Strengthening health system's capacity for linkage to HIV care for adolescent girls and young women and adolescent boys and young men in South Africa (SheS'Cap-Linkage): Protocol for a mixed methods study in KwaZulu-Natal, South Africa.

INTRODUCTION: Adolescent girls and young women (AGYW) aged 15-24 years and adolescent boys and young men (ABYM) aged 15-34 years represent one of the populations at highest risk for HIV-infection in South Africa. The National Department of Health adopted the universal test and treat (UTT) strategy in 2016, resulting in increases in same-day antiretroviral therapy initiations and linkage to care. Monitoring progress towards attainment of South Africa's 95-95-95 targets amongst AGYW and ABYM relies on high quality data to identify and address gaps in linkage to care. The aim of this study is to describe the current approaches for engaging AGYW and ABYM in the treatment continuum to generate knowledge that can guide efforts to improve linkage to, and retention in, HIV care among these populations in KwaZulu-Natal, South Africa. METHODS AND ANALYSIS: This is a mixed methods study, which will be conducted in uMgungundlovu district of KwaZulu-Natal, over a 24-month period, in 22 purposively selected HIV testing and treatment service delivery points (SDPs). For the quantitative component, a sample of 1100 AGYW aged 15-24 years and ABYM aged 15-35 years old will be recruited into the study, in addition to 231 healthcare providers (HCPs) involved in the implementation of the UTT program. The qualitative component will include 30 participating patients who were successfully linked to care, 30 who were not, and 30 who have never tested for HIV. Key informant interviews will also be conducted with 24 HCPs. Logistic regression will be used to model the primary outcomes on SDP types, while a time to event analysis will be conducted using a Cox regression model and adjusting the standard errors of the hazard ratio for the clustering of participants within SDPs. For qualitative data, a general inductive approach of analysis will be used. DISSEMINATION: Findings from the study will be communicated to the study population and results will be presented to stakeholders and at appropriate local and international conferences. Outputs will also include a policy brief, peer reviewed journal articles and research capacity building through research degrees.

Strengthening health system's capacity for pre-exposure prophylaxis for adolescent girls and young women and adolescent boys and young men in South Africa (SHeS'Cap-PrEP): Protocol for a mixed methods study in KwaZulu-Natal, South Africa.

INTRODUCTION: Pre-exposure prophylaxis (PrEP) is an effective prevention intervention that can be used to control HIV incidence especially among people who are at increased risk for HIV such as adolescent girls and young women (AGYW) and adolescent boys and young men (ABYM). In South Africa, various approaches of delivering PrEP have been adopted at different service delivery points (facility-based only, school-based only, community-based only and hybrid school-facility and community-facility models) to overcome challenges associated with individual, structural, and health systems related barriers that may hinder access to and uptake of PrEP among these populations. However, little is known about how to optimize PrEP implementation and operational strategies to achieve high sustained uptake of good quality services for AGYW and ABYM. This study aims to identify effective and feasible PrEP models of care for improving PrEP uptake, continuation, and adherence among AGYW and ABYM. METHODS AND ANALYSIS: A sequential explanatory mixed-methods study will be conducted in 22 service delivery points (SDPs) in uMgungundlovu district, KwaZulu-Natal, South Africa. We will recruit 600 HIV negative, sexually active, high risk, AGYW (aged 15-24 years) and ABYM (aged 15-35 years). Enrolled participants will be followed up at 1-, 4- and 7-months to determine continuation and adherence to PrEP. We will conduct two focus group discussions (with 8 participants in each group) across four groups (i. Initiated PrEP within 1 month, ii. Did not initiate PrEP within 1 month, iii. Continued PrEP at 4/7 months and iv. Did not continue PrEP at 4/7 months) and 48 in-depth interviews from each of the four groups (12 per group). Twelve key informant interviews with stakeholders working in HIV programs will also be conducted. Associations between demographic characteristics stratified by PrEP initiation and by various service-delivery models will be assessed using Chi-square/Fishers exact tests or t-test/Mann Whitney test. A general inductive approach will be used to analyze the qualitative data. ETHICS AND DISSEMINATION: The protocol was approved by the South African Medical Research Council Health Research Ethics Committee (EC051-11/2020). Findings from the study will be communicated to the study population and results will be presented to stakeholders and at appropriate local and international conferences. Outputs will also include a policy brief, peer-reviewed journal articles and research capacity building through research degrees.

