Peer and land-based approaches for fostering empowering and healthy relationships with Indigenous and northern young people in the Northwest Territories.

Indigenous and Northern women in Canada experience high rates of intimate partner violence (IPV), and this is particularly true in the Northwest Territories (NWT). Adolescents are also at increased risk of IPV, which has far-reaching, lifelong effects. Indigenous youth are particularly vulnerable to IPV due to ongoing effects of intergenerational trauma caused by colonialism, racism and residential school legacies. We explored attitudes towards IPV and the healthy relationship knowledge, skills, and experiences among participants of Fostering Open eXpression among Youth (FOXY) and Strength, Masculinities, and Sexual Health (SMASH) Peer Leader Retreats in the NWT. Multi-method approaches included quantitative surveys youth completed before and immediately following retreats. Quantitative analysis from retreats (2018-2021) included 240 participants aged 12-19 (mean age 14.5) who reported ever having an intimate partner. Most were from the FOXY program (64.2%), Indigenous (69.6%) and heterosexual (66.4%). Qualitative methods included Focus Group Discussions (FGD) (n = 69) conducted with peer leaders and apprentices (n = 311) and youth and adult staff (n = 14 FGDs, n = 165 participants). We thematically analysed FGDs to explore healthy relationship knowledge and skills, alongside paired t-tests to examine pre/post retreat changes in attitudes towards IPV. Qualitative findings suggest that leadership and embodied learning were effective in equipping youth with violence prevention and healthy relationship skills. While young women were committed to sharing knowledge and skills about healthy relationships in their communities, young men resonated with values of respect and appreciated support to identify and express emotions. Participants across programmes demonstrated their belief that healthy intimate relationships have communal, relational and intergenerational benefits. Quantitatively, we found a statistically significant reduction in attitudes accepting of IPV among young women, but no changes were noted among young men. Findings contribute to emergent evidence on strengths-based, culturally-responsive IPV prevention programming. Components of effective IPV prevention programming with young men merit further exploration.

Esengo ya Bosembo ("Joy of Equity"): Development of an Advocacy Video to Reduce Stigma and to Promote Sexual and Reproductive Health and Rights of Women Sex Professionals in Pointe-Noire, Congo Republic.

Sex workers experience elevated risks of sexual and gender-based violence (SGBV) from intimate partners, clients, and community members that harms health and human rights. While SGBV contributes to poorer sexual and reproductive health (SRH) outcomes among sex workers, including elevated human immunodeficiency virus (HIV) vulnerabilities, stigma targeting sex workers reduces SRH service access and uptake. The Congo Republic is an exemplar context to address stigma toward sex workers. Sex workers' HIV prevalence (8.1%) in Congo Republic is double the national prevalence, yet research indicates that nearly one-fifth (17.2%) of sex workers in Congo Republic avoid health care because of stigma and discrimination. This Resources, Frameworks, & Perspectives article describes the process of developing Esengo ya Bosembo ("Joy of Equity"), a culturally tailored advocacy video that aims to reduce health care and community stigma toward women sex professionals (e.g., sex workers) in Pointe-Noire, Congo Republic. This knowledge translation product stems from a participatory mapping intervention with sex professionals in Pointe-Noire that revealed the need for sensitization tools and activities to reduce sex work stigma among health care providers and community members. The video incorporates three overarching key messages: (1) sex professionals are human beings with equal rights to dignity, protection, and health services; (2) elevated risks of SGBV and stigma targeting sex workers reduce SRH service access and uptake; and (3) participatory mapping is a potential way to empower sex professionals to share their experiences and recommendations for change. This article details how health promotion practitioners and sex professionals may use the video to advocate for change.

Empowering and supporting frontline providers in the paediatric-adolescent HIV response: results from participatory priority-setting and group discussions in twenty-four sites in twelve high HIV-burden African countries.

