Living a private lie: intersectional stigma, depression and suicidal thoughts for selected young key populations living with HIV in Zambia.

BACKGROUND: Limited research has been conducted on the forms, manifestations and effects of intersectional stigma among young HIV-positive men who have sex with men (MSM) and transgender women (TGW) in Zambia. In this study, we aimed to address this gap by elucidating the experiences of these in a small group of young, HIV + MSM and TGW in Zambia. METHODS: We applied a mixed-methods design. Data were collected from January 2022 to May 2022. Qualitative data were collected using in-depth interviews while quantitative data were collected using a questionnaire. Qualitative transcripts were coded using thematic analysis while paper-based questionnaire data were entered into Kobo Connect. Descriptive statistics, using chi-squared tests were calculated using Excel. In this paper, we provide a descriptive profile of the sample and then focus on the qualitative findings on intersectional stigma, depression, and contemplation of suicide. RESULTS: We recruited 56 participants from three sites: Lusaka, Chipata, and Solwezi districts. Participants' mean age was 23 years. The study found that 36% of all participants had moderate to significant symptoms of depression, 7% had major depression, 30% had moderate signs of anxiety, 11% had high signs of anxiety, 4% had very high signs of anxiety and 36% had contemplated suicide at least once. A greater proportion of TGW had moderate to significant symptoms of depression (40%) or major depression (10%) compared to MSM, at 33% and 6%, respectively (X2 = 0.65; p = 0.42). Similarly, more TGW (55%) had contemplated suicide than MSM peers (36%, X2=1.87; p = 0.17). In the qualitative data, four emergent themes about the forms, manifestations, and effects of intersectional stigma were (1) HIV, sexual orientation, and gender identity disclosure; (2) Dual identity; (3) Challenges of finding and maintaining sexual partners; (4) Coping and resilience. Overall, having to hide both one's sexuality and HIV status had a compounding effect and was described as living "a private lie." CONCLUSION: Effectively addressing stigmas and poor mental health outcomes among young HIV-positive MSM and TGW will require adopting a socio-ecological approach that focuses on structural interventions, more trauma-informed and identity-supportive care for young people with HIV, as well as strengthening of authentic community-informed public health efforts.

Health technology assessment for sexual reproductive health and rights benefits package design in sub-Saharan Africa: A scoping review of evidence-informed deliberative processes.

BACKGROUND: Health technology assessment uses a multidisciplinary approach to support health benefits package design towards universal health coverage. The evidence-informed deliberative process framework has been used alongside Health technology assessment to enhance stakeholder participation and deliberations in health benefits package design. Applying the evidence-informed deliberative framework for Health assessment could support the morally diverse sexual reproductive health and rights (SRHR) benefits package design process. However, evidence on participation and deliberations for stakeholders in health technology assessment for SRHR benefits package design has not been curated in sub-Saharan Africa. This study synthesises literature to fill this gap. METHODS: This scoping review applies the preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews, and deductive analysis following the evidence-informed deliberative processes framework. The search strategy uses the Guttmacher-Lancet Commission-proposed comprehensive definition of SRHR and the World Health Organisation's universal health coverage compendium of SRHR interventions to generate search terms. Six databases and biographical hand searches were used to identify studies in Sub-Saharan Africa from 1994. RESULTS: A total of 14 studies met the inclusion criteria. Evidence for yearly public budgets and explicit SRHR health technology assessment processes was not found. In 12 of the studies reviewed, new advisory committees were set up specifically for health technology assessment for SRHR priority-setting and benefits package design. In all decision-making processes reviewed, the committee member roles, participation and deliberations processes, and stakeholder veto powers were not clearly defined. Patients, the public, and producers of health technology were often excluded in the health technology assessment for the SRHR benefits package design. Most health technology assessment processes identified at least one decision-making criterion but failed to use this in their selection and appraisal stages for SRHR benefits design. The identification, selection, and scoping stages in health technology assessment for SRHR were non-existent in most studies. In 11 of the 14 processes of the included studies, stakeholders were dissatisfied with the health policy recommendation from the appraisal process in health technology assessment. Perceived benefits for evidence-informed deliberative processes included increased stakeholder engagement and fairness in decision-making. CONCLUSION: To support the integration of diverse social values in health technology assessment for fairer SRHR benefits package design, evidence from this review suggests the need to institutionalise health technology assessment, establish prioritisation decision criteria, involve all relevant stakeholders, and standardise the process and assessment methodological approaches.

