Assessment of Consent Comprehension Among Kenyan Adolescents, Young Adults, and Parents: Comparison of Enhanced and Standard Consenting Procedures.

PURPOSE: Youth aged 15-19 years and parents of minors aged 15-17 years in sub-Saharan Africa are under-represented in empirical consent research. Thus, knowledge is limited concerning the adequacy of consent procedures and need for strategies to improve consent comprehension among these groups. We assessed comprehension following standard consent procedures and evaluated an enhanced procedure among Kenyan youth and parents. METHODS: Participants were adolescents aged 15-17 years (n = 273), their parents (n = 196), and young adults aged 18-19 years (n = 196). We used a quasi-experimental cohort design to implement standard and enhanced (single condition: extended discussion, test/feedback) consent procedures. Participants completed a 21-item informed consent comprehension assessment instrument. RESULTS: After standard consent procedures, mean comprehension scores were 11.36, 13.64, and 13.43 (score range: 0-21) among adolescents, young adults, and parents, respectively. About 6.2% of adolescents, 19.6% of young adults, and 21.4% of parents answered ≥ 80% of the questions correctly. After the enhanced procedures, comprehension scores (15.87 adolescents, 17.81 young adults, and 16.77 parents) and proportions answering ≥ 80% of the questions correctly (44.9% adolescents, 76.8% young adults, and 64.3% parents) increased significantly. Regression analysis indicated statistically significant differences (p < .001) in comprehension scores between the enhanced and standard groups (ß = 3.87 adolescents, ß = 4.03 young adults, and ß = 3.60 parents) after controlling for sociodemographic factors. DISCUSSION: Enhancing consent procedures with extended discussions, quizzes, and additional explanation where understanding is inadequate is a promising approach for improving comprehension. However, poorer comprehension among adolescents compared to young adults and parents underscores the need for research to identify additional approaches to improve understanding.

Does Venue of HIV Testing and Results Disclosure in the Context of a Research Study Affect Adolescent Health and Behavior? Results from a Study in Western Kenya.

Ethical concerns about risks to minor adolescents participating in HIV prevention research is a barrier to their inclusion. One concern is whether HIV testing and results disclosure venue affects the health and behavior of adolescent participants. We assessed for differential effects on quality of life (QOL), depressive symptoms, and sexual behavior due to (1) testing venue (home or health facility) and (2) test result (HIV-positive, HIV-negative, indeterminate). We collected data at three timepoints (baseline, 2-month follow-up, 12-month follow-up) from 113 Kenyan adolescents aged 15-19 (51% female). We analyzed the data using linear mixed effects models for the QOL and depressive symptoms outcomes and a logistic model for the sexual behavior outcome. Results showed a small mental health benefit for adolescents tested for HIV at a health facility compared with home. There was little evidence that testing venue influenced sexual behavior or that test results moderated the effects of HIV testing across all outcomes. The decision to conduct HIV testing at home or a health facility may not be very consequential for adolescents' health and behavior. Findings underscore the need to critically examine assumptions about adolescent vulnerability to better promote responsible conduct of HIV prevention research with youth in sub-Saharan Africa.

Suicide behaviour among adolescents in a high HIV prevalence region of western Kenya: A mixed-methods study.

The study purpose was to determine the prevalence and determinants of suicidal thoughts and behaviours in a rural community sample of 15-19-year-old Kenyan adolescents in a region with high HIV burden. Data were from an observational study examining ethical issues in adolescent HIV research (N=4084). Participants reporting suicidal ideation were assessed for suicide risk. Directed content analyses were conducted using assessment reports. Logistic regression was used to identify factors associated with suicide outcomes. Prevalence of suicidal ideation was 16%. Of these, 38% were low risk and 12% were moderate/high-risk. Females and sexually active adolescents had higher odds of suicidal ideation and being categorised as moderate/high-risk. Adolescents with higher depression scores had higher odds of reporting ideation. Pregnancy was protective for females while impregnating a partner was a risk factor for males. Abuse from a family member, financial stress and health concerns were the most frequently mentioned precipitants of ideation. However, only abuse increased odds of suicide behaviour. Effective programmes to identify and support sexually active, pregnant, and distressed adolescents at risk for suicide are needed. Approaches involving families, schools, health facilities, and community gatekeepers may have the most promise in sub-Saharan African rural areas with limited mental health services.

Pathways to Depression and Poor Quality of Life Among Adolescents in Western Kenya: Role of Anticipated HIV Stigma, HIV Risk Perception, and Sexual Behaviors.

