Protective factors for adolescent sexual risk behaviours and experiences linked to HIV infection in South Africa: a three-wave longitudinal analysis of caregiving, education, food security, and social protection.

BACKGROUND: Structural interventions are endorsed to enhance biomedical and behavioural HIV prevention programmes for adolescents. Aiming to inform future interventions, we evaluated longitudinal associations between six protective factors that link closely to existing structural HIV prevention interventions, and five sexual risk behaviours for HIV transmission in a cohort of adolescents in South Africa. METHODS: We used three rounds of data between 2014-2018 on 1046 adolescents living with HIV and 473 age-matched community peers in South Africa's Eastern Cape (Observations = 4402). We estimated sex-specific associations between six time-varying protective factors - number of social grants, education enrolment, days with enough food, caregiver supervision, positive caregiving, and adolescent-caregiver communication; and five HIV risk behaviours - multiple sexual partners, transactional sex, age-disparate sex, condomless sex, and sex on substances. HIV risk behaviours were analysed separately in multivariable random effects within-between logistic regression models that accounted for correlation of repeated observations on the same individual. We calculated prevalence ratios (PR), contrasting adjusted probabilities of HIV risk behaviours at 'No' and 'Yes' for education enrolment, and average and maximum values for the other five protective factors. RESULTS: The sample mean age was 15.29 (SD: 3.23) years and 58% were girls. Among girls, within-individuals, increases from mean to maximum scores in positive caregiving were associated with lower probability of transactional sex (PR = 0.79; 95%CI = 0.67-0.91); in caregiver supervision were associated with lower probability of transactional sex (PR = 0.75; 95%CI = 0.66-0.84), and age-disparate sex (PR = 0.84; 95%CI = 0.73-0.95); in adolescent-caregiver communication were associated with higher probability of transactional sex (PR = 1.70; 95%CI = 1.08-2.32); and in days with enough food at home were associated with lower probability of multiple sexual partners (PR = 0.89; 95%CI = 0.81-0.97), and transactional sex (PR = 0.82; 95%CI = 0.72-0.92). Change from non-enrolment in education to enrolment was associated with lower probability of age-disparate sex (PR = 0.49; 95%CI = 0.26-0.73). Between-individuals, relative to mean caregiver supervision scores, maximum scores were associated with lower probability of multiple sexual partners (PR = 0.59; 95%CI = 0.46-0.72), condomless sex (PR = 0.80; 95%CI = 0.69-0.91), and sex on substances (PR = 0.42; 95%CI = 0.26-0.59); and relative to non-enrolment, education enrolment was associated with lower probability of condomless sex (PR = 0.59; 95%CI = 0.39-0.78). Among boys, within-individuals, increases from mean to maximum scores in positive caregiving were associated with lower probability of transactional sex (PR = 0.77; 95%CI = 0.59-0.96), and higher probability of condomless sex (PR = 1.26; 95%CI = 1.08-1.43); in caregiver supervision were associated with lower probability of multiple sexual partners (PR = 0.73; 95%CI = 0.64-0.82), transactional sex (PR = 0.63; 95%CI = 0.50-0.76), age-disparate sex (PR = 0.67; 95%CI = 0.49-0.85), and sex on substances (PR = 0.61; 95%CI = 0.45-0.78), and in days with enough food at home were associated with lower probability of transactional sex (PR = 0.91; 95%CI = 0.84-0.98). CONCLUSION: Effective structural interventions to improve food security and education enrolment among adolescent girls, and positive and supervisory caregiving among adolescent girls and boys are likely to translate into crucial reductions in sexual risk behaviours linked to HIV transmission in this population.

Can a combination of interventions accelerate outcomes to deliver on the Sustainable Development Goals for young children? Evidence from a longitudinal study in South Africa and Malawi.

BACKGROUND: This study aimed to identify possible entry points for interventions that can act as development accelerators for children and adolescents in South Africa and Malawi. METHODS: This study was a secondary data analysis. Data were sourced from the Child Community Care longitudinal study which tracked child well-being outcomes among 989 children (4-13 years) and their caregivers affected by HIV and enrolled in community-based organizations in South Africa and Malawi. We examined associations between five hypothesized accelerating services/household provisions-measured as access at baseline and follow-up and 12 child outcomes that relate to indicators within the Sustainable Development Goals (SDGs) framework. We calculated the adjusted probabilities of experiencing each SDG aligned outcome conditional on receipt of single, combined or all identified accelerators. RESULTS: The results show household food security is associated with positive child education and cognitive development outcomes. Cash grants were positively associated with nutrition and cognitive development outcomes. Living in a safe community was positively associated with all mental health outcomes. Experiencing a combination of two factors was associated with higher probability of positive child outcomes. However, experiencing all three accelerators was associated with better child outcomes, compared with any of the individual factors by themselves with substantial improvements noted in child education outcomes. CONCLUSIONS: Combined delivery of specific interventions or services may yield greater improvements in child outcomes across different developmental domains. It is recommended that multiple support avenues in combination like improving food security and safe communities, as well as social protection grants, should be provided for vulnerable children to maximize the impact.

