Disseminating Evidence-Based Interventions for Adolescent HIV Treatment and Prevention in Sub-Saharan Africa.

Over two-thirds of adolescents living with HIV worldwide reside in sub-Saharan Africa (SSA). Despite widespread availability and access to evidence-based HIV prevention and treatment, dissemination has been inadequate. This commentary distinguishes between implementation and dissemination, reflecting on the unique barriers to dissemination of evidence-based programs in SSA. We present a seven-strategy blueprint developed by United States Agency for International Development (USAID) that emphasizes targeted communication about research findings. Two case studies from the Adolescent HIV Implementation Science Alliance are presented to illustrate the value of planning for dissemination. We propose recommendations to strengthen dissemination recognizing that these may not be possible or appropriate in all situations, including developing a plan early in the process, engaging a dissemination technical team for support, the application of methodological rigor and theory to inform dissemination, active involvement of youth voices and digital tools to maximize message reach, and a keen recognition of evolving contexts and shifting priorities in order to nimbly tailor messages as needed.

Investigating Longitudinal Associations Between Racial Microaggressions, Coping, Racial/Ethnic Identity, and Mental Health in Black Girls and Women.

Racial microaggressions pose significant risk to health and well-being among Black adolescents and adults. Yet, protective factors (i.e., coping, racial/ethnic identity) can moderate the impact of racial microaggressions over time. Unfortunately, few studies have evaluated the role of these protective factors longitudinally or specifically among Black girls and women. In the current study, we focused on the experiences of Black girls and women and investigated the longitudinal links between racial microaggressions and mental health symptoms over 1 year. We then explored the role of two key protective factors as moderators-coping with racial discrimination and racial/ethnic identity-for mental health. Participants included 199 Black adolescent girls (Mage = 16.02) and 199 Black women (Mage = 42.82) who completed measures on two types of racial microaggressions, three types of coping strategies, racial/ethnic identity, and mental health symptomology. Girls and women completed measures at three time points over 1 year. Results indicated both types of microaggressions predicted increased mental health symptoms in Black women. Among Black girls, assumptions of criminality predicted increased externalizing symptoms only when protective factors were included in the model. Analysis of the protective factors indicated a potential direct benefit rather than a moderating role of coping with racial discrimination through positive thinking for mental health in both Black girls and women. Evidence suggests that coping may have had a direct rather than an indirect effect on Black girls' mental health over time. We conclude with future directions for research and considerations for practice.

An individually randomized controlled trial of a mother-daughter HIV/STI prevention program for adolescent girls and young women in South Africa: IMARA-SA study protocol.

BACKGROUND: South Africa has the world's largest HIV epidemic, but South African adolescent girls and young women (AGYW) acquire HIV at twice the rate of and seroconvert on average 5-7 years earlier than their male peers. Female caregivers (FC) are an untapped resource for HIV/STI prevention in South Africa and offer a novel opportunity to strengthen AGYW prevention efforts. This study will evaluate the effectiveness and cost-effectiveness of an evidence-based mother-daughter HIV/STI prevention program tested in the United States and adapted for South Africa, Informed Motivated Aware and Responsible Adolescents and Adults (IMARA), to decrease STI incident infections and increase HIV testing and counseling (HTC) and PrEP uptake in AGYW. METHODS: This is a 2-arm individually randomized controlled trial comparing IMARA to a family-based control program matched in time and intensity with 525 15-19-year-old Black South African AGYW and their FC-dyads in Cape Town's informal communities. AGYW will complete baseline, 6-, and 12-month assessments. Following randomization, AGYW-FC dyads will participate in a 2-day group workshop (total 10 h) that includes joint and separate mother and daughter activities. Primary outcomes are AGYW STI incidence, HTC uptake, and PrEP uptake at 6 months. Secondary outcomes are AGYW STI incidence, HTC uptake, and PrEP uptake at 12 months, sexual behavior (e.g., condom use, number of partners), HIV incidence, and ART/PrEP adherence and intervention cost-effectiveness. AGYW who test positive for a STI will receive free treatment at the study site. HIV positive participants will be referred to ART clinics. DISCUSSION: Primary prevention remains the most viable strategy to stem new STI and HIV transmissions. HIV and STI disparities go beyond individual level factors, and prevention packages that include supportive relationships (e.g., FC) may produce greater reductions in HIV-risk, improve HTC and PrEP uptake, and increase linkage, retention, and adherence to care. Reducing new HIV and STI infections among South African AGYW is global public health priority. TRIAL REGISTRATION: ClinicalTrials.gov Number NCT04758390 , accepted 02/16/2021.

