Differences in condom access and use and associated factors between persons with and without disabilities receiving social cash transfers in Luapula province, Zambia-A cross-sectional study.

Persons with disabilities are disadvantaged in accessing sexual and reproductive health services, including condoms. In this study, we investigated whether condom access and use and their associated factors differed between persons with and without disabilities. We used data from adults in households receiving the Government of Zambia social cash transfers (SCT) in four districts of Luapula province. Condom access and use was the outcome. Disability, defined by the Washington Group Short Set Questions on Disability, was the main predictor. We performed logistic regression analyses to determine the associations between condom access and use and disability. In multivariable analyses, we controlled for covariates including age, sex, marital status, poverty status, HIV testing, and receiving the SCT. The sample comprised 1,143 people aged 16-49, with a median age of 21 years (interquartile range 18-28); 57.4% (n = 656) were female, 86.5% (n = 989) accessed and used condoms, and 17.9% (n = 205) were disabled, rating themselves with a 3 or a 4 on a scale of 1 = "not limited" to 4 = "cannot at all" in performing any of the six daily functions (seeing, hearing, walking, cognition, self-care, or communicating). Nearly sixty percent(58.5% (n = 120)) of persons with disabilities were female, 79.5% (n = 163) reported being very poor, 87.8% (n = 180) reported receiving SCT, and 86.3% (n = 177) reported accessing and using condoms. Condom access and use did not differ between persons with and without disabilities (adjusted odds ratio: 1.09; 95% confidence interval [CI]: 0.60-1.98]). We found no differences between persons with and without disabilities in condom access and use. We established that individual-level factors such as age, sex, marital status, and knowledge of being HIV positive might play a more important role in condom access and use than disability. Condom promotion interventions should account for these factors.

Digital tools for youth health promotion: principles, policies and practices in sub-Saharan Africa.

Although digital health promotion (DHP) technologies for young people are increasingly available in low- and middle-income countries (LMICs), there has been insufficient research investigating whether existing ethical and policy frameworks are adequate to address the challenges and promote the technological opportunities in these settings. In an effort to fill this gap and as part of a larger research project, in November 2022, we conducted a workshop in Cape Town, South Africa, entitled 'Unlocking the Potential of Digital Health Promotion for Young People in Low- and Middle-Income Countries'. The workshop brought together 25 experts from the areas of digital health ethics, youth health and engagement, health policy and promotion and technology development, predominantly from sub-Saharan Africa (SSA), to explore their views on the ethics and governance and potential policy pathways of DHP for young people in LMICs. Using the World Café method, participants contributed their views on (i) the advantages and barriers associated with DHP for youth in LMICs, (ii) the availability and relevance of ethical and regulatory frameworks for DHP and (iii) the translation of ethical principles into policies and implementation practices required by these policies, within the context of SSA. Our thematic analysis of the ensuing discussion revealed a willingness to foster such technologies if they prove safe, do not exacerbate inequalities, put youth at the center and are subject to appropriate oversight. In addition, our work has led to the potential translation of fundamental ethical principles into the form of a policy roadmap for ethically aligned DHP for youth in SSA.

Identifying potential catalysts to accelerate the achievement of Sustainable Development Goals (SDGs) among adolescents living in Nigeria.

