'Remember there is that thing called confidentiality': experiences of institutional discrimination in the health system among adolescent boys and young men living with HIV in the Eastern Cape province of South Africa.

Adolescents and men are two populations that perform poorly within the HIV cascade of care, having worse AIDS-related health outcomes, and experiencing higher levels of HIV-related stigma. This paper explores institutional health system discrimination as experienced by adolescent boys with perinatally-acquired HIV, situating them within the social and gendered contexts of the Eastern Cape Province, South Africa. Life history narratives (n = 36) and in-depth semi-structured interviews (n = 32) with adolescent boys living with HIV aged 13-22 were conducted in 2017-2018. In-depth semi-structured interviews with biomedical and traditional health practitioners (n = 14), analysis of health facility files (n = 41) and clinic observations were also conducted. Together, triangulated sources point to an incongruence between the complex needs of adoelscent boys and young men living with HIV and their experiences within the health system. Two institutional discrimination-related deterrents to retention in care were identified: (1) lack of confidentiality due to health facility layouts and practices that visibilised people living with HIV; and (2) mistreatment in the form of shouting. This article contributes to the limited literature on the experiences of young men within the HIV continuum of care, focusing on how stigma influences how young men experience and engage with the health sector.

Traditional and biomedical health practices of adolescent boys and young men living with perinatally-acquired HIV in the Eastern Cape Province of South Africa.

Men are less vulnerable to HIV acquisition than women, but have poorer HIV-related health outcomes. They access HIV services less, and are more likely to die on antiretroviral therapy. The adolescent epidemic presents further challenges, and AIDS-related illness is the leading cause of death among adolescents in sub-Saharan Africa. We explored the health practices of adolescent boys and young men (aged 13-22) living with perinatally-acquired HIV and the processes through which these practices are formed and sustained. We engaged health-focused life history narratives (n = 35), semi-structured interviews (n = 32) and analysis of health facility files (n = 41), alongside semi-structured interviews with traditional and biomedical health practitioners (n = 14) in the Eastern Cape, South Africa. Participants did not access traditional products and services for HIV, a finding that deviates from much of the literature. Findings suggest that health practices are mediated not only by gender and culture, but also childhood experiences of growing up deeply embedded in the biomedical health system.

'Foreign body': a social history of Implanon in South Africa's Eastern Cape.

This article explores the reception of the contraceptive implant, Implanon, by healthcare workers and patients in family planning units in South Africa's public health sector. Based on observations conducted at public health facilities in the Eastern Cape Province, and on interviews with nurses and patients in the same province, the study explored real-world experiences of the implant. This article examines the strategies used by nurses to promote use of the device, and explores how patients themselves responded to a widescale, national rollout of the implant within government family planning services. The study examines the reception of Implanon in the context of the post-Apartheid era in South Africa, in which the vestiges of Apartheid-era healthcare provision, and lack thereof, continue to animate personal experiences of contraception.

Blood and Blood: Anti-retroviral Therapy, Masculinity, and Redemption among Adolescent Boys in the Eastern Cape Province of South Africa.

Adolescents living with perinatally acquired HIV are among the first generation in South Africa to grow up with anti-retroviral therapy and democratic freedoms. In this article, we explore the biosocial lives of adolescent boys and young men living with HIV in the Eastern Cape Province of South Africa. We conducted qualitative research with 36 adolescent boys and young men in 2016-2018, including life history narratives, semi-structured interviews, and analysis of health facility files. [masculinity, South Africa, HIV, adolescence].

Power to participants: methodological and ethical reflections from a decade of adolescent advisory groups in South Africa.

ABSTRACTWhilst the HIV response has made significant progress in increasing representation of adults affected by HIV, the meaningful inclusion of children and adolescents has lagged. But this may be a pivotal moment of change. We report on a decade of conducting adolescent advisory groups in South Africa, to reflect on youth advisory processes. Data was collected from 2008 to 2018 from adolescent advisors (n = 60) and researchers (n = 25), and included feedback sessions, social media, anonymous "post-boxes" and interviews. Findings include the value of adolescent involvement in multiple stages of research co-creation and engagement in policy processes, the need for a safe environment and supporting adolescents living in extreme vulnerability. We also discuss the reconfiguring of power and personal relationships, and logistical and financial needs of adolescent advisory groups. Findings suggest that adolescent co-creation of research is feasible, even with very vulnerable adolescents, although ethical considerations need to be carefully addressed. Benefits include increased methodological rigour, enhanced adolescent acceptability of research and the recalibration of research dynamics for the empowerment of their target beneficiaries. Future studies could benefit from meaningfully involving adolescents through youth advisory groups.

