Addressing the Know-Do Gap in Adolescent HIV: Framing and Measuring Implementation Determinants, Outcomes, and Strategies in the AHISA Network.

Implementation science (IS) uses systematic methods to close gaps between research and practice by identifying and addressing barriers to implementation of evidence-based interventions (EBIs). To reach UNAIDS HIV targets, IS can support programs to reach vulnerable populations and achieve sustainability. We studied the application of IS methods in 36 study protocols that were part of the Adolescent HIV Prevention and Treatment Implementation Science Alliance (AHISA). Protocols focused on youth, caregivers, or healthcare workers in high HIV-burden African countries and evaluated medication, clinical and behavioral/social EBIs. All studies measured clinical outcomes and implementation science outcomes; most focused on early implementation outcomes of acceptability (81%), reach (47%), and feasibility (44%). Only 53% used an implementation science framework/theory. Most studies (72%) evaluated implementation strategies. Some developed and tested strategies, while others adapted an EBI/strategy. Harmonizing IS approaches allows cross study learning and optimization of delivery of EBIs and could support attainment of HIV goals.

Integrated Health Care Delivery for Adolescents Living with and at Risk of HIV Infection: A Review of Models and Actions for Implementation.

Integrated service delivery, providing coordinated services in a convenient manner, is important in HIV prevention and treatment for adolescents as they have interconnected health care needs related to HIV care, sexual and reproductive health and disease prevention. This review aimed to (1) identify key components of adolescent-responsive integrated service delivery in low and middle-income countries, (2) describe projects that have implemented integrated models of HIV care for adolescents, and (3) develop action steps to support the implementation of sustainable integrated models. We developed an implementation science-informed conceptual framework for integrated delivery of HIV care to adolescents and applied the framework to summarize key data elements in ten studies or programs across seven countries. Key pillars of the framework included (1) the socioecological perspective, (2) community and health care system linkages, and (3) components of adolescent-focused care. The conceptual framework and action steps outlined can catalyze design, implementation, and optimization of HIV care for adolescents.

Impact of COVID-19 on Adolescent HIV Prevention and Treatment Research in the AHISA Network.

Members of the Adolescent HIV Prevention and Treatment Implementation Science Alliance (AHISA) network conduct research aiming to close gaps between what is known to be impactful across the HIV prevention and treatment cascade, and services delivered to optimize outcomes for adolescents/young adults (AYA) in high HIV-prevalence settings. The COVID-19 pandemic introduced new challenges which threaten to exacerbate care and access disparities. We report results of a survey among AHISA teams with active AYA HIV research programs in African countries to determine how the pandemic has impacted their efforts. Results highlighted the detrimental impact of the pandemic on research efforts and the expanded need for implementation research to help provide evidence-based, context-specific pandemic recovery support. Key lessons learned included the viability of remote service delivery strategies and other innovations, the need for adaptive systems that respond to evolving contextual needs, and the need for organized documentation plans, within empathic and flexible environments.

Using the Implementation Research Logic Model as a Lens to View Experiences of Implementing HIV Prevention and Care Interventions with Adolescent Sexual Minority Men-A Global Perspective.

Adolescents and sexual minority men (SMM) are high priority groups in the United Nations' 2021 - 2016 goals for HIV prevention and viral load suppression. Interventions aimed at optimizing HIV prevention, testing and viral load suppression for adolescents must also attend to the intersectional realities influencing key sub-populations of SMM. Consequently, there is not a robust evidence-base to guide researchers and program partners on optimal approaches to implementing interventions with adolescent SMM. Using a multiple case study design, we integrated the Implementation Research Logic Model with components of the Consolidated Framework for Implementation Research and applied it as a framework for a comparative description of ten HIV related interventions implemented across five countries (Ghana, Kenya, Nigeria, Tanzania and United States). Using self-reported qualitative survey data of project principal investigators, we identified 17 of the most influential implementation determinants as well as a range of 17 strategies that were used in 90 instances to support intervention implementation. We highlight lessons learned in the implementation research process and provide recommendations for researchers considering future HIV implementation science studies with adolescent SMM.