Investing in adolescents in Africa holds great promise for the development of the continent. The steps involved in identifying factors linked to interventions that may accelerate the attainment of multiple SDGs for adolescents in Nigeria are described. Data from a survey to investigate the well-being of 1800 adolescents aged 10-19 years in Southwest Nigeria was analysed. A four-step process was employed: 1) Mapping of variables deemed as suitable proxies for SDG targets; 2) Mapping hypothesised protective factors (accelerators) from the study instruments. Consequently, SDG targets related to elimination of hunger, good health, gender equality and peace; and seven accelerators (safe schools, parenting support, good mental health, no survival work, food security, stable childhood, and regular physical activity) were identified; 3) evaluating associations using bivariate analysis and multivariable logistic regression, 4) calculating adjusted probabilities. The mean age of the adolescents was 15.02 ± 2.27 years (48.6% female). Good mental health, not doing survival work, safe schools, stable childhood and parental support were significantly associated with at least two SDG targets. For example, food security was significantly associated with the highest number of SDG outcomes: one SDG target related to child survival (no substance use: x2 = 3.39, p = <0.001); three SDG targets related to educational outcomes (school progression: x2 = 5.68, p = 0.017, ability to concentrate in school: x2 = 26.92, p = <0.001, and school attendance: x2 = 25.89, p = <0.001); and four SDG targets related to child protection (no risky sexual behaviours: x2 = 16.14, p = <0.001, no perpetration of violence: x2 = 15.74, p = <0.001, no community violence: x2 = 39.06, p =<0.001, and no sexual abuse: x2 = 7.66, p = 0.006). Interventions centred around good mental health, not doing survival work, safe schools, small family size, stable childhood and parental support are potential accelerators for the attainment of SDG outcomes by adolescents living in Nigeria.

Achieving the health and well-being Sustainable Development Goals among adolescent mothers and their children in South Africa: Cross-sectional analyses of a community-based mixed HIV-status cohort.

The Sustainable Development Goals (SDGs) are a visionary and multi-sectoral agenda for human development. With less than a decade left to reach these targets, it is important to identify those at greatest risk of not meeting these ambitious targets. Adolescent mothers and their children are a highly vulnerable group. We mapped 35 SGD-related targets among 1,046 adolescent mothers and their oldest child (n = 1046). Questionnaires using validated scales were completed by 10- to 24-year-old adolescent girls and young women who had their first child before age 20 in an HIV-endemic district in the Eastern Cape province of South Africa. Maternal outcomes included 26 SDG-aligned indicators, while child-related outcomes included 9 indicators. Data was collected by trained researchers, following informed voluntary consent by the adolescent mothers and their caregivers. Frequencies and chi-square tests were conducted to compare progress along SDG-aligned indicators among adolescent mothers by HIV status. Overall, adolescent mothers reported low attainment of SDG-aligned indicators. While four in five adolescent mothers lived in poor households, nearly 93% accessed at least one social cash transfer and 80% accessed a child support grant for their children. Food security rates among adolescent mothers (71%) were lower than among their children (91%). Only two-thirds of adolescent mothers returned to school after childbirth, and only one-fifth were either studying or employed. Over half of adolescent mothers had experienced at least one type of violence (domestic, sexual or community). HIV-positive status was associated with higher rates of hunger and substance use, poorer school attendance, and higher rates of exposure to violence. Understanding progress and gaps in meeting the SDGs among highly vulnerable groups is critical, particularly for adolescent mothers and their children. These complex vulnerabilities suggest that programming for adolescent mothers must address their unique needs.

Accelerating progress towards the sustainable development goals for adolescents in Ghana: a cross-sectional study.

Since the adoption of the sustainable development goals (SDGs) by the United Nations (UN), the search has been on to identify interventions that have effects on multiple SDG-targets simultaneously. Like other developing countries, Ghana has a youthful population and would require creative, urgent, youth-focused interventions to be able to attain the SDGs by 2030. This paper describes the application of the accelerator model on data from a sample of Ghanaian adolescents to identify potential accelerators towards selected SDG targets involving youth. The data for 944 adolescents, 10-19 years (mean age 12.31 ± 3.51 years), extracted from two cross-sectional surveys on children and adolescents aged 6-19 years in Kumasi, Ghana, were analysed in this paper. Variables considered suitable proxies for SDG targets and potential accelerators were identified from the study instruments. Consequently, four aligned SDG targets (good mental health, access to ICT, school completion and no open defaecation) and five accelerators (cognitive stimulation, no relative poverty, low student-teacher ratio, high caregiver education and safe water) were extracted. Associations between accelerators and SDG targets were assessed using multivariable logistic regression adjusting for sociodemographic covariates and multiple testing. Cumulative effects were tested by marginal effects modelling. The three hypothesised accelerators identified were cognitive stimulation, low student-teacher ratio, and no relative poverty. A combination of all three accelerators was associated with a higher likelihood of adolescents having access to Information and Communication Technology (ICT) by +73% (CI 0.72-0.74), no open defecation by +44% (CI 0.43-0.46), school completion by +27% (CI 0.26-0.27) and good mental health by +9% (CI 0.08-0.10). Three hypothesized accelerators showed association across all four SDG aligned targets. The accelerator model has been further validated in this dataset from Ghana. Robust interventions designed around these accelerators may represent an opportunity for achieving the SDGs in Ghana.

