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


Abstract and Figures

Social protection can reduce HIV-risk behavior in general adolescent populations, but evidence among HIV-positive adolescents is limited. This study quantitatively tests whether social protection is associated with reduced unprotected sex among 1060 ART-eligible adolescents from 53 government facilities in South Africa. Potential social protection included nine ‘cash/cash-in-kind’ and ‘care’ provisions. Analyses tested interactive/additive effects using logistic regressions and marginal effects models, controlling for covariates. 18 % of all HIV-positive adolescents and 28 % of girls reported unprotected sex. Lower rates of unprotected sex were associated with access to school (OR 0.52 95 % CI 0.33–0.82 p = 0.005), parental supervision (OR 0.54 95 % CI 0.33–0.90 p = 0.019), and adolescent-sensitive clinic care (OR 0.43 95 % CI 0.25–0.73 p = 0.002). Gender moderated the effect of adolescent-sensitive clinic care. Combination social protection had additive effects amongst girls: without any provisions 49 % reported unprotected sex; with 1–2 provisions 13–38 %; and with all provisions 9 %. Combination social protection has the potential to promote safer sex among HIV-positive adolescents, particularly girls.
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School, Supervision and Adolescent-Sensitive Clinic Care:
Combination Social Protection and Reduced Unprotected Sex
Among HIV-Positive Adolescents in South Africa
Elona Toska
Lucie D. Cluver
Mark E. Boyes
Maya Isaacsohn
Rebecca Hodes
Lorraine Sherr
Published online: 8 September 2016
ÓThe Author(s) 2016. This article is published with open access at
Abstract Social protection can reduce HIV-risk behavior in
general adolescent populations, but evidence among HIV-
positive adolescents is limited. This study quantitatively
tests whether social protection is associated with reduced
unprotected sex among 1060 ART-eligible adolescents from
53 government facilities in South Africa. Potential social
protection included nine ‘cash/cash-in-kind’ and ‘care’
provisions. Analyses tested interactive/additive effects using
logistic regressions and marginal effects models, controlling
for covariates. 18 % of all HIV-positive adolescents and
28 % of girls reported unprotected sex. Lower rates of
unprotected sex were associated with access to school (OR
0.52 95 % CI 0.33–0.82 p=0.005), parental supervision
(OR 0.54 95 % CI 0.33–0.90 p=0.019), and adolescent-
sensitive clinic care (OR 0.43 95 % CI 0.25–0.73
p=0.002). Gender moderated the effect of adolescent-
sensitive clinic care. Combination social protection had
additive effects amongst girls: without any provisions 49 %
reported unprotected sex; with 1–2 provisions 13–38 %; and
with all provisions 9 %. Combination social protection has
the potential to promote safer sex among HIV-positive
adolescents, particularly girls.
Resumen La proteccio
´n social puede reducir los com-
portamientos de riesgo asociados al VIH en los adoles-
centes en general, siendo los datos limitados en cuanto a
adolescentes VIH-positivo se refiere. Este estudio se evalu
cuantitativamente si la proteccio
´n social esta
´asociada con
la reduccio
´n de relaciones sexuales sin proteccio
´n en una
muestra de 1060 adolescentes elegibles para el tratamiento
antirretroviral, en 53 instalaciones gubernamentales en
´frica. En este estudio la proteccio
´n social se midio
usando nueve tipos de medidas de proteccio
´n incluyendo
efectivo, pago en especie y servicios de atencio
´n a la salud.
Los efectos interactivos y aditivos de estas medidas se
analizaron usando regresiones logı
´sticas y modelos de
efectos marginales, controlando por covariables. El 18 %
de todos los adolescentes VIH positivo y el 28 % de las
chicas adolescentes declararon haber tenido relaciones
sexuales sin proteccio
´n. Menores tasas de relaciones
sexuales sin proteccio
´n estuvieron asociadas con el acceso
a la escuela (OR 0.52 95 % CI 0.33–0.82 p=0.005), la
´n parental (OR 0.54 95 % CI 0.33–0.90
p=0.019), y la atencio
´n clı
´nica adecuada a las necesida-
des de los adolescentes (OR 0.43 95 % CI 0.25–0.73
p=0.002). El ge
´nero modero
´el efecto de la atencio
´nica adecuada a las necesidades de los adolescentes. La
Selected classifications 1.002: Condom use; 1.003: Community
interventions; 1.009: Prevention policy; 4.001: Adolescents; 5.010:
Southern Africa; 1.010: Risk behavior measurement; 1.011: Risk
correlates and predictors.
&Elona Toska;
Centre for Evidence-Based Intervention, Department of
Social Policy & Intervention, University of Oxford Barnett
House, 32 Wellington Square, Oxford OX1 2ER, UK
AIDS and Society Research Unit, Centre for Social Science
Research, University of Cape Town, 4.26 Leslie Building,
Private Bag Rondebosch, Cape Town, Western Cape 7701,
South Africa
Department of Psychiatry and Mental Health, Groote Schuur
Hospital, University of Cape Town, J-Block, Observatory,
Cape Town 7925, South Africa
Health Psychology and Behavioural Medicine Research
Group, School of Psychology and Speech Pathology, Curtin
University, Perth, WA, Australia
Tulane University School of Medicine, 1430 Tulane Ave,
New Orleans, LA 70112, USA
University College London, London, UK
AIDS Behav (2017) 21:2746–2759
DOI 10.1007/s10461-016-1539-y
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
´n de medidas de proteccio
´n social tuvo efectos
en las chicas adolescentes: sin ninguna medida de atencio
el 49 % de las chicas declaro haber mantenido relaciones
sexuales sin proteccio
´n, mientras que con una o dos
medidas el 13–38 %, y con todas las medidas solo el 9 %.
La combinacio
´n de medidas de proteccio
´n social tiene el
potencial de promover relaciones sexuales seguras en los
adolescentes VIH positivo, en particular en las chicas
Keywords HIV-positive adolescents Social protection
Unprotected sex Secondary prevention South Africa
There are an estimated 1.3–2.2 million HIV-positive ado-
lescents in Sub-Saharan Africa, both vertically and hori-
zontally infected [1]. Studies have documented high rates
of unprotected sex reported by HIV-positive adolescents
even after HIV infection (27–90 %) [25]. While rates of
unprotected sex among HIV-positive adolescents are
comparable to those among the general adolescent popu-
lation [2], HIV-positive adolescents are a key population
for reducing onwards HIV transmission to sexual partners
and children. In addition, HIV-positive adolescents expe-
rience a range of vulnerabilities that are likely to reduce the
efficacy of HIV prevention programmes aimed at general
populations, including cognitive and mental health issues
[6,7], family-related challenges [8,9] and material depri-
vation [10,11].