Depression is a major cause of disease burden and is linked to poor quality of life (QOL) among adolescents. We examined the roles of sexual behaviors, HIV risk perception, and anticipated HIV stigma on depressive symptomatology and QOL among 4096 adolescents in a rural region of western Kenya with a high burden of HIV. Participants were aged 15-19 years, had not been tested for HIV in the previous 6 months, and had never been diagnosed with HIV. Anticipated stigma and risk perception were directly associated with depressive symptomatology and QOL. There was evidence of small indirect effects-through stigma-of risk perception on depressive symptomatology and QOL. Gender moderated relationships between sexual behavior and risk perception, depressive symptomatology, and QOL. Results suggest that developing effective gender-based interventions to address stigma, sexual behavior, and risk perception may be important for improving adolescent well-being in high HIV prevalence contexts.

RESUMEN: La depresión es una de las principales causas de carga de morbilidad y se asocia con una pobre calidad de vida (CdV) de los adolescentes. Nosotros estudiamos el papel de los comportamientos sexuales, la percepción de riesgo del VIH, y el estigma anticipado del VIH en relación con la sintomatología depresiva y la CdV de 4 096 adolescentes provenientes de una región rural del oeste de Kenia con alta carga de VIH. Los participantes, adolescentes de entre 15 y 19 años, no se habían hecho la prueba de detección del VIH en los últimos 6 meses y, además, nunca habían sido diagnosticados con VIH. El estigma anticipado y la percepción de riesgo estaban asociados directamente con la sintomatología depresiva y la CdV. Hubo evidencia de pocos efectos indirectos de percepción de riesgo­generados por el estigma­en la sintomatología depresiva y la CdV. El género moderó las relaciones entre el comportamiento sexual y la percepción de riesgo, la sintomatología depresiva y la CdV. Los resultados sugieren que desarrollar intervenciones con enfoque de género para abordar el tema del estigma, los comportamientos sexuales y la percepción de riesgo, puede ser importante para mejorar el bienestar de los adolescentes que viven en un contexto con alta prevalencia de VIH.

Consent Challenges and Psychosocial Distress in the Scale-up of Voluntary Medical Male Circumcision Among Adolescents in Western Kenya.

In priority sub-Saharan African countries, on the ground observations suggest that the success of voluntary medical male circumcision (VMMC) programs should not be based solely on numbers of males circumcised. We identify gaps in the consent process and poor psychosocial outcomes among a key target group: male adolescents. We assessed compliance with consent and assent requirements for VMMC in western Kenya among males aged 15-19 (N = 1939). We also examined differences in quality of life, depression, and anticipated HIV stigma between uncircumcised and circumcised adolescents. A substantial proportion reported receiving VMMC services as minors without parent/guardian consent. In addition, uncircumcised males were significantly more likely than their circumcised peers to have poor quality of life and symptoms of depression. Careful monitoring of male adolescents' well-being is needed in large-scale VMMC programs. There is also urgent need for research to identify effective strategies to address gaps in the delivery of VMMC services.

"If the mother does not know, there is no way she can tell the adolescent to go for drugs": Challenges in promoting health and preventing transmission among pregnant and parenting Kenyan adolescents living with HIV.

Adolescents living with HIV (ALHIV) who are pregnant, or parenting, are an important but understudied group. This study explores the challenges in promoting the health of these adolescents and preventing onward transmission. We used existing semi-structured interview data from a 2014 study conducted among Kenyan ALHIV (ages 15-19), their family members, and local health staff to examine adolescent HIV-testing, disclosure, and treatment engagement, focusing on participants who were pregnant, had given birth, or had fathered a child. A total of 28 participant interviews were analyzed, including those conducted with nine ALHIV, four family members, and 15 HIV providers. Four adolescent participants were not in care at the time of their interview. Our analysis also included a transcript from a stakeholder meeting involving HIV providers and associated administrators, held to disseminate and garner feedback on, preliminary findings from the original study. Based on our analysis, adolescents frequently reported being alone during testing, experiencing fear and denial on receiving their results, and delaying disclosure to family and linkage to treatment. They also mentioned a lack of contraceptive counseling, with some reporting multiple pregnancies. Providers voiced misgivings and uncertainty about disclosing HIV diagnoses to minor adolescents without a family member present and reported severe shortages of personnel and resources to adequately serve ALHIV in rural clinics. These findings highlight gaps in services that limit adolescent engagement in HIV treatment prior to sexual debut and conceiving a child, and in PMTCT during and after pregnancy. Greater research attention is needed to address ALHIV reproductive health needs, improve linkage to HIV treatment, and prevent onward sexual transmission. Empirical ethics studies of current adolescent disclosure policies are also warranted to examine cultural and developmental appropriateness, and effectiveness in fostering support and engagement in HIV services.