Children and adolescents living with HIV in Africa experience poor outcomes across the HIV cascade of care. Paediatric and adolescent-friendly services are crucial to their well-being, and recent years have seen a call for urgent service improvements. While frontline health workers are responsible for these services, less attention has been given to their contextual realities, and what constitutes an enabling service delivery environment. We engaged participatory priority-setting and group discussions across twenty-four sites in twelve high HIV-burden African countries in November 2022 with 801 frontline paediatric-adolescent providers. Data were analysed using thematic analysis and priority mapping. We constructed a socio-ecological model for supportive and empowering service delivery environments for frontline paediatric-adolescent HIV services. Individual-level themes related to well-being, self-care and mental health. Interpersonal themes included supportive supervision/mentorship, teamwork and acknowledgement. At the organisational level, resources, physical infrastructure and confidential spaces were included. The community level included feeling appreciated and positive stakeholder relationships. The structural level included funding, discriminatory SRHR policies and guidelines. Results provide insight into priorities, challenges and needs of frontline providers in the paediatric-adolescent HIV response. Improving the well-being of HIV-affected children and adolescents requires greater investment and attention to creating more caring, supportive environments for their frontline providers.

The path towards an HIV-free generation: engaging adolescent boys and young men (ABYM) in sub-Saharan Africa from lessons learned and future directions.

This paper highlights the pressing need to address the HIV epidemic among adolescent boys and young men (ABYM) in sub-Saharan Africa. Despite progress in HIV prevention, ABYM still experience low diagnosis rates, treatment adherence, and linkage to care. The paper emphasizes ABYM's vulnerability due to societal norms, limited healthcare access, and economic pressures. It calls for gender-responsive interventions, including comprehensive sexual education, youth-friendly health services, community engagement, and targeted outreach. Comprehensive sexual education is pivotal in HIV prevention for ABYM, providing them with age-appropriate sexual health knowledge and safer sexual practices to reduce HIV incidence. Harmful masculine norms must be countered to promote respectful relationships, benefiting boys, men, and their partners. Inadequate access to youth-friendly health services hampers HIV prevention. Establishing spaces with confidential, non-judgmental care offering testing, counselling, circumcision, and provision of pre-exposure prophylaxis (PrEP) is essential, especially considering ABYM's unique clinic experiences. Engaging communities, leaders, educators, and peers combats stigma and discrimination. ABYM's input in intervention design, targeted outreach, and innovative technology enhances effectiveness of HIV prevention programmes. Economic factors should also be addressed. Comprehensive multi-sectoral interventions, including conditional cash transfers, effective for AGYW, could benefit ABYM. Addressing structural factors alongside behaviour change and social support is key.

'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.

Factors Associated with Preferences for Long-Acting Injectable Antiretroviral Therapy Among Adolescents and Young People Living with HIV in South Africa.

Long-acting injectable anti-retroviral therapy (LAART) may overcome barriers to long-term adherence and improve the survival of adolescents and young people living with HIV (AYLHIV). Research on the acceptability of LAART for this age-group is limited. We asked 953 AYLHIV about their preferred (theoretical) ART mode of delivery (pill, injectable, or other) in 2017-2018, before LAART was available or known to AYLHIV in South Africa. One in eight (12%) AYLHIV preferred LAART over single or multiple pill regimens. In multivariate analyses, six factors were associated with LAART preference: medication stock-outs (aOR = 2.56, 95% CI 1.40-4.68, p = 0.002), experiencing side-effects (aOR = 1.84, 95% CI 1.15-2.97, p = 0.012), pill-burden (aOR = 1.88, 95% CI 1.20-2.94, p = 0.006), past-year treatment changes (aOR = 1.63, 95% CI 1.06-2.51, p = 0.025), any HIV stigma (aOR = 2.22, 95% CI 1.39-3.53, p ≤ 0.001) and recent ART initiation (aOR = 2.02, 95% CI 1.09-3.74, p = 0.025). In marginal effects modelling, 66% of adolescents who experienced all factors were likely to prefer LAART, highlighting the potential high acceptability of LAART among adolescents and young people living with HIV struggling to adhere and have good HIV treatment outcomes. Adolescent boys who reported high ART pill burden were more likely to prefer LAART than their female peers in moderation analyses, suggesting that LAART may be particularly important to improve treatment outcomes among male AYLHIV as they become older. Adding LAART to existing treatment options for AYLHIV, particularly higher risk groups, would support AYLHIV to attain and sustain viral suppression-the third 95, and reduce their risk of AIDS-related mortality.

