HIV Stigma, Health, and Violence: A Longitudinal Study among Adolescent Boys with HIV in Soweto, South Africa.

There are over 1.4 million adolescents living with HIV in sub-Saharan Africa, the majority of whom acquired the virus through perinatal transmission (PHIV). HIV stigma is particularly high among adolescents living with HIV and is associated with several outcomes that worsen health and increase the risk of onward HIV transmission. We tested associations between internalized HIV stigma and four of these outcomes over a one-year period among a sample of adolescent boys living with PHIV in Soweto, South Africa. Participants (N = 241) answered questions about internalized HIV stigma at baseline. They completed weekly mobile surveys over the following year to answer questions about their experiences with depression, binge drinking, medication adherence, and violence victimization. Using generalized linear mixed models, we found that baseline internalized HIV stigma was associated with increased odds of depression (OR 1.74), alcohol misuse (OR 2.09), and violence victimization (OR 1.44) and decreased odds of medication adherence (OR 0.60) over the course of a year. These outcomes negatively impact the health and wellbeing of adolescents living with PHIV and increase their risk of transmitting HIV to their partners in the future. Our findings provide novel, longitudinal evidence for the deleterious effects of HIV stigma. To improve health outcomes for adolescents with PHIV, it will be crucial to develop effective HIV stigma reduction interventions that address specific developmental, gendered, and cultural experiences.

Implementing ecological momentary assessments to measure violence and adolescent HIV transmission risk: Lessons from Johannesburg, South Africa.

Ecological Momentary Assessment (EMA) is an important methodology to understand risky behaviour and holds promise for HIV research. EMA is still novel in sub-Saharan Africa. We describe challenges and lessons learned on a novel study implementing mobile phone EMAs with adolescent boys in South Africa. The Tsamaisano study was a longitudinal study from 2020-2023 to recruit adolescent boys aged 15-19 years; including those without HIV and those perinatally infected and living with HIV. Participants were prompted to complete 52 weekly mobile phone survey on emotional state, exposure to and perpetration of violence, and sexual risk behaviour. Surveys were delivered using a random algorithm to choose the day. We incorporated mechanisms to assess challenges and optimize survey completion: weekly team meetings with youth representation and real-time data monitoring. Additionally, 20 frequent vs infrequent survey submitters participated in qualitative interviews about barriers and recommendations. Real-time monitoring indicated low (defined as <50%) survey completion in the first months of study implementation. To ensure that both the adolescent participant and their caregiver understood the commitment required for successful EMA, we created and implemented a guided discussion around mobile phone access during the enrolment visit. We identified a need for increased and ongoing technical support; addressed by creating technical guides, implementing a standard two-week check-in call after enrolment, adding an automated request button for call-back assistance, creating a WhatsApp messaging stream, and reaching out to all participants failing to submit two sequential surveys. Entry-level smartphones, including those initially distributed by the study, did not have capacity for certain updates and had to be replaced with more expensive models. Participants struggled with randomly allocated survey days; completion improved with set completion days and targeted reminder messages. Together, these steps improved survey completion from 40% in December 2020 to 65% in April 2022. We describe key lessons learned to inform future study designs with mobile phone EMAs, drawing on our experience implementing such among adolescent boys, including persons living with HIV, in a low-and-middle income setting. The key lessons learned through the Tsamaisano study are important to inform future study designs with EMA utilizing mobile phone, electronic data collection among adolescent boys in low-and-middle-income settings.

"It Was a Mistake, but We Knew That Something Might Happen": Narratives of Teenage Girls' Experiences With Unintended Teenage Pregnancy.

It has been over a quarter of a century since the sexual reproductive health of young people came under the spotlight. The upsurge in human immunodeficiency virus (HIV) infections spurred on an era of intense development of services and strategies to ensure people's reproductive health rights were attainable, including the right to choose when to fall pregnant and have a baby. The statistics on teenage pregnancy are more than just numbers, but a represent stark reality for some girls in South African schools. Given that pregnancy in the teenage years is largely unintentional, prevention strategies need to extend beyond addressing risky sexual behavior; gaining deeper insights into teenagers' experiences and the events leading up to pregnancy would serve to better inform pregnancy prevention programs. This study explored the experiences of teenage mothers and pregnant teenagers, with the objective of acquiring a broader understanding of alternative approaches to preventing unintended pregnancy. A qualitative study was conducted in Ekurhuleni's township in the east of Johannesburg, South Africa. Fifteen narrative interviews with girls aged 13-19 years were conducted between July 2015 and July 2016, and were analyzed chronologically through narrative analysis. The findings revealed that participants who had engaged in socio-sexual and romantic relationships had no intention of falling pregnant and were familiar with existing strategies to prevent pregnancy. Social-sexual relationships were presented as an important aspect of their lives and demonstrated their ability to create spaces and opportunities to spend time with their social sexual partners and engage in sexual activity. Focusing on how teenage girls evaluate their sexual activity against the consequences of their actions is critical. However, sexual and reproductive health programs should refrain from representing young people's sexual behavior as a pathological condition, framing it instead as an integral component of creative sexual development. Programs should include relevant practical advice in relation to sexual engagement and be considered an extension of the State's existing Road to Health program.