Economic Well-being and Associated Mediating Pathways to Improved Antiretroviral Therapy Adherence Among Adolescents Living With HIV: A Prospective Cohort Study in South Africa.

BACKGROUND: Adolescents living with HIV exhibit lower levels of adherence to antiretroviral therapy (ART) than other age groups. Poverty is a key barrier to ART adherence. This study aims at understanding how alleviating poverty through structural and internal pathways can help increase ART adherence among adolescents. SETTING: Eastern Cape province, South Africa. METHODS: One thousand forty-six adolescents living with HIV were recruited from 53 public health care facilities and interviewed at 3 data collection waves with a retention rate of 89% and a mortality rate of 3%. Data were collected by face-to-face, device-assisted interviews. Hybrid probit regressions and a structural equation path analysis were used to estimate the association between poverty reduction (increased access to basic necessities) and the pathways by which it could improve ART adherence. RESULTS: Self-reported ART adherence ranged from an average of 66% (n = 615) at baseline to 75% (n = 700) in the last wave. Within-person and between-person improvements in economic well-being were associated with significant increases in adolescent ART adherence. On average, adolescents with access to 3 additional basic needs experienced a 4 percentage-point increase in the probability of ART adherence. Structural pathways to improved ART adherence included participants having enough money to travel to the clinic and sufficient food to eat when taking medication. Internal pathways included improved psychological well-being and reduced internalized HIV stigma. CONCLUSION: Poverty reduction programs such as HIV-sensitive social protection can address structural and psychological pathways to increase ART adherence among economically disadvantaged adolescents by incentivizing demand-side interventions and the provision of quality essential services.

Associations of Sustainable Development Goals Accelerators With Adolescents' Well-Being According to Head-of-Household's Disability Status-A Cross-Sectional Study From Zambia.

Objectives: We examined associations between accelerators (interventions impacting ≥2 SDG targets) and SDG-aligned well-being indicators among adolescents 16-24 years old in Zambia. Methods: We surveyed adults from 1,800 randomly sampled households receiving social cash transfers. We examined associations between accelerators (social cash transfers, life-long learning, mobile phone access) and seven well-being indicators among adolescents using multivariate logistic regressions. Results: The sample comprised 1,725 adolescents, 881 (51.1%) girls. Mobile phone access was associated with no poverty (adjusted Odds Ratio [aOR] 2.08, p < 0.001), informal cash transfers (aOR 1.82, p = 0.004), and seeking mental health support (aOR 1.61, p = 0.020). Social cash transfers were associated with no disability-related health restrictions (aOR 2.56, p = 0.004) and lesser odds of seeking mental health support (aOR 0.53, p = 0.029). Life-long learning was associated with informal cash transfers (aOR 3.49, p < 0.001) and lower school enrollment (aOR 0.70, p = 0.004). Adolescents with disabled head-of-household reported worse poverty, good health but less suicidal ideation. Conclusions: Social cash transfers, life-long learning, and mobile phone access were positively associated with well-being indicators. Adolescents living with disabled head-of-household benefited less. Governments should implement policies to correct disability-related inequalities.

Uncovering ART adherence inconsistencies: An assessment of sustained adherence among adolescents in South Africa.