Accelerating progress towards improved mental health and healthy behaviours in adolescents living in adversity: findings from a longitudinal study in South Africa.

Adolescents exposed to high levels of adversity are vulnerable to developing mental health challenges, with long-lasting adverse consequences. Promoting the psychological well-being of adolescents and protecting them from adverse experiences is crucial for their quality of life. There is a need for evidence on which combinations of protective factors can improve the wellbeing of adolescents to inform future programming efforts. We used data from a longitudinal study that took place in Khayelitsha, South Africa, a semi-urban impoverished community in Cape Town. Data were collected from adolescents when they were 12-14 years of age (n = 333) and again at follow-up when they were aged 16-19 years (n = 314). A path analysis was used to estimate associations between access to service, food security, safe environment, family support, and social support and five outcomes related to adolescent mental health and risky behaviours. The fitted model was used to calculate adjusted mean differences comparing different combinations of risk factors. Two protective factors (food security and safe environment) were positively associated with three outcomes relating to mental health and the absence of risky behaviours. Further investigation revealed that the presence of high food security and safer environments was associated with higher adjusted mean scores: +16.2% (p < .0001) in no substance use; +16.5% (p < .0001) in no internalising behaviour, +19.5% (p < .0001) in self-esteem; +12.2% (p < .0001) in positive peer relationships; and +11.4% (p < .0001) in no suicidal ideation. Interventions targeting adolescents, that aim to improve food security together with improving the safety of their environment, are likely to impact their well-being.

Accelerating Sustainable Development Goals for South African adolescents from high HIV prevalence areas: a longitudinal path analysis.

BACKGROUND: Adolescents experience a multitude of vulnerabilities which need to be addressed in order to achieve the Sustainable Development Goals (SDGs). In sub-Saharan Africa, adolescents experience high burden of HIV, violence exposure, poverty, and poor mental and physical health. This study aimed to identify interventions and circumstances associated with three or more targets ("accelerators") within multiple SDGs relating to HIV-affected adolescents and examine cumulative effects on outcomes. METHODS: Prospective longitudinal data from 3401 adolescents from randomly selected census enumeration areas in two provinces with > 30% HIV prevalence carried out in 2010/11 and 2011/12 were used to examine six hypothesized accelerators (positive parenting, parental monitoring, free schooling, teacher support, food sufficiency and HIV-negative/asymptomatic caregiver) targeting twelve outcomes across four SDGs, using a multivariate (multiple outcome) path model with correlated outcomes controlling for outcome at baseline and socio-demographics. The study corrected for multiple-hypothesis testing and tested measurement invariance across sex. Percentage predicted probabilities of occurrence of the outcome in the presence of the significant accelerators were also calculated. RESULTS: Sample mean age was 13.7 years at baseline, 56.6% were female. Positive parenting, parental monitoring, food sufficiency and AIDS-free caregiver were variously associated with reductions on ten outcomes. The model was gender invariant. AIDS-free caregiver was associated with the largest reductions. Combinations of accelerators resulted in a percentage reduction of risk of up to 40%. CONCLUSION: Positive parenting, parental monitoring, food sufficiency and AIDS-free caregivers by themselves and in combination improve adolescent outcomes across ten SDG targets. These could translate to the corresponding real-world interventions parenting programmes, cash transfers and universal access to antiretroviral treatment, which when provided together, may help governments in sub-Saharan Africa more economically to reach their SDG targets.

Violence prevention accelerators for children and adolescents in South Africa: A path analysis using two pooled cohorts.