'Yummy or crummy?' The multisensory components of medicines-taking among HIV-positive youth.

The global rollout of Antiretroviral Treatment (ART) has revealed an urgent need to understand the medicines-taking practices of HIV-positive adolescents. In the last decade, the literature on the social determinants of health has broadened the evidence-base on ART adherence. Interdisciplinary studies have expanded conceptions of medicines-taking beyond clinical or health systems frameworks, recognising the importance of socio-structural conditions and of patients' beliefs and experiences. Participatory research techniques which foreground the perspectives of adolescents provide greater insights still into their adherence. This article explores the use of participatory methods within a broader study on the social determinants of ART adherence among HIV-positive adolescents in South Africa. We describe how participatory methods were incorporated into this study (n = 1,059 in the quantitative baseline). We focus on an exercise, 'Yummy or crummy?', that explored the multisensory dimensions of medicines-taking, including their colour, smell, shape, and delivery mechanism. We describe two principal findings: first, adolescents' preference for greater understanding of the chemical workings of medicines, manifested in their preferences for colour, taste and shape of medicines; and second, the vital relationship between sensory preferences and the social imperatives of discretion and confidentiality regarding HIV-status.

Pharmaceuticals and modern statecraft in South Africa: the cases of opium, thalidomide and contraception.

This article provides a history of three pharmaceuticals in the making of modern South Africa. Borrowing and adapting Arthur Daemmrich's term 'pharmacopolitics', we examine how forms of pharmaceutical governance became integral to the creation and institutional practices of this state. Through case studies of three medicaments: opium (late 19th to early 20th century), thalidomide (late 1950s to early 1960s) and contraception (1970s to 2010s), we explore the intertwining of pharmaceutical regulation, provision and consumption. Our focus is on the modernist imperative towards the rationalisation of pharmaceutical oversight, as an extension of the state's bureaucratic and ideological objectives, and, importantly, as its obligation. We also explore adaptive and illicit uses of medicines, both by purveyors of pharmaceuticals, and among consumers. The historical sweep of our study allows for an analysis of continuities and changes in pharmaceutical governance. The focus on South Africa highlights how the concept of pharmacopolitics can usefully be extended to transnational-as well as local-medical histories. Through the diversity of our sources, and the breadth of their chronology, we aim to historicise modern pharmaceutical practices in South Africa, from the late colonial era to the Post-Apartheid present.

Multitype violence exposures and adolescent antiretroviral nonadherence in South Africa.

OBJECTIVES: HIV-positive adolescents have low-ART adherence, with consequent increased risks of mortality, morbidity, and viral resistance. Despite high rates of violence against children in the Africa region, no known studies have tested impacts on HIV-positive adolescents. We examine associations of ART adherence with adolescent violence victimization by caregivers, teachers, peers, community members, and healthcare providers. DESIGN AND METHODS: HIV-positive adolescents were interviewed (n = 1060), and clinic biomarker data collected. We sampled all 10-19-year olds ever ART-initiated within 53 clinics in 180 South African communities (90.1% reached). Analyses examined associations between nonadherence and nine violence types using sequential multivariate logistic regressions. Interactive and additive effects were tested with regression and marginal effects. RESULTS: Past-week self-reported ART nonadherence was 36%. Nonadherence correlated strongly with virologic failure (OR 2.3, CI 1.4-3.8) and symptomatic pulmonary tuberculosis (OR 1.49, CI 1.18-2.05). Four violence types were independently associated with nonadherence: physical abuse by caregivers (OR 1.5, CI 1.1-2.1); witnessing domestic violence (OR 1.8, CI 1.22-2.66); teacher violence (OR 1.51, CI 1.16-1.96,) and verbal victimization by healthcare staff (OR 2.15, CI 1.59-2.93). Past-week nonadherence rose from 25% with no violence to 73.5% with four types of violence exposure. CONCLUSION: Violence exposures at home, school, and clinic are major and cumulating risks for adolescent antiretroviral nonadherence. Prevention, mitigation, and protection services may be essential for the health and survival of HIV-positive adolescents.

Incursions from the epicentre: Southern theory, social science, and the global HIV research domain.