Adolescent girls and young women bear a dispropor-
tionate burden of the epidemic: three-quarters of all new
HIV infections in Africa are among adolescent girls, and
80 % of all HIV-positive adolescent girls live in Sub-Sa-
haran Africa [12,13]. While notable research and resources
are focused on supporting adolescent girls and young
women to remain HIV-negative, there is a dearth of
research and programming for HIV-positive girls. HIV-
positive adolescent girls face multiple potential risks: low
rates of condom and contraceptive use, greater rates of
unwanted pregnancies and related health complications, as
well as lower enrollment, adherence to, and retention in
prevention-of-mother-to-child transmission programmes,
and, consequently, increased risk of transmitting HIV to
their partners and children [1418].
Increasingly, social protection provisions are showing
potential to reduce the negative impacts of structural
deprivations faced by adolescents in high-prevalence con-
texts, and to improve their long-term health outcomes [19].
Although traditionally defined as a set of economic mea-
sures such as welfare payments or social cash transfers,
recent conceptualisations of social protection recognise
that it may take one of multiple forms [1921]: ‘cash/cash-
in-kind’ provisions to address economic barriers to food
security, school access and health services, or psychosocial
‘care’ provisions such as support groups, supportive par-
enting or community services [22]. Most evidence to date
has focused on impacts of social cash transfers in
addressing structural vulnerabilities to HIV-infection
among adolescents in Sub-Saharan Africa [13]. But recent
studies suggest that combinations of ‘cash/cash-in-kind’
and ‘care’ social protection provisions may have greater
potential for reducing HIV risk-behaviour than single
interventions [23,24]. Two studies from South Africa and
Kenya suggest that social protection may function differ-
ently for boys and girls [23,25]. A longitudinal study of
n=2668 South African adolescents found that different
combinations of ‘cash’ and ‘care’ social protection were
associated with reductions in sexual risk-taking among
adolescent girls compared to adolescent boys [23]. The
evaluation of the Kenya cash transfer programme for
orphans and vulnerable children showed overall reductions
in sexual debut with greater impact among girls compared
to boys [25]. A recent review in Eastern and Southern
Africa reported an increasing evidence base on how social
protection can reduce HIV infection among HIV-negative
adolescents, but found no studies that investigate the role
of social protection in preventing onwards HIV-transmis-
sion among HIV-positive adolescents [21]. There is a need
for evidence on whether social protection provisions alone
or in combination can reduce HIV-risk behavior for HIV-
positive adolescents, and to understand potential gender
To date, only a few programmes have tested any inter-
ventions to improve sexual and reproductive health among
HIV-positive adolescents in Sub-Saharan Africa. A small-
scale randomised trial of a behavioural intervention among
14–21 year old HIV-positive youth in Uganda reported that
intervention youth (n =50) increased consistent condom
use and reduced number of sexual partners significantly
compared to controls (n =50) [26]. Three studies suggest
that ‘care’ interventions of support groups may be helpful
in reducing risk behaviors amongst HIV-positive adoles-
cents [2729]. A pre-post test pilot study of structured
support group sessions for HIV-positive adolescents
(n =65) in South Africa found improvements in self-re-
ported condom use [27]. A qualitative study (n =13) in
the Democratic Republic of Congo, consisting of a 6-ses-
sion group-based healthy living intervention reported better
communication with sexual partners [29]. However, no
large-scale or quantitative research has examined impacts
of either ‘cash/cash-in-kind’ or ‘care’ social protection
provisions, alone or in combination, on the sexual practices
of HIV-positive adolescents. Combination social protection
may have cumulative effects, that is beneficiaries of two or
AIDS Behav (2017) 21:2746–2759 2747
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more provisions may do better than those receiving each
provision alone. These effects may be multiplicative or
additive [23].
This study aims to address this essential research gap.
It uses the world’s largest community-traced sample of
HIV-positive adolescents to investigate whether different
types of social protection provisions: ‘cash/cash-in-kind’
or ‘care’, are associated with lower rates of unprotected
sex. Based on a review of literature on social protection
for HIV prevention [21], the following nine social pro-
tection provisions were tested: ‘cash/cash-in-kind’: social
cash transfers, past-week food security, free school access
(no fees and school materials), school feeding, and
clothing, and psychosocial ‘care’ provisions: positive
parenting, strong parental supervision, support groups,
adolescent-sensitive care at clinics (respectful treatment
by sexual health service providers). It tests (1) associa-
tions of each social protection provisions with unprotected
sex, (2) the effects of gender on social protection provi-
sions significantly associated with unprotected sex, (3)
potential interactive effects of significant social protection
provisions, and (4) potential additive effects of combi-
nation social protection provisions.
Participants and Procedures
1060 HIV-positive adolescents (10–19 year olds) were
recruited from a health district in the Eastern Cape pro-
vince, South Africa. This was selected as a resource-lim-
ited setting with high HIV-prevalence rates [30]. The study
was designed in collaboration with South African Depart-
ments of Health and Basic Education, UNICEF, PEPFAR-
USAID, Pediatric AIDS Treatment for Africa (PATA) and
local NGOs. Ethical approval for this study was provided
by Research Ethics Committees at the Universities of
Oxford (SSD/CUREC2/12-21) and Cape Town (CSSR
2013/4), Eastern Cape Departments of Health and Basic
Education, and ethical review boards of participating
The study aimed to include all 10–19 year old adoles-
cents within the health district who were eligible to initiate
ART. First, all healthcare facilities providing ART were
visited (n =83): all facilities who reported more than five
ART-eligible adolescents were included in the study
(n =39). As the study progressed, the South African
Department of Health implemented a primary healthcare
reengineering programme, as a result of which the ado-
lescents receiving care in the initial 39 facilities were
transferred to a total of 53 healthcare facilities including
hospitals, community healthcare centres, and primary
healthcare clinics. All 53 facilities were then included in
the study.