BACKGROUND: The INSPIRE framework was developed by 10 global agencies as the first global package for preventing and responding to violence against children. The framework includes seven complementary strategies. Delivering all seven strategies is a challenge in resource-limited contexts. Consequently, governments are requesting additional evidence to inform which 'accelerator' provisions can simultaneously reduce multiple types of violence against children. METHODS AND FINDINGS: We pooled data from two prospective South African adolescent cohorts including Young Carers (2010-2012) and Mzantsi Wakho (2014-2017). The combined sample size was 5,034 adolescents. Each cohort measured six self-reported violence outcomes (sexual abuse, transactional sexual exploitation, physical abuse, emotional abuse, community violence victimisation, and youth lawbreaking) and seven self-reported INSPIRE-aligned protective factors (positive parenting, parental monitoring and supervision, food security at home, basic economic security at home, free schooling, free school meals, and abuse response services). Associations between hypothesised protective factors and violence outcomes were estimated jointly in a sex-stratified multivariate path model, controlling for baseline outcomes and socio-demographics and correcting for multiple-hypothesis testing using the Benjamini-Hochberg procedure. We calculated adjusted probability estimates conditional on the presence of no, one, or all protective factors significantly associated with reduced odds of at least three forms of violence in the path model. Adjusted risk differences (ARDs) and adjusted risk ratios (ARRs) with 95% confidence intervals (CIs) were also calculated. The sample mean age was 13.54 years, and 56.62% were female. There was 4% loss to follow-up. Positive parenting, parental monitoring and supervision, and food security at home were each associated with lower odds of three or more violence outcomes (p < 0.05). For girls, the adjusted probability of violence outcomes was estimated to be lower if all three of these factors were present, as compared to none of them: sexual abuse, 5.38% and 1.64% (ARD: -3.74% points, 95% CI -5.31 to -2.16, p < 0.001); transactional sexual exploitation, 10.07% and 4.84% (ARD: -5.23% points, 95% CI -7.26 to -3.20, p < 0.001); physical abuse, 38.58% and 23.85% (ARD: -14.72% points, 95% CI -19.11 to -10.33, p < 0.001); emotional abuse, 25.39% and 12.98% (ARD: -12.41% points, 95% CI -16.00 to -8.83, p < 0.001); community violence victimisation, 36.25% and 28.37% (ARD: -7.87% points, 95% CI -11.98 to -3.76, p < 0.001); and youth lawbreaking, 18.90% and 11.61% (ARD: -7.30% points, 95% CI -10.50 to -4.09, p < 0.001). For boys, the adjusted probability of violence outcomes was also estimated to be lower if all three factors were present, as compared to none of them: sexual abuse, 2.39% to 1.80% (ARD: -0.59% points, 95% CI -2.24 to 1.05, p = 0.482); transactional sexual exploitation, 6.97% to 4.55% (ARD: -2.42% points, 95% CI -4.77 to -0.08, p = 0.043); physical abuse from 37.19% to 25.44% (ARD: -11.74% points, 95% CI -16.91 to -6.58, p < 0.001); emotional abuse from 23.72% to 10.72% (ARD: -13.00% points, 95% CI -17.04 to -8.95, p < 0.001); community violence victimisation from 41.28% to 35.41% (ARD: -5.87% points, 95% CI -10.98 to -0.75, p = 0.025); and youth lawbreaking from 22.44% to 14.98% (ARD -7.46% points, 95% CI -11.57 to -3.35, p < 0.001). Key limitations were risk of residual confounding and not having information on protective factors related to all seven INSPIRE strategies. CONCLUSION: In this cohort study, we found that positive and supervisory caregiving and food security at home are associated with reduced risk of multiple forms of violence against children. The presence of all three of these factors may be linked to greater risk reduction as compared to the presence of one or none of these factors. Policies promoting action on positive and supervisory caregiving and food security at home are likely to support further efficiencies in the delivery of INSPIRE.

Screening and supporting through schools: educational experiences and needs of adolescents living with HIV in a South African cohort.

BACKGROUND: Many adolescents living with HIV remain disconnected from care, especially in high-prevalence settings. Slow progressors-adolescents infected perinatally who survive without access to lifesaving treatment-remain unidentified and disconnected from heath systems, especially in high-prevalence settings. This study examines differences in educational outcomes for ALHIV, in order to i) identify educational markers for targeting HIV testing, counselling and linkages to care, and ii) to identify essential foci of educational support for ALHIV. METHODS: Quantitative interviews with N = 1063 adolescents living with HIV and N = 456 HIV-free community control adolescents (10-19 year olds) included educational experiences (enrolment, fee-free school, school feeding schemes, absenteeism, achievement), physical health, cognitive difficulties, mental health challenges (depression, stigma, and trauma), missing school to attend clinic appointments, and socio-demographic characteristics. Voluntary informed consent was obtained from adolescents and caregivers (when adolescent < 18 years old). Analyses included multivariate logistic regressions, controlling for socio-demographic covariates, and structural equation modelling using STATA15. RESULTS: ALHIV reported accessing educational services (enrolment, free schools, school feeding schemes) at the same rates as other adolescents (94, 30, and 92% respectively), suggesting that school is a valuable site for identification. Living with HIV was associated with poorer attendance (aOR = 1.7 95%CI1.1-2.6) and educational delay (aOR1.7 95%CI1.3-2.2). Adolescents who reported educational delay were more likely to be older, male, chronically sick and report more cognitive difficulties. A path model with excellent model fit (RMSEA = 0.027, CFI 0.984, TLI 0.952) indicated that living with HIV was associated with a series of poor physical, mental and cognitive health issues which led to worse educational experiences. CONCLUSION: Schools may provide an important opportunity to identify unreached adolescents living with HIV and link them into care, focusing on adolescents with poor attendance, frequent sickness, low mood and slow learning. Key school-based markers for identifying unreached adolescents living with HIV may be low attendance, frequent sickness, low mood and slow learning. Improved linkages to care for adolescents living with HIV, in particular educational support services, are necessary to support scholastic achievement and long-term well-being, by helping them to cope with physical, emotional and cognitive difficulties.

Pathways to poor educational outcomes for HIV/AIDS-affected youth in South Africa.

A recent systematic review of studies in the developing world has critically examined linkages from familial HIV/AIDS and associated factors such as poverty and child mental health to negative child educational outcomes. In line with several recommendations in the review, the current study modelled relationships between familial HIV/AIDS, poverty, child internalising problems, gender and four educational outcomes: non-enrolment at school, non-attendance, deficits in grade progression and concentration problems. Path analyses reveal no direct associations between familial HIV/AIDS and any of the educational outcomes. Instead, HIV/AIDS-orphanhood or caregiver HIV/AIDS-sickness impacted indirectly on educational outcomes via the poverty and internalising problems that they occasioned. This has implications for evidence-based policy inferences. For instance, by addressing such intervening variables generally, rather than by seeking to target families affected by HIV/AIDS, interventions could avoid exacerbating stigmatisation, while having a more direct and stronger impact on children's educational outcomes. This analytic approach also suggests that future research should seek to identify causal paths, and may include other intervening variables related to poverty (such as child housework and caring responsibilities) or to child mental health (such as stigma and abuse), that are linked to both familial HIV/AIDS and educational outcomes.

