From the periphery to inclusion within the health system: promoting community health worker empowerment as a way forward.

BACKGROUND: Community health worker programmes have the potential to contribute critically towards universal health coverage. However, CHWs globally have often continued to operate on the periphery of the health care system, viewed as a non-essential cadre. This results in a workforce that often remains disempowered and under-supported. This paper presents evidence from a study conducted in a rural part of South Africa, to better understand issues of CHW prioritisation, integration, and empowerment. METHODS: We applied an analytical lens based on empowerment theory and conducted a secondary analysis of qualitative data emerging from a sub-study of a cRCT evaluating the effectiveness of supportive supervision for CHWs within a large-scale national CHW programme. The cRCT was conducted between 2017 and 2022, and 39 CHWs were included in the study. RESULTS: We organised our findings across the four domains of structural empowerment; information, resources, support, and opportunity, and mapped these domains against the domains of psychological empowerment. Our findings show how CHWs are still working in the periphery of the healthcare system. Without sufficient prioritisation, high level-support from national and district governments, and sufficient investments in programmatic domains-such as training, equipment, and supportive supervision-it is likely that the CHW cadre will continue to be seen as informal health care workers. CONCLUSIONS: CHW empowerment could be a lever to potentially transform the current health system towards universal coverage; however, this process can only happen with sufficient high-level prioritization and investment.

Social scripts of violence among adolescent girls and young women in Zambia: Exploring how gender norms and social expectations are activated in the aftermath of violence.

Adolescent girls and young women ages 15-24 experience high rates of gender-based violence (GBV), underpinned by gender and social norms that shape their transitions to adulthood. For interventions that seek to leverage and build on existing infrastructure for health service provision, it is important to understand how gender norms operate in the background and how they shape service engagement or non-engagement. In formative work for our project, Screen & Support, outside of Lusaka, Zambia, we engaged in community conversations with adolescent girls and young women to understand common types and experiences of violence, perceptions of what causes violence, and pathways to post-violence service access. This manuscript explores emerging findings surrounding social and gender norms. We engaged n = 12 adolescent girls and young women ages 15-24, including survivors of GBV, young women living with HIV, and young married women in separate conversations conducted in a mix of Nyanja, Bemba, and English. Arts-based activities accompanied guided focus group discussions. Translated transcripts were coded and thematically analysed by two authors using Dedoose software. Key themes emerged around two major themes-understanding the norms underpinning violence, and observing how these norms were activated in the aftermath of violence. Sub-themes focused on power differentials supporting violence, social expectations and community-enacted sanctions, and understanding dominant norms and assumptions. Considering what unfolded in the aftermath of violence, young women participants considered key reference groups upholding norms, explored the contexts where norms may be contested or become more complicated, and described how accepting silence was a common means of closure. We discuss the implications of these findings for programme design, delivery, and evaluation, as well as the potential, and roadmap, for shifting norms that negative affect adolescent girls and young women.

Development of a school-based programme for mental health promotion and prevention among adolescents in Nepal and South Africa.

Introduction: Adolescence is a critical time for mental health promotion and prevention and establishing healthy behaviours. Implementing universal, school-based psychosocial interventions can improve short- and long-term health trajectories for adolescents. While these interventions may offer important opportunities for fostering skills and relationships, few school-based interventions have been developed for and tested in low- and middle-income countries (LMICs) where adolescent mental health needs may be significant and under-served. This manuscript details the development of a multi-component, universal school-based intervention, Health Action in ScHools for a Thriving Adolescent Generation (HASHTAG), for adolescents aged 12-15 years in Nepal and South Africa. Methods and results: We describe HASHTAG's development over four phases, combining methods and results as each phase was iteratively conducted between 2018 and 2021. Phase 1 included a systematic review and components analysis, building from WHO guidelines for adolescent mental health. Seven components were strongly supported by the evidence: emotional regulation, stress management, mindfulness, problem-solving, interpersonal skills, assertiveness training, and alcohol and drug education. Phase 2 encompassed site selection, theory of change development, and formative research engagements; research teams in each site engaged adolescents and key adult stakeholders to identify priorities for intervention. Stakeholders voiced preferences for external facilitators and key content and delivery for intervention sessions. These findings informed Phase 3, a draft manual of HASHTAG, including a whole-school component, called Thriving Environment in Schools, and a classroom-based, six-session component, Thrive Together. In Phase 4, participants engaged in consultative workshops to review and contextualise content by country, preparing HASHTAG for implementation in a feasibility trial. Minor adaptations were made in Nepal, including using school nurses and adjusting take-home materials; both country's workshops identified practical considerations for implementing activities. Conclusions: HASHTAG was designed around core evidence-based components to increase translatability across LMICs, while enabling country-specific tailoring to enhance feasibility. Future research will test whether this multi-component, whole-school approach can improve adolescent mental health.