Early and unintended pregnancy in Eastern and Southern Africa: analysis of adolescent sexual and reproductive health and rights policies.

In 2019, there were 21 million pregnancies among adolescents aged 15-19 years globally; close to half of these pregnancies were unintended. Early and unintended pregnancy (EUP) remains a pressing concern with severe socioeconomic and health outcomes for adolescent girls aged 15-19 years, their offspring and society. In Eastern and Southern Africa (ESA), Zambia, the United Republic of Tanzania, the Democratic Republic of Congo, Malawi and Uganda have adolescent fertility rates (AFR) of more than 100 live births per 1000 adolescent girls aged 15-19 years. Ministers of Health and Education, through the ESA Ministerial Commitment, aimed to reduce EUP by 75% by 2020; the renewed ESA Ministerial Commitment aims to reduce EUP by 40% by 2030. This descriptive policy content analysis assesses the prioritisation of EUP within adolescent sexual and reproductive health and rights (ASRHR) policies. An assessment of nine countries in the region shows that EUP is a key policy priority among countries; however, other than Kenya, the majority of ASRHR policies in the region do not set out clear and costed interventions for EUP, and few have monitoring and evaluation frameworks in place. Despite AFRs declining in Kenya and strong policies in place, the gains made are at risk due to the rollback on SRHR, and the country has not renewed the ESA Ministerial Commitment. This policy content analysis points towards the gaps we are still to meet within the universal health coverage agenda: better planning, prioritisation, sound policy frameworks and long-term commitments to meet the needs of adolescents.

The role of the social sciences and humanities in pandemic preparedness responses: insights gained from COVID-19, HIV and AIDS and related epidemics.

The COVID-19 pandemic, particularly from 2020 to mid-2022, debilitated the management of the HIV epidemic in Africa. The multiple effects included well-documented HIV service interruptions, curtailment of HIV prevention programmes, the associated marked increase in both the risk for HIV infection among key populations and vulnerability of sub-populations (e.g. adolescent girls and young women) who are the focus of these programmes and - as importantly but less well-documented - the diverse negative socio-economic effects that accentuate HIV risk and vulnerability generally (e.g. loss of earnings, gender-based violence, stigma, police harassment of people during "lockdowns"). The global biomedical response to COVID-19 was necessary and remarkable for mitigating the bio-physical impacts of the pandemic (e.g. wide-spread surveillance coupled with rapid updates on the epidemiology of infections, rapid development of vaccines and revisions of treatment). However, drawing upon the widespread criticisms of state responses to the socio-economic effects of the COVID-19 pandemic and of "lockdowns" themselves, this article elaborates a core argument within those criticisms, namely that key lessons learnt during the HIV and AIDS and other pandemics were ignored, at least during the early stages of COVID-19. Our critique is that better integration of the social sciences and humanities in responses to pandemics can counter the reflex tendency to uncritically adopt a biomedical paradigm and, more importantly, to enable consideration of the social determinants of health in pandemic responses. At root, we re-assert a key value of 'integrated' interventions, namely the accommodation of context-sensitive considerations in the formulation of strategies, policies, plans and programme designs.

The Social Ecological Model: A Framework for Understanding COVID-19 Vaccine Uptake among Healthcare Workers-A Scoping Review.

Vaccination plays a crucial role in combating the global COVID-19 pandemic. Immunizing all healthcare workers (HCWs) is essential for increasing vaccine confidence and acceptance within the general population. Understanding the factors that hinder or facilitate vaccine uptake among HCWs is of utmost importance, considering they are among the first to be vaccinated. This review follows Arksey and O'Malley's five-stage methodological framework. We searched PubMed, Web of Science, ProQuest, WorldCat Discovery, and Google Scholar for peer-reviewed articles published from 2020 to 2023. A descriptive analysis and narrative synthesis approach were employed to collect and synthesize data. Using the social-ecological model as a framework, the literature was categorized into themes at the intrapersonal, interpersonal, organizational, community, and policy levels. We reviewed a total of fifty-three published academic articles, with the majority of studies conducted in Ethiopia and Nigeria. The intention for vaccine uptake resulted in an unsatisfactory (52%) overall uptake rate among HCWs. Individual-level determinants associated with vaccine uptake included being male, middle-aged, being a physician, having a higher level of education, and having a chronic illness. This review identified significant barriers at each level, such as safety concerns, perceived scientific uncertainty, vaccine ineffectiveness, lack of trust in stakeholders, and religious beliefs. Additionally, we identified facilitators at each level, with the most common factors promoting intention to uptake being the desire to protect oneself and others and a high perceived susceptibility to contracting COVID-19. This review highlights the existence of significant barriers to vaccine uptake on the African continent. Given that HCWs play a crucial role in guiding the public's vaccination decisions, it is imperative to prioritize education and training efforts about the safety and effectiveness of COVID-19 vaccines.