The Impact of Participation in Research About Abuse and Intimate Partner Violence: An Investigation of Harms, Benefits, and Regrets in Young Adolescents in the Western Cape of South Africa.

There is very little evidence whether recalling and answering questions about abuse or interpersonal violence has a positive or negative impact on participants of such research. This is an important ethical dilemma to ensure an appropriate risk-benefit ratio in research with young people is maintained. We assessed reported harms, benefits, and regrets of young adolescents who participated in a sensitive research project, and compared the harms and benefits in those who had and had not been victims and/or perpetrators of abuse or intimate partner violence. Participants were 3,264 adolescents aged 12 to 15 years in 41 public schools in the Western Cape, South Africa, who completed a survey about intimate partner violence, verbal, physical, and sexual abuse, as part of an HIV prevention cluster randomized controlled trial. The majority of participants reported research participation as beneficial (70.3%), while 27.7% reported harms and 14% regrets. Victims of abuse were more likely than non-victims to report benefits (71.9% vs. 67.1%; p = .02) and harms (31% vs. 20.9%; p < .01) and were less likely to report regret (13.1% vs. 16.7%; p = .02). Perpetrators of abuse were less likely than non-perpetrators to report benefits (67.4% vs. 72.8%; p = .01) and more likely to report harms (36.4% vs. 26.1%; p < .01) and regrets (17.4% vs. 13.3%; p = .01). Our findings suggested that research participation was more likely to have a positive rather than a negative emotional impact on young adolescents and that relatively few regretted participating. Victims and perpetrators of abuse were more likely to report benefits than harms, supporting the ethical appropriateness of ongoing research on abuse and violence. We recommend that further research is required to clarify and standardize terminology and instruments to quantify these kinds of evaluations, including measurement of the severity and intensity of reported benefits, harms and regrets, and the longer term impact of participation in sensitive research.

Exposure to violence and mental health of adolescents: South African Health and Well-being Study.

BACKGROUND: Material and social environmental stressors affect mental health in adolescence. Protective factors such as social support from family and friends may help to buffer the effects of adversity. AIMS: The association of violence exposure and emotional disorders was examined in Cape Town adolescents. METHOD: A total of 1034 Grade 8 high school students participated from seven government co-educational schools in Cape Town, South Africa. Exposure to violence in the past 12 months and post-traumatic stress disorder (PTSD) symptoms were measured by the Harvard Trauma Questionnaire, depressive and anxiety symptoms by the Short Moods and Feelings Questionnaire and the Self-Rating Anxiety Scale. RESULTS: Exposure to violence was associated with high scores on depressive (odds ratio (OR)=6.23, 95% CI 4.2-9.2), anxiety (OR=5.40, 95% CI 2.4-12.4) and PTSD symptoms (OR=8.93, 95% CI 2.9-27.2) and increased risk of self-harm (OR=5.72, 95% CI 1.2-25.9) adjusting for gender and social support. CONCLUSIONS: We found that high exposure to violence was associated with high levels of emotional disorders in adolescents that was not buffered by social support. There is an urgent need for interventions to reduce exposure to violence in young people in this setting. DECLARATION OF INTEREST: None. COPYRIGHT AND USAGE: © The Royal College of Psychiatrists 2017. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license.

HIV Prevalence and Risk Factors Among Male Foreign Migrants in Cape Town, South Africa.

While migration has been shown to be a risk factor for HIV, variation in HIV prevalence by subgroups of migrants needs further exploration. This paper documents the HIV prevalence and key characteristics among male foreign migrants in Cape Town, South Africa and the effectiveness of respondent-driven sampling (RDS) to recruit this population. Participants in this cross-sectional study completed a behavioral risk-factor questionnaire and provided a dried blood sample for HIV analysis. Overall HIV prevalence was estimated to be 8.7 % (CI 5.4-11.8) but varied dramatically by country of origin. After adjusting for country of origin, HIV sero-positivity was positively associated with older age (p = 0.001), completing high school (p = 0.025), not having enough money for food (p = 0.036), alcohol use (p = 0.049), and engaging in transactional sex (p = 0.022). RDS was successful in recruiting foreign migrant men. A better understanding of the timing of HIV acquisition is needed to design targeted interventions for migrant men.