How do new crises impact HIV risk behaviour - exploring HIV risk behaviour according to COVID-19-related orphanhood status in South Africa?

The COVID-19 pandemic resulted in high death rates globally, and over 10.5 million children lost a parent or primary caregiver. Because HIV-related orphanhood has been associated with elevated HIV risk, we sought to examine HIV risk in children affected by COVID-19 orphanhood. Four hundred and twenty-one children and adolescents were interviewed, measuring seven HIV risk behaviours: condom use, age-disparate sex, transactional sex, multiple partners, sex associated with drugs/alcohol, mental health and social risks. Approximately 50% (211/421) experienced orphanhood due to COVID-19, 4.8% (20/421) reported living in an HIV-affected household, and 48.2% (203/421) did not know the HIV status of their household. The mean age of the sample was 12.7 years (SD:2.30), of whom 1.2% (5/421) were living with HIV. Eighty percent (337/421) reported at least one HIV risk behaviour. HIV sexual risk behaviours were more common among children living in HIV-affected households compared to those not living in HIV-affected households and those with unknown household status (35.0% vs. 13.6% vs.10.8%, X2 = 9.25, p = 0.01). Children living in HIV-affected households had poorer mental health and elevated substance use (70.0% vs. 48.5%, X2 = 6.21, p = 0.05; 35.0% vs. 19.9%, X2 = 4.02, p = 0.1306, respectively). HIV-affected households may require specific interventions to support the health and well-being of children and adolescents.

Healthcare provisions associated with multiple HIV-related outcomes among adolescent girls and young women living with HIV in South Africa: a cross-sectional study.

INTRODUCTION: Adolescent girls and young women (AGYW) living with HIV experience poor HIV outcomes and high rates of unintended pregnancy. Little is known about which healthcare provisions can optimize their HIV-related outcomes, particularly among AGYW mothers. METHODS: Eligible 12- to 24-year-old AGYW living with HIV from 61 health facilities in a South African district completed a survey in 2018-2019 (90% recruited). Analysing surveys and medical records from n = 774 participants, we investigated associations of multiple HIV-related outcomes (past-week adherence, consistent clinic attendance, uninterrupted treatment, no tuberculosis [TB] and viral suppression) with seven healthcare provisions: no antiretroviral therapy (ART) stockouts, kind and respectful providers, support groups, short travel time, short waiting time, confidentiality, and safe and affordable facilities. Further, we compared HIV-related outcomes and healthcare provisions between mothers (n = 336) and nulliparous participants (n = 438). Analyses used multivariable regression models, accounting for multiple outcomes. RESULTS: HIV-related outcomes were poor, especially among mothers. In multivariable analyses, two healthcare provisions were "accelerators," associated with multiple improved outcomes, with similar results among mothers. Safe and affordable facilities, and kind and respectful staff were associated with higher predicted probabilities of HIV-related outcomes (p<0.001): past-week adherence (62% when neither accelerator was reported to 87% with both accelerators reported), clinic attendance (71%-89%), uninterrupted ART treatment (57%-85%), no TB symptoms (49%-70%) and viral suppression (60%-77%). CONCLUSIONS: Accessible and adolescent-responsive healthcare is critical to improving HIV-related outcomes, reducing morbidity, mortality and onward HIV transmission among AGYW. Combining these provisions can maximize benefits, especially for AGYW mothers.

Identifying Adolescents at Highest Risk of ART Non-adherence, Using the World Health Organization-Endorsed HEADSS and HEADSS+ Checklists.