Associations of Social Support with Sexual Practices, Health Behaviours, and Health Outcomes Among Adolescent Girls and Young Women: Evidence From a Longitudinal Study in KwaZulu-Natal, South Africa.

BACKGROUND: Several studies have reported on the benefits of social support for health behaviour, including risky sex. Social support may thus be an important resource for promoting individual health and well-being, particularly in regions where HIV rates are high and healthcare resources are scarce. However, prior research on the implications of social support for the health behaviour of young women has yielded mixed and inconclusive findings. Using prospective data from young women in South Africa, this study examines the associations of social support with subsequent sexual practices, health behaviour, and health outcomes. METHOD: We used two rounds of longitudinal data from a sample of n = 1446 HIV-negative emerging adult women, aged 18 to 29 years, who participated in a population-based HIV study in KwaZulu-Natal, South Africa. Applying the analytic template for outcome-wide longitudinal designs, we estimated the associations between combinations of social support (i.e. tangible, educational, emotional) and ten HIV risk-related outcomes. RESULTS: Combinations of tangible, educational, and emotional support, as well as tangible support by itself, were associated with lower risk for several outcomes, whereas educational and emotional support, by themselves or together, showed little evidence of association with the outcomes. CONCLUSION: This study highlights the protective role of tangible support in an environment of widespread poverty, and the additional effect of combining tangible support with non-tangible support. The findings strengthen recent evidence on the benefits of combining support in the form of cash and food with psychosocial care in mitigating risk behaviours associated with HIV and negative health outcomes among young women.

HIV Focused Sexual Risk-Reduction Interventions Targeting Adolescent Boys and Young Men in Sub-Saharan Africa: A Scoping Review.

Adolescent girls and young women's exceptionalism with HIV interventions has left adolescent boys and young men (ABYM) trailing behind, thus becoming a marginalized and underserved population. The scoping review aimed to provide an overview of interventions that have targeted sexual risk behaviors in ABYM in Sub-Saharan Africa (SSA) over the previous 21 years with critical insights on 'what works' in preventing the sexual transmission of HIV. A scoping review guided by Arksey and O'Malley's (in Int J Soc Res Methodol 8(1):19-32, 16) framework and the 2015 Johanna Briggs Institute's guidelines was conducted. A search of literature published between 2000 and 2020 was reviewed and twenty nine interventions from nine Sub Saharan African countries that met the eligibility criteria were reviewed. The review provides evidence on the successes and the limitations of sexual risk behavior interventions for ABYM in SSA. There is clear and consistent evidence that interventions reduce sexual risk behaviors in adolescent boys and young men. Their efficiency seems to grow with the length and intensity of the intervention. Positive effects were generally observed in condom use and on measures of HIV knowledge, attitudes and sexual behaviors as well as uptake of HIV tests and voluntary male circumcision. This review shows that sexual-risk interventions engaging men and boys in SSA are promising and warrant further rigorous development in terms of conceptualization, design and evaluation.

Children and young women in eastern and southern Africa are key to meeting 2030 HIV targets: time to accelerate action.

New HIV infections and AIDS-related deaths among children and adolescent girls and young women (aged 15-24 years) in eastern and southern Africa continue to occur at unacceptably high rates. The COVID-19 pandemic has also severely undermined ongoing initiatives for HIV prevention and treatment, threatening to set the region back further in its efforts to end AIDS by 2030. Major impediments exist to attaining the UNAIDS 2025 targets among children, adolescent girls, young women, young mothers living with HIV, and young female sex workers residing in eastern and southern Africa. Each population has specific but overlapping needs with regard to diagnosis and linkage to and retention in care. Urgent action is needed to intensify and improve programmes for HIV prevention and treatment, including sexual and reproductive health services for adolescent girls and young women, HIV-positive young mothers, and young female sex workers.