Adolescents were recruited at clinics where they were
receiving antiretroviral treatment and care, or traced into
their home communities for those not reachable at the
clinics. All caregivers and adolescents participating in the
study gave written informed consent prior to interviews,
which took place in the language of their choice and lasted
an average of 90 min. Of all study-eligible adolescents,
n=1060 (90.1 %) were interviewed, 4.1 % refused par-
ticipation (either adolescent or caregiver), 0.9 % were
excluded due to severe cognitive disability, 1.2 % were
excluded due to living in very unsafe areas, and 3.7 % were
untraceable. Participants who asked for help or disclosed
abuse, neglect, defaulting from antiretroviral treatment or
clinic care, severe hunger, or risk of significant harm were
immediately assisted and linked to existing services
(n =66, 6.2 %). Due to high HIV-stigma rates, the study
was presented in participating communities as a general
study on adolescent access to health and social services. In
order not to draw attention to HIV-affected families, when
participants were traced and interviewed in communities,
an additional n =467 cohabitating or neighbouring age-
peers were interviewed using a non HIV-specific version of
the questionnaire (not included in this analysis).
Quantitative and qualitative research were combined
iteratively during the study: qualitative research guided the
design and content of the quantitative data collection tools
and processes, preliminary quantitative analysis provided
themes to be further explored by qualitative research, and
these in-depth explorations shaped quantitative analyses.
Quantitative questionnaires used standardised scales and
validated measures when available. Tools were translated
into Xhosa and back-translated for improved conceptual
validity [31], then piloted with 25 HIV-positive adolescents
from rural and urban sites in the health district. Question-
naires included graphics, interactive games and vignettes to
introduce questions around sensitive topics. Interviews
were administered by trained research assistants or via
tablet-assisted self-interviewing, based on the participants’
literacy levels.
Unprotected sex at last sexual intercourse was measured as
no condom use at most recent sexual encounter. It was
dichotomised as: ‘1 =unprotected sex’ and ‘0 =absti-
nence or protected sex’. Adolescents were coded as STI
symptomatic if they reported having at least one of the
following four STI symptoms: genital sores/warts, burning
whilst urinating, genital itching/redness, or anal itch-
ing/soreness/bleeding, in the last 6 months, following
WHO guidelines for syndromatic diagnosis of STIs [32].
2748 AIDS Behav (2017) 21:2746–2759
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Adolescent pregnancy among girls was defined as ever
having been pregnant before or during data collection,
measured using an item from the National Survey of HIV
and Risk Behaviour Amongst Young South Africans [33].
Socio-demographic characteristics (age, gender, home
language, housing situation, urban/rural location) were
measured using items from South Africa’s Census [34].
Housing was coded as 1 =informal if the adolescent lived
in a hut, rondavel (traditional home), or a shack, and
0=formal if they lived in a brick/concrete house or
apartment. Orphanhood status was coded as death of either
mother or father or both [35].
HIV-Related Factors
Mode of infection was assessed following similar studies
and modelling from Southern Africa [36,37]: adolescents
were coded as vertically-infected if they had started ART
prior to age 12 or if they had been on treatment for more
than 5 years, based on the year of widely available ART
access in the study area. Adolescent’s knowledge of their
own HIV-positive status was determined through a step-
wise process: initially healthcare providers’ report, fol-
lowed by confirmation by caregiver during the consent
process. Additional checks on adolescent knowledge of
own HIV-status were conducted using a screening on
recent health and medication-taking histories to avoid
unintentional disclosure. Adolescents who did not know
their own HIV-positive status responded to a questionnaire
on ‘illness’ and ‘medication’ instead of ‘HIV’ and ‘an-
tiretrovirals’, respectively. Most recent viral loads were
extracted from patient records for a random sub-sample
(n =266, 25 %). Participants with viral load counts[1000
copies/ml were coded as reporting virological failure using
WHO standards [38].
Social Protection Provisions
‘Cash/cash-in-kind’ provisions of social protection inclu-
ded the following: Social cash transfers referred to partic-
ipants’ household receiving at least one of South Africa’s
five social welfare grants: child support grant, foster child
grant, pension, disability or care dependency. Past-week
food security, defined as at least two meals daily for the
past week, was measured through items from the National
Food Consumption Survey [39]. Access to school was
defined as access to free schooling or ability to afford
school fees, uniform and equipment. School feeding
referred to receiving at least one free meal at school daily.
Sufficient clothing was measured using an item from the
South African Social Attitudes Survey [40]. Psychosocial
‘care’ provisions included: Positive parenting—including
items on praise and positive reinforcement from care-
giver—and good parental supervision—including moni-
toring of adolescent social activities and home rule-
setting—measured using two sub-scales of the Alabama
Parenting Questionnaire [41]. Attending an HIV-support
group was measured as past-month attendance at either a
youth-focused or general HIV-support group. Adolescent-
sensitive care at clinics was measured through two items
asking adolescents about their experience obtaining con-
traception at the clinic: whether they felt disrespected or
were scolded. These items were developed based on
extensive qualitative research and consultations with HIV-
positive adolescents in the study’s teen advisory group
Data Analysis
Data analysis consisted of five steps: first, the included
sample (90.1 %) was compared to the rest of the eligible
sample across available key demographics (age, gender and
residential location) to check for any differences.
Descriptive statistics of socio-demographic characteristics,
access to each social protection provision, and rates of
unprotected sex were calculated for the full included
sample and by gender. Covariates and social protection
provisions were excluded from further analysis if sub-
group sizes were too small for reliable analysis (cut-off
n\100 in the full sample, n \50 per gender). To check
the extent of risk for onwards HIV-transmission, we tested
whether unprotected sex was associated with virological
failure, a marker of high HIV-transmission risk through
unprotected sex [42].
Second, validation checks for self-reported unprotected
sex were conducted by testing associations between a)
unprotected sex and STI symptomology (full sample) and
b) unprotected sex and pregnancy (females only). These
used multivariate logistic regression models controlling for
all potential covariates.
Third, we tested potential associations of unprotected
sex and seven social protection provisions: three ‘cash-in-
kind’ and four ‘care’, using a multivariate logistic regres-
sion model, controlling for covariates. Covariates entered
included: adolescent age, gender, language, housing type,
residential location, maternal and paternal orphanhood,
living with biological caregiver, mode of infection, and
knowledge of own HIV-positive status.