Brief tools are necessary to identify adolescents at greatest risk for ART non-adherence. From the WHO's HEADSS/HEADSS+ adolescent wellbeing checklists, we identify constructs strongly associated with non-adherence (validated with viral load). We conducted interviews and collected clinical records from a 3-year cohort of 1046 adolescents living with HIV from 52 South African government facilities. We used least absolute shrinkage and selection operator variable selection approach with a generalized linear mixed model. HEADSS constructs most predictive were: violence exposure (aOR 1.97, CI 1.61; 2.42, p < 0.001), depression (aOR 1.71, CI 1.42; 2.07, p < 0.001) and being sexually active (aOR 1.80, CI 1.41; 2.28, p < 0.001). Risk of non-adherence rose from 20.4% with none, to 55.6% with all three. HEADSS+ constructs were: medication side effects (aOR 2.27, CI 1.82; 2.81, p < 0.001), low social support (aOR 1.97, CI 1.60; 2.43, p < 0.001) and non-disclosure to parents (aOR 2.53, CI 1.91; 3.53, p < 0.001). Risk of non-adherence rose from 21.6% with none, to 71.8% with all three. Screening within established checklists can improve identification of adolescents needing increased support. Adolescent HIV services need to include side-effect management, violence prevention, mental health and sexual and reproductive health.

Lessons From Implementing Ask-Boost-Connect-Discuss, a Peer-Delivered Psychosocial Intervention for Young Mothers Living With HIV in Malawi, Tanzania, Uganda, and Zambia.

Adolescent girls and young women in sub-Saharan Africa are at high risk of HIV, unintended pregnancy, and early motherhood. These intersecting risks can adversely affect their developmental trajectories and lifelong well-being. Because young mothers living with HIV in these settings experience high levels of stigma, shame, and isolation, tailored psychosocial intervention approaches for this group are critical yet unavailable. Enlisting young peer supporters may be a promising way to expand the reach of health services and enhance psychosocial well-being. To date, few peer-based interventions have targeted young mothers living with HIV. In 2019-2021, we codeveloped a peer-based, facility-embedded intervention package, Ask-Boost-Connect-Discuss (ABCD), with young peer supporters to address the psychosocial needs of young mothers living with HIV in Malawi, Tanzania, Uganda, and Zambia. We then analyzed programmatic data from ABCD to assess the feasibility of using young peers to deliver psychosocial support. Data sources included post-intervention interviews, focus groups, and written feedback from multiple stakeholders (participants, peer supporters, their supervisors, and clinic-based mentors), which were analyzed thematically. We organized our findings according to Bowen et al.'s feasibility framework. Findings spoke to the acceptability, practicality, and integration of the ABCD program. We found that young peer supporters were seen as acceptable program implementers; able to adopt responsive, engaging, and nonjudgmental approaches; and supported through training, technical skills development, and supervision, alongside purposeful facility integration. Importantly, we also found evidence reflecting the roles of demand and adaptation in program delivery (i.e., how peers responded to emerging participant needs or pivoted in their approach based on shifting circumstances). We conclude that considerations of intervention feasibility and/or program fidelity should be attuned to the dynamic qualities of young peer supporters as implementers and should extend beyond standard modes of assessment to consider intervention codevelopment and implementation as an iterative and adaptive process.

Community Health Workers' experiences of a package providing increased support and supervision - a qualitative study of a home visiting model in rural South Africa.

Deploying Community Health Workers is a crucial strategy to improve health at a community level in low and middle income countries. While there is substantial evidence for CHW effectiveness, there is a need for more research on the mechanisms through which these programs work. Understanding CHWs experiences of how programmes function is important. This article examines CHW's experiences of three key programmatic domains; training, logistical support and supervision. Data were gathered using a qualitative study embedded within a cluster randomized controlled trial of an enhanced supervision package delivered to government-employed CHWs in the rural Eastern Cape, South Africa. We interviewed CHWs (n = 16) and two supervisors. Three overarching areas and five sub-themes emerged from our interviews. CHW knowledge and confidence increased through additional training, that CHW motivation and community acceptance improved because of added logistical support, and that CHW supervision led to improved sense of accountability, feelings of respect, and sense of being supported. Our findings highlight the importance of a functional support system within which CHWs can operate, in a context where most CHWs operate in isolation and without support. CHWs receiving supportive supervision reported positive impacts on their motivation and ability to carry out their work effectively.

Key normative, legal, and policy considerations for supporting pregnant and postpartum adolescents in high HIV-burden settings: a critical analysis.