Factors Influencing the Intention and Uptake of COVID-19 Vaccines on the African Continent: A Scoping Review.

The COVID-19 pandemic is a severe concern worldwide, particularly in Africa. Vaccines are crucial in the fight against the COVID-19 pandemic. This scoping review examined existing literature from 2020 to 2022 on individual, interpersonal, and structural barriers and facilitators to COVID-19 vaccination within Africa to facilitate more informed health promotion interventions to improve vaccine uptake. This review was conducted using Arksey and O'Malley's five-stage methodological framework. A comprehensive search was undertaken from 2021 to 2022 using six electronic databases: EBSCOhost, PubMed, Web of Science, ProQuest, WorldCat Discovery, and Google Scholar. Data was collected, charted into themes, and summarized using a standard data extraction sheet in Microsoft Excel. A total of forty (n = 40) published academic articles were reviewed, with many conducted in Nigeria (n = 10), followed by Ethiopia (n = 5) and Ghana (n = 4) and the rest elsewhere in Africa. Thematic narratives were used to report data into six themes: attitudes and perceptions about COVID-19 vaccines, intention to uptake COVID-19 vaccines; factors and barriers associated with COVID-19 vaccine uptake; socio-demographic determinants affecting the intention and uptake; and information sources for COVID-19 vaccines. The intention for uptake ranged from 25% to 80.9%, resulting in a suboptimal uptake intention rate (54.2%) on the African continent. Factors that promoted vaccine acceptance included confidence in the COVID-19 vaccines and the desire to protect people. Age, education, and gender were the most common factors significantly associated with vaccine acceptance. Most studies revealed that considerable barriers to vaccine uptake exist in Africa. Concerns about potential side effects, vaccine ineffectiveness, a perceived lack of information, and inaccessibility were among the individual, interpersonal, and structural barriers to COVID-19 vaccine uptake. The unwillingness to receive the COVID-19 vaccine was strongly correlated with being female. Mass and social media were the main sources of information regarding COVID-19 vaccines. To encourage vaccine uptake, governments should pay attention to refuting misinformation through integrated community-based approaches, such as creating messages that convey more than just information.

HIV incidence and associated risk factors in adolescent girls and young women in South Africa: A population-based cohort study.

BACKGROUND: In sub-Saharan Africa, high HIV incidence rates in adolescent girls and young women (AGYW) persist despite extensive HIV prevention efforts. METHODS: A prospective cohort of 2,710 HIV-negative AGYW (15-24 years) in KwaZulu-Natal, South Africa were interviewed at baseline and followed-up approximately 18 months later (2014-2017). Associations between HIV seroconversion and socio-demographic and behavioural variables measured at baseline and follow-up were examined using Cox regression and a proximate determinants framework. Inter-relationships between determinants were measured using logistic regression. Separate models were built for 15-19 and 20-24-year-olds. RESULTS: Weighted HIV incidence was 3.92 per 100 person-years (95% confidence interval: 3.27-4.69; 163 seroconversions over 4,016 person-years). Among 15-19-year-olds, absence of family support (adjusted hazards ratio (aHR): 3.82 (1.89-7.72)), having a circumcised partner (aHR: 0.5 (0.27-0.94)) or one who was HIV-positive and not on antiretroviral therapy (ART) (aHR: 6.21 (2.56-15.06)) were associated with HIV incidence. Those reporting an absence of family support were also more likely to report >1 partner during follow-up (odds ratio (OR): 2.7(1.11-6.57)). Among 20-24-year-olds, failure to complete secondary school (aHR: 1.89 (1.11-3.21)), inconsistent condom use (aHR: 3.01 (1.14-7.96)) and reporting partner(s) who were HIV-positive and not on ART (aHR: 7.75 (3.06-19.66)) were associated with HIV incidence. Failure to complete secondary school among 20-24-year-olds was associated with inconsistent condom use (OR: 1.82 (1.20-2.77)) and reporting an HIV-positive partner not on ART (OR: 3.53(1.59-7.82)) or an uncircumcised partner (OR: 1.39 (1.08-1.82). CONCLUSION: Absence of family support and incomplete schooling are associated with risky sexual behaviours and HIV acquisition in AGYW. In addition, partner-level prevention-condom use, medical circumcision, and viral suppression-continue to play an important role in reducing HIV risk in AGYW. These findings support the use of combination HIV prevention programs that consider structural as well as biological and behavioural HIV risk factors in their design.