RESUMEN: La terapia antirretroviral inyectable de acción prolongada (TAR LA) puede superar las barreras a la adherencia y mejorar la supervivencia de los adolescentes y jóvenes que viven con el VIH (AJVVIH). La investigación sobre la aceptabilidad del TAR LA para este grupo de edad es limitada. Preguntamos a 953 AJVVIH sobre su modo preferido (teórico) de administración de ART (píldora, inyectable u otro) en 2017­2018, antes de que TAR LA estuviera disponible o fuera conocido por los AJVVIH en Sudáfrica. Uno de cada ocho (12%) AJVVIH prefirió TAR LA sobre los regímenes de píldoras simples o múltiples. En los análisis multivariantes, seis factores se asociaron con la preferencia de TAR LA: agotamiento de la medicación (odd ratio ajustada [ORa] = 2,56, IC95% 1,40­4,68 p = 0,002), experimentar efectos secundarios (ORa = 1,84, IC95% 1,15­2,97 p = 0,012), carga de píldoras (ORa = 1. 88, IC95% 1,20­2,94 p = 0,006), cambios de tratamiento en el último año (ORa = 1,63, IC95% 1,06­2,51 p = 0,025), cualquier estigma del VIH (ORa = 2,22, IC95% 1,39­3,53 p ≤ 0,001) y el inicio reciente del TAR (ORa = 2,02, IC95% 1,09­3,74 p = 0,025). En la modelización de efectos marginales, el 66% de los adolescentes que experimentaron todos los factores eran propensos a preferir la TAR LA, lo que pone de relieve la alta aceptabilidad potencial de la TAR LA entre los adolescentes y los jóvenes que viven con el VIH que luchan por adherirse y tener buenos resultados en el tratamiento del VIH. Los adolescentes varones que informaron de una alta carga de píldoras para el tratamiento antirretroviral eran más propensos a preferir la TAR LA que sus pares mujeres en los análisis de moderación, lo que sugiere que la TAR LA puede ser particularmente importante para mejorar los resultados del tratamiento entre los hombres que viven con el VIH a medida que crecen. La adición de la TAR LA a las opciones de tratamiento existentes para las personas que viven con el VIH, en particular los grupos de mayor riesgo, ayudaría a las personas que viven con el VIH a alcanzar y mantener la supresión vírica -el tercer 95- y a reducir el riesgo de mortalidad relacionada con el sida.

Exploring uptake of HIV/STI knowledge and safer sex-efficacy in an arts-based sexual health workshop among Northern and Indigenous adolescents in the Northwest Territories, Canada.

ABSTRACTLimited research has evaluated sexual health promotion projects with adolescents living in Arctic regions. The study objective was to examine changes in STI knowledge and safer sex efficacy among youth in the Northwest Territories (NWT), Canada who participated in arts-based sexual health workshops. We used a pre/post-test design with a convenience sample of students aged 13-18 years recruited from 17 NWT communities. We conducted summary statistics and comparisons between pre and post-test scores using paired t-tests. Among participants (n = 610), we found statistically significant increases in STI knowledge overall (mean difference = 3.9; p < 0.001) and across gender and age stratifications. There were statistically significant increases in safer sex efficacy overall (mean difference = 0.9, p < 0.001), across genders, and among participants: aged <15 years, in rural communities, reporting food insecurity, reporting dating violence, and Indigenous youth. No statistically significant differences in safer sex efficacy were observed among participants who were aged ≥15, sexually active, reporting consistent condom use, and using drugs/alcohol. Findings signal the promise of youth-targeted, arts-based sexual health workshops for improving STI knowledge and safer sex efficacy among adolescents in the NWT. Further research can explore how safer sex efficacy may be shaped by age, substance use, and sexual experience to inform tailored interventions.

Mobile Health-Supported Virtual Reality and Group Problem Management Plus: Protocol for a Cluster Randomized Trial Among Urban Refugee and Displaced Youth in Kampala, Uganda (Tushirikiane4MH, Supporting Each Other for Mental Health).

