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ISSUE ADDRESSED: The accessibility of opioid substitution therapy (OST), one of the recommended treatments for opioid dependence, remains low. This study sought to explore the perceived effectiveness of OST from the perspectives of peer outreach workers and OST clients in a community-based harm reduction programme. METHODS: The research was done within the Community-Oriented Substance Use Programme (COSUP) in Tshwane, South Africa. Fifteen peer educators (13 males and 2 females) took part in two focus group discussions. Thereafter, there were semi-structured interviews in which 15 OST clients (11 males and 4 females) participated. A convenience cross-sectional study was used. Interviews were audio-recorded. Using thematic analysis, themes were examined to evaluate how OST and the harm reduction approach were perceived to contribute to the improved health status of people with opioid dependence. RESULTS: Peer outreach workers and COSUP clients significantly endorsed OST as an effective treatment for opioid dependence. Participants perceived greater effectiveness of OST compared to abstinence-centred inpatient rehabilitation programmes. However, there were sentiments that more community education on OST was needed to motivate people with opioid dependence to access services and to address misconceptions about OST. CONCLUSIONS: There is a lack of multi-level and multi-sectoral engagement of various stakeholders in opioid dependence services, needed to accelerate utilisation of OST services. SO WHAT?: The research unpacks the need for an integrated approach to service use optimisation, and the need to evaluate the role that increased awareness and community education on harm reduction strategies can play in enhancing the utilisation of OST services.

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BACKGROUND: Despite increasing substance use globally, substance use treatment utilisation remains low. This study sought to explore and measure substance use treatment barriers among young adults in South Africa. METHODS: The study was done in collaboration with the Community-Oriented Substance Use Programme run in Tshwane, South Africa. A mixed methods approach employing focus group discussions with key informants (n = 15), a survey with a random sample of people using substances and receiving treatment (n = 206), and individual semi-structured interviews (n = 15) was used. Descriptive statistics and thematic analysis were used to analyse data. RESULTS: Contextual barriers seemed more prominent than attitudinal barriers in the South African context. Fragmented services, stigma-related factors, an information gap and lack of resources and support (contextual factors), perceived lack of treatment efficacy, privacy concerns, and denial and unreadiness to give up (attitudinal factors) were treatment barriers that emerged as themes in both quantitative and qualitative data. Culture and religion/spirituality emerged as an important barrier/facilitator theme in the qualitative data. CONCLUSION: Interventions need to embrace contextual factors such as culture, and more resources should be channelled towards substance use treatment. Multi-level stakeholder engagement is needed to minimise stigmatising behaviours from the community and to raise awareness of available treatment services. There is a need for strategies to integrate cultural factors, such as religion/spirituality and traditional healing, into treatment processes so that they complementarily work together with pharmacological treatments to improve health outcomes.

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Khuluma is a psychosocial and peer-to-peer mHealth intervention that uses text messaging to facilitate support groups for adolescents living with HIV (ALWH) with the aim of contributing toward positive health outcomes. Although use of mobile technology in the form of mHealth interventions has proliferated recently in the field of health, published literature describing methods and processes of its application are limited. We present a set of methods and processes utilised to develop and pilot the Khuluma mHealth intervention amongst young people (15-20 years) in South Africa. We recruited and enrolled 52 adolescents (15-20-year olds) from four clinics in Pretoria and Cape Town to participate in a 6-month pilot of Khuluma. Participants were ALWH, aware of their status, on antiretroviral therapy for more than 12 months, and not suffering from severe depression. We conducted four pre and post intervention focus group discussions (FGDs) with a proportion of ALWH (n = 36) enrolled in the pilot study using participatory methods. Several processes were utilised to then implement this pilot study. These included engaging ALWH for minor study implementation modifications; forming virtual groups; activating the mHealth platform; facilitating and delivering the Khuluma intervention. The acceptability of the intervention was informed by follow-up focus group discussions and text message data. The initial participatory processes helped to tailor the intervention design to participants' needs. The peer-led facilitation of the groups allowed for the provision of sensitive psychosocial support that allowed young people to express themselves freely, develop a sense of self-worth, and interact more. The nature of the mobile technology also allowed participants to build friendships beyond their geographic area and interact with their peers in real time. Within the evolving context of COVID-19, establishing evidence-based processes and methods for intervention design and curation in virtual spaces is critical.