Fourth, we tested whether gender acted as a moderator
for each social protection provision. Moderator analyses
were conducted using logistic regression models with two-
way interaction terms of gender and each social protection
provisions entered in separate models, controlling for
AIDS Behav (2017) 21:2746–2759 2749
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covariates found significant in the above step. Subse-
quently, based on existing literature suggesting different
social protection provisions may work for adolescent boys
and girls, and because a moderator effect was found,
multivariate logistic regressions were run separately for
HIV-positive girls and boys.
Fifth, effects of combinations of social protection
provisions on unprotected sex were tested for the full and
then gender-disaggregated samples. To check for potential
interaction effects, all significant social protection vari-
ables, covariates and interaction terms from stage 3 above
(p \.05) were added in a stepwise multivariate logistic
regression model, following processes applied by similar
studies [23]. Step 1—all covariates significant from the
model in stage 3, step 2—all significant social protection
variables, step 3—all two-way interaction terms of sig-
nificant social protection variables, step 4—all three-way
and higher order interaction terms of significant social
protection variables. Subsequently, marginal effect anal-
ysis in STATA tested potential additive effects of sig-
nificant social protection provisions by computing
predicted probabilities of unprotected sex under each
potential combination of significant social protection
provisions, with all significant covariates held at mean
Socio-Demographic and HIV-Related Factors
(Table 1)
Over half the sample was female (55 %) with average age
13.8 (SD =2.8). 19 % lived in informal housing. 22 %
lived in rural areas. Almost all participants spoke Xhosa at
home (97 %) and just under half lived with a biological
caregiver (45 %). 44 % were maternal orphans, 30 %
paternal orphans, and 15.4 % had lost both parents. 67 %
were vertically-infected and 75 % knew their own HIV-
positive status. Due to small sub-sample sizes of non-
Xhosa speakers (\50 for each gender), home language was
excluded from further analyses. There were no significant
differences between the included (n =1060) and excluded
eligible participants (n =116), when compared across age,
gender and residential location.
Sexual Outcomes: (Table 2)
18 % of HIV-positive adolescents reported having unpro-
tected sex at last intercourse, with girls reporting signifi-
cantly higher rates than boys (28 % vs. 4 %, OR 8.46,
95 % CI 5.27–13.58 pB.001). 32 % of HIV-positive girls
Table 1 Socio-demographic characteristics of the sample by gender
Factor grouping Factor Excluded eligible
sample n =166
N (%)
Included eligible
sample n =1060
N (%)
Total sample n =1060
(55.1 %)
(44.9 %)
Age Years [mean (SD)] 14.8 (2.91) 13.8 (2.8) 14.3 (3.0) 13.3 (2.5)
10–14 659 (62.2) 324 (55.5) 335 (70.4)
15–19 401 (37.8) 260 (44.5) 141 (29.6)
Gender Female 66 (56.9) 584 (55.1) 584 (100) n/a
Language Xhosa 1028 (97.0) 572 (97.9) 456 (95.8)
Housing Formal 861 (81.3) 469 (80.3) 392 (82.5)
Informal 198 (18.7) 115 (19.7) 83 (17.5)
Residence Urban 140 (77.6) 828 (78.4) 451 (77.5) 377 (79.5)
Rural 26 (22.4) 228 (21.6) 131 (22.5) 97 (20.5)
Family and caregiver
Maternal orphan 464 (43.8) 250 (42.8) 214 (45.0)
Paternal orphan 320 (30.2) 183 (31.3) 137 (28.8)
Living with biological caregiver 476 (44.9) 275 (47.1) 201 (42.2)
HIV-related factors Vertical infection 708 (66.8) 348 (59.6) 360 (75.6)
Horizontal infection 352 (33.2) 236 (40.4) 116 (24.4)
Knows HIV-positive status 794 (74.9) 442 (75.7) 352 (73.9)
Statistical tests comparing the excluded and included eligible participants were non significant
N (%) reported unless noted otherwise
2750 AIDS Behav (2017) 21:2746–2759
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were STI symptomatic compared to 27 % of boys (OR 1.23
95 % CI 0.99–1.69 p=0.059), with 13 % of all HIV-
positive girls reporting past or current pregnancy.
Transmission Risk
Unprotected sex was strongly associated with virological
failure in the sub-sample for whom viral load data was
available (n =266, OR 2.57 95 % CI 1.01–6.53 p=0.048),
suggesting that a sub-group of HIV-positive adolescents who
are not virally suppressed and engagein unprotected sex are at
high risk for HIV-transmission to uninfected sexual partners
and children. Gender-disaggregated analyses were not possi-
ble due to small sub-sample sizes.
Access to Social Protection Provisions (Table 2)
‘Cash/cash-in-kind’: 95 % of adolescents reported that
their household received at least one cash grant and 77 %
had enough food to eat in the past week. 66 % had no
economic barriers to access school, 93 % received regular
school feeding, and 67 % had enough clothes to stay warm
and dry. ‘Care’: 13 % attended any HIV support group,
41 % reported high parental supervision and 50 % reported
high positive parenting. HIV-positive adolescent boys
reported higher rates of food security (V
(df) =9.395 [1],
p=0.002), greater access to school (V
(df) =15.393 [1],
pB0.001), and more adolescent-sensitive SRH care at
clinics (V
(df) =16.610 [1], pB0.001) than girls. Due to
the very small groups of adolescents not receiving social
cash transfers and school feeding schemes (\100 in the full
sample, \50 by gender), these provisions were excluded
from further analyses.
Validating Self-Reported Unprotected Sex (Table 3)
In multivariate logistic regression, self-reported unpro-
tected sex was strongly associated with STI symptomology
in the full sample (OR 1.54 95 % CI 1.00–2.38 p=0.05)
and with adolescent pregnancy among girls only (OR 5.72
95 % CI 2.51–13.03 pB0.001).
Associations of Individual Social Protection
Provisions with Unprotected Sex (Table 4)
Table 4shows the results of the multivariate regression model
of the included social protection provisions. In the full sample,
‘cash-in-kind’ provision of school access (OR 0.52 95 % CI
0.33–0.82 p=0.005), ‘care’ good parental supervision (OR
0.54 95 % CI 0.33–0.90 p=0.019), and adolescent-sensitive
‘care’ at the clinic (OR 0.43 95 % CI 0.25–0.73 p=0.002)
were associated with less unprotected sex.