Psychometric Properties of the Aggressive Behaviors Scale from the Youth Self-Report in Juvenile Offenders.

The study of aggression in juvenile offenders, a high priority from clinical and public health standpoints, depends on properly measuring and modeling aggression. The Aggressive Behaviors scale from the Youth Self-Report (YSR-AB) has been widely used to measure youth aggression, often functioning as a stand-alone scale in analyses (of note, even when analyzed alone, the YSR-AB must be administered as part of the full YSR to retain its integrity). However, knowledge of its factor analytic structure among juvenile offenders is lacking. We addressed this gap. Factor analyses of YSR-AB data from 310 probation youth (M age = 16 years, 90% African American, 66% male) supported a hierarchical structure, with 2 lower order factors distinguishing aggression targeting others (e.g., physical attack) from related symptoms (e.g., mood swings). The targeted aggression items showed significantly stronger associations with other externalizing symptoms than did the related symptom items; the opposite pattern emerged for internalizing symptoms. In further support of the convergent and discriminant validity of these subscales, the related symptoms were differentially linked to gender, with females reporting significantly higher levels than males. The hierarchical solution appeared to be stable over 1 year. Implications for interpreting past findings and conducting future research with the YSR-AB are discussed.

Evaluating the Role of Family Context Within a Randomized Adolescent HIV-Risk Prevention Trial.

Project STYLE is a multi-site 3-arm RCT comparing family-based, adolescent-only, and general health promotion interventions with 721 adolescents in mental health treatment. This study reports 12-month outcomes for family context and sexual risk behaviors, and explores the role of baseline family context in modifying treatment response. Using the full sample, there were sustained benefits for parent-reported sexual communication (d = 0.28), and adolescent-reported parental monitoring (d = 0.24), with minimal differences in risk behaviors. Latent profile analysis identified four family context classes: struggling (n = 177), authoritative (n = 183), authoritarian (n = 175), and permissive (n = 181). The authoritarian and permissive classes were also distinguished by disagreement between parent and adolescent report of family context. Classes differed in terms of baseline mental health burden and baseline sexual risk behavior. Classes showed different patterns of treatment effects, with the struggling class showing consistent benefit for both family context and sexual risk. In contrast, the authoritarian class showed a mixed response for family context and increased sexual risk.

Associations of ethnic/racial discrimination with internalizing symptoms and externalizing behaviors among juvenile justice-involved youth of color.

INTRODUCTION: Youth of color (e.g., Black/African American and Latinx/Hispanic) are overrepresented in the juvenile justice system and experience greater health disparities compared to non-Hispanic White youth. Ethnic/racial discrimination (ERD) is a risk marker for poor mental health and behavioral outcomes among youth of color, and traumatic stress and emotion dysregulation have been implicated in these pathways. Despite the relevance of these factors for justice-involved youth of color, understanding of their interrelations within this demographic is lacking. METHODS: Participants were 173 recently arrested adolescents (86% African American; 45% girls; ages 13-18) on probation in a large Midwest city in the United States. Participants completed surveys assessing ERD, traumatic stress, emotion dysregulation, internalizing symptoms, and externalizing behaviors. Using linear regression and path analysis, this study tested the cross-sectional links among two types of ERD (i.e., interpersonal experiences and perceptions of group experiences), traumatic stress symptoms, emotion dysregulation, and internalizing symptoms and externalizing behaviors. RESULTS: Interpersonal ERD (e.g., hearing racial insults) was associated with increased internalizing symptoms and externalizing behaviors; for internalizing symptoms, the relation was stronger for girls than boys. Gender differences were partially accounted for by traumatic stress symptoms and emotion dysregulation. CONCLUSIONS: This study offers new insights into ERD experiences among juvenile justice-involved youth of color, gender differences in ethnic/racial discrimination experiences, and the potential value of gender-sensitive and culturally responsive programming in strengthening youths' ability to cope with ERD.

Contextualizing pubertal development: The combination of sexual partners' age and girls' pubertal development confers risk for externalizing but not internalizing symptoms among girls in therapeutic day schools.