INTRODUCTION: Antiretroviral treatment (ART) adherence rates are lower among adolescents living with HIV (ALHIV) than among adults and children, but more evidence is needed on long-term sustained ART adherence among ALHIV. This study assesses rates of sustained ART adherence in a cohort of adolescents in South Africa. METHODS: A prospective cohort of adolescents (10-19 years) living with HIV (baseline sample N = 1 046, 55% female, mean age 13.6) in the Eastern Cape Province in South Africa were interviewed at baseline (2014-15) and followed-up twice (2015-16, 2017-18). All adolescents ever initiated on treatment in 52 government health facilities were traced (with 90% uptake, 94% retention at Wave 2, and 97% retention at Wave 3, 3.4% mortality) and their clinic records were extracted where available. We investigate sustained ART adherence among adolescents interviewed at all three waves of data collection (N = 933). To quantify adherence at each study wave, we used self-reported past-week adherence (including weekdays and weekends). Self-reported adherence was validated using HIV-1 RNA viral load (>50 copies/mL cut-off) reported in clinic records, in a random-intercept logistic regression. RESULTS AND DISCUSSION: At baseline, approximately 66% (N = 615) of adolescents reported past-week ART adherence, and of these 45.3% reported adherence at both baseline and follow-up. Only 37.1% of the sample reported sustained past-week ART adherence over the three waves of the study. Most adolescents (N = 587, 62.9%) report inconsistent adherence across time (including 6.4% disengaged from care). Older (P = 0.007) and adolescents with horizontally acquired HIV (P = 0.002) were more likely to report inconsistent adherence across time. Controlling for socio-demographic characteristics, past-week adherence was associated with non-detectable viral load (aOR 1.72, 95%CI 1.14-2.59, P = 0.009). Overall, of the adolescents with viral load measurements at study Wave 1 and Wave 2, 50.6% maintained undetectable viral load for the preceding year. CONCLUSIONS: Adolescents living with HIV reported very low rates of sustained ART adherence. Adherence reported at a single time may mask high rates of variability in adherence over time. These findings highlight the urgent need for enhanced and effective interventions to assist ALHIV with ART adherence through the challenging years of adolescence.

Consistent Provisions Mitigate Exposure to Sexual Risk and HIV Among Young Adolescents in South Africa.

Exposure to sexual risk in early adolescence strongly predicts HIV infection, yet evidence for prevention in young adolescents is limited. We pooled data from two longitudinal South African surveys, with adolescents unexposed to sexual risk at baseline (n = 3662). Multivariable logistic regression tested associations between intermittent/consistent access to eight provisions and reduced sexual risk exposure. Participants were on average 12.8 years, 56% female at baseline. Between baseline and follow-up, 8.6% reported sexual risk exposure. Consistent access to caregiver supervision (OR 0.53 95%CI 0.35-0.80 p = 0.002), abuse-free homes (OR 0.55 95%CI 0.37-0.81 p = 0.002), school feeding (OR 0.55 95%CI 0.35-0.88 p = 0.012), and HIV prevention knowledge (OR 0.43, 95%CI 0.21-0.88 p = 0.021) was strongly associated with preventing early sexual risk exposure. While individual factors reduced the odds of sexual risk exposure, a combination of all four resulted in a greater reduction, from 12.9% (95%CI 7.2-18.7) to 1.0% (95%CI 0.2-1.8). Consistent access to provisions in early adolescence may prevent sexual risk exposure among younger adolescents.

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.

Improving lives by accelerating progress towards the UN Sustainable Development Goals for adolescents living with HIV: a prospective cohort study.