The Relationship Between Social Support, HIV Serostatus, and Perceived Likelihood of Being HIV Positive Among Self-Settled Female, Foreign Migrants in Cape Town, South Africa.

Female cross-border migrants experience elevated risks for HIV, and migrants in South Africa may face additional risks due to the country's underlying HIV prevalence. These risks may be mitigated by the receipt of social support. A behavioral risk-factor survey was administered using respondent-driven sampling. Multivariable regression models assessed the relationships between social support and two HIV outcomes: HIV serostatus and perceived HIV status. Low social support was not significantly associated with HIV status (aOR = 1.03, 95 % CI 0.43-2.46), but was significantly related to a perception of being HIV positive (aPR = 1.36, 95 % CI 1.04-1.78). Age, marital status, and education level were significantly associated with HIV serostatus. Illegal border-crossing, length of time in South Africa, anal sex, and transactional sex were significantly associated with aperception of being HIV positive. Future research should investigate how HIV risks and the receipt of social support change throughout the migration process.

Coming of age? Women's sexual and reproductive health after twenty-one years of democracy in South Africa.

This paper is a sequel to a 2004 article that reviewed South Africa's introduction of new sexual and reproductive health (SRH) and rights laws, policies and programmes, a decade into democracy. Similarly to the previous article, this paper focuses on key areas of women's SRH: contraception and fertility, abortion, maternal health, HIV, cervical and breast cancer and sexual violence. In the last decade, South Africa has retained and expanded its sexual and reproductive health and rights (SRHR) policies in the areas of abortion, contraception, youth and HIV treatment (with the largest antiretroviral treatment programme in the world). These are positive examples within the SRHR policy arena. These improvements include fewer unsafe abortions, AIDS deaths and vertical HIV transmission, as well as the public provision of a human papillomavirus vaccine to prevent cervical cancer. However, persistent socio-economic inequities and gender inequality continue to profoundly affect South African women's SRHR. The state shows mixed success over the past two decades in advancing measurable SRH social justice outcomes, and in confronting and ameliorating social norms that undermine SRHR.

Predictors of poor adherence among people on antiretroviral treatment in Cape Town, South Africa: a case-control study.

A case-control study was conducted to describe the frequency with which structural- and individual-level barriers to adherence are experienced by people receiving antiretroviral (ARV) treatment and to determine predictors of non-adherence. Three hundred adherent and 300 non-adherent patients from 6 clinics in Cape Town completed the LifeWindows Information-Motivation-Behavioral Skills ART Adherence Questionnaire, the Substance Abuse and Mental Illness Symptoms Screener and the Structural Barriers to Clinic Attendance (SBCA) and Medication-taking (SBMT) scales. Overall, information-related barriers were reported most frequently followed by motivation and behaviour skill defects. Structural barriers were reported least frequently. Logistic regression analyses revealed that gender, behaviour skill deficit scores, SBCA scores and SBMT scores predicted non-adherence. Despite the experience of structural barriers being reported least frequently, structural barriers to medication-taking had the greatest impact on adherence (OR: 2.32, 95% CI: 1.73 to 3.12), followed by structural barriers to clinic attendance (OR: 2.06, 95% CI: 1.58 to 2.69) and behaviour skill deficits (OR: 1.34, 95% CI: 1.05 to 1.71). Our data indicate the need for policy directed at the creation of a health-enabling environment that would enhance the likelihood of adherence among antiretroviral therapy users. Specifically, patient empowerment strategies aimed at increasing treatment literacy and management skills should be strengthened. Attempts to reduce structural barriers to antiretroviral treatment adherence should be expanded to include increased access to mental health care services and nutrition support.