OBJECTIVE: Early pubertal development is associated with negative health and mental health outcomes. Research on the influence of puberty on mental health underscores a need to examine the interplay between puberty and exposure to environmental risk. This study investigates a more rarely studied aspect of girls' environments - romantic relationships with boyfriends. Specifically, this study examined sexual partner age and the timing of girls' pubertal development in relation to externalizing and internalizing symptoms among female students attending therapeutic day schools in the United States, a population at elevated risk for negative mental health outcomes. METHODS: A total of 121 13 to 19-year-old adolescent girls (Mean age = 15.4; SD = 1.5) reported on the relative age of their past 3 sexual partners, their age of pubertal onset, and mental health challenges via clinical assessments of externalizing and internalizing symptoms. RESULTS: Forty-three percent of participants qualified for at least one mental health diagnosis. Earlier pubertal onset predicted greater internalizing symptoms, and this effect did not depend on the age of girls' sexual partners. However, early-developing girls who also reported having a sexual partner more than 2 years older than them were at increased risk for externalizing symptoms. CONCLUSIONS: Findings underscore that sexual relationships are an important risk factor for early-developing girls already at risk for mental health problems. Early developing girls with older partners may experience stronger social pressure to stay in relationships that expose them to partner violence and delinquency-related pressure, which combine with interpersonal stress to predict externalizing symptoms.

Can Mother-Daughter Communication Buffer Adolescent Risk for Mental Health Problems Associated With Maternal Depressive Symptoms?

The current study sought to test whether higher quality mother-daughter communication would buffer associations between maternal depressive symptoms and girls' internalizing and externalizing psychopathology symptoms among urban African American girls across a 12-month period. One hundred ninety-four treatment-seeking urban African American adolescent girls, ages 12-16, and their mothers participated in the study. Every 6 months (for up to 3 assessments), daughters reported on their internalizing and externalizing symptoms, mothers reported on their depressive symptoms, and both mothers and daughters reported on the quality of their dyadic communication. Daughters additionally reported on the extent to which they felt accepted by their mothers at each assessment. Results of multilevel modeling revealed that quality of communication significantly interacted with maternal depressive symptoms to predict externalizing and internalizing symptoms in daughters, such that the risk associated with maternal depressive symptoms was fully buffered for daughters in high-quality communication dyads. Secondary analyses demonstrated that these patterns of results were not accounted for by higher levels of social status or maternal acceptance. Drawing on a vulnerable and understudied population of urban African American adolescent girls, this work suggests that family communication may contribute to important intergenerational psychopathology transmission processes, above and beyond more general features of the family environment.

Affect recognition among adolescents in therapeutic schools: relationships with posttraumatic stress disorder and conduct disorder symptoms.

BACKGROUND: Posttraumatic stress disorder (PTSD) and conduct disorder (CD) symptoms often co-occur in adolescence, but little is known about whether they show common or distinct emotional processing deficits. METHOD: We examined the effects of PTSD and CD symptoms on facial affect processing in youth with emotional and behavior problems. Teens enrolled in therapeutic day schools (N = 371; ages 13-19) completed a structured diagnostic assessment and the Diagnostic Analysis of Nonverbal Accuracy-2 facial affect recognition task. RESULTS: PTSD symptoms were associated with deficits in the recognition of angry facial expressions, specifically the false identification of angry faces as fearful. CD symptoms were associated with greater difficulty correctly identifying sadness. CONCLUSIONS: Findings suggest specificity in the relationships of PTSD and CD symptoms with emotional processing.

Prescription opioid misuse and mental health among young injection drug users.

BACKGROUND: Prescription opioid (PO) misuse is a significant concern in the United States. OBJECTIVES: This study describes the prevalence and timing of PO misuse, diagnoses of opiate abuse and dependence, and their associations with psychiatric disorders in a sample of young people who inject drugs (PWID). METHODS: Participants were 570 young (18-25 years) PWID, primarily heroin users, recruited through outreach and respondent-driven sampling. Trained interviewers administered a semi-structured psychiatric interview. Diagnoses of substance use and mental disorders were based on DSM-IV diagnostic criteria. RESULTS: Estimated rates of lifetime PO abuse and dependence were 19% and 17%, respectively. Past year PO misuse was significantly associated with anti-social personality disorder (ASPD, OR = 2.15, 95% CI 1.43-3.24), past year substance-induced major depression (SIMD, OR = 1.81, 95% CI 1.16-2.83), and prior post-traumatic stress disorder (PTSD, OR = 2.45, 95% CI 1.31-4.60). Among male PO users, PTSD was a significant predictor of PO abuse (prior, OR = 7.62, 95% CI 2.16-26.88; past year, OR = 21.67 95% CI 2.46-190.75), and dependence (prior, OR = 4.82, 95% CI 1.48-15.67; past year, OR = 9.65, 95% CI 1.75-53.32). CONCLUSION: Among young PWID, PTSD is a significant risk factor for PO misuse for both men and women, and men with PTSD are in addition at increased risk for PO abuse and dependence. These findings have implications for harm reduction and substance abuse prevention efforts.