Preferences, beliefs, and attitudes about oral fluid and blood-based HIV self-testing among truck drivers in Kenya choosing not to test for HIV.

Introduction: Clinical trials in sub-Saharan Africa support that HIV self-testing (HIVST) can increase testing rates in difficult-to-reach populations. However, trials mostly evaluate oral fluid HIVST only. We describe preferences for oral fluid vs. blood-based HIVST to elucidate prior trial results and inform testing programs. Methods: Participants were recruited from a HIVST randomized controlled trial in Nakuru County, Kenya, which aimed to test the effect of choice between oral HIVST and facility-based testing compared to standard-of-care on HIV testing among truck drivers. We conducted in-depth interviews (IDIs) with purposively sampled trial participants who declined HIV testing at baseline or who were offered access to oral fluid HIVST and chose not to pick up the kit during follow-up. IDIs were conducted with all consenting participants. We first describe IDI participants compared to the other study participants, assessing the statistical significance of differences in characteristics between the two samples and then describe preferences, beliefs, and attitudes about HIVST biospecimen type expressed in the IDIs. Results: The final sample consisted of 16 men who refused HIV testing at baseline and 8 men who did not test during follow-up. All IDI participants had tested prior to study participation; mean number of years since last HIV test was 1.55, vs. 0.98 among non-IDI participants (p = 0.093). Of the 14 participants who answered the question about preferred type of HIVST, nine preferred blood-based HIVST, and five, oral HIVST. Preference varied by study arm with four of five participants who answered this question in the Choice arm and five of nine in the SOC arm preferring blood-based HIVST. Six key themes characterized truckers' views about test type: (1) Rapidity of return of test results. (2) Pain and fear associated with finger prick. (3) Ease of use. (4) Trust in test results; (5) fear of infection by contamination; and (6) Concerns about HIVST kit storage and disposal. Conclusion: We found no general pattern in the themes for preference for oral or blood-based HIVST, but if blood-based HIVST had been offered, some participants in the Choice arm might have chosen to self-test. Offering choices for HIVST could increase testing uptake.

Predictors of migration in an HIV hyper-endemic rural South African community: evidence from a population-based cohort (2005-2017).

Globally, South Africa hosts the highest number of people living with HIV (PLHIV) and the unique legacy of internal labour migration continues to be a major driver of the regional epidemic, interrupting treatment-as-prevention efforts. The study examined levels, trends, and predictors of migration in rural KwaZulu-Natal Province, South Africa, using population-based surveillance data from 2005 through 2017. We followed 69 604 adult participants aged 15-49 years and recorded their migration events (i.e., out-migration from the surveillance area) in 423 038 person-years over 525 397 observations. Multiple failure Cox-regression models were used to measure the risk of migration by socio-demographic factors: age, sex, educational status, marital status, HIV, and community antiretroviral therapy (ART) coverage. Overall, 69% of the population cohort experienced at least one migration event during the follow-up period. The average incidence rate of migration was 9.96 events and 13.23 events per 100 person-years in women and men, respectively. Migration rates declined from 2005 to 2008 then peaked in 2012 for both women and men. Adjusting for other covariates, the risk of migration was 3.4-times higher among young women aged 20-24 years compared to those aged ≥ 40 years (adjusted Hazard Ratio [aHR] = 3.37, 95% Confidence Interval [CI]: 3:19-3.57), and 2.9-times higher among young men aged 20-24 years compared to those aged ≥ 40 years (aHR = 2.86, 95% CI:2.69-3.04). There was a 9% and 27% decrease in risk of migration among both women (aHR = 0.91, 95% CI: 0.83 - 0.99) and men (aHR = 0.73, 95% CI 0.66 - 0.82) respectively per every 1% increase in community ART coverage. Young unmarried women including those living with HIV, migrated at a magnitude similar to that of their male counterparts, and lowered as ART coverage increased over time, reflecting the role of improved HIV services across space in reducing out-migration. A deeper understanding of the characteristics of a migrating population provides critical information towards identifying and addressing gaps in the HIV prevention and care continuum in an era of high mobility.

Determining HIV risk for Adolescent Girls and Young Women (AGYW) in relationships with "Blessers" and age-disparate partners: a cross-sectional survey in four districts in South Africa.