Improving the counselling skills of lay counsellors in antiretroviral adherence settings: a cluster randomised controlled trial in the Western Cape, South Africa.

Little research has investigated interventions to improve the delivery of counselling in health care settings. We determined the impact of training and supervision delivered as part of the Options: Western Cape project on lay antiretroviral adherence counsellors' practice. Four NGOs employing 39 adherence counsellors in the Western Cape were randomly allocated to receive 53 h of training and supervision in Options for Health, an intervention based on the approach of Motivational Interviewing. Five NGOs employing 52 adherence counsellors were randomly allocated to the standard care control condition. Counselling observations were analysed for 23 intervention and 32 control counsellors. Intervention counsellors' practice was more consistent with a client-centred approach than control counsellors', and significantly more intervention counsellors engaged in problem-solving barriers to adherence (91 vs. 41 %). The Options: Western Cape training and supervision package enabled lay counsellors to deliver counselling for behaviour change in a manner consistent with evidence-based approaches.

Antiretroviral adherence interventions in Southern Africa: implications for using HIV treatments for prevention.

There is concern that the expansion of ART (antiretroviral treatment) programmes to incorporate the use of treatment as prevention (TasP) may be associated with low levels of adherence and retention in care, resulting in the increased spread of drug-resistant HIV. We review research published over the past year that reports on interventions to improve adherence and retention in care in Southern Africa, and discuss these in terms of their potential to support the expansion of ART programmes for TasP. We found eight articles published since January 2012, seven of which were from South Africa. The papers describe innovative models for ART care and adherence support, some of which have the potential to facilitate the ongoing scale- up of treatment programmes for increased coverage and TasP. The extent to which interventions from South Africa can be effectively implemented in other, lower-resource Southern African countries is unclear.

Lay counselors' ability to deliver counseling for behavior change.

OBJECTIVE: Options for Health is an evidence-based sexual risk reduction intervention based on motivational interviewing (MI). Thirty-nine antiretroviral adherence lay counselors were trained to deliver Options for Health to help their patients to optimize their antiretroviral treatment adherence. An evaluation of counselors' ability to deliver the intervention after 35 hr of training revealed that counselors struggled with elements of the 8-step Options protocol and failed to achieve proficiency in MI. The current study aimed to determine the impact of refresher training and supervision on counselors' proficiency in the intervention. METHOD: Audio-recordings of counseling sessions were collected for 22 of 39 counselors after 18 hr of refresher training and supervision had been delivered over a 12-month period. Recordings were transcribed, translated, and analyzed for fidelity to the Options protocol and the MI approach. Analysis was conducted using the Motivational Interviewing Treatment Integrity Tool and an instrument developed by the researchers. Results were compared to findings from an evaluation of counselors' performance immediately following the initial 35-hr training. RESULTS: Counselors improved their delivery of some intervention steps, but not others; their use of micro-counseling skills and therapeutic approach improved to such an extent that they closely approximated the MI approach. CONCLUSIONS: This study contributes evidence for the positive impact of ongoing training and supervision on lay health worker practice. Although counselors did not achieve complete proficiency in the Options protocol, refresher training and supervision improved counselors' basic counseling communication skills and therapeutic approach, enabling them to deliver better quality counseling for behavior change.

Illegal yet developmentally normative: a descriptive analysis of young, urban adolescents' dating and sexual behaviour in Cape Town, South Africa.

