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Social networks expand rapidly in adolescence, increasing HIV status disclosure considerations and concerns for young people living with HIV, especially in settings where HIV-related stigma is prevalent. This study examines HIV disclosure and enacted stigma among adolescents and young adults living with HIV in South Africa. This study uses survey data from a sample of 1186 youth living with HIV, aged 14-24, and enrolled in peer support groups led by community-based organizations in KwaZulu Natal and Gauteng provinces, South Africa. Study participants completed a questionnaire on sociodemographic details, physical health, school attendance, who knew the individual's HIV status, and experiences of HIV-related mistreatment. Mixed effects logistic regression examined the association between experiences of HIV-related mistreatment and factors that may inadvertently disclose one's status, such as poor physical health and missed school, and knowledge of an individual's HIV-positive status by their caregiver, household, friends, educators, and most recent sexual partner. Almost a quarter of the sample reported an experience of HIV-related mistreatment in the past six months. After controlling sociodemographic characteristics, missed school due to illness (AOR = 1.75, 95% CI = 1.27-2.43), and knowledge of HIV status by non-family members (AOR = 2.19, 95% CI = 1.60-3.00) were significantly associated with HIV-related mistreatment. Findings suggest that experiences of enacted stigma are common among youth and linked to poor physical health and knowledge of HIV status outside the family. Effective community-level stigma reduction interventions are urgently needed. In the meantime, adolescents need individualized disclosure counseling and support managing their physical health to prevent further inadvertent disclosure and discrimination.

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Adolescents and young adults living with HIV (AYLHIV) in sub-Saharan Africa experience poorer HIV outcomes than adults, including lower ART adherence and virologic suppression. They also have high rates of unprotected sex, increasing the risk of adverse sexual health outcomes and onward transmission. This one-arm, pre-post study investigates a structured 14-session support group aiming to boost treatment adherence and sexual protective behavior for AYLHIV in South Africa. Logistic and Poisson regression analyses were performed on self-reported pre- and post-intervention survey data collected approximately 7.5 months apart from a cohort of 548 AYLHIV. Participants were significantly more likely to report at least 95% adherence at follow-up and rate their health as "good;" they also demonstrated greater treatment knowledge and had fewer absences from school overall and due to illness. Among sexually active AYLHIV, contraception use at last sex increased significantly, while condom use did not. Effects were small, and greater programmatic emphasis on adherence and multifaceted service packages is likely necessary to promote viral suppression. Nonetheless, the intervention addresses an important gap in service provision for AYLHIV in South Africa. Findings denote the potential for incorporating care and treatment components into sexual and reproductive health interventions tailored for AYLHIV.

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This study examined adherence to antiretroviral therapy (ART) among adolescents and young adults living with HIV in South Africa. Using survey data from 857 youth on ART, the study employed latent class analysis to identify subgroups based on self-reported reasons for missed ART doses. Three distinct classes emerged: the largest class (85%) occasionally forgot to take their medication or missed a dose because others were around, the second class (9%) missed doses only due to feeling sick, and the third class (6%) faced multiple barriers such as forgetting, feeling sick, worrying about side effects, or doubting the effectiveness of ART. Youth who reported multiple barriers to adherence had significantly lower adjusted odds (AOR = 0.35, 95% CI = 0.16-0.78) of reporting 90% past month adherence compared to those who occasionally forgot their medication. Additionally, contextual factors such as food security, being treated well at the clinic, and being accompanied to the clinic were associated with higher odds of adherence. The findings highlight the importance of considering co-occurring barriers to adherence and tailoring interventions accordingly. Addressing contextual factors, such as ensuring food security and providing supportive clinic environments, is also crucial for promoting optimal adherence among adolescents and young adults living with HIV.