Research about HIV constitutes a global domain of academic knowledge. The patterns that structure this domain reflect inequalities in the production and dissemination of knowledge, as well as broader inequalities in geopolitics. Conventional metrics for assessing the value and impact of academic research reveal that "Northern" research remains dominant, while "Southern" research remains peripheral. Southern theory provides a framework for greater critical engagement with knowledge produced by researchers within the global South. With a focus on HIV social science, we show that investigators working in and from Africa have produced and disseminated knowledge fundamental to the global domain of HIV research, and argue that their epistemological contribution may be understood within the framework of Southern theory. Through repurposing a bibliometrical measure of citation count, we constitute a new archive of highly cited social science research. With a focus on South Africa, we situate this archive within changing historical contexts, connecting research findings to developments in medicine, health sciences and politics. We focus on two key themes in the evolution of HIV knowledge: (1) the significance of context and locality - the "setting" of HIV research; and (2) sex, race and risk - changing ideas about the social determinants of HIV transmission.

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.

Incursions from the epicentre: Southern theory, social science, and the global HIV research domain

Research about HIV constitutes a global domain of academic knowledge. The patterns that structure this domain reflect inequalities in the production and dissemination of knowledge, as well as broader inequalities in geopolitics. Conventional metrics for assessing the value and impact of academic research reveal that "Northern" research remains dominant, while "Southern" research remains peripheral. Southern theory provides a framework for greater critical engagement with knowledge produced by researchers within the global South. With a focus on HIV social science, we show that investigators working in and from Africa have produced and disseminated knowledge fundamental to the global domain of HIV research, and argue that their epistemological contribution may be understood within the framework of Southern theory. Through repurposing a bibliometrical measure of citation count, we constitute a new archive of highly cited social science research. With a focus on South Africa, we situate this archive within changing historical contexts, connecting research findings to developments in medicine, health sciences and politics. We focus on two key themes in the evolution of HIV knowledge: (1) the significance of context and locality ­ the "setting" of HIV research; and (2) sex, race and risk ­ changing ideas about the social determinants of HIV transmission

School, Supervision and Adolescent-Sensitive Clinic Care: Combination Social Protection and Reduced Unprotected Sex Among HIV-Positive Adolescents in South Africa.

Social protection can reduce HIV-risk behavior in general adolescent populations, but evidence among HIV-positive adolescents is limited. This study quantitatively tests whether social protection is associated with reduced unprotected sex among 1060 ART-eligible adolescents from 53 government facilities in South Africa. Potential social protection included nine 'cash/cash-in-kind' and 'care' provisions. Analyses tested interactive/additive effects using logistic regressions and marginal effects models, controlling for covariates. 18 % of all HIV-positive adolescents and 28 % of girls reported unprotected sex. Lower rates of unprotected sex were associated with access to school (OR 0.52 95 % CI 0.33-0.82 p = 0.005), parental supervision (OR 0.54 95 % CI 0.33-0.90 p = 0.019), and adolescent-sensitive clinic care (OR 0.43 95 % CI 0.25-0.73 p = 0.002). Gender moderated the effect of adolescent-sensitive clinic care. Combination social protection had additive effects amongst girls: without any provisions 49 % reported unprotected sex; with 1-2 provisions 13-38 %; and with all provisions 9 %. Combination social protection has the potential to promote safer sex among HIV-positive adolescents, particularly girls.

Negotiations of Blame and Care among HIV-positive Mothers and Daughters in South Africa's Eastern Cape.

Research delineates two epidemiological categories among HIV-positive adolescents: those who contract the virus sexually and those who inherit it as infants. In this article, we are interested in how tacit inferences about adolescents' mode of infection contribute to their experiences of HIV-related blame, and their ability to achieve care, in their intimate, everyday settings. The analysis arises from ethnographic research with 23 HIV-positive adolescents living in South Africa's Eastern Cape. From these, we draw particularly on the narratives of four HIV-positive teenage girls and their HIV-positive mothers. The article explores the social stakes entailed in ascriptions of adolescents' mode of infection, particularly in terms of how blame was allocated between mothers and daughters. It further considers how these families have sought to negotiate repudiation and thereby sustain intergenerational care. The article furthers limited research on the life projects and dilemmas of this HIV-positive adolescent cohort.

Coming of age? Women's sexual and reproductive health after twenty-one years of democracy in South Africa.