Rates of adolescent pregnancy within sub-Saharan Africa are increasing. Adolescent mothers ages 10-19 years face a distinct set of risks to their own and their children's health, compounded by many economic, social, and epidemiological challenges, such as living with HIV. In navigating this complex developmental period, many adolescent mothers face structural barriers impeding safe transitions to adulthood and motherhood. Drawing on existing literature and emerging data, we outline three normative, legal, and policy issues - violence and gender inequity, access to sexual and reproductive health services, and access to social and structural supports - which affect the health, wellbeing and development of adolescent mothers and their children. We also highlight emergent evidence about programming and policy changes that can better support adolescent mothers and their children. These key proposed responses include removing barriers to SRH and HIV service integration; ensuring implementation of return-to-school policies; and extending social protection systems to cater for adolescent mothers. Despite ongoing global crises and shifts in funding priorities, these normative, legal, and policy considerations remain critical to safeguard the health and wellbeing of adolescent mothers and their children.

'Community health workers are unable to work because they don't have supervisors' - mid-level providers' experiences of a CHW program in rural South Africa.

INTRODUCTION: The World Health Organization has called for more than 4 million community health workers (CHWs) globally; yet there are gaps in the evidence of CHWs' impact where studies have not had consistent results. South Africa is currently investing in CHW programs. However, there are significant concerns about the implementation and effectiveness of the program. METHODS: We interviewed mid-level supervisors involved in eight rural clinics in a deeply rural South African municipality to identify the strengths and weaknesses of the CHW programs currently being implemented. Half of these clinics were part of a program providing enhanced supervision to CHWs, and the remainder were operating as usual. We hypothesized that stakeholders would provide valuable insights on how to improve the implementation of CHW programs. Fourteen interviews with supervisors from three levels of clinic and non-governmental organizations were conducted. Interviews were transcribed and translated from isiXhosa to English, and thematically analysed using ATLAS.ti. RESULTS: Two overarching themes emerged: challenges at the national CHW program level (loss of political support, inadequacy of supervision and access to resources, human resource considerations); and experiences of the enhanced-supervision model provided (engagement and buy-in, link between CHW program and healthcare facilities, improvements through the intervention). Our findings suggest that CHWs operate largely unsupported, with limited access to training, equipment and supervision. The enhanced-supervision intervention appeared to mitigate some of these shortfalls. To make CHW programs efficient, we need to recruit CHWs based on social and administrative competence (rather than network referrals), provide improved higher quality training, provide more resources, especially equipment and transport, and ensure that CHWs receive supportive supervision that goes beyond simply administrative supervision. Furthermore, our findings suggest that the intervention in this study has somewhat mitigated these challenges through a package of supportive supervision and additional resources, highlighting the importance of stakeholder engagement and buy-in. It is clear that the governmental CHW program has many challenges - a number of which were temporarily mitigated by the intervention tested in this research's parent study. A list of recommendations for practice was developed from this work. First, contracts and reimbursements are important for CHW motivation, and are seen as essential prerequisites for CHW program success. Second, CHWs and other stakeholders must be involved in the design and implementation of the CHW program. Third, good-quality training and refresher trainings for CHWs is critical. Fourth, access to equipment such as scales is needed. Fifth, transport is critical in rural areas to access patients in remote areas. Lastly, supportive supervision was described as of upmost importance. CONCLUSION: CHWs have the potential to provide invaluable support in communities, and in rural communities in particular - but they need to operate in a functional supportive system. More resources need to be allocated to training, equipment and supportive supervision.

Protocol for the OCAY study: a cohort study of orphanhood and caregiver loss in the COVID-19 era to explore the impact on children and adolescents.

INTRODUCTION: Globally, no person has been untouched by the COVID-19 pandemic. Yet, little attention has been given to children and adolescents in policy, provision and services. Moreover, there is a dearth of knowledge regarding the impact of COVID-19-associated orphanhood and caregiver loss on children. This study aims to provide early insights into the mental health and well-being of children and adolescents experiencing orphanhood or caregiver loss in South Africa. METHODS AND ANALYSIS: Data will be drawn from a quantitative longitudinal study in Cape Town, South Africa. A sample of children and adolescents between the ages of 9 and 18 years, experiencing parental or caregiver loss from COVID-19, will be recruited together with a comparison group of children in similar environments who did not experience loss. The study aims to recruit 500 children in both groups. Mental health and well-being among children will be explored through the use of validated and study-specific measures. Participants will be interviewed at two time points, with follow-up data being collected 12-18 months after baseline. A combination of analytical techniques (including descriptive statistics, regression modelling and structural equation modelling) will be used to understand the experience and inform future policy and service provision. ETHICS AND DISSEMINATION: This study received ethical approval from the Health Research Ethics Committee at Stellenbosch University (N 22/04/040). Results will be disseminated via academic and policy publications, as well as national and international presentations including high-level meetings with technical experts. Findings will also be disseminated at a community level via various platforms.