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Objective: The study explored whether orphanhood status as well as coping strategies predicted mental health outcomes in orphans and vulnerable adolescents who participated in an NGO-supported programme in rural South Africa.Method: Participants comprised 175 adolescents (aged 11-18 years) from a low-resource community, and included non-orphans (n = 57), orphans due to AIDS (n = 62) and orphans due to other causes (n = 56). All participants rated themselves on the age-appropriate Youth Self-Report scales and 95 completed the Children's Coping Strategies Checklist (CCSC). Little's test of data missing completely at random revealed that the CCSC missing data did not display a specific pattern.Results: Active coping negatively predicted internalising, externalising and general psychological problems, while avoidant coping predicted general psychological problems. Orphanhood group status, sex and age did not predict coping strategies used. A higher proportion of orphans by AIDS had elevated scores of internalising problems and all participants on somatic complaints.Conclusions: Active coping strategies minimise the risk for emotional and behavioural problems among the participants. Our findings suggest that agencies and non-governmental organisations that provide services to vulnerable adolescents can facilitate active coping skills to enhance their psychological well-being.

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The COVID-19 pandemic and ensuing lockdown had a profound effect on human life. This research explores the influence of COVID-19-related experiences on the emotional wellbeing and mental health of South African university students 3 months into the pandemic. Research data were obtained from an online survey completed by 5074 students. Students reported difficulties in coping with psychological challenges during the lockdown: 45.6% and 35.0% reported subjective experiences of anxiety and depression, respectively. Students scored low on the mental health continuum. Hierarchical stepwise multiple regression analyses showed that some different dimensions predicted emotional difficulties or wellbeing and mental health - confirming the two continuum theory of Keyes. Students' serious discomfort during lockdown, difficulty adjusting academically and feeling socially isolated contributed most to emotional difficulties. Females, students in their early years of study and students residing in informal settlements were most at risk of experiencing emotional difficulties. Mental health was most predicted by students' hopefulness. Social, academic, spiritual and physical wellbeing and positive coping strategies influenced both emotional difficulties and mental health. The research serves to alert university authorities to students' emotional wellbeing, especially of first-year students and students with limited resources. The results could assist university psychological services to provide appropriate support services to enhance students' adjustment and promote their mental health amid a public health crisis.

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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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Mothers living with HIV are faced with the dilemma of when and how to disclose their HIV-positive status to their young uninfected children. In this study, a South African sample of mothers living with HIV, with young uninfected children (6-10 years) in the city of Tshwane was studied. In the sample of 406 mothers, 11.6% reported that they disclosed their HIV status to their young uninfected children. The research compared 47 mothers who disclosed (29 full disclosure and 18 partial disclosure) and a random sample of 50 mothers who did not disclose to their children, in terms of depression symptoms, parenting stress and coping strategies. The results showed that single and widowed mothers disclosed significantly more to their uninfected young children than mothers who had partners or were married. Mothers in the three disclosure groups did not differ in their experience of depression symptoms, parental distress and coping styles. Mothers who disclosed partially reported less parent-child dysfunctional interaction. Time since disclosure did not influence level of disclosure and was not significantly related to psychological outcome of mothers. Mothers who disclosed reported significantly more emotional and instrumental support as coping strategies than mothers who did not disclose. Mothers thus mostly disclose their status to their children to gain support and family closeness. Mothers who disclosed and had not disclosed did not differ in terms of psychological variables. Some mothers perceived partial disclosure as age-appropriate for young children. It is recommended that HIV-positive mothers receive psychosocial support services to equip them to disclose their health status in an age-appropriate way to their children, as it is documented that maternal disclosure benefits both mother and child.