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BACKGROUND: Accurate estimation of intervention coverage is a vital component of malaria program monitoring and evaluation, both for process evaluation (how well program targets are achieved), and impact evaluation (whether intervention coverage had an impact on malaria burden). There is growing interest in maximizing the utility of program data to generate interim estimates of intervention coverage in the periods between large-scale cross-sectional surveys (the gold standard). As such, this study aimed to identify relevant concepts and themes that may guide future optimization of intervention coverage estimation using routinely collected data, or data collected during and following intervention campaigns, with a particular focus on strategies to define the denominator. METHODS: We conducted a scoping review of current practices to estimate malaria intervention coverage for insecticide-treated nets (ITNs); indoor residual spray (IRS); intermittent preventive treatment in pregnancy (IPTp); mass drug administration (MDA); and seasonal malaria chemoprevention (SMC) interventions; case management was excluded. Multiple databases were searched for relevant articles published from January 1, 2015 to June 1, 2018. Additionally, we identified and included other guidance relevant to estimating population denominators, with a focus on innovative techniques. RESULTS: While program data have the potential to provide intervention coverage data, there are still substantial challenges in selecting appropriate denominators. The review identified a lack of consistency in how coverage was defined and reported for each intervention type, with denominator estimation methods not clearly or consistently reported, and denominator estimates rarely triangulated with other data sources to present the feasible range of denominator values and consequently the range of likely coverage estimates. CONCLUSIONS: Though household survey-based estimates of intervention coverage remain the gold standard, efforts should be made to further standardize practices for generating interim measurements of intervention coverage from program data, and for estimating and reporting population denominators. This includes fully describing any projections or adjustments made to existing census or population data, exploring opportunities to validate available data by comparing with other sources, and explaining how the denominator has been restricted (or not) to reflect exclusion criteria.

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RATIONALE: Interventions that promote sexual health communication between adolescents and their parents or other primary caregivers are an important tool for reducing female adolescents' behavioral risk. Understanding the mechanisms by which interventions effectively foster communication can inform future programs. OBJECTIVE: An initial evaluation of Let's Talk, a structured, family-centered HIV prevention intervention for vulnerable adolescents in South Africa, found an increase in caregiver-adolescent sexual communication. This analysis expands upon initial findings to explore the role of parental knowledge, the quality of the parent-adolescent relationship, and the mental health of both parties on caregiver-adolescent sexual health communication. METHOD: Using mixed methods data collected in 2015 and 2016, structural equation modeling of differenced pre- and postintervention survey data from 64 female Let's Talk participants ages 13-17 and their caregivers was used to explore the pathway to increased frequency of caregiver-adolescent sexual health communication. Focus group discussions (FGDs) were held with intervention participants (n = 25) and facilitators (n = 6). RESULTS: The path analysis indicates that caregivers' mental health indirectly affected caregiver-adolescent relationship quality, and adolescents' mental health exerted a direct effect. Relationship quality, in turn, directly affected the level of parental sexual communication reported by the adolescent. FGDs suggested that cultural norms inhibit frank discussions between caregivers and adolescents about sexual health, but that thoughtfully designed interventions such as Let's Talk can mitigate this barrier. Qualitative findings also echoed quantitative findings about the role of caregiver-adolescent relationship quality and mental health on communication frequency and highlighted the importance of enhancing participants' technical knowledge and particularly their skills related to expression, listening, and anger management to help enable sensitive conversations. CONCLUSIONS: Findings overall suggest that a holistic intervention approach emphasizing caregiver-adolescent relationship development and designed to support the mental health of both parties may hold significant promise for enhancing sexual health communication.

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BACKGROUND: Child and youth care workers (CYCWs) are a crucial and growing component of South Africa's national response to HIV and AIDS and other issues affecting children and families. CYCWs use the community-centred Isibindi model of care to reach the most vulnerable with key services including psychosocial, health, economic and education support. Like others in similar professions, they may be at risk for occupational challenges affecting retention. METHODS: This study uses data from the first nationally representative survey of CYCWs in South Africa to identify factors associated with workers' retention intentions. Data were collected in 2015 as part of a formative evaluation conducted around the mid-point of a nationwide Isibindi programme expansion. A total of 1158 CYCWs from 78 sites participated. The response rate for the sample was 87%. Questions addressed demographics, work history, retention intentions, training, mentorship and supervision experiences, workload and remuneration. Mixed effects regression models with random intercepts for project site and mentor were used to estimate factors associated with retention intentions. RESULTS: High-quality mentorship and frequent supervision support retention intentions among CYCWs. Respondents who indicated that wanting to help children or the community was their primary motivator for seeking work as a CYCW were also more likely to report intending to continue working as a CYCW. High perceived workloads and feeling threatened or unsafe on the job were negatively associated with retention intentions. As CYCWs gained experience, they were also less likely to intend to stay. CONCLUSIONS: Understanding the factors affecting retention in the CYCW workforce is vital to helping vulnerable children and families across South Africa access key social and health services. Findings highlight the importance of mentoring and supervision as part of the Isibindi model and the value of support for manageable workloads, workplace safety, and career advancement opportunities for promoting worker retention.