From violence exposure to development of sexual risk in low-income urban girls: the role of psychopathology.

This longitudinal study examined psychopathology as an explanatory mechanism linking childhood violence exposure (CVE) to sexual risk in 177 African American girls recruited from mental health clinics serving low-income communities in Chicago. Beginning at average age 14, girls completed five interviews over 2 years and a sixth assessment including trauma history. CVE reflected sexual, physical, or witnessed violence before age 12. Latent growth modeling accounted for developmental change across the six time points. Externalizing, but not internalizing, symptoms mediated the pathway from CVE to number of partners (indirect effect = .16, 95 % CIBCBS = .04-.29) and inconsistent condom use (indirect effect = .11, CIBCBS = .004-.21). Externalizing problems associated with CVE may help to explain its relationship with sexual risk in low-income, treatment-seeking African American girls. Behavioral interventions addressing aggression, impulsivity, and general risk-taking may be most effective in reducing sexual risk in this population.

Externalizing symptoms moderate associations among interpersonal skills, parenting, and depressive symptoms in adolescents seeking mental health treatment.

Adolescents' interpersonal skills are associated with fewer teen depressive symptoms and more positive parenting, but little is known about how teens' externalizing problems moderate these relationships. This study examines links among teens' interpersonal skills, parenting, and withdrawn-depressed symptoms in adolescents seeking outpatient psychiatric treatment with elevated or non-elevated externalizing problems. Adolescents (N = 346; 42 % female; 61 % African-American) ages 12-19 years old (M = 14.9; SD = 1.8) and parents completed assessments at baseline and 6 months. At baseline parents and teens reported on teen withdrawn-depressed and externalizing symptoms, and were observed interacting to assess teen interpersonal skills. At 6 months adolescents reported on parenting, and parents and teens reported on teen withdrawn-depressed symptoms. Structural equation modeling tested two models (one with teen reported symptoms and one with parent reported symptoms). Model fit was better for youth with elevated externalizing problems regardless of reporter. For youth with elevated externalizing problems, baseline teen positive interpersonal skills were not directly associated with 6-month withdrawn-depressed symptoms, but more positive parenting was associated with fewer withdrawn-depressed symptoms. In the teen report model, more positive teen interpersonal skills were associated with more positive parenting, and there was a trend for parenting to indirectly account for the relationship between interpersonal skills and withdrawn-depressed symptoms. The findings extend research on the role of externalizing problems in teens' depression risk. Interventions for depression that target interpersonal skills may be particularly effective in youth with elevated externalizing problems.

Childhood violence exposure and the development of sexual risk in low-income African American girls.

Low-income, urban African American (AA) girls are at heightened risk for sexually transmitted infections (STIs), and violence exposure may be an important risk factor. AA girls (N = 177) from low-income communities in Chicago completed a 2-year longitudinal study of HIV-risk behavior involving five waves of data collection (ages 12-16 at baseline) and a sixth wave (ages 14-22) assessing lifetime trauma and victimization history. Childhood exposure to violence (CEV) represented reports of physical, sexual, or witnessed violence before age 12. Latent growth curve analysis examined CEV as a covariate of sexual experience, number of sexual partners, and inconsistent condom use trajectories. CEV was associated with greater sexual risk, although the pattern differed across the three outcomes. Overall, findings emphasize the need for early interventions to reduce sexual risk among low-income urban girls who have experienced violence. Efforts to address or prevent violence exposure may also reduce rates of STIs in this population.

Family environment, coping, and mental health in adolescents attending therapeutic day schools.

OBJECTIVE: This study examined associations among family environment, coping, and emotional and conduct problems in adolescents attending therapeutic day schools due to mental health problems. METHODS: Adolescents (N = 417; 30.2% female) ages 13-20 (M = 15.25) reported on their family environment (affective involvement and functioning), coping (emotion-focused support-seeking, cognitive restructuring, avoidant actions), and emotional and conduct problems. RESULTS: Poorer family environment was associated with less emotion-focused support-seeking and cognitive restructuring, and more emotional and conduct problems. Emotional problems were negatively associated with cognitive restructuring, and conduct problems were negatively associated with all coping strategies. Cognitive restructuring accounted for the relationship between family environment and emotional problems. Cognitive restructuring and emotion-focused support-seeking each partially accounted for the relationship between family functioning and conduct problems, but not the relationship between family affective involvement and conduct problems. CONCLUSIONS: Findings implicate the role of coping in the relationship between family environment and adolescent mental health.