Integrating Adolescent Mental Health into HIV Prevention and Treatment Programs: Can Implementation Science Pave the Path Forward?

Adolescent mental health (AMH) is a critical driver of HIV outcomes, but is often overlooked in HIV research and programming. The implementation science Exploration, Preparation, Implementation, Sustainment (EPIS) framework informed development of a questionnaire that was sent to a global alliance of adolescent HIV researchers, providers, and implementors working in sub-Saharan Africa with the aim to (1) describe current AMH outcomes incorporated into HIV research within the alliance; (2) identify determinants (barriers/gaps) of integrating AMH into HIV research and care; and (3) describe current AMH screening and referral systems in adolescent HIV programs in sub-Saharan Africa. Respondents reported on fourteen named studies that included AMH outcomes in HIV research. Barriers to AMH integration in HIV research and care programs were explored with suggested implementation science strategies to achieve the goal of integrated and sustained mental health services within adolescent HIV programs.

Impact of COVID-19 on Adolescent HIV Prevention and Treatment Services in the AHISA Network.

We investigated perceived impacts of COVID-19 on the delivery of adolescent HIV treatment and prevention services in sub-Saharan Africa (SSA) by administering a survey to members of the Adolescent HIV Prevention and Treatment Implementation Science Alliance (AHISA) from February to April 2021. We organized COVID-19 impacts, as perceived by AHISA teams, under three themes: service interruptions, service adjustments, and perceived individual-level health impacts. AHISA teams commonly reported interruptions to prevention programs, diagnostic testing, and access to antiretroviral therapy (ART). Common service adjustments included decentralization of ART refills, expanded multi-month ART distribution, and digital technology use. Perceived individual-level impacts included social isolation, loss to follow-up, food insecurity, poverty, and increases in adolescent pregnancies and sexually transmitted infections. The need for collaboration among stakeholders were commonly cited as lessons learned by AHISA teams. Survey findings highlight the need for implementation science research to evaluate the effects of pandemic-related HIV service adaptations in SSA.

"I am not alone with tears": embodying stigma and longing among youth living with perinatally acquired HIV in Tanzania through a collaborative arts-based approach.

It is estimated that 4 million youth aged 15-24 years live with HIV globally, 85% of whom live in sub-Saharan Africa. For youth living with perinatally acquired HIV (YPHIV), stigma is frequently linked with negative health outcomes. YPHIV face distinct HIV stigma experiences across the lifespan, particularly because of the centrality of the family context in their HIV experience and the reality that they have lived with HIV since birth. Nevertheless, our understanding and measurement of stigma remains limited. One way to improve our understanding of HIV stigma for YPHIV is through in-depth exploration of embodied narratives of HIV experience. This paper is based on fieldwork that incorporated a collaborative arts-based approach with a group of six YPHIV in Tanzania. Using artwork and a theoretical framework of embodiment, this paper phenomenologically describes their narratives of HIV experience, perceptions of stigma over time and imaginations of the future. This paper highlights that collective solidarity, habitus and participants' desire to reframe others' perceptions about them and relieve the suffering of others shape the embodied experience with HIV. Moreover, this paper argues that stigma experiences for YPHIV are temporal and have changed over time with increased age, interventions and biomedical advances. Broadly, while HIV stigma continues to exist, participants report responding to stigma with agency by creating alternative solidarities and pushing boundaries of possibility, reframing others' perceptions of them and acting on dreams for better futures.

Sauti ya Vijana (SYV; The Voice of Youth): Longitudinal Outcomes of an Individually Randomized Group Treatment Pilot Trial for Young People Living with HIV in Tanzania.