BACKGROUND: Although mental health challenges disproportionately affect people in humanitarian contexts, most refugee youth do not receive the mental health support needed. Uganda is the largest refugee-hosting nation in Africa, hosting over 1.58 million refugees in 2022, with more than 111,000 living in the city of Kampala. There is limited information about effective and feasible interventions to improve mental health outcomes and mental health literacy, and to reduce mental health stigma among urban refugee adolescents and youth in low- and middle-income countries (LMICs). Virtual reality (VR) is a promising approach to reduce stigma and improve mental health and coping, yet such interventions have not yet been tested in LMICs where most forcibly displaced people reside. Group Problem Management Plus (GPM+) is a scalable brief psychological transdiagnostic intervention for people experiencing a range of adversities, but has not been tested with adolescents and youth to date. Further, mobile health (mHealth) strategies have demonstrated promise in promoting mental health literacy. OBJECTIVE: The aim of this study is to evaluate the feasibility and effectiveness of two youth-tailored mental health interventions (VR alone and VR combined with GMP+) in comparison with the standard of care in improving mental health outcomes among refugee and displaced youth aged 16-24 years in Kampala, Uganda. METHODS: A three-arm cluster randomized controlled trial will be implemented across five informal settlements grouped into three sites, based on proximity, and randomized in a 1:1:1 design. Approximately 330 adolescents (110 per cluster) are enrolled and will be followed for approximately 16 weeks. Data will be collected at three time points: baseline enrollment, 8 weeks following enrollment, and 16 weeks after enrollment. Primary (depression) and secondary outcomes (mental health literacy, attitudes toward mental help-seeking, adaptive coping, mental health stigma, mental well-being, level of functioning) will be evaluated. RESULTS: The study will be conducted in accordance with CONSORT (Consolidated Standards of Reporting Trials) guidelines. The study has received ethical approval from the University of Toronto (#40965; May 12, 2021), Mildmay Uganda Research Ethics Committee (MUREC-2021-41; June 24, 2021), and Uganda National Council for Science & Technology (SS1021ES; January 1, 2022). A qualitative formative phase was conducted using focus groups and in-depth, semistructured key informant interviews to understand contextual factors influencing mental well-being among urban refugee and displaced youth. Qualitative findings will inform the VR intervention, SMS text check-in messages, and the adaptation of GPM+. Intervention development was conducted in collaboration with refugee youth peer navigators. The trial launched in June 2022 and the final follow-up survey will be conducted in November 2022. CONCLUSIONS: This study will contribute to the knowledge of youth-tailored mental health intervention strategies for urban refugee and displaced youth living in informal settlements in LMIC contexts. Findings will be shared in peer-reviewed publications, conference presentations, and with community dissemination. TRIAL REGISTRATION: ClinicalTrials.gov NCT05187689; https://clinicaltrials.gov/ct2/show/NCT05187689. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/42342.

Todurujo na Kadurok (empowering youth): study protocol of an HIV self-testing and edutainment comic cluster randomised trial among refugee youth in a humanitarian setting in Uganda.

INTRODUCTION: Refugees experience HIV vulnerabilities due to the confluence of displacement, violence and poverty. HIV self-testing, understudied with refugees, is a promising method to increase testing uptake, yet challenges remain with linkages to confirmatory testing following a positive HIV self-test. This study aims to evaluate the effectiveness of HIV self-testing kits and 'edutainment' comics in increasing HIV testing and HIV status knowledge among refugee youth aged 16-24 years in Bidi Bidi Refugee Settlement, Uganda. METHODS AND ANALYSIS: This study will be conducted in Bidi Bidi. We conducted a qualitative formative phase with focus groups (n=40) to generate knowledge of barriers and facilitators of HIV prevention, testing and care among refugee youth (aged 16-24) in Bidi Bidi. These findings were used to create comic scenarios aligning with edutainment approaches to health promotion and inform a four-arm cluster randomised controlled trial in Bidi Bidi using a 2×2 factorial design: (1) HIV self-testing alongside edutainment comics, (2) HIV self-testing alone, (3) edutainment comic alone and (4) standard of care. The target sample size will be 120 youth (30 per arm), who will be enrolled in the trial and followed for 3 months. Data will be collected at baseline and 3 months after enrolment. The primary outcomes (HIV testing frequency, HIV status knowledge) and secondary outcomes (linkage to confirmatory HIV testing, HIV care linkage, HIV self-test kit use, HIV-related stigma, HIV knowledge, safer sex efficacy, condom use, adolescent sexual and reproductive health (SRH) stigma, sexual relationship power, access to SRH services) will be evaluated using descriptive statistics and regression analyses. ETHICS AND DISSEMINATION: This study was approved by the University of Toronto Research Ethics Board, Mildmay Uganda Research Ethics Committee and the Uganda National Council for Science and Technology. Results will be shared in peer-reviewed publications and community knowledge sharing. TRIAL REGISTRATION NUMBER: NCT05213689.