BACKGROUND: Low-income and middle-income countries (LMICs) face major challenges in achieving the UN's Sustainable Development Goals (SDGs) for vulnerable adolescents. We aimed to test the UN Development Programme's proposed approach of development accelerators-provisions that lead to progress across multiple SDGs-and synergies between accelerators on achieving SDG-aligned targets in a highly vulnerable group of adolescents in South Africa. METHODS: We did standardised interviews and extracted longitudinal data from clinical records at baseline (2014-15) and 18-month follow-up (2016-17) for adolescents aged 10-19 years living with HIV in the Eastern Cape province of South Africa. We used standardised tools to measure 11 SDG-aligned targets-antiretroviral therapy adherence, good mental health, no substance use, HIV care retention, school enrolment, school progression, no sexual abuse, no high-risk sex, no violence perpetration, no community violence, and no emotional or physical abuse. We also assessed receipt at both baseline and follow-up of six hypothesised development accelerators-government cash transfers to households, safe schools (ie, without teacher or student violence), free schools, parenting support, free school meals, and support groups. Associations of all provisions with SDG-aligned targets were assessed jointly in a multivariate path model, controlling for baseline outcomes and sociodemographic and HIV-related covariates, and adjusted for multiple outcome testing. Cumulative effects were tested by marginal effects modelling. FINDINGS: 1063 (90%) of 1176 eligible adolescents were interviewed. Three provisions were shown to be development accelerators. Parenting support was associated with good mental health (odds ratio 2·13, 95% CI 1·43-3·15, p<0·0001), no high-risk sex (2·44, 1·45-5·03, p=0·005), no violence perpetration (2·59, 1·63-4·59, p<0·0001), no community violence (2·43, 1·65-3·86, p<0·0001), and no emotional or physical abuse (2·38, 1·65-3·76; p<0·0001). Cash transfers were associated with HIV care retention (1·87, 1·15-3·02, p=0·010), school progression (2·05, 1·33-3·24, p=0·003), and no emotional or physical abuse (1·76, 1·12-3·02, p=0·025). Safe schools were associated with good mental health (1·74, 1·30-2·34, p<0·0001), school progression (1·57, 1·17-2·13, p=0·004), no violence perpetration (2·02, 1·45-2·91, p<0·0001), no community violence (1·81, 1·30-2·55, p<0·0001), and no emotional or physical abuse (2·20, 1·58-3·17, p<0·0001). For five of 11 SDG-aligned targets, a combination of two or more accelerators showed cumulative positive associations, suggesting accelerator synergies of combination provisions. For example, the fitted probability of adolescents reporting no emotional or physical abuse (SDG 16.2) with no safe schools, cash transfers, or parenting support was 0·25 (0·16-0·34). With cash transfer alone it was 0·37 (0·33-0·42), with safe school alone 0·42 (0·30-0·55), and with parenting support alone 0·44 (0·30-0·59). With all three development accelerators combined, the probability of adolescents reporting no emotional or physical abuse was 0·76 (0·67-0·84). After correcting for multiple tests, four of the SDG-aligned targets (antiretroviral therapy adherence, no substance use, school enrolment, and no sexual abuse) were not associated with any hypothesised accelerators. INTERPRETATION: The findings suggest the UN's accelerator approach for this high-risk adolescent population has policy and potential financing usefulness. Services that simultaneously promote several SDG targets, or combine to support particular targets, might be important to meet not only health-related targets, but also to ensure that adolescents in LMICs thrive within a new development framework. FUNDING: Nuffield Foundation, UK Research and Innovation Global Challenges Research Fund, UKAID, Janssen Pharmaceutica, International AIDS Society, John Fell Fund, European Research Council, Economic and Social Research Council, Philip Leverhulme Trust, and UNICEF.

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.

The stuff that dreams are made of: HIV-positive adolescents' aspirations for development.