BACKGROUND: HIV incidence among adolescent girls and young women (AGYW) remains high, with their male partners a prominent factor in sustaining these elevated rates. Partnership characteristics remain important metrics for determining HIV risk, with evidence indicating that AGYW engaged in transactional and age-disparate relationships face greater HIV exposure. This study examines the risk posed to AGYW in a relationship with a "Blesser", defined as male who provides his female partner with their material needs or desires in exchange for a sexual relationship, an age-disparate (5 or more years older) partner, and the potential compounded risk of being a relationship with a partner or partners who are considered both a "Blesser" and age-disparate. METHODS: A cross -sectional household based representative sample of AGYW (aged between 12-24 years) were enrolled in the study (n = 18 926) from the districts of City of Johannesburg and Ekurhuleni in the Gauteng province and the Districts of eThekwini and uMgungundlovu in the province of KwaZulu-Natal (KZN) in South Africa between March 13, 2017 to June 22, 2018. Participants completed a structured questionnaire and provided finger-prick blood samples for laboratory measurements. Our analysis used descriptive statistics and multiple binary logistic regressions accounting for survey weights, clustering and stratification. FINDINGS: The median age of the sample was 21 years old (Interquartile range: 19-23) and nearly three quarters (73.7%) were currently attending school. Whilst all relationships exposed AGYW to potential HIV risk, multiple binary logistic regression analysis revealed that AGYW in a relationship with both a Blesser and an age-disparate partner were more likely to be HIV positive (AOR: 3.12, 95% CI: 1.76-5.53, p < 0.001), diagnosed with an STI (AOR: 4.60, 95% CI: 2.99-7.08, p < 0.001), had 2 or more sexual partners in the previous 12 months (AOR: 6.37, 95% CI: 3.85-10.54, p < 0.001), engaged in sexual activity at age 15 or younger (AOR: 3.67, 95% CI: 2.36-5.69, p < 0.001) and more likely to have ever been pregnant (AOR: 2.60, 95% CI: 1.24-5.45, p < 0.05) than those not in a relationship with either a Blesser or age-disparate partner. CONCLUSION: Different relationships present different HIV risk to AGYW. AGYW who had engaged in relationships with both a Blesser and an age-disparate partner were at greater HIV risk when examined against these relationships independent of one another. The data reveals the compounded HIV risk of being in both a transactional and age-disparate relationship.

Association of HIV Intervention Uptake With HIV Prevalence in Adolescent Girls and Young Women in South Africa.

Importance: In South Africa, adolescent girls and young women aged 15 to 24 years are among the most high-risk groups for acquiring HIV. Progress in reducing HIV incidence in this population has been slow. Objective: To describe HIV prevalence and HIV risk behaviors among a sample of adolescent girls and young women and to model the association between exposure to multiple or layered interventions and key HIV biological and behavioral outcomes. Design, Setting, and Participants: This cross-sectional survey was conducted between March 13, 2017, and June 22, 2018, in 2 districts in Gauteng province and in 2 districts in KwaZulu-Natal province in South Africa. A stratified cluster random sampling method was used. Participants included adolescent girls and young women aged 12 to 24 years who lived in each sampled household. Overall, 10 384 participants were enrolled in Gauteng province and 7912 in KwaZulu-Natal province. One parent or caregiver was interviewed in each household. Data analysis was performed from March 12, 2021, to March 1, 2022. Exposures: DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe)-like interventions. Main Outcomes and Measures: The primary outcome was HIV prevalence. HIV status was obtained from laboratory-based testing of peripheral blood samples. Secondary outcomes included HIV testing and antiretroviral therapy uptake as well as numerous HIV risk variables that the DREAMS program sought to improve, such as pregnancy, sexually transmitted infection, intimate partner violence, and age-disparate sex. Results: The final sample included 18 296 adolescent girls and young women (median [IQR] age, 19 [15-21] years) in 10 642 households. Approximately half of participants (49.9%; n = 8414) reported engaging in sexual activity, and 48.1% (n = 3946) reported condom use at the most recent sexual encounter. KwaZulu-Natal province had a higher HIV prevalence than Gauteng province (15.1% vs 7.8%; P < .001). Approximately one-fifth of participants (17.6%; n = 3291) were not exposed to any interventions, whereas 43.7% (n = 8144) were exposed to 3 or more interventions. There was no association between exposure to DREAMS-like interventions and HIV status. Adolescent girls and young women who accessed 3 or more interventions were more likely to have undergone HIV testing (adjusted odds ratio, 2.39; 95% CI, 2.11-2.71; P < .001) and to have used condoms consistently in the previous 12 months (adjusted odds ratio, 1.68; 95% CI, 1.33-2.12; P < .001) than those who were not exposed to any interventions. Conclusions and Relevance: Results of this study suggest that self-reported exposures to multiple or layered DREAMS-like interventions were associated with favorable behavioral outcomes. The beneficial aspects of layering HIV interventions warrant further research to support the sexual and reproductive health of adolescent girls and young women.