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A mobile-based behavioural change program iloveLive.mobi was implemented to prevent HIV among young people (12-24 years) in South Africa. The mobile site offered access to sexual and reproductive health and psychosocial information through interactive learning. The site provided incentives for positive behaviour (such as HIV testing). The research aimed to evaluate the effectiveness of the iloveLife.mobi site in promoting protective behaviour of users. A mixed-methods approach was used, including document review, KAPB survey (n = 1882), group discussions (n = 68) and telephonic interviews (n = 175) with users and interviews with 46 project and community stakeholders. The SRH and psychosocial information on the site was age-appropriate and useful to young people (82.2%). The site reached young men who are generally difficult to reach with SRH information. High-frequency users reported more confidence related to condom use and HIV testing and more protective behaviour (condom use, VMMC) compared to low-frequency users. Users also reported more protective behaviour (HIV testing, VMMC, condom use) than a comparable national sample. iloveLife.mobi became a repository for learning to reach young people with health information. The research highlights key issues to consider when implementing an mHealth platform in a low- or middle-income country, where literacy levels and technical infrastructure may cause challenges.

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The study explored constructions of sexuality among young people of Venda in Limpopo, South Africa, and cultural practices that can be used to develop context-specific HIV prevention programmes. HIV prevention can be promoted by including some cultural practices in prevention programmes and changing some aspects of culture that may contribute negatively to health. Six focus group discussions were held with school-going young people (Grades 10 to 12) in urban and rural areas to explore their constructions of sexuality and HIV risk. Four focus group discussions were held with community leaders in the same areas to explore their constructions of young people's sexuality and cultural practices relevant to HIV prevention. Through discourse analysis, the following dominant discourses that influence young people's sexual risk behaviour were identified: rite of passage, the male sexual drive discourse (sex is natural and unavoidable); discourse of hegemonic masculinity (sex to prove masculinity); sex as a commodity; non-adherence to cultural practices; and HIV is normalised (AIDS is like flu). Some alternative constructions and shifts in gender norms were noticed, especially among female participants. The constructions of young people were not culture-specific but similar to those identified in other South African cultures. Community leaders identified a few cultural practices that could be considered in HIV prevention, for example, reinstating the rite of passage to provide age-appropriate sex and HIV education (behavioural intervention), and promoting traditional male circumcision (biological intervention). Cultural practices that contribute negatively to health should be challenged such as current constructions of gender roles (masculinity and femininity) and the practice that parents do not talk to young people about sex (both structural interventions).

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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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A critical component of an AIDS-free generation is to reduce HIV-related stigma. Previous research predicted that stigma would decline over time with increased contact with PLWH, understanding of the disease and availability of treatment. The aim of the research was to explore change in stigma over a 12-year period, by comparing data collected from two large cross-sectional samples from South African communities in 2004 (before the roll-out of antiretroviral treatment (ART)) and in 2016. Students recruited respondents according to criteria related to age, gender, race and area of living. A survey assessing moral judgement and interpersonal distance was used to assess personal and perceived community stigma. Responses to ten identical items used in the 2004 and 2016 data collection were compared. Personal stigma attached to HIV decreased significantly over time, except in respect of having close contact with PLWH, such as dating and befriending. Perceived community stigma remained high in all subgroups. It is argued that perceived community stigma contributes to high levels of internalised stigma among PLWH. Interventions should focus on helping PLWH to cope with perceived stigma and strategies to address stereotyping, which contributes to perceived community stigma.

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The study explores the experiences of volunteer community care workers working with HIV-affected families, participating in laughter therapy. Laughter therapy is being used as an intervention to positively influence individuals experiencing various forms of emotional distress. Community care workers play a vital role in the support of the HIV/AIDS-infected and -affected members in communities. The nature of this type of work and their limited training contributes to high levels of secondary trauma and emotional exhaustion. The purpose of the study was firstly, to explore the effects of working with orphans and vulnerable children (OVC) on the community care workers and secondly, to establish the impact that laughter therapy has to positively combat stresses of working within the care workers' environment. All the community care workers from a community-based organisation that provides care for HIV/AIDS-infected and -affected OVC and their families in the greater region of Soweto, South Africa, took part in daily laughter therapy sessions for one month. To assess the experiences of participants of laughter therapy, seven community care workers agreed to participate in a mixed method assessment. Interviews were conducted before and after the intervention using the Interpretative Phenomenological Analysis as framework. As supportive data, a stress and anxiety and depression scale were added in the interview. Participants reported more positive emotions, positive coping, improved interpersonal relationships and improvement in their care work after exposure to laughter therapy. Quantitative results on stress, anxiety and depression for each participant confirmed observed changes. Laughter therapy as a self-care technique has potential as a low-cost intervention strategy to reduce stress and counteract negative emotions among people working in highly emotional environments.