"I think the parent should be there because no one was born alone": Kenyan adolescents' perspectives on parental involvement in HIV research.

Despite a pressing need for adolescent HIV research in sub-Saharan Africa, ethical guidance for conducting research among minor adolescents is lacking. One ethical issue is the degree to which parents should be involved in the research process. The existing discourse is predominantly speculative and focuses on negative consequences of parental involvement. We use empirical data to describe the perspectives of Kenyan adolescents on parental involvement in consent and disclosure of HIV test results within a research study context. We conducted two rounds of focus group discussions with 40 adolescents in western Kenya to ask about minor adolescent participation in HIV research. We analysed data using codes and matrices. Kenyan adolescents were largely in favour of parental involvement during the research process. Half felt adolescent minors should solicit parental consent to participate, and nearly all said parents should learn the HIV test results of adolescent minors in order to provide necessary support. From their perspective, involvement of parents in research extends beyond obtaining their consent to providing essential support for youth, regardless of HIV status, both during and beyond the research study. Ethical guidelines that prioritise adolescent autonomy in research must consider reasons to involve parents considered important by adolescents themselves, particularly in low-resource settings.

The Significance of Benefit Perceptions for the Ethics of HIV Research Involving Adolescents in Kenya.

Assessment of benefits is traditionally regarded as crucial to the ethical evaluation of research involving human participants. We conducted focus group discussions (FGDs) with health and other professionals engaged with adolescents, caregivers/parents, and adolescents in Siaya County, Kenya, to solicit opinions about appropriate ways of conducting HIV research with adolescents. Our data revealed that many focus group participants have a profoundly positive conception of participation in health research, including studies conferring seemingly few benefits. In this article, we identify and analyze five different but interrelated types of benefits as perceived by Kenyan adolescent and adult stakeholders in HIV research, and discuss their ethical significance. Our findings suggest that future empirical and conceptual research should concentrate on factors that may trigger researcher obligations to improve benefit perceptions among research participants.

A School Support Intervention and Educational Outcomes Among Orphaned Adolescents: Results of a Cluster Randomized Controlled Trial in Kenya.

Globally, significant progress has been made in primary school enrollment. However, there are millions of adolescents-including orphans in sub-Saharan Africa-who still experience barriers to remaining in school. We conducted a 4-year cluster randomized controlled trial (cRCT) (N = 835) in a high HIV prevalence area in western Kenya to test whether providing orphaned adolescents with a school support intervention improves their educational outcomes. The school support intervention consisted of directly paying tuition, exam fees, and uniform costs to primary and secondary schools for those students who remained enrolled. In addition, research staff monitored intervention participants' school attendance and helped to address barriers to staying in school. This school support intervention had significant positive impacts on educational outcomes for orphaned adolescents. Over the course of the study, school absence remained stable for intervention group participants but increased in frequency for control group participants. Intervention group participants were less likely to drop out of school compared to the control group. Furthermore, the intervention participants were more likely to make age-appropriate progression in grade, matriculate into secondary school, and achieve higher levels of education by the end of the study. The intervention also increased students' expectations of graduating from college in the future. However, we found no significant intervention impact on primary and secondary school test scores. Results from this cRCT suggest that directly covering school-related expenses for male and female orphaned adolescents in western Kenya can improve their educational outcomes.

Influence of school support on early marriage experiences and health services utilization among young orphaned women in Zimbabwe.

School support programs reduce school dropout, early marriage, and early pregnancy for a majority of young orphaned women. We used a mixed-methods approach to examine why these programs are less effective for a significant minority by exploring their influence on marriage and health services utilization. Participants were from a randomized controlled trial testing school support as HIV prevention. Half as many intervention as control participants had been married; married intervention participants had 1 more year of education compared with married control participants. Receiving school support did not appear to improve health-related factors. Pregnancy was among the most common reasons for marriage across both groups. The greatest benefit of school support appears to be in delaying marriage and pregnancy while increasing educational attainment.

'I thought if I marry the prophet I would not die': The significance of religious affiliation on marriage, HIV testing, and reproductive health practices among young married women in Zimbabwe.