Gender Effects (Tables 5,6)
Of all social protection provisions only the interaction
between gender and adolescent-sensitive clinic care was
significant (OR 0.08 95 % CI 0.01–0.69 p=0.021), sug-
gesting that the effect of adolescent-sensitive clinic care on
reducing unprotected sex was significantly greater among
Table 2 Outcome measures and access to social protection provisions by gender
Factor grouping Factor Female
(55.1 %)
(44.9 %)
(100 %)
Outcome Unprotected sex at last
164 (28.1) 21 (4.4) 185 (17.5)
STI symptomatic 187 (32.0) 127 (26.7) 314 (29.6)
Pregnant (current or ever) 78 (13.4) n/a n/a
Virological failure
33 (24.8) 35 (26.3) 68 (25.6)
Economic ‘cash/cash-in-kind’ social protection
Social cash transfers 553 (94.7) 450 (94.7) 1003 (94.7)
Food security 431 (73.8) 389 (81.7) 820 (77.4)
Access to school 355 (60.8) 344 (72.3) 699 (65.9)
School feeding 538 (92.1) 448 (94.1) 986 (93.0)
Clothing 393 (67.3) 318 (66.8) 711 (67.1)
Psychosocial ‘care’ social protection provisions Positive parenting 298 (51.0) 233 (49.1) 531 (50.1)
Good parental supervision 227 (38.9) 206 (43.4) 433 (40.9)
HIV support group 76 (13.0) 65 (13.7) 141 (13.3)
Adolescent-sensitive clinic care 487 (83.4) 437 (91.8) 924 (87.2)
Virological failure defined as [1000 copies/ml
Sample size for viral load data n =266, n =133 girls (50 %) and n =133 boys (50 %)
AIDS Behav (2017) 21:2746–2759 2751
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HIV-positive adolescent girls than boys (Fig. 1): adjusted
probabilities of reporting unprotected sex among HIV-
positive girls who accessed adolescent-sensitive clinic
services was 14 % compared to 28 % among those who did
not. The effect of accessing adolescent-sensitive clinic
services was weaker among HIV-positive adolescent boys:
with access to services 3 % were likely to report unpro-
tected sex compared to 6 % among those who did not
report adolescent-sensitive clinic services.
In subsequent gender-disaggregated regression analyses
(Table 6), lower odds of unprotected sex among HIV-
positive girls were significantly associated with three social
protection provisions: school access (OR 0.49 95 % CI
0.29–0.82 p=0.007), good parental supervision (OR 0.54
95 % CI 0.30–0.98 p=0.043) and adolescent-sensitive
clinic care (OR 0.32 95 % CI 0.17–0.58 pB0.001). No
social protection provisions were associated with unpro-
tected sex amongst HIV-positive boys.
Table 3 Associations of unprotected sex with pregnancy and STI symptomology among HIV-positive adolescent
Factors Model 1: HIV-positive adolescents girls (n =584) Model 2: HIV-positive adolescents (n =1060)
OR (95 % CI) p OR (95 % CI) p
Outcome: unprotected sex at last intercourse
Age 1.607 (1.419–1.819) B.001 1.723 (1.554–1.910) B.001
Gender Not entered in model 6.591 (3.884–11.155) B.001
Informal housing .832 (.455–1.522) .551 .869 (.510–1.481) .607
Rural residence 1.499 (.858–2.622) .155 1.384 (.848–2.260) .194
Maternal orphan .524 (.266–1.030) .061 .619 (.349–1.095) .100
Paternal orphan .773 (.461–1.296) .329 .722 (.464–1.122) .147
Lives with biological caregiver .726 (.370–1.426) .353 .803 (.454–1.422) .452
Knows own HIV-positive status 1.396 (.640–3.049) .402 1.236 (.772–1.979) .377
Mode of infection—horizontal 1.076 (.618–1.872) .796 .958 (.501–1.830) .896
Pregnancy 5.717 (2.507–13.033) B.001 Not entered in model
STI symptomology Not entered in model 1.542 (1.000–2.380) .050
Table 4 Logistic regression of
all social protection provisions
and covariates
Factors OR (95 % CI) p
Outcome: unprotected sex (full sample of HIV-positive adolescents n =1060)
Age 1.644 (1.476–1.830) B.001
Gender 5.727 (3.339–9.824) B.001
Informal housing .927 (.532–1.614) .788
Rural residence 1.447 (.865–2.422) .159
Maternal orphan .596 (.331–1.074) .085
Paternal orphan .711 (.451–1.121) .142
Lives with biological caregiver .737 (.408–1.332) .312
Knows own HIV-positive status .956 (.476–1.921) .900
Mode of infection—horizontal 1.272 (.778–2.079) .337
Cash-in-kind—past-week food security .778 (.459–1.318) .351
Cash-in-kind—access to school .523 (.333–.823) .005
Cash-in-kind—clothing 1.051 (.638–1.733) .844
Care—positive parenting 1.471 (.936–2.314) .095
Care—parental supervision .544 (.327–.904) .019
Care—HIV support group 1.472 (.828–2.616) .188
Care—adolescent-sensitive clinic care .429 (.254–.726) .002
2752 AIDS Behav (2017) 21:2746–2759
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Potential Interactive and Additive Effects (Tables 7,8)
No significant interactive/multiplicative effects of social
protection provisions were found in the full sample or for
adolescent girls.