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The aim of the research was to gain increased knowledge regarding the sexual risk behaviour of school-going young people in South Africa after two decades of HIV-education in schools, to contribute to the development of improved HIV prevention strategies. In collaboration with the Department of Education, a sample of 5305 learners (between 10 and 18 years in Grades 5-12) from high-risk communities were identified. They completed a survey that assessed self-reported sexual risk behaviour and variables that potentially underlie sexual risk, such as attitudes towards preventive behaviour, perceived social norms and self-efficacy (based on the theory of planned behaviour [TPB]) and social factors like caregiver relationships and gender norms (based on the social ecological theory). Lifetime sex was reported by 49.4% of boys and 30.5% of girls in Grades 8-12, while 56% of the sexually active young people reported consistent condom use. Accurate knowledge about HIV transmission was low (37.8%). Regression analysis showed that risk behaviour was more prominent among older male youths, who perceived social norms as encouraging sexual activity, who use alcohol excessively, and who have negative attitudes towards abstinence. Perceived traditional community gender norms and negative relationships with caregivers were also associated with sexual risk behaviour. This research showed that the TPB can be used in planning HIV prevention interventions for young people. It also revealed that HIV-prevention strategies should focus beyond educating the individual, to address community factors such as improving caregiver relationships, the culture of substance abuse, peer group norms and inequality in community gender norms. These community processes influence young people's behaviour and need to be addressed to allow the youth to make healthy behavioural choices.

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OBJECTIVE: We examined several indicators of psychological health in a sample of orphans and vulnerable children (OVC) to determine if there were significant differences between those orphaned by AIDS and those orphaned by other causes, and if there were gender differences. METHOD: Our sample consisted of 119 young children (ages 6-10 years) who participated in a non-governmental organisation (NGO)-supported social services programme in a low-resource, non-urban community in South Africa. We collected data on three groups: non-orphans (OVC1; n = 45); orphans due to AIDS (OVC2; n = 43); and other orphans (OVC3; n = 31). Parents of non-orphans and legal guardians of orphans rated their children on a 112-item, age appropriate Child Behaviour Checklist (CBCL), South Africa version. RESULTS: Children in the OVC2 group were significantly different from their peers on Internalising Problems and Somatic Complaints, while OVC3 group had a higher proportion of children in the at-risk range on Social Problems compared to OVC2. Females had elevated scores on the anxious/depressed, internalising problems, total problems, and sluggish cognitive tempo scales compared to males. There was an interaction between factors, such that boys in OVC2 had elevated mean scores on Somatic Complaints. These findings suggest increased vulnerability for girls on emotional issues and for boys on somatic problems.

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The HIV testing, treatment and care programme of the South African public healthcare system depends on HIV counselling and testing (HCT) that is primarily delivered by lay counsellors. Lay counsellors are expected to educate clients about HIV/AIDS, advocate behaviour change, convey test results and support those infected and affected to cope with the emotional and social challenges associated with HIV/AIDS. This research focuses on the emotional wellbeing of lay HCT counsellors because this influences the quality of services they provide. A mixed methods approach was used. The emotional wellbeing, level of burnout, depression and coping style of 50 lay HCT counsellors working at the City of Tshwane clinics were assessed. Additionally, five focus group discussions were conducted. The results showed that HCT counsellors reported average emotional wellbeing, high levels of emotional exhaustion and depression. They had a sense of personal accomplishment and positive coping skills. The results revealed that they may have difficulty dealing with clients' emotional distress without adequate training and supervision. This creates a dilemma for service delivery. In the light of the important role they play in service delivery, the role of the lay HCT counsellor needs to be reconsidered. HCT should develop as a profession with specific training and supervision to develop their emotional competencies to conduct effective counselling sessions.