Multi-level factors associated with pregnancy among urban adolescent women seeking psychological services.

The purpose of this study was to examine the prevalence of pregnancy as well as multi-level factors (i.e., individual, family, and environment) associated with history of pregnancy among a sample of urban adolescent women seeking psychological services. Data were collected from a total of 264 sexually active, 13-18-year-old, adolescent women who participated in a larger HIV prevention study. Adolescents and one participating parent completed an audio computer-assisted self-interviewing survey. A total of 17.4% of participants reported a history of pregnancy. A multivariable logistic regression model suggests that after controlling for empirically derived sociodemographic and behavioral covariates, absence of father in the home, family support and cohesion, and neighborhood risk were positively related to pregnancy. This study is among the first to examine multi-level factors associated with pregnancy among adolescent women diagnosed with psychological disorders. Consideration of such factors is crucial both in terms of clinical practice and in the design of pregnancy prevention programs. Collaboration between physicians and mental health providers working with adolescent women is crucial and represents an ideal opportunity to promote parental involvement and access to supportive community resources, including pregnancy prevention programs for this vulnerable population of adolescents.

History of sexual abuse and development of sexual risk behavior in low-income, urban African American girls seeking mental health treatment.

OBJECTIVE: This study examined relationships between sexual abuse and patterns of sexual risk-taking among low-income, urban African American adolescent girls seeking mental health treatment. METHOD: Participants (N = 158) were 12- to 16-year-old African American girls recruited from outpatient mental health clinics serving urban, mostly low-socioeconomic status communities in Chicago, Illinois and followed for two years between 2003 and 2010. This study included self-reports of sexual abuse and four waves (T2-T5) of self-reported data on sexual experience and sexual risk-taking (number of partners, inconsistent condom use, and sex with a risky partner). Latent curve modeling was used to examine patterns of sexual behavior over the four time points with sexual abuse and mental health symptoms as covariates. RESULTS: Sexual abuse was significantly associated with T2 sexual experience, T2-T4 number of partners, T3 inconsistent condom use, and T2-T3 having a risky partner. These relationships decreased when mental health symptoms were controlled. CONCLUSIONS: This longitudinal study revealed a complex relationship between sexual abuse and sexual risk that would be missed if sexual risk were assessed at a single time point. Findings supported early intervention to delay onset of sexual risk behavior among low-income African American girls with mental health concerns and histories of sexual abuse.

Preliminary effectiveness and implementation outcomes of the IMARA-South Africa sexual health intervention on adolescent girls and young women: A pilot randomized trial.

Family-based interventions may help reduce the risk of HIV and other sexually transmitted infections (STI) among adolescent girls and young women (AGYW) in sub-Saharan Africa but few have been tested. We examined the preliminary effectiveness and implementation outcomes of Informed, Motivated, Aware, and Responsible Adolescents and Adults-South Africa (IMARA-SA), an evidence-based intervention for South African AGYW (15-19 years) and their female caregivers. We piloted IMARA-SA in the Western Cape using an individually randomized experimental design and average follow-up at 11 months. Primary outcomes were HIV Testing and Counselling (HTC) uptake, STI incidence (gonorrhea, chlamydia), and pre-exposure prophylaxis (PrEP) uptake. Secondary outcomes were self-reported sexual risk behavior (condom use at last sex, consistency of condom use, substance use during sex, and number of sexual partners) and PrEP adherence. We examined four implementation outcomes: reach, feasibility, acceptability, and fidelity. Data from 59 AGYW (mean = 17.2 years) were analyzed at baseline (n = 29 from IMARA-SA, 30 from a health promotion control group). At follow-up, 51 (86%) completed surveys and 39 (66%) presented for HTC, STI testing, and/or PrEP. Compared to controls, fewer IMARA-SA participants tested positive for an STI (22% versus 38%), more IMARA-SA participants took up PrEP (68% versus 45%), and four of five secondary outcomes favored the IMARA-SA group at follow-up. These differences did not reach statistical significance. HTC uptake at follow-up was 100% in both groups. All AGYW-FC dyads agreed to participate in the study (reach). In the IMARA-SA group, 76% of dyads completed the intervention (feasibility), and over 76% of acceptability ratings from AGYW and their FC had the highest Likert rating. Fidelity of intervention delivery was 95%. IMARA-SA is a promising strategy for reducing HIV/STI risk among South African AGYW. We found strong evidence of reach, feasibility, acceptability, and fidelity. A fully powered randomized controlled trial is warranted. Trial registration: Clinical trials.gov registration number: NCT05504954.

