substantial proportion of variability in patient encounter-level outcomes.

DISCUSSION

This protocol will allow us to take advantage of a unique national training initiative to gather comprehensive data on multi-level factors associated with the implementation of SBIRT in HIV service settings. In the long-term, this research can help to advance the implementation of integrated alcohol-HIV services, providing lessons that can extend to other low-and-middle income countries confronting dual epidemics.

Bullying and ART Nonadherence Among South African ALHIV: Effects, Risks, and Protective Factors

BACKGROUND

Identifying risk and protective factors for adolescent antiretroviral therapy (ART) adherence is a public health priority, given high HIV-related mortality in this population. An area that merits further investigation is the relationship between bullying victimization, mental health problems, and ART nonadherence among adolescents living with HIV (ALHIV). However, no known studies assess effects of bullying on adolescent nonadherence or risk and protective factors that could moderate this relationship.

SETTING

This study investigates (1) the direct longitudinal relationship between bullying exposure and ART nonadherence, and the indirect relationship via psychological distress, and (2) potential risk and modifiable protective factors moderating these pathways, among vertically and horizontally infected ALHIV who initiated treatment across 53 public health care facilities in a South African health district.

METHODS

Survey data were collected at 2 time points, between 2014 and 2017, with 1046 ALHIV (94% retention). Various mediation and moderated mediation models were run as part of a staged analysis approach.

RESULTS

A significant longitudinal relationship was found between bullying victimization and nonadherence, operating indirectly through psychological distress [B = 0.07; 95% confidence interval (CI): (0.03 to 0.13)]. Moderation analyses indicated that older adolescents exposed to bullying are more at risk of nonadherence [B = 0.52; 95% CI: (0.07 to 0.97) P < 0.05], and parental monitoring is a potential protective factor buffering indirect effects of bullying on nonadherence [B = -0.22; 95% CI: (-0.42 to -0.02) P < 0.05].

CONCLUSIONS

These findings underscore the importance of interventions that address bullying and psychological distress, and strengthen parental monitoring, particularly among older ALHIV.

Relationships with caregivers and mental health outcomes among adolescents living with HIV: a prospective cohort study in South Africa

BACKGROUND

Mental health problems may impact adherence to anti-retroviral treatment, retention in care, and consequently the survival of adolescents living with HIV. The adolescent-caregiver relationship is an important potential source of resilience. However, there is a lack of longitudinal research in sub-Saharan Africa on which aspects of adolescent-caregiver relationships can promote mental health among adolescents living with HIV. We draw on a prospective longitudinal cohort study undertaken in South Africa to address this question.

METHODS

The study traced adolescents aged 10-19 initiated on antiretroviral treatment in government health facilities (n = 53) within a health district of the Eastern Cape province. The adolescents completed standardised questionnaires during three data collection waves between 2014 and 2018. We used within-between multilevel regressions to examine the links between three aspects of adolescent-caregiver relationships (caregiver supervision, positive caregiving, and adolescent-caregiver communication) and adolescent mental health (depression symptoms and anxiety symptoms), controlling for potential confounders (age, sex, rural/urban residence, mode of infection, household resources), n=926 adolescents.

RESULTS

Improvements in caregiver supervision were associated with reductions in anxiety (0.98, 95% CI 0.97-0.99, p=0.0002) but not depression symptoms (0.99, 95% CI 0.98-1.00, p=.151), while changes in positive caregiving were not associated with changes in mental health symptoms reported by adolescents. Improvements in adolescent-caregiver communication over time were associated with reductions in both depression (IRR=0.94, 95% CI 0.92-0.97, p<.0001) and anxiety (0.91, 95% CI 0.89-0.94, p<.0001) symptoms reported by adolescents.

CONCLUSIONS

Findings highlight open and supportive adolescent-caregiver communication and good caregiver supervision as potential factors for guarding against mental health problems among adolescents living with HIV in South Africa. Several evidence-informed parenting programmes aim to improve adolescent-caregiver communication and caregiver supervision, and their effect on depression and anxiety among adolescents living with HIV should be rigorously tested in sub-Saharan Africa. How to improve communication in other settings, such as schools and clinics, and provide communication support for caregivers, adolescents, and service providers through these existing services should also be considered.