This paper is a sequel to a 2004 article that reviewed South Africa's introduction of new sexual and reproductive health (SRH) and rights laws, policies and programmes, a decade into democracy. Similarly to the previous article, this paper focuses on key areas of women's SRH: contraception and fertility, abortion, maternal health, HIV, cervical and breast cancer and sexual violence. In the last decade, South Africa has retained and expanded its sexual and reproductive health and rights (SRHR) policies in the areas of abortion, contraception, youth and HIV treatment (with the largest antiretroviral treatment programme in the world). These are positive examples within the SRHR policy arena. These improvements include fewer unsafe abortions, AIDS deaths and vertical HIV transmission, as well as the public provision of a human papillomavirus vaccine to prevent cervical cancer. However, persistent socio-economic inequities and gender inequality continue to profoundly affect South African women's SRHR. The state shows mixed success over the past two decades in advancing measurable SRH social justice outcomes, and in confronting and ameliorating social norms that undermine SRHR.

Changing Donor Funding and the Challenges of Integrated HIV Treatment.

Donor financing for HIV prevention and treatment has shifted from supporting disease-specific ("vertical") programs to health systems strengthening ("horizontal") programs intended to integrate all aspects of care. We examine the consequences of shifting resources from three perspectives: first, through a broad analysis of the changing policy context of health care financing; second, through an account of changing priorities for HIV treatment in South Africa; and third, through a description of some clinical consequences that the authors observed in a research study examining adherence to antiretroviral therapy (ART) and sexual health among adolescents. We note that AIDS responses are neither completely vertical nor horizontal but rather increasingly diagonal, as disease-specific protocols operate alongside integrated supply chain management, human resource development, and preventive screening. We conclude that health care programs are better conceived of as networks of policies requiring different degrees of integration into communities.

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.

Social protection: potential for improving HIV outcomes among adolescents.

INTRODUCTION: Advances in biomedical technologies provide potential for adolescent HIV prevention and HIV-positive survival. The UNAIDS 90-90-90 treatment targets provide a new roadmap for ending the HIV epidemic, principally through antiretroviral treatment, HIV testing and viral suppression among people with HIV. However, while imperative, HIV treatment and testing will not be sufficient to address the epidemic among adolescents in Southern and Eastern Africa. In particular, use of condoms and adherence to antiretroviral therapy (ART) remain haphazard, with evidence that social and structural deprivation is negatively impacting adolescents' capacity to protect themselves and others. This paper examines the evidence for and potential of interventions addressing these structural deprivations. DISCUSSION: New evidence is emerging around social protection interventions, including cash transfers, parenting support and educational support ("cash, care and classroom"). These interventions have the potential to reduce the social and economic drivers of HIV risk, improve utilization of prevention technologies and improve adherence to ART for adolescent populations in the hyper-endemic settings of Southern and Eastern Africa. Studies show that the integration of social and economic interventions has high acceptability and reach and that it holds powerful potential for improved HIV, health and development outcomes. CONCLUSIONS: Social protection is a largely untapped means of reducing HIV-risk behaviours and increasing uptake of and adherence to biomedical prevention and treatment technologies. There is now sufficient evidence to include social protection programming as a key strategy not only to mitigate the negative impacts of the HIV epidemic among families, but also to contribute to HIV prevention among adolescents and potentially to remove social and economic barriers to accessing treatment. We urge a further research and programming agenda: to actively combine programmes that increase availability of biomedical solutions with social protection policies that can boost their utilization.

Sex and secrecy: How HIV-status disclosure affects safe sex among HIV-positive adolescents.