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The reproductive desires of people living with HIV/AIDS (PLHIV) of low socioeconomic standing attending public health facilities in South Africa were studied. HIV-positive men, pregnant and non-pregnant women were recruited from two clinics at a large public hospital in Tshwane, South Africa. Individual interviews were used to explore the reproductive desires of HIV-positive participants. HIV counsellors' perceptions of their clients' reproductive desires were explored during focus group discussions. Parenthood proved to be an important factor to all participants in continuation of the family and establishing their gender identities, despite the possible risk of HIV transmission and community stigmatization. Different cultural procreation rules for men and women and stigmatizing attitudes towards PLHIV affected their reproductive decision making. Women had the dilemma of choosing which community expectations they wanted to fulfil. Community stigmatization towards PLHIV was visible in the negative attitudes of some HIV counsellors regarding HIV and procreation. Because the reproductive desires of PLHIV are currently not given high priority in HIV prevention and family planning in the public health sector in South Africa, the prevention of HIV transmission may be jeopardized. These results necessitate the integration of HIV and sexual and reproductive health counselling on a primary health care level.

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This paper presents the evaluation of post-programme outcomes of the ISIBINDI model, a community-based intervention to promote physical and psychosocial well-being of orphans and vulnerable children (OVC) in South Africa. A mixed methods quasi-experimental design was used to investigate the differences between former ISIBINDI participants (18 years and older) and a control group of similar background. ISIBINDI ex-participants at 12 sites (n=427) and a control group of non-participants (n=177) completed a questionnaire which explored level of education and employment, psychosocial well-being and HIV risk behaviour. Focus group discussions were conducted with various stakeholders. Ex-participants reported higher self-esteem and problem-solving abilities, family support and lower HIV risk behaviour than the control group. High levels of unemployment especially in rural areas resulted in unemployment of out-of-school OVC which creates new forms of vulnerability. The benefits of the programme may be compromised by the lack of community resources. An effective exit strategy is needed to contribute to financial independence of OVC after exiting the programme.

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OBJECTIVE: South Africa has a high prevalence of sexual abuse of children and adolescents. Among the numerous adverse consequences of sexual abuse is the difficulty survivors may experience in developing positive self-esteem and maintaining positive relationships. In a low resource setting, an expressive art group intervention tailored to female adolescents who have been sexually abused was implemented and its value explored. METHOD: Six adolescents met for 10 weekly sessions which included expressive art activities, followed by reflective group discussions. The value of the intervention was explored using a qualitative research design with limited quantitative data. RESULTS: The participants reported that the group intervention relieved their sense of isolation and contributed to their ability to express emotions and develop self-awareness. Participants reported more positive self-esteem and improved interpersonal closeness. The intervention helped participants to find new meaning in painful experiences which contributed to personal growth. CONCLUSIONS: The group dynamics, expressive art activities and reflective group discussions contributed to the therapeutic value of the intervention. The expressive art group intervention showed value as an alternative therapeutic strategy in a low resource setting for female adolescents who have experienced sexual abuse. An experimental design could follow to confirm the effectiveness of the intervention.

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OBJECTIVE: The objective of this study is to assess the efficacy of an intervention designed to promote resilience in young children living with their HIV-positive mothers. DESIGN/METHODS: HIV-positive women attending clinics in Tshwane, South Africa, and their children, aged 6-10 years, were randomized to the intervention (I) or standard care (S). The intervention consisted of 24 weekly group sessions led by community care workers. Mothers and children were in separate groups for 14 sessions, followed by 10 interactive sessions. The primary focus was on parent-child communication and parenting. Assessments were completed by mothers and children at baseline and 6, 12 and 18 months. Repeated mixed linear analyses were used to assess change over time. RESULTS: Of 390 mother-child pairs, 84.6% (I: 161 and S: 169) completed at least two interviews and were included in the analyses. Children's mean age was 8.4 years and 42% of mothers had been ill in the prior 3 months. Attendance in groups was variable: only 45.7% attended more than 16 sessions. Intervention mothers reported significant improvements in children's externalizing behaviours (ß = -2.8, P = 0.002), communication (ß = 4.3, P = 0.025) and daily living skills (ß = 5.9, P = 0.024), although improvement in internalizing behaviours and socialization was not significant (P = 0.061 and 0.052, respectively). Intervention children reported a temporary increase in anxiety but did not report differences in depression or emotional intelligence. CONCLUSION: This is the first study demonstrating benefits of an intervention designed to promote resilience among young children of HIV-positive mothers. The intervention was specifically designed for an African context and has the potential to benefit large numbers of children, if it can be widely implemented.

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