"Every day I grew stronger and stronger being there".: empowerment through land-and art-based Peer Leader retreats with Indigenous and Northern young people.

Indigenous adolescents in Canada are among those shouldering the impacts of colonialism and racism. Peer approaches and art-and-land-based programming have demonstrated promise to support empowerment and well-being, yet little is known about their efficacy with Northern and Indigenous adolescents in Canada or of how this group conceptualises empowerment. Fostering Open eXpression among Youth (FOXY) and Strength, Masculinities, and Sexual Health (SMASH) conduct land-and-arts-based Peer Leader Retreats with adolescents from the Northwest Territories, Nunavut and the Yukon Territories. Retreats (2017-2019) included 286 participants (n=196 women [trans-inclusive], n=84 men [trans-inclusive], n=5 non-binary), aged 12-19, the majority of whom (n=235) were Indigenous. Participants completed surveys immediately before and following retreats and 6 months after. Focus group discussions (FGDs) (n=24) were conducted with participants (peer leaders and apprentices) (n=232) following the retreat, and youth staff members (peer facilitators) (aged 14-21, n=7 FGDs). Applying thematic analysis, we explored retreat experiences (FGDs), and Wilcoxon signed-rank tests to examine pre/post retreat changes in leadership, empowerment, and self-confidence (surveys). Quantitatively, there were statistically significant increases in leadership and empowerment in post-retreat scores compared to pre-retreat. Qualitatively, findings demonstrate how Peer Leader Retreats premised on land-and-art-based approaches can support empowerment, confidence, leadership, and social-connectedness.

Health and development-related priorities and challenges of adolescents and young people: findings from South Africa and Kenya prior to and during COVID-19 pandemic.

Growing evidence documents the effects of the COVID-19 pandemic on adolescents in East and Southern Africa. We present and explore the longitudinal health and development-related priorities and challenges of adolescent advisors in South Africa and Kenya, including prior to, and during the COVID-19 pandemic. Findings were co-generated with adolescent advisors in the Eastern Cape Province of South Africa (n=15, ages 18-22 in 2019) and Kisumu, Kenya (n=16, ages 10-14 in 2020). Prior to COVID-19, adolescent advisors engaged in a participatory exercise to share and explore their health and development-related priorities and challenges in 2019 and 2020. During the COVID-19 pandemic in 2020 and 2021, members of the same groups shared their experiences, challenges and coping strategies in semi-structured telephone interviews (Eastern Cape: n=14, aged 19-23; Kisumu n=12, aged 11-16) and group-based remote participatory social media activities (n=27 activities with n=12 advisors, Eastern Cape). We thematically analysed COVID-19 activities, considering them alongside pre-pandemic priorities and challenges. Many of the health and development-related priorities and challenges identified prior to COVID-19 remained issues of concern during COVID-19. These included education; victimization and violence; teenage pregnancy; substance use; household tension, conflict and inadequate family and caregiver support; health and medication concerns (South Africa) and water and food shortages (Kenya). Other issues such as financial insecurity, mental health, and crime were strong themes that emerged during COVID-19, which were not directly reported as priorities prior. Although almost all of adolescent advisors' most pressing pandemic-related challenges were also priorities for them prior to COVID-19, these issues were often discussed as new, and caused by the onset of COVID-19. While demonstrating how COVID-19 has exacerbated pre-existing vulnerabilities, we also suggest that the pandemic may have brought about a new way for adolescents to make sense of, and articulate pre-existing challenges.

Sexual and reproductive health outcomes for forcibly displaced persons living in urban environments in low- and middle-income countries: a scoping review protocol.