This study examines the association between religious affiliation and reasons for marriage, perceived church attitudes, and reproductive health-seeking behaviors, including HIV testing, among young women in eastern rural Zimbabwe. The sample comprised women (N = 35) who had married by 2012 while participating in a larger randomized controlled trial (RCT) to test the effects of school support on HIV-related risk. The RCT sample was identified in 2007 as all female sixth graders in 25 rural eastern Zimbabwe primary schools whose parents, one or both, had died (N = 328). In our previous RCT analyses, we found that participants who affiliated with an Apostolic church were more than four times more likely to marry than those from non-Apostolic churches and that control group participants were twice as likely to marry as those in the intervention group. Other studies had found that marriage greatly increased the odds of HIV infection among adolescent women. Given the link between Apostolic affiliation and marriage, we conducted semi-structured interviews to explore type of marriage, reasons for marrying, church affiliation and attitudes, family planning, HIV testing, schooling, and family life. We were interested in differences, as perceived by our sample of young married women congregants, among Apostolic sects and other denominations in their attitudes about marriage and health-seeking behaviors. We were also interested in the influence of church affiliation on intervention participants' decision to marry, since they had comprehensive school support and education is highly valued in Zimbabwe, but costly and often out of financial reach. Interviews were conducted from October 2012 through November 2013; data were analyzed using a general inductive approach. We found that pressure or perceived deception for coitus or marriage was reported only by intervention participants affiliated with Apostolic denominations. Other reasons for marriage were similar between Apostolic and non-Apostolic adherents, as well as intervention and control conditions. All participants believed HIV testing was important, but while all non-Apostolic denominations encouraged HIV testing and clinic/hospital care, there was considerable heterogeneity in attitudes among Apostolics, with ultraconservative denominations most likely to proscribe non-religious health care. We conclude that some, but not all, Apostolic-affiliated women are afforded discretion in their health-seeking behaviors. Since HIV screening and treatment depend on access to clinic/hospital care, continued public health efforts to engage Apostolic leaders is needed, along with monitoring of progress in access and outcomes.

Marital Age Disparity Among Orphaned Young Women and Their Husbands: A Mixed Methods Study in Rural Zimbabwe.

Our study reports the results from a mixed method study comparing age-similar (AS) marriages of orphaned young women to age disparate (AD) marriages, defined as spousal age difference of 5 or more years. Research in Zimbabwe and sub-Saharan Africa suggests that AD sexual relationships between older men and young women increase the risk for HIV but few studies have examined this association among married couples or explored why young women marry much older men. In this study, a total of 35 orphaned young women aged 17-26 years in rural Zimbabwe participated in semi-structured interviews during 2012-2013. Twenty-four were in AD marriages and 11 AS. All had participated in a 5-year HIV prevention trial, during which they had married and dropped out of school. We examined two research questions: were AD wives more likely than AS to cite economic considerations as a reason to marry, and were AD marriages associated with different health and economic outcomes compared to AS? Our results showed that the reasons the women married were essentially the same among the two groups; economic considerations for marriage were uncommon. Nevertheless, AD wives generally fared somewhat better than AS wives on economic and well-being measures. HIV prevalence was similar; however, the AD group accounted for all five cases of herpes simplex virus-2. Findings suggest the complexity of sexual and reproductive health in rural Africa, where AD marriages are common and accepted. The challenge for primary prevention is to develop strategies to mitigate the risk of sexually transmitted infections, as well as the potential abuse of young women, within the appropriate cultural context.

Educational Outcomes for Orphan Girls in Rural Zimbabwe: Effects of a School Support Intervention.

Educational achievement has important implications for the health and well-being of young women in sub-Saharan Africa. The authors assessed the effects of providing school support on educational outcomes of orphan girls in rural Zimbabwe. Data were from a randomized controlled trial offering the intervention group comprehensive schooling support and controls no treatment initially and then fees only. Results indicated comprehensive support reduced school dropout and absence but did not improve test scores. Providing support to orphan girls is promising for addressing World Health Organization Millennium Development Goals, but further research is needed about contextual factors affecting girls' school participation and learning.

Use of HIV and HSV-2 biomarkers in sub-saharan adolescent prevention research: a comparison of two approaches.