Sexual experience among emotionally and behaviorally disordered students in therapeutic day schools: an ecological examination of adolescent risk.

OBJECTIVE: This study examined gender differences in family, peer, partner, and mental health characteristics related to sexual experience among emotionally and behaviorally disordered students in therapeutic day schools, a population at elevated risk for negative sexual health outcomes. METHODS: A total of 417 13- to 20-year-old adolescents reported on their family functioning, peer and partner relationship characteristics, mental health problems, and self-reported sexual behavior. RESULTS: For boys and girls, peer influence and conduct problems predicted sexual experience, and family dysfunction was related to negative peer influence. Greater rejection sensitivity was related to less sexual experience for boys and girls. The final path model revealed indirect effects of family dysfunction on boys' but not girls' sexual experiences. CONCLUSIONS: Findings underscore the utility of an ecological approach to understand social and personal mechanisms that increase risk and mitigate negative outcomes among emotionally and behaviorally disordered boys and girls in therapeutic day schools.

Bidirectional linkages between psychological symptoms and sexual activities among African American adolescent girls in psychiatric care.

The current study examines longitudinal associations between light and heavy sexual experiences and psychiatric symptoms in African American adolescent girls receiving mental health care. Research supports bidirectional associations between adolescent romantic and sexual behaviors and depression and other mental health problems, but this finding has not been examined among African American youth or in clinical samples. African American girls in psychiatric treatment suffer disparities in HIV/AIDS vulnerability, and understanding the context of girls' risk-taking (and how psychological symptoms contribute) may aid prevention efforts. Two-hundred-sixty-five African American girls seeking psychiatric care were assessed for mental health symptoms and light and heavy sexual behaviors. Participants completed a 6-month follow-up. Baseline light sexual activity predicted increased internalizing and externalizing symptoms and substance use at follow-up. Internalizing and externalizing symptoms predicted increased heavy sexual behaviors over time, including HIV-risk behaviors. Results support the association between romantic involvement and depression. Psychological symptoms may play a key role in the emergence of risky sexual behaviors among African American adolescent girls in psychiatric care and should be considered in prevention program development.

Results of the Kigali Imbereheza Project: A 2-Arm Individually Randomized Trial of TI-CBT Enhanced to Address ART Adherence and Mental Health for Rwandan Youth Living With HIV.

BACKGROUND: Adolescents living with HIV have elevated mental distress and suboptimal antiretroviral therapy (ART) adherence. SETTING: Two urban clinics in Kigali, Rwanda. METHODS: A 2-arm individual randomized controlled trial compared Trauma-Informed Cognitive Behavioral Therapy enhanced to address HIV (TI-CBTe) with usual care (time-matched, long-standing, unstructured support groups) with 356 12- to 21-year-old (M = 16.78) Rwandans living with HIV. TI-CBTe included 6 group-based 2-hour sessions led by trained and supervised 21- to 25-year-old Rwandans living with HIV. Participants reported their ART adherence, depression/anxiety, and Post-Traumatic Stress Disorder symptoms at baseline, 6, 12, and 18 months. RESULTS: ART adherence was relatively high at baseline, and youth reported elevated rates of depression/anxiety and trauma symptoms. There were no differential treatment effects on adherence, but depression/anxiety improved over time. Youth with lower depression/anxiety at baseline seemed to benefit more from TI-CBTe than usual care, whereas women with high baseline distress seemed to benefit more from usual care. Youth were less likely to score in high Post-Traumatic Stress Disorder symptom categories at the follow-up, with no differential treatment effects. CONCLUSIONS: TI-CBTe did not outperform usual care on ART adherence, possibly reflecting relatively high adherence at baseline, simplified medication regimens over time, a strong comparison condition, or because youth assigned to TI-CBTe returned to their support groups after the intervention. TI-CBTe was more effective for youth with lower depression/anxiety symptoms, whereas youth with high distress benefitted more from the support groups. TI-CBTe was feasible and acceptable, and young adults living with HIV were able to deliver a mental health intervention with fidelity. The powerful nature of the comparison group, ongoing support groups, points to the potential value of locally crafted interventions in low-resource settings.