Toward a Contextually Sensitive Understanding of Polyvictimization: A Latent Class Analysis of Violence, Risks, and Protections Among South African Adolescents From Highly Deprived Settings.

South African adolescents experience a high prevalence of violence victimization alongside the health and economic burdens of HIV/AIDS and poverty. Polyvictimization is a useful theory and framework that allows for a nuanced understanding of lived adolescent experience patterns. Polyvictimization examinations are further enriched by person-centered analytical approaches. This study used latent class analysis to differentiate a sample of South African adolescents from highly deprived communities by their polyvictimization profiles and contextual violence risk and protective factors. Adolescents were sampled twice (2010/2011; 2011/2012), and data reflected their lifetime (sexual abuse) or recent (all other forms of assessed abuse/violence) violence victimizations, as well as individual, household, and community characteristics. Model fit indices supported a seven-class model with adolescents in high, moderate, and low polyvictimization classes. Adolescents in the high polyvictimization classes experienced a heavy burden of poverty and multiple forms of violence across contexts and were distinguished by HIV/AIDS and disability. Adolescents in the low polyvictimization class experienced relatively little violence, despite living in violent communities, and low household and individual burdens of HIV/AIDS and disability. Findings emphasize the importance of considering adolescent violence through a contextually sensitive polyvictimization lens to understand the complex web of violence that adolescents experience. This work supports previous research in low-resource South African settings highlighting the interconnected nature of violence, poverty, disability, and HIV/AIDS. Future research should explore these complex violence patterns and their effects, while program and policy actions must target and prevent adolescent violence especially for those impacted by poverty, disability, and HIV/AIDS.

The hidden harm of home-based care: pulmonary tuberculosis symptoms among children providing home medical care to HIV/AIDS-affected adults in South Africa.

Millions of children in sub-Saharan Africa undertake personal and medical care for family members who are unwell with AIDS. To date, no research has investigated whether such care provision places children at heightened risk for pulmonary tuberculosis. This study aimed to address this gap by identifying risk factors for paediatric pulmonary tuberculosis symptomatology. In 2009-2011, 6002 children aged 10-17 years were surveyed using door-to-door household sampling of census enumeration areas. These were randomly sampled from six urban and rural sites with over 30% HIV prevalence, within South Africa's three highest tuberculosis-burden provinces. Validated scales and clinical tuberculosis symptom checklists were modelled in multivariate logistic regressions, controlling for socio-demographic co-factors. Findings showed that, among children, severe pulmonary tuberculosis symptomatology was predicted by primary caregiver HIV/AIDS-illness [odds ratio (OR): 1.63, confidence interval (CI): 1.23-2.15, p<0.001], and AIDS-orphanhood (OR: 1.44, CI: 1.04-2.00, p<0.029). Three-fold increases in severe tuberculosis symptoms were predicted by the child's exposure to body fluids through providing personal or medical care to an ill adult (OR: 3.12, CI: 1.96-4.95, p<0.001). Symptoms were also predicted by socio-economic factors of food insecurity (OR: 1.52, CI: 1.15-2.02, p<0.003) and household overcrowding (OR: 1.35, CI: 1.06-1.72, p<0.017). Percentage probability of severe tuberculosis symptoms rose from 1.4% amongst least-exposed children, to 18.1% amongst those exposed to all above-stated risk factors, independent of biological relationship of primary caregiver-child and other socio-demographics. Amongst symptomatic children, 75% had never been tested for tuberculosis. These findings identify the risk of tuberculosis among children providing home medical care to their unwell caregivers, and suggest that there are gaps in the health system to screen and detect these cases of paediatric tuberculosis. There is a need for effective interventions to reduce childhood risk, as well as further support for community-based contact-tracing, tuberculosis screening and anti-tuberculosis treatment for children caring for ill adults in contexts with a high burden of HIV and tuberculosis.

Impacts of intimate partner violence and sexual abuse on antiretroviral adherence among adolescents living with HIV in South Africa.