Self-report of sexual behavior among adolescents is notoriously inconsistent, yet such measures are commonly used as outcomes for human immunodeficiency virus (HIV) prevention intervention trials. There has been a growing interest in the use of HIV and other sexually transmitted disease biomarkers as more valid measures of intervention impact in high HIV prevalence areas, particularly in sub-Saharan Africa. We examine the challenges, benefits, and feasibility of including HIV and herpes simplex virus type 2 (HSV-2) biomarker data, with details about different data collection and disclosure methods from two adolescent prevention trials in Kenya and Zimbabwe. In Kenya, whole blood samples were collected using venipuncture; adult guardians were present during biomarker procedures and test results were disclosed to participants and their guardians. In contrast, in Zimbabwe, samples were collected using finger pricks for dried blood spots (DBS); guardians were not present during biomarker procedures, and results were not disclosed to participants and/or their guardians. In both countries, prevalence in the study samples was low. Although the standard of care for testing for HIV and other sexually transmitted infections includes disclosure in the presence of a guardian for adolescents under age 18, we conclude that more research about the risks and benefits of disclosure to adolescents in the context of a clinical trial is needed. Notably, current serological diagnosis for HSV-2 has a low positive predictive value when prevalence is low, resulting in an unacceptable proportion of false positives and serious concerns about disclosing test results to adolescents within a trial. We also conclude that the DBS approach is more convenient and efficient than venipuncture for field research, although both approaches are feasible. Manufacturer validation studies using DBS for HSV-2, however, are needed for widespread use.

Alcohol Outlet Density and Young Women's Perpetration of Violence Toward Male Intimate Partners.

This paper examines the relationships between alcohol outlet density, alcohol use, and perpetration of intimate partner violence (IPV) among young adult women in the US. Data were from Wave III of the National Longitudinal Study of Adolescent Health (Add Health; N = 4,430 in present analyses). Multinomial logistic regression was used to examine occurrence of past year IPV perpetration toward a male partner based on tract-level on-premise and off-premise alcohol outlet density, controlling for individuals' demographic, alcohol use, and childhood abuse characteristics and neighborhood socio-demographic factors. Higher off-premise alcohol outlet density was found to be associated with young women's perpetration of physical only IPV, controlling for individual-level and ecological factors. Alcohol use had an independent association with IPV perpetration but was not a mediator of the outlet density-IPV relationship. Findings suggest that considering alcohol-related environmental factors may help efforts aimed at preventing young women's use of physical violence toward partners.

Perpetration of intimate partner violence by young adult males: the association with alcohol outlet density and drinking behavior.

OBJECTIVE: This study examined the association between alcohol outlet density and male to female intimate partner violence (IPV). METHOD: Data were analyzed from a national probability sample of males who reported a current heterosexual relationship (N=3194). Multinomial logistic regression was used to examine the likelihood of having perpetrated IPV. RESULTS: High alcohol outlet density was associated with having perpetrated physical only IPV (odds ratio [OR]=2.51; 95% confidence interval [CI]: 1.21-5.20). Outlet density was not associated with greater odds of sexual IPV perpetration. CONCLUSIONS: Alcohol outlet density was found to be associated with perpetration of physical IPV. Developing environmental strategies with respect to alcohol outlets could potentially reduce perpetration of male-to-female physical IPV.

Preventing HIV by providing support for orphan girls to stay in school: does religion matter?

OBJECTIVE: The paper examines the influence of religion on attitudes, behaviors, and HIV infection among rural adolescent women in Zimbabwe. DESIGN: We analyzed data from a 2007 to 2010 randomized controlled trial in rural eastern Zimbabwe testing whether school support can prevent HIV risk behaviors and related attitudes among rural adolescent orphan girls; supplementary data from the 2006 Zimbabwe Demographic and Health Survey (ZDHS) were also analyzed. The present study design is largely cross-sectional, using the most recent available survey data from the clinical trial to examine the association between religious affiliation and religiosity on school dropout, marriage, and related attitudes, controlling for intervention condition, age and orphan type. The ZDHS data examined the effect of religious denomination on marriage and HIV status among young rural women, controlling for age. RESULTS: Apostolic Church affiliation greatly increased the likelihood of early marriage compared to reference Methodist Church affiliation (odds ratio = 4.5). Greater religiosity independently reduced the likelihood of school dropout, increased gender equity attitudes and disagreement with early sex, and marginally reduced early marriage. Young rural Apostolic women in the ZDHS were nearly four times as likely to marry as teenagers compared to Protestants, and marriage doubled the likelihood of HIV infection. CONCLUSIONS: Findings contradict an earlier seminal study that Apostolics are relatively protected from HIV compared to other Christian denominations. Young Apostolic women are at increased risk of HIV infection through early marriage. The Apostolic Church is a large and growing denomination in sub-Saharan Africa and many Apostolic sects discourage medical testing and treatment in favor of faith healing. Since this can increase the risk of undiagnosed HIV infection for young married women and their infants in high prevalence areas, further study is urgently needed to confirm this emerging public health problem, particularly among orphan girls. Although empirical evidence suggests that keeping orphan girls in school can reduce HIV risk factors, further study of the religious context and the implications for prevention are needed.