Role of Schooling and Comprehensive Sexuality Education in Reducing HIV and Pregnancy Among Adolescents in South Africa.

BACKGROUND: Comprehensive sexuality education (CSE) seeks to reduce risky sexual behaviour and subsequent incidence of unintended pregnancy and HIV among schoolgoing adolescents. This study estimates the association between exposure to CSE and key biomedical and behavioural indicators among adolescent girls in South Africa. SETTING: Four DREAMS implementation districts in Gauteng and KwaZulu-Natal provinces in South Africa. METHODS: Data from a household-based representative sample of adolescent girls (between the ages 12-18 years) (n = 9673) was collected. Independent variables included school attendance and exposure to CSE, with outcome variables measuring prevalence of HIV, pregnancy, and sexual risky behaviour, including condom use, incidence of age-disparate relationships, and transactional sex. RESULTS: Adolescent girls in school and who had attended CSE classes in the previous 12 months were associated with reduced adjusted odds of being HIV-positive [full sample: adjusted odds ratios (AOR): 0.76, 95% confidence interval [CI]: 0.61 to 0.95, P < 0.05; sexually active sample: AOR: 0.62, 95% CI: 0.40 to 0.96, P < 0.05]. Those in school who attended CSE in the previous 12 months were also more likely to get tested for HIV (AOR: 1.48, 95% CI: 1.32 to 1.65, P < 0.001). CONCLUSIONS: The results indicate that school attendance and exposure to CSE is associated with a reduction in risky sexual behaviour. Exposure to CSE is also associated with increased access to HIV testing for adolescent girls both in and out of school. Keeping adolescent girls in school produces the greatest positive sexual behavioural effect; this, coupled with the delivery of quality CSE, is a key strategy for reducing HIV risk.

COVID-19 vaccines for children and adolescents in Africa: aligning our priorities to situational realities.

The evolving COVID-19 pandemic is an unprecedented global public health crisis that continues to have a major impact on the African continent. Most countries within Africa are facing significant challenges vaccinating their populations for COVID-19. Inadequate COVID-19 vaccine supply, weaknesses in health system infrastructure, COVID-19 misinformation and disinformation, and ineffective health risk communication are contributing to low adult vaccination rates on the continent. Without sufficient COVID-19 vaccine coverage on the African continent, the prolonged social, economic and health impacts of this public health crisis are likely to exacerbate pre-existing social-structural issues in this part of the world. In this paper, we highlight trends in SARS-CoV-2 infections among children and adolescents (CA), compare COVID-19 vaccination patterns in Africa to those in high-income countries, and discuss some of the benefits, challenges and unknowns associated with vaccinating CA for COVID-19. In light of ongoing COVID-19 vaccine supply challenges and the slow progress that the African continent is making towards vaccinating the adult population, we suggest that the immediate priority for Africa is to accelerate COVID-19 vaccinations among adults (particularly high-risk populations) and vulnerable CA (ie, those who are immunocompromised and/or living with certain medical conditions). Accelerating the roll-out of COVID-19 vaccines and rapidly achieving high levels of vaccination coverage in the adult population will free up capacity to vaccinate CA sooner rather than later. While we hope that COVID-19 vaccines will soon become available to CA throughout Africa, countries must continue to prioritise non-pharmaceutical interventions.

Depression symptoms, HIV testing, linkage to ART, and viral suppression among women in a high HIV burden district in KwaZulu-Natal, South Africa: A cross-sectional household study.