Sauti ya Vijana is a mental health and life skills intervention delivered by young adult group leaders for the improvement of HIV outcomes in young people living with HIV in Tanzania. This pilot randomized controlled trial estimated exploratory intervention effectiveness compared to standard of care. YPLWH (N = 105) were randomized to receive intervention or SOC. The mean age of participants was 18.1 years and 53% were female. Mean scores on mental health measures (Patient Health Questionnaire [PHQ-9], Strengths and Difficulties Questionnaire [SDQ], UCLA Trauma) were asymptomatic to mild in both study arms through 30-month follow-up with a non-significant fluctuation of 1-2 points. The mean self-reported adherence was higher in the intervention arm across all time points (but the confidence interval contained the null at all time points except 6 months). Risk ratio of virologic suppression (HIV RNA < 400 copies/mL) in the intervention arm compared to SOC was 1.15 [95% CI = 0.95, 1.39]) at 6-months, 1.17 [95% CI: 0.92, 1.48] at 12-months, and 0.99 [95% CI 0.76, 1.31] at 18-months. Though these findings were not powered for statistical significance, the trends in HIV outcomes suggest that SYV holds promise for improving antiretroviral therapy (ART) adherence and virologic suppression in YPLWH.

Feasibility and acceptability of a peer youth led curriculum to improve HIV knowledge in Northern Tanzania: resilience and intervention experience from the perspective of peer leaders.

BACKGROUND: Youth Living with HIV (YLWH) have reduced adherence to antiretroviral therapy (ART) and worse virologic outcomes compared to children and adults. HIV peer youth led (PYL) interventions contribute to improved retention in care and psychosocial wellbeing. The study objective was to assess the feasibility and acceptability of a PYL HIV curriculum and describe change in participants' knowledge and impact of leadership on peer leaders' lives. METHODS: An HIV curriculum was taught during monthly Saturday adolescent HIV clinics at two clinical sites in Moshi, Tanzania (2018-2019). Youth attending clinics were ages 12 to 24 years and received the HIV curriculum during routine clinical care. Peer leaders previously participated in a mental health and life skills intervention called Sauti ya Vijana (The Voice of Youth; SYV) and were recommended for leadership by SYV facilitators and clinic staff. Peer leaders were trained and supervised weekly in curriculum delivery using a "train the trainer" model. Data were collected and analyzed using mixed methods. Fidelity checklists were used to measure adherence to the curriculum. Youth participants answered written pre- and post-knowledge questions and evaluated PYL teaching. Semi-structured interviews and the Connor Davidson Resilience scale were conducted with peer leaders before and after assuming the leadership role. RESULTS: Peer leaders (N = 4 male; 3 female) demonstrated high fidelity (96%) to activities in each lesson and participant feedback was positive for curriculum delivery. Participants' knowledge improved in nine of ten sessions. All but one leader-who moved away before the study ended-demonstrated stable or improved resilience with a mean difference of 3.8 (SD = 7.0) from before the intervention to after assuming the leadership role. Peer leaders reported improved leadership confidence and resilience, and their perception was that the curriculum helped normalize the HIV experience for YLWH attending clinic. Nevertheless, anticipated stigma, difficulty disclosing HIV status, and teaching ability remained barriers. CONCLUSIONS: This study demonstrated that a PYL curriculum to improve HIV knowledge integrated into routine adolescent HIV clinic in Tanzania was feasible, acceptable, and improved knowledge while also benefiting peer leaders, thus providing evidence to continue to support efforts to scale and sustain PYL interventions for YLWH.

A group-based mental health intervention for young people living with HIV in Tanzania: results of a pilot individually randomized group treatment trial.