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Let's Talk is a structured, family-centered adolescent HIV prevention program developed for use in South Africa using key components adapted from programs successfully implemented in the US and South Africa. It is designed to address individual HIV transmission risk factors common among orphaned and vulnerable adolescents, including elevated risk for poor psychological health and sexual risk behavior. These efforts are accentuated through parallel programing to support caregivers' mental health and parenting skills. Twelve Let's Talk groups, each serving approximately 10 families, were piloted by two local community-based organizations in Gauteng and Kwa-Zulu Natal provinces, South Africa. Face-to-face interviews were conducted among participating caregivers and adolescents at baseline and three months post-intervention to explore the potential effects of the program on intermediate outcomes that may support HIV preventive behavior. Specifically, generalized estimation equations were used to estimate average change on HIV prevention knowledge and self-efficacy, caregiver and adolescent mental health, and family dynamics. Among the 105 adolescents and their 95 caregivers who participated in Let's Talk and completed both surveys, statistically significant improvements were found for adolescents' HIV and condom use knowledge as well as condom negotiation self-efficacy, but not sexual refusal self-efficacy. Both caregivers and adolescents demonstrated significantly better mental health at post-test. Adolescent/caregiver connection and communication about healthy sexuality also improved. These preliminary results highlight the potential of HIV prevention interventions that engage caregivers alongside the vulnerable adolescents in their care to mitigate adolescent HIV risk factors. A more rigorous evaluation is warranted to substantiate these effects and identify their impact on adolescents' risk behavior and HIV incidence.

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Preventing HIV among young people is critical to achieving and sustaining global epidemic control. Evidence from Western settings suggests that family-centred prevention interventions may be associated with greater reductions in risk behaviour than standard adolescent-only models. Despite this, family-centred models for adolescent HIV prevention are nearly non-existent in South Africa - home to more people living with HIV than any other country. This paper describes the development and formative evaluation of one such intervention: an evidence-informed, locally relevant, adolescent prevention intervention engaging caregivers as co-participants. The programme, originally consisting of 19 sessions for caregivers and 14 for adolescents, was piloted with 12 groups of caregiver-adolescent dyads by community-based organizations (CBOs) in KwaZulu-Natal and Gauteng provinces. Literature and expert reviews were employed in the development process, and evaluation methods included analysis of attendance records, session-level fidelity checklists and facilitator feedback forms collected during the programme pilot. Facilitator focus group discussions and an implementer programme workshop were also held. Results highlighted the need to enhance training content related to cognitive behavioural theory and group management techniques, as well as increase the cultural relevance of activities in the curriculum. Participant attendance challenges were also identified, leading to a shortened and simplified session set. Findings overall were used to finalize materials and guidance for a revised 14-week group programme consisting of individual and joint sessions for adolescents and their caregivers, which may be implemented by community-based facilitators in other settings.

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To our knowledge, this is the first study to document correlates of complicated grief among bereaved adolescents in sub-Saharan Africa. Participants included 339 female adolescents in South Africa who experienced the loss of a loved one at least six months prior to the survey; their primary caregivers were also surveyed. One-fifth of adolescents were classified as having complicated grief using the Inventory of Complicated Grief Revised for Children in conjunction with grief-induced functional impairment. The loss of a biological parent, the primary caregiver's level of grief, and economic stressors since the loss were associated with increased odds of complicated grief among adolescents. Adolescents' age, residential changes, time since the loss, multiple losses, bereavement due to death by illness, and caregiver depression did not affect the odds. Findings signal the potential of family-centered interventions and economic support services for bereaved adolescents.