However, the independently significant effects of social
protection provisions in Table 4suggested potential addi-
tive effects. Strong additive effects were shown in the full
sample and among HIV-positive adolescent girls. Among
all HIV-positive adolescents, who had no access to school,
Table 5 Gender moderation effects for HIV-positive adolescents (n =1060)
Outcome: unprotected sex
Age Gender Social protection Gender 9social
OR (95 % CI) p OR (95 % CI) p OR (95 % CI) p OR (95 % CI) p
Past-week food
1.734 (1.591–1.890) B.001 8.045 (2.788–23.213) B.001 .907 (.093–8.842) .933 .832 (.247–2.801) .766
Access to
1.713 (1.571–1.867) B.001 8.031 (3.581–18.010) B.001 .852 (.121–6.013) .872 .771 (.269–2.209) .628
Clothing 1.747 (1.602–1.905) B.001 10.012 (4.246–23.608) B.001 1.886 (.258–13.793) .532 .608 (.208–1.781) .365
1.753 (1.607–1.912) B.001 6.492 (3.322–12.688) B.001 .701 (.099–4.994) .723 1.260 (.438–3.622) .668
1.718 (1.574–1.874) B.001 7.390 (4.009–13.622) B.001 .783 (.096–6.395) .820 .809 (.259–2.531) .716
HIV support
1.749 (1.605–1.907) B.001 7.777 (4.326–13.981) B.001 2.034 (.210–19.673) .540 .765 (.220–2.667) .675
clinic care
1.703 (1.562–1.858) B.001 62.987 (7.708–514.724) B.001 46.297 (.679–3157.684) .075 .078 (.009–.685) .021
Results for logistic regression models including age, gender, social protection provision and the interaction term for gender and each social
protection term
Table 6 Gender-disaggregated logistic regressions of social protection provisions and covariates
Factors Unprotected sex (HIV-positive adolescent girls) Unprotected sex (HIV-positive adolescent boys)
OR (95 % CI) p OR (95 % CI) p
Age 1.667 (1.474–1.887) B.001 1.559 (1.228–1.979) B.001
Informal housing .878 (.474–1.626) .679 1.168 (.287–4.759) .828
Rural residence 1.537 (.854–2.766) .152 1.030 (.291–3.646) .964
Maternal orphan .450 (.221–.917) .028 1.483 (.446–4.932) .520
Paternal orphan .761 (.451–1.285) .307 .582 (.204–1.660) .312
Caregiving arrangement .654 (.321–1.330) .241 .958 (.269–3.407) .947
Mode of infection—horizontal 1.402 (.793–2.479) .245 1.033 (.360–2.967) .952
Knows own HIV-positive status 1.152 (.516–2.571) .729 .627 (.142–2.770) .538
Cash-in-kind—past-week food security .868 (.474–1.590) .648 .629 (.185–2.137) .458
Cash-in-kind—access to school .489 (.290–.823) .007 .638 (.228–1.789) .393
Cash-in-kind—clothing .958 (.535–1.717) .886 1.195 (.398–3.582) .751
Care—parental supervision .542 (.300–.982) .043 .606 (.207–1.778) .362
Care—positive parenting 1.616 (.958–2.725) .072 1.019 (.370–2.809) .971
Care—HIV support group 1.512 (.764–2.992) .236 1.622 (.521–5.049) .404
Care—adolescent-sensitive clinic care .317 (.174–.579) B.001 3.598 (.428–30.229) .238
AIDS Behav (2017) 21:2746–2759 2753
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
good parental supervision, nor adolescent-sensitive clinic
care, 22 % reported unprotected sex at last intercourse.
Those receiving one social protection 11–15 % reported
unprotected sex, and with any two: 6–8 % probability of
unprotected sex. Adolescents receiving all three social
protection provisions were likely to report just under 4 %
unprotected sex. Amongst HIV-positive girls, rates of
unprotected sex dropped from 49 % with no social pro-
tection provisions, to 23–38 % with one, 13–24 % with
two and just under 9 % with all three social protection
provisions (Fig. 2). As no social protection provisions
were significantly associated with unprotected sex among
HIV-positive boys, marginal effects models were not
Findings from this study have several important implica-
tions. First, we found high rates of unprotected sex reported
by HIV-positive adolescents, and significantly higher rates
of virological failure amongst HIV-positive adolescents
engaging in unprotected sex, suggesting greater transmis-
sion risk to uninfected peers. It is clear that effective pro-
gramming to reduce sexual risk behavior for this
vulnerable group is essential.
Second, we identify three types of social protection
provisions that are strongly associated with reduced
unprotected sex among HIV-positive adolescents: access to
schools, good parental supervision, and adolescent-sensi-
tive sexual health care at clinics. These findings reflect
emerging evidence on combinations of social protection for
reducing sexual risk-taking among general samples of
adolescents [23]. They support recent calls for adolescent-
sensitive HIV-inclusive social protection, that is social
protection that reaches HIV-positive and HIV-affected
adolescents without using HIV status as a targeting con-
dition [21]. This study’s results show that HIV-inclusive
social protection has the potential to reduce HIV risk-tak-
ing without the associated stigma of HIV-specific
Third, we extend this existing research by showing that
combining two types of social protection: ‘cash-in-kind’
(school access) and ‘care’ (good parental supervision and
adolescent-sensitive sexual health clinic care) has the
greatest potential to reduce unprotected sex the most.
Compared to those receiving none or one social protection
provision, adolescents who receive two types of social
protection reported lower rates of unprotected sex, with
those receiving three types of social protection reporting
the lowest rates. These findings suggest that ‘care’ social
protection may act as the ‘glue’ for cash social protection
no adolescent-sensive clinic care adolescent-sensive clinic care
Boys Girls
% predicted probabilies of unprotected sex among HIV-posive
adolescents boys and girls by access to adolescent-sensive clinic care
(controlling for significant factors)
Fig. 1 Effects of adolescent-
sensitive clinic care by gender
2754 AIDS Behav (2017) 21:2746–2759
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to have positive effects, or vice versa. Additional research
is needed to elucidate these potential mechanisms.
Fourth, our findings highlight the importance of
receiving social protection in three key locations for ado-
lescents: school, home and clinic. These findings confirm
evidence from the region on adolescents more generally,
with access to school serving as a ‘social vaccine’, bol-
stering social pathways associated with improved resi-
lience [13]. Additionally, receiving adolescent-sensitive
‘care’ services from sexual healthcare providers at clinics
was also associated with lower rates of unprotected sex.
This finding supports qualitative reports from South Africa
on the negative effect of poor clinic care on adolescent
sexual and reproductive health outcomes [43]. Further
analyses, including in-depth qualitative research, are nee-
ded to better understand the mechanisms through which
classroom- and clinic-level support is linked to reduced
unprotected sex.