BACKGROUND: Increasing numbers of young people living with HIV (YPLWH) have unaddressed mental health challenges. Such challenges are associated with poor antiretroviral therapy (ART) adherence and high mortality. Few evidence-based mental health interventions exist to improve HIV outcomes among YPLWH. METHODS: This pilot group treatment trial individually randomized YPLWH from two clinical sites in Tanzania, evaluated acceptability, feasibility, and preliminary effectiveness of a mental health intervention, Sauti ya Vijana (SYV; The Voice of Youth), was compared to the local standard-of-care (SOC) for improving ART adherence and virologic suppression. Enrolled YPLWH were 12-24 years of age and responded to mental health and stigma questionnaires, self-reported adherence, objective adherence measures (ART concentration in hair), and HIV RNA at baseline and 6-months (post-intervention). Feasibility and acceptability were evaluated, and potential effectiveness was assessed by comparing outcomes between arms using mixed effects modeling. RESULTS: Between June 2016 and July 2017, 128 YPLWH enrolled; 105 were randomized and 93 (55 in SYV) followed-up at 6-months and were thereby included in this analysis. Mean age was 18.1 years; 51% were female; and 84% were HIV-infected perinatally. Attendance to intervention sessions was 86%; 6-month follow-up was 88%, and fidelity to the protocol approached 100%. Exploratory analyses of effectiveness demonstrated self-reported adherence improved by 7.3 percentage points (95% CI: 2.2, 12.3); and the pooled standard deviation for all ART concentration values increased by 0.17 units (95% CI: - 0.52, 0.85) in the SYV arm compared to SOC. Virologic suppression rates (HIV RNA < 400 copies/mL) at baseline were 65% in both arms but increased to 75% in the SYV arm while staying the same in the SOC arm (RR 1.13; 95% CI: 0.94, 1.36). CONCLUSIONS: YPLWH often have poor HIV outcomes, making interventions to improve outcomes in this population critical. This pilot trial of the Tanzania-based SYV intervention demonstrated trends towards improvement in ART adherence and virologic outcomes among YPLWH, supporting efforts to scale the intervention into a fully-powered effectiveness trial. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02888288 . Registered August 9, 2016. Retrospectively registered as first participant enrolled June 16, 2016.

Building resilience: a mental health intervention for Tanzanian youth living with HIV.

Despite a growing population of youth living with HIV, few interventions have been developed to address their unique mental health needs and to promote resilience. Based on our prior needs assessment, a mental health intervention, Sauti ya Vijana ( The Voice of Youth), was developed to address identified mental health needs and promote resilience. The intervention emphasized resilience strategies for identifying and coping with stressful events, supporting strong familial and social relationships, and planning for a safe and healthy living environment through stigma reduction, planning for disclosure, and instilling hope for the future. Ten group sessions (two of which were joint youth/caregiver sessions) and two individual sessions were developed around these three resilience domains. Youth living with HIV (average age 17.4 years), who were receiving antiretroviral therapy and attending HIV adolescent clinic in Tanzania were randomized to intervention or treatment as usual. Trained group leaders led the intervention sessions. Near perfect program fidelity by the group leaders and unanimous acceptance of the intervention by the youth was documented. SYV successfully promoted youth resilience as measured by youth-reported utilization of new coping skills, improved peer and caregiver relationships, reduced stigma, and improved confidence to live positively according to their personal values.

Caregiver role in HIV medication adherence among HIV-infected orphans in Tanzania.

Youth living with HIV in sub-Saharan Africa face numerous challenges in adhering to HIV treatment. The AIDS epidemic has left many of these youth orphaned due to AIDS-related death of one or both parents. It is imperative to understand the family context of youth living with HIV in order to develop responsive interventions to improve adherence to antiretroviral therapy. We conducted qualitative in-depth interviews with 17 HIV-infected AIDS orphans, ages 13-24 years, screened positive for mental health difficulties according to the Patient Health Questionaire-9 (PHQ-9) or UCLA PTSD Reaction Index (PTSD-RI), and receiving outpatient HIV care at an adolescent medical clinic in Moshi, Tanzania. Treatment-related support varied by orphan status. Paternal orphans cared for by their biological mothers and maternal orphans cared for by grandmothers described adherence support such as assistance taking medication and attending clinic. Double orphans did not report adherence support. Several maternal and double orphans faced direct interference from caregivers and household members when they attempted to take their medications. Caregivers play a significant role in treatment adherence and must be considered in interventions to increase medication adherence in HIV-infected orphans. Findings from this study informed caregiver participation in Sauti ya Vijana (The Voice of Youth), a mental health intervention for youth living with HIV in Tanzania.

Evaluating mental health difficulties and associated outcomes among HIV-positive adolescents in Tanzania.