Enhancing a peer supporter intervention for young mothers living with HIV in Malawi, Tanzania, Uganda, and Zambia: Adaptation and co-development of a psychosocial component.

ABSTRACTYoung mothers living with HIV (YMHIV) experience heightened risks to their mental health, as their transition to adulthood is marked by social stigma, health and socioeconomic challenges. Targeted psychosocial interventions may improve the mental health of YMHIV; however, no evidence-based interventions have been developed for this group. Peer support models, more common for youth living with HIV, show promise as a design to reach YMHIV in a non-stigmatising way. This manuscript describes the process of adapting and co-developing an evidence-based psychosocial component (Boost) of a larger intervention called Ask-Boost-Connect-Discuss. Peer supporters in Malawi, Tanzania, Uganda, and Zambia used ABCD to guide group sessions with YMHIV. The research team partnered with an implementing partner, Paediatric-Adolescent Treatment Africa, to undertake this work in three phases: 1) formative research, 2) content adaptation and development, and 3) consultation, refinement, and modification. YMHIV (n = 4), peer supporters (n = 21), and technical advisors (n = 4) were engaged as co-developers, shaping the resulting Boost intervention component at each phase. Peer support models may effectively reach young mothers, and consultation, co-creation, and integration with existing programming can offer rich insights to inform these models. We discuss the implications and promise of this approach.

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

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

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.

Community health workers' experiences of supervision in maternal and child health programmes in low- and middle-income countries: A qualitative evidence synthesis.

Maternal and child health programmes often use Community Health Workers (CHWs) to help address poor access to health care, particularly in low- and middle-income countries (LMIC). Supervision has long been recognised as a critical ingredient of successful CHW programmes, yet it is often reported as either of poor quality or absent. There is little research on CHWs' own perception of supervision and to the best of our knowledge, there are no reviews synthesising the evidence of CHWs' experiences of supervision. This review identified and synthesised qualitative research evidence about the experiences and perceptions of supervision by CHWs in programmes targeting maternal and child health (MCH) in LMIC. Electronic searches were performed in the following databases: EMBASE, Medline, PsycINFO, ASSIA, ERIC and CINAHL. This review included studies during the period from 2000 to 2021. In total, 10,505 titles were screened for inclusion, of which 177 full-text articles were retrieved and assessed. Ultimately, 19 articles were included in this review. Data extraction was based on the thematic synthesis approach: coding the text of included studies line-by-line; developing descriptive themes; and generating analytical themes. Four themes emerged: (1) frequency of supervision, (2) type of supervision, (3) supervision and motivation and (4) supportive supervision. Careful consideration needs to be taken of the model of supervision used, as primary care facility-based supervisors (usually nurses), although skilled, may not have sufficient time to supervise. Employing supervisors whose sole responsibility is to supervise CHWs may be a good strategy to alleviate these issues. Sufficient time and resources need to be allocated to supervisors and they should be expected to perform regular in-the-field supervision. Involving some aspects of community oversight should also be considered. Supervisor skills and training and the long-term retention of trained supervisors also need to be an important area of focus.

From surviving to thriving: integrating mental health care into HIV, community, and family services for adolescents living with HIV.