OBJECTIVE: We are failing to reach 95-95-95 for adolescents living with HIV (ALHIV). Sexual abuse and intimate partner violence (IPV) may impact antiretroviral therapy (ART) adherence, with high rates of 17.4 and 29.7%, respectively, across the southern sub-Saharan African region. However, evidence on their associations with adolescent ART adherence remains limited, with only three cross-sectional studies globally. DESIGN: A prospective cohort of ALHIV (sample N = 980, 55% female individuals, baseline mean age 13.6 years) were recruited from 53 health facilities in South Africa's Eastern Cape Province and responded to a structured questionnaire at 18-month and 36-month follow-up (2015-2016, 2017-2018). METHODS: A repeated-measures random effects model assessed multivariable associations of self-reported sexual abuse and IPV with past-week ART adherence, controlling for individual, socioeconomic, and HIV-related factors. Past-week adherence was defined based on currently taking ART and not having missed any doses in the past 7 days (including weekends). We further fitted a moderation model by sex. RESULTS: Fifty-one percent of adolescents reported consistent ART adherence at both time points. Exposure to IPV was associated with lower odds of self-reported ART adherence (aOR 0.39, 95% CI 0.21-0.72, P = 0.003), as was sexual abuse (aOR 0.54, 95% CI 0.29-0.99, P = 0.048). The marginal predicted probability of ART adherence for adolescents with no exposure to either IPV or sexual abuse was 72% (95% CI 70-74%) compared with 38% (95% CI 20-56%) for adolescents with exposure to both IPV and sexual abuse. Moderation results showed similar associations between sexual violence and ART adherence by sex. CONCLUSION: Sexual violence prevention and postviolence care may be essential components of supporting adolescent ART adherence. Integration of HIV and violence prevention services will require accessible services and simple referral systems.

Persisting mental health problems among AIDS-orphaned children in South Africa.

BACKGROUND: By 2008, 12 million children in sub-Saharan Africa were orphaned by AIDS. Cross-sectional studies show psychological problems for AIDS-orphaned children, but until now no longitudinal study has explored enduring psychological effects of AIDS-orphanhood in the developing world. METHODS: A 4-year longitudinal follow-up of AIDS-orphaned children with control groups of other-orphans and non-orphans. 1021 children (M = 13.4 years, 50% female, 98% isiXhosa-speaking) were interviewed in 2005 and followed up in 2009 with 71% retention (49% female, M = 16.9 years), in poor urban South African settlements. Children were interviewed using sociodemographic questionnaires and well-validated standardised scales for assessing depression, anxiety, and post-traumatic stress. Data were analysed using mixed-design ANOVA and backward-stepping regression. RESULTS: AIDS-orphaned children showed higher depression, anxiety, and post-traumatic stress disorder (PTSD) scores in both 2005 and 2009 when compared with other-orphans and non-orphans. Backward-stepping regression, controlling for baseline mental health, and sociodemographic cofactors such as age, gender, and type of bereavement, revealed that being AIDS-orphaned in 2005 was associated with depression, anxiety, and PTSD scores in 2009. This was not the case for other-orphaned or non-orphaned children. Age interacted with orphan status, such that there was a steep rise in psychological distress in the AIDS-orphaned group, but no rise with age amongst other-orphans and non-orphans. CONCLUSIONS: Negative mental health outcomes amongst AIDS-orphaned children are maintained and worsen over a 4-year period. It is important that psychosocial support programmes are sustained, and focus on youth as well as young children.

AIDS-orphanhood and caregiver HIV/AIDS sickness status: effects on psychological symptoms in South African youth.

OBJECTIVE: Research has established that AIDS-orphaned youth are at high risk of internalizing psychological distress. However, little is known about youth living with caregivers who are unwell with AIDS or youth simultaneously affected by AIDS-orphanhood and caregiver AIDS sickness. METHODS: 1025 South African youth were interviewed in 2005 and followed up in 2009 (71% retention). Participants completed standardized measures of anxiety, depression, and posttraumatic stress. Comparison groups were youth who were AIDS-orphaned, other-orphaned, and nonorphaned, and those whose caregivers were sick with AIDS, sick with another disease, or healthy. RESULTS: Longitudinal analyses showed that both AIDS-orphanhood and caregiver AIDS sickness predicted increased depression, anxiety, and posttraumatic stress symptoms over a 4-year period, independently of sociodemographic cofactors and of each other. Caregiver sickness or death by non-AIDS causes, and having a healthy or living caregiver, did not predict youth symptomatology. Youths simultaneously affected by caregiver AIDS sickness and AIDS-orphanhood showed cumulative negative effects. CONCLUSIONS: Findings suggest that policy and interventions, currently focused on orphanhood, should include youth whose caregivers are unwell with AIDS.

Food security reduces multiple HIV infection risks for high-vulnerability adolescent mothers and non-mothers in South Africa: a cross-sectional study.