Fifth, our gender-disaggregated analyses resulted in
different significant social protection for boys and girls,
though this may also be due to reduced power and the
lower rates of sexual activity reported by the HIV-positive
adolescent boys in our sample [15]. Three of the social
protection provisions we tested have significant effects on
HIV-positive adolescent girls: access to schools, good
parental supervision, and adolescent-sensitive sexual health
clinic care. Supporting adolescent girls beyond the home
setting, at school and clinics, will not only ensure they
Table 7 Logistic regression
models of all significant
potential social protection
factors, interaction terms, and
Outcome: unprotected sex All HIV-positive adolescents (n =1060)
Step 1 OR (95 % CI) p DR
Age 1.650 (1.512–1.801) B.001 .517*** B.001
Gender 6.226 (3.683–10.523) B.001
Maternal orphan Not included
Cash-in-kind—school access .530 (.349–.804) .003
Care—good parental supervision .616 (.383–.992) .046
Care—adolescent-sensitive clinic care .424 (.254–.707) .001
Step 2 OR (95 % CI) p DR
Age 1.653
B.001 .517 .906
Gender 6.329
Maternal orphan Not included
Cash-in-kind –school access .457 (.183–1.142) .094
Care—good parental supervision 1.831 (.477–7.031) .378
Care—adolescent-sensitive clinic care .435 (.195–.970) .042
Interaction—school access 9parental supervision .740 (.281–1.951) .543
Interaction—school access 9adolescent-sensitive clinic care 1.359 (.486–3.798) .558
Interaction—parental supervision 9adolescent-sensitive
clinic care
.336 (.087–1.297) .114
Step 3 OR (95 % CI) p DR
Age 1.653 (1.513–1.806) B.001 .516 .926
Gender 6.332 (3.731–10.747) B.001
Maternal orphan Not included
Cash-in-kind –school access .447 (.167–1.195) .109
Care—good parental supervision 1.703 (.281–10.327) .563
Care—adolescent-sensitive clinic care .428 (.184–.996) .049
Interaction—school access 9parental supervision .850 (.071–10.155) .898
Interaction—school access 9adolescent-sensitive
clinic care
1.398 (.452–4.323) .561
Interaction—parental supervision 9adolescent-
sensitive clinic care
.366 (.052–2.603) .316
Interaction—school access 9parental
supervision 9adolescent-sensitive clinic care
.849 (.057–12.578) .905
AIDS Behav (2017) 21:2746–2759 2755
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
reach services critical to their long-term well-being, but
also support them in engaging in safer sex. Notably, these
three provisions are—when available—targeted at all
adolescents, whether HIV-positive or not. This suggests
that social protection that reaches at-risk populations such
as adolescents, even when not targeted to HIV-positive
ones, can be effective to reduce their vulnerabilities. These
findings resonate with advocacy for generalised social
protection in the Sustainable Development Goals [13].
They also underline the importance of ensuring that HIV-
positive adolescents are not excluded from accessing social
This study has several methodological limitations.
Cross-sectional analyses always limit our ability to reach
conclusions on the direction of the observed associations,
due to potential reverse causality for significant associa-
tions. Future research can valuably test these associations
in longitudinal quasi-experimental studies or randomised
controlled trials. Second, self-reported sexual health out-
comes contain risk of social desirability bias. As a check
for validity, we tested associations of self-reported unpro-
tected sex with two other sexual and reproductive health
outcomes. Unprotected sex was significantly associated
with pregnancy and STI symptomology. Third, although
over 90 % of all eligible adolescents in the health district
were included in this sample, it is possible that adolescents
at highest risk were those who refused or were untraceable.
However, comparison of the sample reached and those not
Table 8 Logistic regression
models of all significant
potential social protection
factors, interaction terms, and
Outcome: unprotected sex HIV-positive adolescents girls (n =584)
Step 1 OR (95 % CI) p DR
Age 1.699 (1.536–1.880) B.001 .528*** B.001
Gender Not included
Maternal orphan .587 (.361–.955) .032
Cash-in-kind—school access .515 (.318–.833) .007
Care—good parental supervision .634 (.364–1.103) .107
Care—adolescent-sensitive clinic care .313 (.174–.564) B.001
Step 2 OR (95 % CI) p DRp
Age 1.716 (1.547–1.903) B.001 .537 .146
Gender Not included
Maternal orphan .591 (.362–.966) .036
Cash-in-kind –school access .513 (.182–1.443) .206
Care—good parental supervision 3.634 (.714–18.490) .120
Care—adolescent-sensitive clinic care .392 (.160–.964) .041
Interaction—school access 9parental supervision .738 (.235–2.321) .604
Interaction—school access 9adolescent-sensitive clinic care 1.147 (.354–3.720) .819
Interaction—parental supervision 9adolescent-sensitive
clinic care
.158 (.030–.819) .028
Step 3 OR (95 % CI) p DR
Age 1.714 (1.545–1.902) B.001 .537 .785
Gender Not included
Maternal orphan .588 (.359–.962) .035
Cash-in-kind—school access .487 (.162–1.464) .200
Care—good parental supervision 3.006 (.361–25.029) .309
Care—adolescent-sensitive clinic care .378 (.147–.969) .043
Interaction—school access 9parental supervision 1.092 (.053–22.650) .955
Interaction—school access 9adolescent-sensitive
clinic care
1.229 (.343–4.407) .752
Interaction—parental supervision 9adolescent-
sensitive clinic care
.197 (.020–1.950) .165
Interaction—school access 9parental
supervision 9adolescent-sensitive clinic care
.634 (.024–16.674) .785
2756 AIDS Behav (2017) 21:2746–2759
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reached showed no significant differences by age, gender
and residential location—the only information available to
us. Despite this limitation, our study is the first and largest
study of HIV-positive adolescents traced into their homes
and communities, and thus may allow more representa-
tivity of the overall population than clinic-based samples
that are thus restricted to those who attend healthcare ser-
vices. Moreover, by including study sites with high HIV
prevalence and relatively poor resources, our findings may
be applicable to contexts with similar socio-economic and
epidemiological profiles.
Participants in our sample reported very high coverage
of certain social protection provisions: social cash transfers
and school feeding ([90 %). These coverage rates not only
limited our ability to conduct sub-group analyses but also
precluded us from reaching any conclusions on whether
they may be associated with sexual health outcomes among
HIV-positive adolescents. However, given prior evidence
from South Africa on the effectiveness of social cash
transfers in reducing sexual risk-taking among AIDS-af-
fected adolescents [24,44], our findings suggest that the
positive effect of additional social protection may extend
gains from the social cash transfer and school feeding
schemes documented by prior studies in the region.
Despite the above limitations, the study provides key
insights for sexual health programming among HIV-posi-
tive adolescents in and out of clinical care. The interven-
tions identified are available in real-life settings and have
statistically and practically significant associations with
reduced unprotected sex, particularly when accessed in
combination. Increasing access to these social protection
provisions among HIV-positive adolescents has the
potential to support HIV-positive adolescents to reduce
unprotected sex, and its related outcomes of unwanted
pregnancies and onwards HIV-transmission.