AIDS-related mortality among HIV-positive adolescents has risen by 50% despite the scale up of antiretroviral therapy (ART). ART maladherence likely plays a role in the increase of AIDS-related deaths among adolescents and has shown to be associated with psychosocial and mental health difficulties. Addressing the specific mental health needs of HIV-positive adolescents is critical to ending the HIV epidemic. This cross-sectional study prospectively enrolled HIV-positive adolescents (12-24 years) in Moshi, Tanzania. A structured questionnaire was administered that included questions about home, school, adherence, and measures of stigma (Berger Stigma Scale) and mental health. Mental health measures included depression (Patient Health Questionnaire-9), emotional/behavioral difficulties (Strengths and Difficulties Questionnaire), and traumatic experiences/post-traumatic stress symptoms (The University of California Los Angeles-post-traumatic stress disorder-Reaction Index). Mental health difficulties were prevalent among HIV-positive adolescents and were associated with incomplete adherence and stigma. Resources are needed to reduce HIV stigma and address mental health among HIV-positive adolescents in low-resource settings. This will improve not only mental health, but may also improve ART adherence and virologic suppression, improving overall health of the individual and reducing the risk of HIV transmission to others.

Low rates of child testing for HIV persist in a high-risk area of East Africa.

Children in low- and middle-income countries (LMIC) are the least touched by recent successes in the diagnosis and treatment of HIV/AIDS globally. Early treatment is essential for a child's longer and higher quality of life; however, by 2011, only a small proportion of HIV-seropositive children in LMIC countries were receiving treatment, in part because of persisting low rates of diagnosis. This study of the prevalence and characteristics of children tested for HIV was embedded in the Coping with HIV/AIDS in Tanzania (CHAT) study in which HIV-seropositive and HIV-seronegative adults, and adults with unknown HIV status were asked about HIV testing for their children. Data were gathered from November 2009 to August 2010 during the scale-up of Prevention of Mother To Child Transmission and Early Infant Diagnosis programs in the region. Reports on 1776 children indicate that 31.7% of all children were reported to have been tested, including only 42.9% of children with an HIV-seropositive caregiver. In general, children more likely to be HIV tested were biological children of study participants, younger, of widowed adults, living in urban areas, and of HIV-seropositive parents/caregivers. Children belonging to the two indigenous tribes, Chagga and Pare, were more likely to be tested than those from other tribes. Rates of testing among children less than two years old were low, even for the HIV-seropositive caregiver group. The persistence of low testing rates is discussed in terms of the accessibility and acceptability of child testing in resource poor settings.

Durability of antiretroviral therapy and predictors of virologic failure among perinatally HIV-infected children in Tanzania: a four-year follow-up.

BACKGROUND: In Tanzania, HIV-1 RNA testing is rarely available and not standard of care. Determining virologic failure is challenging and resistance mutations accumulate, thereby compromising second-line therapy. We evaluated durability of antiretroviral therapy (ART) and predictors of virologic failure among a pediatric cohort at four-year follow-up. METHODS: This was a prospective cross-sectional study with retrospective chart review evaluating a perinatally HIV-infected Tanzanian cohort enrolled in 2008-09 with repeat HIV-1 RNA in 2012-13. Demographic, clinical, and laboratory data were extracted from charts, resistance mutations from 2008-9 were analyzed, and prospective HIV RNA was obtained. RESULTS: 161 (78%) participants of the original cohort consented to repeat HIV RNA. The average age was 12.2 years (55% adolescents ≥12 years). Average time on ART was 6.4 years with 41% receiving second-line (protease inhibitor based) therapy. Among those originally suppressed on a first-line (non-nucleoside reverse transcriptase based regimen) 76% remained suppressed. Of those originally failing first-line, 88% were switched to second-line and 72% have suppressed virus. Increased level of viremia and duration of ART trended with an increased number of thymidine analogue mutations (TAMs). Increased TAMs increased the odds of virologic failure (p = 0.18), as did adolescent age (p < 0.01). CONCLUSIONS: After viral load testing in 2008-09 many participants switched to second-line therapy. The majority achieved virologic suppression despite multiple resistance mutations. Though virologic testing would likely hasten the switch to second-line among those failing, methods to improve adherence is critical to maximize durability of ART and improve virologic outcomes among youth in resource-limited settings.