BACKGROUND: In South Africa, it is illegal for adolescents under age 16 years to engage in any sexual behaviour whether kissing, petting, or penetrative sex, regardless of consent. This cross-sectional study investigated the extent to which young adolescents engage in various sexual behaviours and the associations between dating status and sexual behaviours. METHOD: Grade 8 adolescents (N = 474, ages 12-15 years, mean = 14.14 years) recruited from Cape Town schools completed surveys providing information about their sociodemographic backgrounds, dating experience, sexual behaviour, and substance use. RESULTS: Lower hierarchy sexual behaviours, such as kissing (71.4% of girls; 88.4% of boys), were more common than oral (3.9% of girls; 13.8% of boys), vaginal (9.3% of girls; 30.0% of boys), or anal (1.4% of girls; 10.5% of boys) sex. Currently dating girls and boys were more likely to engage in sexual behaviours including several risk behaviours in comparison to their currently non-dating counterparts. These risk behaviours included penetrative sex (21.1% of dating vs. 4.5% of non-dating girls; 49.4% of dating vs. 20.2% of non-dating boys), sex with co-occurring substance use (22.2% of dating vs. 0 non-dating girls; 32.1% of dating vs. 40% of non-dating boys), and no contraceptive use (26.1% of sexually experienced girls; 44.4% of sexually experienced boys). Among girls, there were significant associations between ever having penetrative sex and SES (OR = 2.592, p = 0.017) and never dating (OR = 0.330, p = 0.016). Among boys, there were significant associations between ever having penetrative sex and never dating (OR = 0.162, p = 0.008). Although the currently dating group of young adolescents appear to be a precocious group in terms of risk behaviour relative to the currently non-dating group, teenagers in both groups had experience in the full range of sexual behaviours. CONCLUSIONS: Many young adolescents are engaging in a variety of sexual behaviours ranging from kissing and touching to intercourse. Of particular concern are those engaging in risky sexual behaviour. These findings indicate that adolescents need to be prepared for sexual negotiation and decision-making from an early age through comprehensive and accessible education and health services; sections of current legislation may be a barrier to adopting such policies and practices.

What do young people think makes their relationships good? Factors associated with assessments of dating relationships in South Africa.

Little is known about the factors and outcomes associated with young people's subjective relationship assessments. Understanding what young people think makes their relationships 'good' or 'bad' would give us insight into what is important to them in their relationships as well as their decision-making and behaviour within them. Self-report data from 757 girls (mean age = 17.09 years) and 642 boys (mean age = 17.23 years) were analysed using logistic regression. Relationship primacy was significantly associated with positive relationships for girls and boys. Among girls, partner education and open communication about sexual and reproductive health were additionally related to relationship assessments. Among boys, very little quarrelling was the only additional factor associated with positive relationship assessment. Although relationship assessment was not associated with depression or problem drinking for either girls or boys, drug use was less likely among both girls and boys who reported having a positive relationship. Boys in positive relationships were also more likely to have used a condom the last time they had sex with their main partner. Intervention programmes should equip teenagers with skills to develop and maintain positive relationships.

From research to practice: lay adherence counsellors' fidelity to an evidence-based intervention for promoting adherence to antiretroviral treatment in the Western cape, South Africa.

In the Western Cape, lay counsellors are tasked with supporting antiretroviral (ARV) adherence in public healthcare clinics. Thirty-nine counsellors in 21 Cape Town clinics were trained in Options for Health (Options), an evidence-based intervention based on motivational interviewing (MI). We evaluated counsellors' ability to deliver Options for addressing poor adherence following 5 days training. Audio-recordings of counselling sessions collected following training were transcribed and translated into English. Thirty-five transcripts of sessions conducted by 35 counsellors were analysed for fidelity to the Options protocol, and using the Motivational Interviewing Treatment and Integrity (MITI) code. Counsellors struggled with some of the strategies associated with MI, such as assessing readiness-to-change and facilitating change talk. Overall, counsellors failed to achieve proficiency in the approach of MI according to the MITI. Counsellors were able to negotiate realistic plans for addressing patients' barriers to adherence. Further efforts aimed at strengthening the ARV adherence counselling programme are needed.

Linking Life Skills and Norms With Adolescent Substance Use and Delinquency in South Africa.

We examined factors targeted in two popular prevention approaches with adolescent drug use and delinquency in South Africa. We hypothesized adolescent life skills to be inversely related, and perceived norms to be directly related to later drug use and delinquency. Multiple regression and a relative weights approach were conducted for each outcome using a sample of 714 South African adolescents ages 15 to 19 years (M = 15.8 years, 57% female). Perceived norms predicted gateway drug use. Conflict resolution skills (inversely) and perceived peer acceptability (directly) predicted harder drug use and delinquency. The "culture of violence" within some South African schools may make conflict resolution skills more salient for preventing harder drug use and delinquency.