OBJECTIVE: The objective of this review is to characterize the state of literature regarding forcibly displaced persons' sexual and reproductive health in urban areas in low- and middle-income countries. Specific objectives include describing the sexual and reproductive health outcomes among forcibly displaced persons relocating in urban environments. INTRODUCTION: As a result of persecution, conflict, violence, human rights violations, and disruptive events, 89.3 million people worldwide were forcibly displaced as of the end of 2021. Forcibly displaced people face a wide range of sexual and reproductive health challenges in their countries of origin, en route to final destinations, and on arrival in host communities. There is a growing urbanization of forcibly displaced persons, yet there is limited attention on sexual and reproductive health outcomes of this population. INCLUSION CRITERIA: This review will consider studies that include sexual and/or reproductive health outcomes and needs of forcibly displaced persons within urban environments in low- and middle-income countries. Published and unpublished evidence, including quantitative, qualitative, mixed methods research, and gray literature, will be eligible for inclusion. METHODS: MEDLINE, Embase, PsycINFO, CINAHL, IBSS, ASSIA, SSCI, and Global Medicus Index will be searched for English-language articles. Titles and abstracts will be screened against the inclusion criteria, followed by full-text review of potentially eligible studies, which will be independently assessed by 2 reviewers. Eligible articles will be extracted and charted. Results from extracted data will be tabulated and accompanied by a narrative summary to summarize and contextualize the extracted data to describe how the results relate to the review's objectives and question.

Consolidate, conceptualize, contextualise: key learnings for future intervention acceptability research with young people in Africa.

Acceptability has become a key consideration in the development, evaluation and implementation of health and social interventions. This commentary paper advances key learnings and recommendations for future intervention acceptability research with young people in Africa, aimed at supporting the achievement of developmental goals. It relates findings of the adolescent acceptability work conducted within the Accelerate Hub, since mid 2020, to broader inter-disciplinary literatures and current regional health and social priorities. We argue that, in order to strengthen the quality and applied value of future acceptability work with young people, we need to do three things better. First, we need to consolidate prior findings on acceptability, within and across intervention types, to inform responses to current public health and social challenges and further the conceptual work in this area. Second, we need to better conceptualise acceptability research with young people, by developing stronger conceptual frameworks that define acceptability and its constructs, and predict its relationship with intervention engagement. Third, we need to better contextualise findings by considering acceptability data within a broader social and political context, which in turn can be supported by better conceptualisation. In this paper we describe contributions of our work to each of these three inter-connected objectives, and suggest ways in which they may be taken forward by researchers and practitioners. These include aggregating evidence from past interventions to highlight potential barriers and enablers to current responses in priority areas; involving key actors earlier and more meaningfully in acceptability research; further developing and testing behavioural models for youth acceptability; and working collaboratively across sectors towards programmatic guidance for better contextualisation of acceptability research. Progress in this field will require an inter-disciplinary approach that draws from various literatures such as socio-ecological theory, political economy analysis, health behaviour models and literature on participatory research approaches.

HIV and SRH healthcare delivery experiences of South African healthcare workers and adolescents and young people during COVID-19.

While substantial research has emerged from the frontlines of the COVID-19 pandemic, as well as from studies with adolescent populations, there has been a dearth of research focused in South Africa on the context-specific experiences of healthcare workers (HCWs) and the adolescents and young people (AYP) to whom they provide services. This article documents the experiences of provision and receipt of HIV and sexual and reproductive health (SRH) services during the COVID-19 pandemic from the perspective of South African HCWs (n = 13) and AYP (n = 41, ages 17-29). Findings highlight several barriers to accessing comprehensive HIV and SRH services during the pandemic including lockdown-related mobility restrictions (reported by HCWs), prioritisation of COVID-19 above other healthcare needs, longer health facility waiting times, poor treatment by HCWs (reported by AYP), discomfort and perceived stigma from having to queue outside health facilities, and fear of contracting COVID-19 (reported by both groups). While HCWs reported that HIV and SRH services continued to be available during the pandemic, AYP described seeking these services - such as long-acting reversible contraception, check-ups for their babies and medical refills - and being told that because they were not considered emergency cases, they should return on a different date. By capturing diverse experiences and perspectives from both groups, our findings reiterate the growing call for health system investments to strengthen the delivery of adolescent services, including investing in appropriate channels of communication between young people and their healthcare providers (for example, through adolescent peer supporters or community healthcare workers) and differentiated models of service delivery (for example, multi-month ART refills and community pick-ups). Closing the gap between the experiences and needs of adolescents and the healthcare workers who serve them may support young people and HCWs in buffering against changes brought about by the COVID-19 pandemic.

Art-based reflections from 12 years of adolescent health and development-related research in South Africa.