Violence victimization of young men in heterosexual relationships: does alcohol outlet density influence outcomes?

This study examined whether alcohol outlet density is associated with male physical and sexual victimization by a female partner. Data were from the National Longitudinal Study of Adolescent Health (Add Health). A total of 3,179 young adult men identified a current heterosexual relationship and had complete intimate partner violence (IPV) victimization data. Almost 16% of this sample reported being the victim of physical only IPV in their relationship over the previous 12 months; an additional 6.4% were victims of sexual only or sexual and physical IPV. Multivariate analyses indicated high alcohol outlet density was associated with greater odds of experiencing physical IPV only (odds ratio [OR] = 2.07). Heavy drinkers experienced increased odds of physical and sexual IPV victimization. Alcohol outlet density should be addressed in prevention efforts.

Relationships among alcohol outlet density, alcohol use, and intimate partner violence victimization among young women in the United States.

Greater access to alcohol has been widely found to be associated with many negative outcomes including violence perpetration. This study examines the relationship between alcohol outlet density, alcohol use, and intimate partner violence (IPV) victimization among young women in the United States. A direct association between alcohol outlet density in one's neighborhood and the likelihood of IPV victimization was examined. Data were from Wave III of the National Longitudinal Study of Adolescent Health (Add Health), which followed a nationally representative sample of adolescents into adulthood. Participants were young adult females age 18 to 26 at Wave III. Of the 4,571 female respondents who reported a current heterosexual relationship and had IPV data, 13.2% reported having been the victim of physical violence only and 6.5% experienced sexual only or physical and sexual violence in the relationship during the past year. In the regression models tested, there was no significant direct association between neighborhood alcohol outlet density and IPV victimization nor was there an association between outlet density and drinking behaviors, thus eliminating the possibility of an indirect association. Results of fully adjusted models indicate females who drank heavily, whether infrequently or frequently, were at significant risk for experiencing sexual only IPV or sexual and physical IPV. Asians and Native Americans were at significantly greater odds of experiencing sexual only or sexual and physical IPV compared with non-Hispanic Whites, while non-Hispanic Blacks were at significantly greater odds for physical only IPV. We conclude that a continuous measure of alcohol outlet density was not associated with IPV in models controlling for individual and other neighborhood characteristics. Young women who drink heavily, whether infrequently or frequently, have greater odds of experiencing sexual only or sexual and physical compared to abstainers. Similar to previous study findings, young women living with or married to their partner were at far greater risk of experiencing physical only and/or sexual only or sexual and physical IPV. The study adds to the growing body of literature that examines how community characteristics such as outlet density influence the likelihood of IPV.

Keeping adolescent orphans in school to prevent human immunodeficiency virus infection: evidence from a randomized controlled trial in Kenya.

PURPOSE: We report the findings from a pilot study in western Kenya, using an experimental design to test whether comprehensive support used to keep adolescent orphans in school can reduce risk factors associated with infection with human immunodeficiency virus. METHODS: Adolescent orphans aged 12-14 years (N = 105) in Nyanza Province were randomized to condition, after stratifying by household, gender, and baseline survey report of sexual behavior. The intervention comprised school fees, uniforms, and a "community visitor" who monitored school attendance and helped to resolve problems that would lead to absence or dropout. Data were analyzed using generalized estimating equations over two time points, controlling for gender and age. RESULTS: Compared with the control group, intervention students were less likely to drop out of school, commence sexual intercourse, or report attitudes supporting early sex. School support also increased prosocial bonding and gender equity attitudes. CONCLUSIONS: After 1 year of exposure to the intervention, we found evidence suggesting that comprehensive school support can prevent school dropout, delay sexual debut, and reduce risk factors associated with infection with human immunodeficiency virus. Further research, with much larger samples, is needed to better understand factors that mediate the association between educational support and delayed sexual debut, and how gender might moderate these relationships.