INTRODUCTION: Adolescent girls and young women, including adolescent mothers, in Southern Africa have high HIV seroconversion and transmission. We need to know which risks drive HIV infections, and what can reduce these risks. METHODS: We interviewed 1712 adolescent girls and young women (11-23 years), including 1024 adolescent mothers who had conceived before age 20 and had a living child, from two health municipalities of South Africa's Eastern Cape Province between March 2018 and July 2019. Recruitment was through multiple community, school and health facility channels. Associations between adolescent motherhood and seven HIV risk behaviours (multiple sexual partners, transactional sex, age-disparate sex, condomless sex, sex on substances, alcohol use and not in education or employment) were investigated using the generalized estimating equations method for multiple outcomes specified with a logit link and adjusting for nine covariates. Using the same model, we investigated associations between having enough food at home every day in the past week (food security) and the same seven HIV risk behaviours. When we found evidence of moderation by HIV status, we report stratum-specific odds ratios. RESULTS: Mean age was 17.51 years (SD: 2.54), 46% participants were living with HIV. Compared to non-mothers, adolescent mothers had lower odds of alcohol use (AOR = 0.47, 95% CI = 0.29-0.75), but higher odds of multiple sexual partners (AOR = 1.93, 95% CI = 1.35-2.74), age-disparate sex (HIV-uninfected AOR = 1.73, 95% CI = 1.03-2.91; living with HIV AOR = 5.10, 95% CI = 2.98-8.73), condomless sex (AOR = 8.20, 95% CI = 6.03-11.13), sex on substances (AOR = 1.88, 95% CI = 1.10-3.21) and not in education/employment (HIV-uninfected AOR = 1.83, 95% CI = 1.19-2.83; living with HIV AOR = 6.30, 95% CI = 4.09-9.69). Among non-mothers, food security was associated with lower odds of multiple sexual partners (AOR = 0.45, 95% CI = 0.26-0.78), transactional sex (AOR = 0.32, 95% CI = 0.13-0.82) and not in education/employment (AOR = 0.48, 95% CI = 0.29-0.77). Among adolescent mothers, food security was associated with lower odds of transactional sex (AOR = 0.17, 95% CI = 0.10-0.28), age-disparate sex (AOR = 0.66, 95% CI = 0.47-0.92), sex on substances (AOR = 0.51, 95% CI = 0.32-0.82), alcohol use (AOR = 0.45, 95% CI = 0.25-0.79) and not in education/employment (AOR = 0.56, 95% CI = 0.40-0.78). CONCLUSIONS: Adolescent motherhood is associated with multiple vulnerabilities to HIV infection and transmission. Social protection measures that increase food security are likely to reduce HIV risk pathways for adolescent girls and young women, especially adolescent mothers.

Clinic and care: associations with adolescent antiretroviral therapy adherence in a prospective cohort in South Africa.

OBJECTIVE: Adolescent antiretroviral treatment (ART) adherence remains critically low. We lack research testing protective factors across both clinic and care environments. DESIGN: A prospective cohort of adolescents living with HIV (sample n = 969, 55% girls, baseline mean age 13.6) in the Eastern Cape Province in South Africa were interviewed at baseline and 18-month follow-up (2014-2015, 2015-2016). We traced all adolescents ever initiated on treatment in 52 government health facilities (90% uptake, 93% 18-month retention, 1.2% mortality). METHODS: Clinical records were collected; standardized questionnaires were administered by trained data collectors in adolescents' language of choice. Probit within-between regressions and average adjusted probability calculations were used to examine associations of caregiving and clinic factors with adherence, controlling for household structure, socioeconomic and HIV factors. RESULTS: Past-week ART adherence was 66% (baseline), 65% (follow-up), validated against viral load in subsample. Within-individual changes in three factors were associated with improved adherence: no physical and emotional violence (12.1 percentage points increase in adjusted probability of adherence, P < 0.001), improvement in perceived healthcare confidentiality (7.1 percentage points, P < 0.04) and shorter travel time to the clinic (13.7 percentage points, P < 0.02). In combination, improvement in violence prevention, travel time and confidentiality were associated with 81% probability of ART adherence, compared with 47% with a worsening in all three. CONCLUSION: Adolescents living with HIV need to be safe at home and feel safe from stigma in an accessible clinic. This will require active collaboration between health and child protection systems, and utilization of effective violence prevention interventions.

Sustainable Survival for adolescents living with HIV: do SDG-aligned provisions reduce potential mortality risk?

INTRODUCTION: The Sustainable Development Goals (SDGs) present a groundbreaking global development agenda to protect the most vulnerable. Adolescents living with HIV in Sub-Saharan Africa continue to experience extreme health vulnerabilities, but we know little about the impacts of SDG-aligned provisions on their health. This study tests associations of provisions aligned with five SDGs with potential mortality risks. METHODS: Clinical and interview data were gathered from N = 1060 adolescents living with HIV in rural and urban South Africa in 2014 to 2015. All ART-initiated adolescents from 53 government health facilities were identified, and traced in their communities to include those defaulting and lost-to-follow-up. Potential mortality risk was assessed as either: viral suppression failure (1000+ copies/ml) using patient file records, or adolescent self-report of diagnosed but untreated tuberculosis or symptomatic pulmonary tuberculosis. SDG-aligned provisions were measured through adolescent interviews. Provisions aligned with SDGs 1&2 (no poverty and zero hunger) were operationalized as access to basic necessities, social protection and food security; An SDG 3-aligned provision (ensure healthy lives) was having a healthy primary caregiver; An SDG 8-aligned provision (employment for all) was employment of a household member; An SDG 16-aligned provision (protection from violence) was protection from physical, sexual or emotional abuse. Research partners included the South African national government, UNICEF and Pediatric and Adolescent Treatment for Africa. RESULTS: 20.8% of adolescents living with HIV had potential mortality risk - i.e. viral suppression failure, symptomatic untreated TB, or both. All SDG-aligned provisions were significantly associated with reduced potential mortality risk: SDG 1&2 (OR 0.599 CI 0.361 to 0.994); SDG 3 (OR 0.577 CI 0.411 to 0.808); SDG 8 (OR 0.602 CI 0.440 to 0.823) and SDG 16 (OR 0.686 CI 0.505 to 0.933). Access to multiple SDG-aligned provisions showed a strongly graded reduction in potential mortality risk: Among adolescents living with HIV, potential mortality risk was 38.5% with access to no SDG-aligned provisions, and 9.3% with access to all four. CONCLUSIONS: SDG-aligned provisions across a range of SDGs were associated with reduced potential mortality risk among adolescents living with HIV. Access to multiple provisions has the potential to substantially improve survival, suggesting the value of connecting and combining SDGs in our response to paediatric and adolescent HIV.