HIV-positive adolescents who engage in unsafe sex are at heightened risk for transmitting or re-acquiring HIV. Disclosure of HIV-status to sexual partners may impact on condom use, but no study has explored the effects of (i) adolescent knowledge of one's HIV-status, (ii) knowledge of partner status and (iii) disclosure to partners, on safer sex behaviour. This study aimed to identify whether knowledge of HIV-status by HIV-positive adolescents and partners was associated with safer sex. Eight fifty eight HIV-positive adolescents (10-19 years old, 52% female, 68.1% vertically infected) who had ever initiated antiretroviral treatment in 41 health facilities in the Eastern Cape, South Africa, were interviewed using standardised questionnaires. Quantitative analyses used multivariate logistic regressions, controlling for confounders. Qualitative research included interviews, focus group discussions and observations with 43 HIV-positive teenagers and their healthcare workers. N = 128 (14.9%) of the total sample had ever had sex, while N = 109 (85.1%) of sexually active adolescents had boy/girlfriend. In total, 68.1% of the sample knew their status, 41.5% of those who were sexually active and in relationships knew their partner's status, and 35.5% had disclosed to their partners. For adolescents, knowing one's status was associated with safer sex (OR = 4.355, CI 1.085-17.474, p = .038). Neither knowing their partner's status, nor disclosing one's HIV-status to a partner, were associated with safer sex. HIV-positive adolescents feared rejection, stigma and public exposure if disclosing to sexual and romantic partners. Counselling by healthcare workers for HIV-positive adolescents focused on benefits of disclosure, but did not address the fears and risks associated with disclosure. These findings challenge assumptions that disclosure is automatically protective in sexual and romantic relationships for HIV-positive adolescents, who may be ill-equipped to negotiate safer sex. There is a pressing need for effective interventions that mitigate the risks of disclosure and provide HIV-positive adolescents with skills to engage in safe sex.

'HIV is like a tsotsi. ARVs are your guns': associations between HIV-disclosure and adherence to antiretroviral treatment among adolescents in South Africa.

OBJECTIVES: WHO guidelines recommend disclosure to HIV-positive children by school age in order to improve antiretroviral therapy (ART) adherence. However, quantitative evidence remains limited for adolescents. This study examines associations between adolescent knowledge of HIV-positive status and ART-adherence in South Africa. DESIGN: A cross-sectional study of the largest known community-traced sample of HIV-positive adolescents. Six hundred and eighty-four ART-initiated adolescents aged 10-19 years (52% female, 79% perinatally infected) were interviewed. METHODS: In a low-resource health district, all adolescents who had ever initiated ART in a stratified sample of 39 health facilities were identified and traced to 150 communities [n = 1102, 351 excluded, 27 deceased, 40 (5.5%) refusals]. Quantitative interviews used standardized questionnaires and clinic records. Quantitative analyses used multivariate logistic regressions, and qualitative analyses used grounded theory for 18 months of interviews, focus groups and participant observations with 64 adolescents, caregivers and healthcare workers. RESULTS: About 36% of adolescents reported past-week ART nonadherence, and 70% of adolescents knew their status. Adherence was associated with fewer opportunistic infection symptoms [odds ratio (OR) 0.55; 95% CI 0.40-0.76]. Adolescent knowledge of HIV-positive status was associated with higher adherence, independently of all cofactors (OR 2.18; 95% CI 1.47-3.24). Among perinatally infected adolescents who knew their status (n = 362/540), disclosure prior to age 12 was associated with higher adherence (OR 2.65; 95% CI 1.34-5.22). Qualitative findings suggested that disclosure was undertaken sensitively in clinical and family settings, but that adults lacked awareness about adolescent understandings of HIV status. CONCLUSION: Early and full disclosure is strongly associated with improved adherence amongst ART-initiated adolescents. Disclosure may be an essential tool in improving adolescent adherence and reducing mortality and onwards transmission.

Piloting antiretroviral treatment in South Africa: the role of partnerships in the Western Cape's provincial roll-out.

In 1999, the government of the Western Cape Province, South Africa, entered into a partnership with Médecins Sans Frontières (MSF) to provide HIV treatment through public health clinics in the peri-urban settlement of Khayelitsha. From 2000 onwards, this partnership ran South Africa's first antiretroviral treatment (ART) programme. Due to the province's limited experience (as of 1999) in implementing and monitoring an ART programme, and the National Department of Health's opposition to the public provision of ART, this partnership was instrumental in piloting and later scaling-up the Western Cape's ART programme. Numerous studies have documented this pilot ART programme from a health system or clinical perspective. This study instead used qualitative methods to examine the factors that facilitated the public provision of ART in the Western Cape. With reference to the role of partnerships in piloting new health interventions, the article explores the partnership that was established between the provincial government, civil society organisations, research institutes, and service providers to support the public provision of ART in Khayelitsha. This partnership has demonstrated that ART programmes can be implemented successfully within resource-constrained settings, achieving high levels of treatment adherence, low rates of loss to follow-up and excellent health outcomes. Lessons from the partnership's components and strategies are therefore of vital significance to realising the roll-out of ART programmes in various contexts across the developing world, demonstrating the crucial role of collaboration and integration in the establishment and maintenance of these programmes.