Achieving the UNAIDS 90-90-90 targets by 2020 is contingent on identifying and addressing mental health challenges that may affect HIV testing and treatment-related behaviors. This study is based on survey data from KwaZulu-Natal, South Africa (2014-2015). HIV positive women who reported higher depression scores had a lower odds of having tested previously for HIV (15-25 years: AOR = 0.90, 95% CI [0.83, 0.98]; 26-49 years: AOR = 0.90, 95% CI [0.84, 0.96]). Because HIV testing behavior represents a gateway to treatment, the findings suggest mental health may be one challenge to attaining the UNAIDS 90-90-90 targets.

Evaluating effect modification by HIV testing history to understand the mechanisms behind the impact of announcing HIV self-testing availability in a clinic system in Kenya.

Background: In sub-Saharan Africa, truckers and female sex workers (FSWs) have high HIV risk and face challenges accessing HIV testing. Adding HIV self-testing (HIVST) to standard of care (SOC) programs increases testing rates. However, the underlying mechanisms are not fully understood. HIVST may decrease barriers (inconvenient clinic hours, confidentiality concerns) and thus we would expect a greater impact among those not accessing SOC testing (barriers prevented previous testing). As a new biomedical technology, HIVST may also be a cue to action (the novelty of a new product motivates people to try it), in which case we might expect the impact to be similar by testing history. Methods: We used data from two randomized controlled trials evaluating the announcement of HIVST availability via text-message to male truckers (n = 2,260) and FSWs (n = 2,196) in Kenya. Log binomial regression was used to estimate the risk ratio (RR) for testing ≤ 2 months post-announcement in the intervention vs. SOC overall and by having tested in the previous 12-months (12m-tested); and we assessed interaction between the intervention and 12m-tested. We also estimated risk differences (RD) per 100 and tested additive interaction using linear binomial regression. Results: We found no evidence that 12m-tested modified the HIVST impact. Among truckers, those in the intervention were 3.1 times more likely to test than the SOC (p < 0.001). Although testing was slightly higher among those not 12m-tested (RR = 3.5, p = 0.001 vs. RR = 2.7, p = 0.020), the interaction was not significant (p = 0.683). Among FSWs, results were similar (unstratified RR = 2.6, p < 0.001; 12m-tested: RR = 2.7, p < 0.001; not 12m-tested: RR = 2.5, p < 0.001; interaction p = 0.795). We also did not find significant interaction on the additive scale (truckers: unstratified RD = 2.8, p < 0.001; 12m-tested RD = 3.8, p = 0.037; not 12m-tested RD = 2.5, p = 0.003; interaction p = 0.496. FSWs: unstratified RD = 9.7, p < 0.001; 12m-tested RD = 10.7, p < 0.001, not 12m-tested RD = 9.1, p < 0.001; interaction p = 0.615). Conclusion: The impact of HIVST was not significantly modified by 12m-tested among truckers and FSWs on the multiplicative or additive scales. Announcing the availability of HIVST likely served primarily as a cue to action and testing clinics might maximize the HIVST benefits by holding periodic HIVST events to maintain the cue to action impact rather than making HIVST continually available.

Experiences of intimate relationships, stigma, social support and treatment adherence among HIV-positive adolescents in Chiredzi district, Zimbabwe.

This study explored experiences of intimate relationships, stigma, social support and treatment adherence among HIV-positive adolescents in Chiredzi district, Zimbabwe. The study adopted an interpretive qualitative methodology to explore the intricacies of living with HIV as an adolescent. Thirty (N = 30) adolescents aged between 13 and 19 years participated in this study. They were recruited while attending social support or during their routine visits to collect antiretrovirals. In-depth interviews were conducted to generate data. Adolescents were asked about their romantic lives and the difficulties they faced while living with HIV. Findings revealed that adolescents living with HIV (ALHIV) are confronted with stigma and discrimination. They also grapple with emotional issues such as dealing with disclosure. However, social support minimises the risk of harbouring suicidal thoughts. To the various challenges ALHIV face, most of them (particularly males) adopt several coping mechanisms. These include (but are not limited to) non-disclosure of their seropositive status to sexual partners, thereby risking reinfection and exposing their partners to HIV. Non-disclosure of seropositive status contributed to either poor antiretroviral therapy (ART) adherence or defaulting on HIV medication. A life-cycle approach to HIV prevention and management is crucial to mitigating the challenges faced by ALHIV because risks of HIV infection, challenges of access to HIV services and solutions to these challenges change at different stages of someone's life. This scenario justifies the necessity of a holistic bio-psychosocial approach to managing HIV among adolescents, not only limited to the client, but also involving appropriate education programmes for the broader community.