STACKing the odds for adolescent survival: health service factors associated with full retention in care and adherence amongst adolescents living with HIV in South Africa.

INTRODUCTION: There are two million HIV-positive adolescents in southern Africa, and this group has low retention in care and high mortality. There is almost no evidence to identify which healthcare factors can improve adolescent self-reported retention. This study examines factors associated with retention amongst antiretroviral therapy (ART)-initiated adolescents in South Africa. METHODS: We collected clinical records and detailed standardized interviews (n = 1059) with all 10- to 19 year-olds ever initiated on ART in all 53 government clinics of a health subdistrict, and community traced to include lost-to-follow-up (90.1% of eligible adolescents interviewed). Associations between full self-reported retention in care (no past-year missed appointments and 85% past-week adherence) and health service factors were tested simultaneously in sequential multivariate regression and marginal effects modelling, controlling for covariates of age, gender, urban/rural location, formal/informal housing, maternal and paternal orphanhood, vertical/horizontal HIV infection, overall health, length of time on ART and type of healthcare facility. RESULTS: About 56% of adolescents had self-reported retention in care, validated against lower detectable viral load (AOR: 0.63, CI: 0.45 to 0.87, p = 0.005). Independent of covariates, five factors (STACK) were associated with improved retention: clinics Stocked with medication (OR: 3.0, CI: 1.6 to 5.5); staff with Time for adolescents (OR: 2.7, CI: 1.8 to 4.1); adolescents Accompanied to the clinic (OR: 2.3, CI: 1.5 to 3.6); enough Cash to get to clinic safely (OR: 1.4, CI: 1.1 to 1.9); and staff who are Kind (OR: 2.6, CI: 1.8 to 3.6). With none of these factors, 3.3% of adolescents reported retention. With all five factors, 69.5% reported retention. CONCLUSIONS: This study identifies key intervention points for adolescent retention in HIV care. A basic package of clinic and community services has the potential to STACK the odds for health and survival for HIV-positive adolescents.

Child and Adolescent Suicide Attempts, Suicidal Behavior, and Adverse Childhood Experiences in South Africa: A Prospective Study.

PURPOSE: This is the first known prospective study of child suicidal behavior in sub-Saharan Africa. Aims were to determine whether (1) cumulative exposure to adverse childhood experiences (ACEs) predicts later suicidality and (2) heightened risks are mediated by mental health disorder and drug/alcohol misuse. METHODS: Longitudinal repeated interviews were conducted 1 year apart (97% retention) with 3,515 adolescents aged 10-18 years in South Africa (56% female; <2.5% refusal). Random selection of census enumeration areas from urban/rural sites within two provinces and door-to-door sampling included all homes with a resident adolescent. Measures included past-month suicide attempts, planning, and ideation, mental health disorders, drug/alcohol use, and ACE, for example, parental death by AIDS or homicide, abuse, and exposure to community violence. Analyses included multivariate logistic regression and multiple mediation tests. RESULTS: Past-month suicidality rates were 3.2% of adolescents attempting, 5.8% planning, and 7.2% reporting ideation. After controlling for baseline suicidality and sociodemographics, a strong, graded relationship was shown between cumulative ACE and all suicide behaviors 1 year later. Baseline mental health, but not drug/alcohol misuse, mediated relationships between ACE and subsequent suicidality. Suicide attempts rose from 1.9% among adolescents with no ACE to 6.3% among adolescents with >5 ACEs (cumulative odds ratio [OR], 2.46; confidence interval [CI], 1.00-6.05); for suicide planning, from 2.4% to 12.5% (cumulative OR, 4.40; CI, 2.08-9.29); and for suicide ideation, from 4.2% to 15.6% (cumulative OR, 2.99; CI, 1.68-5.53). CONCLUSIONS: Preventing and mitigating childhood adversities have the potential to reduce suicidality. Among adolescents already exposed to adversities, effective mental health services may buffer against future suicidality.

Poverty, AIDS and child health: identifying highest-risk children in South Africa.