Adolescents are a crucial generation, with the potential to bring future social and economic success for themselves and their countries. More than 90% of adolescents living with HIV reside in sub-Saharan Africa, where their mental health is set against a background of poverty, familial stress, service gaps, and an HIV epidemic that is now intertwined with the COVID-19 pandemic. In this Series paper, we review systematic reviews, randomised trials, and cohort studies of adolescents living with and affected by HIV. We provide a detailed overview of mental health provision and collate evidence for future approaches. We find that the mental health burden for adolescents living with HIV is high, contributing to low quality of life and challenges with adherence to antiretroviral therapy. Mental health provision is scarce, infrastructure and skilled providers are missing, and leadership is needed. Evidence of effective interventions is emerging, including specific provisions for mental health (eg, cognitive behavioural therapy, problem-solving, mindfulness, and parenting programmes) and broader provisions to prevent drivers of poor mental health (eg, social protection and violence prevention). We provide evidence of longitudinal associations between unconditional government grants and improved mental health. Combinations of economic and social interventions (known as cash plus care) could increase mental health benefits. Scalable delivery models include task sharing, primary care integration, strengthening families, and a pyramid of provision that differentiates between levels of need, from prevention to the care of severe disorders. A turning point has now been reached, from which complacency cannot persist. We conclude that there is substantial need, available frameworks, and a growing evidence base for action while infrastructure and skill acquisition is built.

How Do Psychosocial Interventions for Adolescents and Young People Living With HIV Improve Adherence and Viral Load? A Realist Review.

PURPOSE: Psychosocial interventions have the potential to support adolescents and young people living with HIV (AYPLHIV) to achieve better HIV outcomes. However, more evidence is needed to understand which interventions are most effective, and the mechanisms driving how they work in practice. METHODS: We used realist methodologies to generate statements based on evidence from intervention studies and linked evidence included in a systematic review of psychosocial interventions for AYPLHIV. Key data were extracted from available sources to generate cases, including context-mechanism-outcome pathways. Higher level themes were refined iteratively to create a mid-range theory of how these interventions may work. RESULTS: From 26 resulting cases, 8 statements were crafted, grouped into 3 overarching categories, to describe how these interventions worked. Interventions were overall found to set off mechanisms to improve adherence when (1) responding to individual-level factors to support AYPLHIV (via incorporating agency and empowerment, personalized and/or contextualized approaches, and self-care skills); (2) tailoring delivery strategies to address specific needs (via diverse strategies, longer duration, and digital delivery); and (3) providing supportive resources (via peer and broader support, and structural support and integration into existing services). DISCUSSION: A collection of diverse mechanisms may individually or collectively drive improved outcomes for AYPLHIV engaged in psychosocial interventions. Recommendations for integrating our findings into practice are discussed.

Two years after lockdown: reviewing the effects of COVID-19 on health services and support for adolescents living with HIV in South Africa.

INTRODUCTION: South Africa's progress towards the 95-95-95 goals has been significantly slower among adolescents living with HIV (ALHIV), among whom antiretroviral therapy (ART) adherence, retention in care and viral suppression remain a concern. After 2 years of living with COVID-19, it is important to examine the direct and indirect effects of the pandemic on healthcare resources, access to HIV services and availability of support structures, to assess their impact on HIV care for ALHIV. DISCUSSION: The COVID-19 response in South Africa has shifted healthcare resources towards combatting COVID-19, affecting the quality and availability of HIV services-especially for vulnerable populations, such as ALHIV. The healthcare system's response to COVID-19 has threatened to diminish fragile gains in engaging ALHIV with HIV services, especially as this group relies on overburdened public health facilities for their HIV care. Reallocation of limited health resources utilized by ALHIV disrupted healthcare workers' capacity to form and maintain therapeutic relationships with ALHIV and monitor ALHIV for ART-related side effects, treatment difficulties and mental health conditions, affecting their ability to retain ALHIV in HIV care. Prevailing declines in HIV surveillance meant missed opportunities to identify and manage opportunistic infections and HIV disease progression in adolescents. "Lockdown" restrictions have limited access to healthcare facilities and healthcare workers for ALHIV by reducing clinic appointments and limiting individual movement. ALHIV have had restricted access to social, psychological and educational support structures, including national feeding schemes. This limited access, coupled with reduced opportunities for routine maternal and sexual and reproductive health services, may place adolescent girls at greater risk of transactional sex, child marriages, unintended pregnancy and mother-to-child HIV transmission. CONCLUSIONS: Adolescent HIV care in South Africa is often overlooked; however, ART adherence among ALHIV in South Africa is particularly susceptible to the consequences of a world transformed by COVID-19. The current structures in place to support HIV testing, ART initiation and adherence have been reshaped by disruptions to health structures, new barriers to access health services and the limited available education and psychosocial support systems. Reflecting on these limitations can drive considerations for minimizing these barriers and retaining ALHIV in HIV care.