BACKGROUND: The Sustainable Development Goals (SDGs) commit to strengthening collaborations between governments and civil society. Adolescents are among the key target populations for global development initiatives, but research studies and programmes rarely include their direct perspectives on how to promote health and wellbeing. This article explores how both the methods and the findings of participatory research provide insights into adolescents' aspirations across the domains of health and social development. It investigates how adolescents conceive of health and social services as interconnected, and how this reflects the multisectoral objectives of the SDGs. METHODS: This research was conducted within a longitudinal, mixed-methods study of HIV-positive adolescents (n = 80 qualitative participants, n = 1060 quantitative interviews). Between November 2013 and February 2014, a participatory exercise - the "dream clinic" - was piloted with 25 adolescents in South Africa's Eastern Cape. Key themes were identified based on the insights shared by participants, and through visual and thematic analysis. These findings were explored through a second participatory exercise, "Yummy or crummy? You are the Mzantsi Wakho masterchef !," conducted in January 2016. Findings are described in relation to emerging quantitative results. RESULTS: Mixed methods explored associations between access to food, medicines, clean water and sanitation in HIV-positive adolescents' aspirations for development. The exercises produced practicable recommendations for innovations in development, based on associations between healthcare, food security, clean water and sanitation, while illustrating the value of partnership and collaboration (the objective of SDG17). Findings capture strong interlinkages between SDGs 2, 3 and 6 - confirming the importance of specific SDGs for HIV-positive adolescents. Study results informed the objectives of South Africa's National and Adolescent and Youth Health Policy (2017). CONCLUSIONS: Participatory research may be used to leverage the perspectives and experiences of adolescents. The methods described here provide potential for co-design and implementation of developmental initiatives to fulfil the ambitious mandate of the SDGs. They may also create new opportunities to strengthen the engagement of adolescents in policy and programming.

Resourcing resilience: social protection for HIV prevention amongst children and adolescents in Eastern and Southern Africa.

Adolescents are the only age group with growing AIDS-related morbidity and mortality in Eastern and Southern Africa, making HIV prevention research among this population an urgent priority. Structural deprivations are key drivers of adolescent HIV infection in this region. Biomedical interventions must be combined with behavioural and social interventions to alleviate the socio-structural determinants of HIV infection. There is growing evidence that social protection has the potential to reduce the risk of HIV infection among children and adolescents. This research combined expert consultations with a rigorous review of academic and policy literature on the effectiveness of social protection for HIV prevention among children and adolescents, including prevention for those already HIV-positive. The study had three goals: (i) assess the evidence on the effectiveness of social protection for HIV prevention, (ii) consider key challenges to implementing social protection programmes that promote HIV prevention, and (iii) identify critical research gaps in social protection and HIV prevention, in Eastern and Southern Africa. Causal pathways of inequality, poverty, gender and HIV risk require flexible and responsive social protection mechanisms. Results confirmed that HIV-inclusive child-and adolescent-sensitive social protection has the potential to interrupt risk pathways to HIV infection and foster resilience. In particular, empirical evidence (literature and expert feedback) detailed the effectiveness of combination social protection particularly cash/in-kind components combined with "care" and "capability" among children and adolescents. Social protection programmes should be dynamic and flexible, and consider age, gender, HIV-related stigma, and context, including cultural norms, which offer opportunities to improve programmatic coverage, reach and uptake. Effective HIV prevention also requires integrated social protection policies, developed through strong national government ownership and leadership. Future research should explore which combinations of social protection work for sub-groups of children and adolescents, particularly those living with HIV.

Medical pluralism predicts non-ART use among parents in need of ART: a community survey in KwaZulu-Natal, South Africa.

Despite documented common use of traditional healers and efforts to scale up antiretroviral treatment (ART) in sub-Saharan Africa, evidence on whether medical pluralism predicts ART use is inconclusive and restricted to clinic settings. This study quantitatively assesses whether medical pluralism predicts ART use among parents in need of ART in South Africa. 2,477 parents or primary caregivers of children were interviewed in HIV-endemic communities of KwaZulu-Natal. Analysis used multiple logistic regression on a subsample of 435 respondents in need of ART, who reported either medical pluralism (24.6 %) or exclusive public healthcare use (75.4 %). Of 435 parents needing ART, 60.7 % reported ART use. Medical pluralism emerged as a persistent negative predictor of ART utilization among those needing it (AOR [95 % CI] = .556 [.344 - .899], p = .017). Use of traditional healthcare services by those who need ART may act as a barrier to treatment access. Effective intersectoral collaboration at community level is urgently needed.