This paper presents empirical and methodological findings from an art-based, participatory process with a group (n = 16) of adolescent and young advisors in the Western Cape Province of South Africa. In a weekend workshop, participants reflected on their participation in 12 years of health and development-related research through theatre, song, visual methodologies and semi-structured interviews. Empirical findings suggest that participants interpreted the group research encounter as a site of empowerment, social support and as a socio-political endeavour. Through song, theatre and a mural illustration, they demonstrated that they value 'unity' in research, with the aim of ameliorating the conditions of adolescents and young people in other parts of South Africa and the continent. Methodological findings document how participants deployed art-based approaches from South Africa's powerful history of activism, including the struggle against apartheid, the fight for anti-retroviral therapy and more recent social movements towards decolonization.

Eliciting critical hope in community-based HIV research with transgender women in Toronto, Canada: methodological insights.

Critical hope centres optimism and possibilities for change in the midst of struggles for social justice. It was a central tenet of early participatory pedagogy and HIV research. However, critical hope has been overlooked in contemporary HIV research that largely focuses on risk and biomedical interventions in ways that obscure collective agency and community strengths. We conducted a community-based study with transgender (trans) women of colour in Toronto, Canada to adapt an evidence-based HIV prevention intervention. Participants resisted a focus on HIV, instead calling researchers to centre journeys to self-love in contexts of social exclusion. In response, we piloted three arts-based, participatory methods generated with community collaborators: (i) affirmation cards sharing supportive messages with other trans women, (ii) hand-held mirrors for reflecting and sharing messages of self-acceptance and (iii) anatomical heart images to visualize coping strategies. Participants generated solidarity and community through shared stories of self-acceptance within contexts of pain, exclusion and loss. Narratives revealed locating agency and self-acceptance through community connectedness. Critical hope was a by-product of this participatory process, whereby participants shared personal and collective optimism. Participatory and arts-based methods that centre self-acceptance and solidarity can nurture resistance to pathologizing discourses in HIV research. Centring critical hope and participant-generated methodologies is a promising approach to transformative health promotion and intervention research. These methodological insights can be engaged in future participatory work with other marginalized groups facing dominant biomedical risk discourses. Critical hope holds potential as a participatory health promotion strategy for envisioning possibilities for sustainable change.

Optimism and possibility for change in the midst of social justice struggles are central to critical hope and change-oriented research. The concept of critical hope guided community-based activism and research, including early in the HIV pandemic. Yet current HIV research largely focuses on individual risks and biomedical solutions, which may overlook critical hope and the important role of community connection in promoting wellbeing. Our community-based study with transgender (trans) women of colour in Toronto, Canada aimed to adapt an HIV prevention intervention. Participants challenged the HIV focus and invited the research team to instead focus on pathways to self-acceptance in larger contexts of social exclusion. In response, we developed three arts-based activities to pilot-test at three workshops: affirmation cards to write supportive messages to other trans women, hand-held mirrors to write messages of self-acceptance, and anatomical heart images to visualize coping strategies. Through these activities, participants shared stories of self-acceptance that occurred over time and through community connectedness, often in the face of exclusion and discrimination. Perspectives on personal and collective optimism, reflecting critical hope, were shared in the workshops. Participant-generated methodologies that offer opportunities to discuss critical hope can be promising approach to transformative health promotion and intervention research.

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].

'Now my life is stuck!': Experiences of adolescents and young people during COVID-19 lockdown in South Africa.

Consequences of COVID-19 pandemic responses have included exacerbated poverty, food insecurity and state and domestic violence. Such effects may be particularly pronounced amongst adolescents and young people living in contexts of precarity and constraint, including in South Africa. However, there are evidence gaps on the lived experiences of this group. We conducted telephonic semi-structured interviews with adolescents and young people in two South African provinces (n = 12, ages 18-25) in April 2020 to explore and document their experiences, challenges and coping strategies during strict COVID-19 lockdown. Participants described indirect effects of COVID-19 including food insecurity, lost livelihoods and changes to social service provisions such as municipal electricity services and sanitation. Psychosocial stressors related to uncertainty over education and work futures were also discussed. The aforementioned challenges were particularly present with young parents, 'working poor' participants, and those with pre-existing mental health challenges. Participants demonstrated excellent COVID-19 transmission and prevention knowledge, showing that they had received and correctly interpreted public health messaging. Despite this, many simultaneously held non-scientific COVID-19 beliefs. Engaging a socio ecological framework, findings demonstrate how the indirect effects of COVID-19 may exacerbate underlying multi-layered vulnerabilities for adolescents and young people living in contexts of precarity and constraint.