BACKGROUND: Identifying children at the highest risk of negative health effects is a prerequisite to effective public health policies in Southern Africa. A central ongoing debate is whether poverty, orphanhood or parental AIDS most reliably indicates child health risks. Attempts to address this key question have been constrained by a lack of data allowing distinction of AIDS-specific parental death or morbidity from other causes of orphanhood and chronic illness. OBJECTIVES: To examine whether household poverty, orphanhood and parental illness (by AIDS or other causes) independently or interactively predict child health, developmental and HIV-infection risks. METHODS: We interviewed 6 002 children aged 10 - 17 years in 2009 - 2011, using stratified random sampling in six urban and rural sites across three South African provinces. Outcomes were child mental health risks, educational risks and HIV-infection risks. Regression models that controlled for socio-demographic co-factors tested potential impacts and interactions of poverty, AIDS-specific and other orphanhood and parental illness status. RESULTS: Household poverty independently predicted child mental health and educational risks, AIDS orphanhood independently predicted mental health risks and parental AIDS illness independently predicted mental health, educational and HIV-infection risks. Interaction effects of poverty with AIDS orphanhood and parental AIDS illness were found across all outcomes. No effects, or interactions with poverty, were shown by AIDS-unrelated orphanhood or parental illness. CONCLUSIONS: The identification of children at highest risk requires recognition and measurement of both poverty and parental AIDS. This study shows negative impacts of poverty and AIDS-specific vulnerabilities distinct from orphanhood and adult illness more generally. Additionally, effects of interaction between family AIDS and poverty suggest that, where these co-exist, children are at highest risk of all.

Child-focused state cash transfers and adolescent risk of HIV infection in South Africa: a propensity-score-matched case-control study.

BACKGROUND: Effective and scalable HIV prevention for adolescents in sub-Saharan Africa is needed. Cash transfers can reduce HIV incidence through reducing risk behaviours. However, questions remain about their effectiveness within national poverty-alleviation programmes, and their effects on different behaviours in boys and girls. METHODS: In this case-control study, we interviewed South African adolescents (aged 10-18 years) between 2009 and 2012. We randomly selected census areas in two urban and two rural districts in two provinces in South Africa, including all homes with a resident adolescent. We assessed household receipt of state-provided child-focused cash transfers, incidence in the past year and prevalence of transactional sex, age-disparate sex, unprotected sex, multiple partners, and sex while drunk or after taking drugs. We used logistic regression after propensity score matching to assess the effect of cash transfers on these risky sexual behaviours. FINDINGS: We interviewed 3515 participants (one per household) at baseline, and interviewed 3401 at follow-up. For adolescent girls (n=1926), receipt of a cash transfer was associated with reduced incidence of transactional sex (odds ratio [OR] 0·49, 95% CI 0·26-0·93; p=0·028), and age-disparate sex (OR 0·29, 95% CI 0·13-0·67; p=0·004), with similar associations for prevalence (for transactional sex, OR 0·47, 95% CI 0·26-0·86; p=0·015; for age-disparate sex, OR 0·37, 95% CI 0·18-0·77; p=0·003). No significant effects were shown for other risk behaviours. For boys (n=1475), no consistent effects were shown for any of the behaviours. INTERPRETATION: National, child-focused cash transfers to alleviate poverty for households in sub-Saharan Africa can substantially reduce unsafe partner selection by adolescent girls. Child-focused cash transfers are of potential importance for effective combination strategies for prevention of HIV. FUNDING: UK Economic and Social Research Council, South African National Research Foundation, Health Economics and AIDS Research Division at University of KwaZulu-Natal, South African National Department of Social Development, Claude Leon Foundation, John Fell Fund, Nuffield Foundation, and Regional Interagency Task Team for Children affected by AIDS-Eastern and Southern Africa.

Pathways from parental AIDS to child psychological, educational and sexual risk: developing an empirically-based interactive theoretical model.

Increasing evidence demonstrates negative psychological, health, and developmental outcomes for children associated with parental HIV/AIDS illness and death. However, little is known about how parental AIDS leads to negative child outcomes. This study used a structural equation modelling approach to develop an empirically-based theoretical model of interactive relationships between parental or primary caregiver AIDS-illness, AIDS-orphanhood and predicted intervening factors associated with children's psychological distress, educational access and sexual health. Cross-sectional data were collected in 2009-2011, from 6002 children aged 10-17 years in three provinces of South Africa using stratified random sampling. Comparison groups included children orphaned by AIDS, orphaned by other causes and non-orphans, and children whose parents or primary caregivers were unwell with AIDS, unwell with other causes or healthy. Participants reported on psychological symptoms, educational access, and sexual health risks, as well as hypothesized sociodemographic and intervening factors. In order to build an interactive theoretical model of multiple child outcomes, multivariate regression and structural equation models were developed for each individual outcome, and then combined into an overall model. Neither AIDS-orphanhood nor parental AIDS-illness were directly associated with psychological distress, educational access, or sexual health. Instead, significant indirect effects of AIDS-orphanhood and parental AIDS-illness were obtained on all measured outcomes. Child psychological, educational and sexual health risks share a common set of intervening variables including parental disability, poverty, community violence, stigma, and child abuse that together comprise chain effects. In all models, parental AIDS-illness had stronger effects and more risk pathways than AIDS-orphanhood, especially via poverty and parental disability. AIDS-orphanhood and parental AIDS-illness impact child outcomes through multiple, interlinked pathways. The interactive model developed in this study suggests key areas of focus for interventions with AIDS-affected children.