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BACKGROUND: Bereavement increases children's risk for psychological disorders, highlighting the need for effective interventions, especially in areas where orphanhood is common. We aimed to assess the effects of an eight-session support group intervention on the psychological health of bereaved female adolescents in South Africa. METHODS: This randomised controlled trial enrolled female adolescents at 11 schools in three peri-urban towns of Free State province, South Africa. 453 bereaved ninth-grade students aged 13-17 years who had expressed interest in taking part in the group were randomly assigned (1:1) to receive the intervention or to be waitlisted for programme enrolment after the study period and serve as the control group. The intervention, Abangane ("friends" in isiZulu), is a locally derived, curriculum-based support group focused on coping with loss incorporating indigenous stories and cognitive behavioural therapy components. Weekly group sessions were facilitated by trained social workers or social auxiliary workers from a local non-profit organisation. The primary outcomes included indicators of grief and depression as reported by adolescents and behavioural problems reported by their caregivers. Grief was measured with three scales: the grief subscale of the Core Bereavement Items to assess normative grief; and the Intrusive Grief Thoughts Scale and the Inventory of Complicated Grief-Revised for Children to assess maladaptive grief symptoms in the past 4 weeks. Depression symptoms in the past 7 days were measured with the Center for Epidemiological Studies-Depression Scale for Children. Caregivers completed the Brief Problem Monitor-Parent Form to report on adolescent's behaviour in the previous 4 weeks. Analysis was intention to treat. This study is registered with ClinicalTrials.gov, number NCT02368808. FINDINGS: Between Sept 30, 2014, and Feb 5, 2015, eligible female participants were identified, of whom 226 were assigned to the intervention, Abangane, and 227 were assigned to the waitlisted control group. Analysis included 382 adolescents who completed both surveys (193 participants assigned to Abangane and 189 assigned to waitlist). At follow up, the intervention group had significantly lower scores for primary outcomes, including intrusive grief (p=0·000, Cohen's d=-0·21), complicated grief (p=0·015, d=-0·14), and depression (p=0·009, d=-0·21) relative to the waitlisted group, while core bereavement scores were similar between groups (p=0·269). Caregivers in the intervention group reported lower levels of behavioural problems among adolescents (p=0·017, d=-0·31). INTERPRETATION: Short-term, structured, theory-based support groups with contextually relevant content show promise in mitigating psychological and behavioural problems among bereaved adolescents. Abangane is replicable in resource limited settings, using freely available curriculum materials, existing programme structures, and appropriately trained personnel to implement it. FUNDING: US Agency for International Development Southern Africa.

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BACKGROUND: Children and adolescents affected by HIV are at elevated risk of depression, yet research on related interventions in this population is scarce in sub-Saharan Africa. This study sought to examine the effects of interpersonal psychotherapy for groups (IPTG) on depressive symptomology among orphaned and vulnerable adolescents in South Africa. METHOD: A cluster randomized controlled trial wherein adolescents ages 14-17 enrolled in community-based programming for HIV-affected and vulnerable families were randomly assigned by geographic cluster to participate in a 16-session IPTG intervention or the standard of care (n = 489). Baseline and postintervention surveys conducted with enrollees included standardized depression screening. Utilizing an intent-to-treat design, mixed effects models were performed to examine treatment effects for all participants and potential moderators including gender and baseline depression level (Clinical Trials registration: ClinicalTrials.gov NCT02386878). RESULTS: While 23% of adolescents in the intervention group did not attend any IPTG sessions, average attendance was 12 out of 16 possible sessions among participants. The intervention was not associated with changes in depression symptomology. CONCLUSIONS: Results underscore the importance of mitigating participation barriers prior to intervention roll-out and the need for increased evidence for psychological health interventions to mitigate depression among orphaned and vulnerable adolescents. This intervention and the study selectively targeted at-risk adolescents versus using diagnostic mental health criteria for enrollment; more research is needed to identify the potential benefits and disadvantages of these approaches.

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HIV places acute stressors on affected children and families; especially in resource limited contexts like sub-Saharan Africa. Despite their importance, the epidemic's potential consequences for family dynamics and children's psychological health are understudied. Using a population-based sample of 2,487 caregivers and 3,423 children aged 8-14 years from the Central Province of Kenya, analyses were conducted to examine whether parental illness and loss were associated with family functioning and children's externalizing behaviors. After controlling for demographics, a significant relationship between parental illness and externalizing behaviors was found among children of both genders. Orphan status was associated with behavioral problems among only girls. Regardless of gender, children experiencing both parental loss and illness fared the worst. Family functioning measured from the perspective of both caregivers and children also had an independent and important relationship with behavioral problems. Findings suggest that psychological and behavioral health needs may be elevated in households coping with serious illness and reiterate the importance of a family-centered approach for HIV-affected children.

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Home visiting is a popular component of programs for HIV-affected children in sub-Saharan Africa, but its implementation varies widely. While some home visitors are lay volunteers, other programs invest in more highly trained paraprofessional staff. This paper describes a study investigating whether additional investment in paraprofessional staffing translated into higher quality service delivery in one program context. Beneficiary children and caregivers at sites in KwaZulu-Natal, South Africa were interviewed after 2 years of program enrollment and asked to report about their experiences with home visiting. Analysis focused on intervention exposure, including visit intensity, duration and the kinds of emotional, informational and tangible support provided. Few beneficiaries reported receiving home visits in program models primarily driven by lay volunteers; when visits did occur, they were shorter and more infrequent. Paraprofessional-driven programs not only provided significantly more home visits, but also provided greater interaction with the child, communication on a larger variety of topics, and more tangible support to caregivers. These results suggest that programs that invest in compensation and extensive training for home visitors are better able to serve and retain beneficiaries, and they support a move toward establishing a professional workforce of home visitors to support vulnerable children and families in South Africa.