Through the looking glass: empowering youth community advisory boards in Tanzania as a sustainable youth engagement model to inform policy and practice.

More young people are living in the world than ever before, 90% of whom reside in low and middle income countries (LMICs). To address their needs, it is critical to have sustainable youth engagement when determining policy and to advance effective implementation of youth-focused interventions. Youth Community Advisory Boards (CABs) are a sustainable mechanism to achieve this goal. This paper describes engagement with youth CAB members across four locations in Tanzania. To set youth CAB meeting agendas and priorities, we asked youth CAB members to write (using free text) the top five challenges faced by young people in their communities (highest to lower priority). The Google Forms survey link was presented at the May 2023 youth CAB meeting and disseminated through WhatsApp. The survey was completed by smartphone, tablet, or paper provided to the youth liaison for data entry. Results were translated from Swahili to English and coded using excel. Findings were then presented back to the youth CABs at the September 2023 meeting. At that meeting, youth CAB members were then asked to write (free text) potential solutions to the most commonly described challenges. The surveys had response rates of 90% (84/93) for challenges and 78% (71/93) for solutions. The number one reported challenge was unemployment and financial instability (45%). Gender based violence (13%), sexual reproductive health issues (8%), and alcohol and drug use (8%) were in the top four both by priority and frequency of report. Other important challenges included physical and mental health, malnutrition, relationships, education, and societal and environmental norms, among others. Solutions included job creation, improved education, expanded legal systems, youth-friendly health care services, and increased social support through peer networks and community support. The National Accelerated Action and Investment Agenda for Adolescent Health and Wellbeing (NAIA-AHW) 2021/22-2024/25 includes most, but not all, of these top challenges and solutions. Ensuring young people have a seat at the policy table is critical to effective youth-empowerment in health and other related programs. Including a youth CAB member to represent this collective in youth-related government activities is a sustainable model to achieve this goal.

Adolescent mental health research in Tanzania: a study protocol for a priority setting exercise and the development of an interinstitutional capacity strengthening programme.

INTRODUCTION: Poor adolescent mental health is a barrier to achieving several sustainable development goals in Tanzania, where adolescent mental health infrastructure is weak. This is compounded by a lack of community and policy maker awareness or understanding of its burden, causes and solutions. Research addressing these knowledge gaps is urgently needed. However, capacity for adolescent mental health research in Tanzania remains limited. The existence of a National Institute for Medical Research (NIMR), with a nationwide mandate for research conduct and oversight, presents an opportunity to catalyse activity in this neglected area. Rigorous research priority setting, which includes key stakeholders, can promote efficient use of limited resources and improve both quality and uptake of research by ensuring that it meets the needs of target populations and policy makers. We present a protocol for such a research priority setting study and how it informs the design of an interinstitutional adolescent mental health research capacity strengthening strategy in Tanzania. METHODS AND ANALYSIS: From May 2021, this 6 month mixed-methods study will adapt and merge the James Lind Alliance approach and validated capacity strengthening methodologies to identify priorities for research and research capacity strengthening in adolescent mental health in Tanzania. Specifically, it will use online questionnaires, face-to-face interviews, focus groups, scoping reviews and a consensus meeting to consult expert and adolescent stakeholders. Key evidence-informed priorities will be collaboratively ranked and documented and an integrated strategy to address capacity gaps will be designed to align with the nationwide infrastructure and overall strategy of NIMR. ETHICS AND DISSEMINATION: National and institutional review board approvals were sought and granted from the National Health Research Ethics Committee of the NIMR Medical Research Coordinating Committee (Tanzania) and the Liverpool School of Tropical Medicine (United Kingdom). Results will be disseminated through a national workshop involving all stakeholders, through ongoing collaborations and published commentaries, reviews, policy briefs, webinars and social media.

A group-based mental health intervention for Tanzanian youth living with HIV: Secondary analysis of a pilot trial.