A systematic review of the role of school-based healthcare in adolescent sexual, reproductive, and mental health.

BACKGROUND: Accessible sexual, reproductive, and mental healthcare services are crucial for adolescent health and wellbeing. It has been reported that school-based healthcare (SBHC) has the potential to improve the availability of services particularly for young people who are normally underserved. Locating health services in schools has the potential to reduce transport costs, increase accessibility and provide links between schools and communities. METHODS: A systematic review of the literature was undertaken. Pubmed, Psychinfo, Psychnet, Cochrane CENTRAL, and Web of Science were searched for English language papers published between January 1990 and March 2012 RESULTS: Twenty-seven studies were found which fitted the criteria, of which, all but one were from North America. Only three measured adolescent sexual, reproductive, or mental health outcomes related to SBHC and none of the studies were randomized controlled trials. The remaining studies explored accessibility of services and clinic utilization or described pertinent contextual factors. CONCLUSIONS: There is a paucity of high quality research which evaluates SBHC and its effects on adolescent sexual, reproductive, and mental health. However, there is evidence that SBHC is popular with young people, and provides important mental and reproductive health services. Services also appear to have cost benefits in terms of adolescent health and society as a whole by reducing health disparities and attendance at secondary care facilities. However, clearer definitions of what constitutes SBHC and more high quality research is urgently needed.

'I think it's about experiencing, like, life': a qualitative exploration of contemporary adolescent intimate relationships in South Africa.

Intimate or dating relationships play an important role in young people's psychosocial development and well-being. Yet, we know relatively little about how teenagers conceptualise and experience them. Research knowledge about young people's intimate relationships is largely gleaned from studies whose primary focus has been on adolescent sexuality and violence. This study explored intimate relationships using qualitative data from 12 focus-group discussions and 25 in-depth individual interviews with Grade 8 (mean age = 14.6 years) and Grade 11 (mean age = 17.2 years) young people recruited from Cape Town schools. Although there is overlap between these findings and previous research, this study delved into the microdynamics of teenagers' relationship practices and conceptualisations. Their discussions provide insight into a nebulous dating landscape that is highly gendered and greatly influenced by peer relations. There was a heterogeneity of experience with relationships and sex. Implications for intervention development are discussed.

Reliability of self report questionnaires for epidemiological investigations of adolescent mental health in Cape Town, South Africa.

OBJECTIVE: This study aimed to assess the reliability of a number of self report questionnaires for epidemiological investigations of adolescents' mental health in Cape Town, South Africa. The scales used were: the Short Mood and Feelings Questionnaire (SMFQ), Zung Self-rating Anxiety Scale (SAS), Self-esteem Questionnaire (SEQ), Harvard Trauma Questionnaire (HTQ) and Multi-Dimensional Scale of Perceived Social Support (MSPSS). METHOD: The self-report questionnaire (available in Afrikaans, English and isiXhosa) was administered to 237 grade 8 students (14-15 years) on 2 occasions in metropolitan Cape Town high schools. The mean interval between first and second administration of the questionnaire was 8.3 days. Test-retest reliability was assessed using Cohen's kappa and observed agreement. Pearson's correlation coefficients were used to assess consistency across total scores between occasion 1 and occasion 2. Cronbach's alpha was used to assess the internal consistency of each scale. RESULTS: All items had at least fair test-retest reliability (kappa > 0.20) apart from two items on the Self-rating Anxiety Scale and one item on the Harvard Trauma questionnaire. Test-retest reliability was strong for the HTQ (Pearson's correlation coefficient >0.75), moderate for the SAS, SEQ and MSPSS (0.50-0.74) and weak for the SMFQ (0.25-0.49). Cronbach's alpha for all scales was acceptable (>0.60). Analysis by the different language versions (Afrikaans/English and isi-Xhosa/ English) of the questionnaire indicated good internal consistency for most measures for all three languages. CONCLUSIONS: The results indicate that many of these instruments may be used reliably in South Africa to assess adolescent mental health and that the different language versions of the instruments used in the questionnaire are generally reliable for use in South African schools. However, some caution is required with the use of the SAS and SEQ in different language groups.