BACKGROUND: Youth living with human immunodeficiency virus (YLWH) are vulnerable to incomplete adherence to antiretroviral therapy in the context of stigma, decreased hope for future, and mental health challenges. Despite these challenges, few mental health interventions have been developed to support YLWH. Previous randomized results from the Sauti ya Vijana (SYV; "The Voice of Youth") mental health intervention were indicative of the intervention's benefits in promoting virologic suppression. METHODS: SYV is a group-based mental health and life skills intervention (pilot, individually randomized group treatment trial) developed alongside YLWH. SYV was comprised of 10, 90-minute sessions based on evidence-based treatment models designed to improve coping, social support, and hope for future as a pathway to improved adherence and virologic suppression. At baseline, YLWH 12 to 24 years of age were randomized to SYV or standard of care. Participants included in this secondary analysis were enrolled in SYV's crossover waves due to either being randomized to standard of care or inability to attend an earlier group, and therefore delayed intervention exposure. Measured outcomes included self-reported mental health measures, self-reported human immunodeficiency virus measures (stigma and adherence), and human immunodeficiency virus ribonucleic acid. Data was collected at baseline, preintervention, and postintervention timepoints. Participants were included if they attended a crossover wave and had data at all 3 timepoints. RESULTS: Twenty-one crossover participants met inclusion criteria. Mean scores of self-reported mental health questionnaires were in an asymptomatic range both pre- and postintervention. Viral suppression was N = 15 (71%) preintervention compared to N = 17 (81%) postintervention. The participants who became virologically suppressed had no change in antiretroviral therapy. CONCLUSIONS: Despite the small sample size, findings from this study demonstrate that mental wellbeing may be an important pathway to improved HIV outcomes for YLWH. The same trend toward virologic suppression pre- to postintervention was demonstrated in the randomized pilot trial and suggests that SYV holds promise to improve HIV outcomes. Data from this analysis support the fully powered trial that is now underway.

IMPAACT 2016: Operationalizing HIV Intervention Adaptations to Inform the Science and Outcomes of Implementation.

Introduction: Uptake of evidence-based interventions for adolescents and young adults living with HIV (AYA-LWH) in sub-Saharan Africa (SSA) is complex, and cultural differences necessitate local adaptations to enhance effective implementation. Few models exist to guide intervention tailoring, yet operationalizing strategies is critical to inform science and implementation outcomes, namely acceptability, appropriateness, feasibility, fidelity, and sustainability. This paper describes operationalizing the ADAPT-ITT framework applied to a manualized trauma-informed cognitive behavioral therapy (TI-CBT) intervention addressing mental and sexual health for AYA-LWH in SSA in preparation for a randomized controlled trial (RCT). Methods: Phase 1 of the RCT focused on operationalizing ADAPT-ITT steps 3-7 to tailor the intervention for use in eight sites across Botswana, Malawi, South Africa, and Zimbabwe. Well-defined processes were developed to supplement the general guidelines for each step to provide clear, consistent direction on how to prepare and conduct each step, including documenting, assessing, and determining adaptations, while maintaining intervention fidelity. The processes provided efficient standardized step-by-step progression designed for future replication. All sites participated in Phase 1 using the created tools and strategies to translate and present the TI-CBT to community stakeholders for feedback informing local adaptations. Results: The research team developed and operationalized materials guiding adaptation. A translation review process verified local adaptability, maintained core concepts, and revealed differing interpretations of words, idioms, and culturally acceptable activities. Strategically designed tools comprised of feedback and translation verification forms resulted in meticulous management of adaptations. Robust collaborations between investigators, research managers, site personnel, and topical experts maximized multidisciplinary expertise, resulting in ~10-15 personnel per site facilitating, collecting, assessing, and integrating local feedback. Processes and tools operationalized in steps 3-7 effectively addressed implementation outcomes during community engagements (n = 108), focus groups (n = 5-8 AYA-LWH and caregivers per group), and strategic training of youth leaders. Discussion: This paper offers a novel generalizable approach using well-defined processes to guide intervention adaptation building on the ADAPT-ITT framework. The processes strengthen the science of implementation and provide much-needed specificity in adaptation steps to optimize and sustain real-world impact and help researchers and community stakeholders maximize existing infrastructure, culture, and resources to inform implementation strategies.