Acknowledgments This study would not be possible without the
experiences shared by over 1500 adolescents, their caregivers and
healthcare providers, to whom we are immensely grateful. A joint
University of Oxford-University of Cape Town team collaborated
with UNICEF, the South African National Departments of Health,
Basic Education and Social Development and Paediatric AIDS
Treatment for Africa, and local CBOs: the Keiskamma Trust, the
Raphael Centre, and Small Projects Foundation to design and con-
ceptualize the study. Research was conducted by a dedicated research
team, including: Julia Rosenfeld, Maya Isaacsohn, Marija Pantelic,
Louis Pilard, Izidora Skracic, Nontuthuzelo Bungane, Janina Steinert,
Rocio Herrero Romero, Craig Carty, Gerry Boon, Luntu Galo, Cheree
Goldswain, Justus Hofmeyr, Sibongile Mandondo and Lulama Sid-
loyi. Rajen Govender, Nicoli Nattrass and Mpumi Zungu provided
advice and mentorship. The study was conducted in collaboration
with the Pediatric AIDS Management Programme of the Eastern Cape
provincial Department of Health, and by 53 health facilities in the
Buffalo City sub-district and Amathole district, Eastern Cape, South
Funding The study was supported by the Nuffield Foundation under
Grant CPF/41513, the International AIDS Society through the
CIPHER grant (155-Hod), the Clarendon-Green Templeton College
Scholarship (ET), the Janssen Global Health Educational Grant Pro-
gramme, and the Evidence for HIV Prevention in Southern Africa, a
DFID programme managed by Mott MacDonald (MM/EHPSA/UCT/
05150014). Analyses and writing were supported by UNICEF—we
22% 15% 13% 11% 8%
7% 6%
49% 38% 33% 23% 24% 16% 13% 9%
none good parental
school access adolescent-sensive
clinic care
school access +
parental supervision
parental supervision +
sensive clinic care
school access +
sensive clinic care
all three social
% predicted probabilies of unprotected sex among HIV-posive adolescents by access to social protecon
intervenons (controlling for socio-demographic co-factors)
All HIV+ adolescents HIV-posive adolescent girls
Fig. 2 Marginal effects model testing for additive effects of combination social protections on unprotected sex among HIV-positive adolescents
AIDS Behav (2017) 21:2746–2759 2757
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thank Anurita Bains, Tom Fenn and Patricia Lim Ah Ken for input
and discussion. Additional support for LC was provided by the
European Research Council (ERC) under the European Union’s
Seventh Framework Programme (FP7/2007–2013)/ERC grant agree-
ment n°313421 and the Philip Leverhulme Trust (PLP-2014-095).
Compliance with Ethical Standards
Conflicts of interest Elona Toska declares that they have no conflict
of interest. Lucie Cluver declares that they have no conflict of interest.
Mark Boyes declares that they have no conflict of interest. Maya
Isaacsohn declares that they have no conflict of interest. Rebecca
Hodes declares that they have no conflict of interest. Lorraine Sherr
declares that they have no conflict of interest.
Informed Consent Informed consent was obtained from all indi-
vidual participants included in the study.
Research Involving Human Participants All procedures performed
in studies involving human participants were in accordance with the
ethical standards of the institutional and/or national research com-
mittee and with the 1964 Helsinki declaration and its later amend-
ments or comparable ethical standards.
Open Access This article is distributed under the terms of the Creative
Commons Attribution 4.0 International License (http://creative, which permits unrestricted use, distri-
bution, and reproduction in any medium, provided you give appropriate
credit to the original author(s) and the source, provide a link to the
Creative Commons license, and indicate if changes were made.
1. UNICEF. Towards an AIDS-free generation—children and
AIDS: sixth stocktaking report. New York; 2013.
2. Mergui A, Giami A. The sexuality of HIV-infected adolescents:
literature review and thinking the unthinkable of sexuality. Arch
Pediatr. 2011;18:797–805.
3. Cataldo F, Malunga A, Rusakaniko S, Umar E, Teles N, Musandu
H. Experiences and challenges in sexual and reproductive health
for adolescents living with HIV in Malawi, Mozambique, Zambia
and Zimbabwe. In: XIX international AIDS conference. Wash-
ington D.C.; 2012. p. MOAD0104.
4. Birungi H, Obare F, Mugisha JF, Evelia H, Nyombi J. Preventive
service needs of young people perinatally infected with HIV in
Uganda. AIDS Care. 2009;21(6):725–31.
5. Beyeza-Kashesya J, Kaharuza F, Ekstrom AM, Neema S, Kulane
A, Mirembe F, et al. To use or not to use a condom: a prospective
cohort study comparing contraceptive practices among HIV-in-
fected and HIV-negative youth in Uganda. BMC Infect Dis.
6. Lowenthal ED, Bakeera-Kitaka S, Marukutira T, Chapman J,
Goldrath K, Ferrand RA. Perinatally acquired HIV infection in
adolescents from Sub-Saharan Africa: a review of emerging
challenges. Lancet Infect Dis. 2014;14:627–39.
7. Sherr L, Croome N, Parra Castaneda K, Bradshaw K, Herrero
Romero R. Developmental challenges in HIV infected children—
an updated systematic review. Child Youth Serv Rev.
8. Amzel A, Toska E, Lovich R, Widyono M, Patel T, Foti C, et al.
Promoting a combination approach to paediatric HIV psychoso-
cial support. AIDS [internet]. 2013;27 Suppl 2:S147–57. http://
9. Wiener LS, Battles HB. Untangling the web: a close look at
diagnosis disclosure among HIV-infected adolescents. J Adolesc
Health. 2006;38:307–9.
10. Mellins CA, Bhana A, Petersen I, Holst H, Alicea S, Myeza N,
et al. The VUKA family project: a family-based mental health
and HIV prevention program for perinatally HIV-positive youth.
In: XIX international AIDS conference. Washington D.C.; 2012.
11. Busza J, Besana GVR, Mapunda P, Oliveras E. I have grown up
controlling myself a lot. Fear and misconceptions about sex
among adolescents vertically-infected with HIV in Tanzania.
Reprod Health Matters. 2013;21(41):87–96.
12. Joint United Nations Programme on HIV/AIDS (UNAIDS),
African Union (AU). Empower young women and adolescents
girls: fast-tracking the end of the AIDS epidemic in Africa [in-
ternet]. Geneva; 2015. p. 32.
13. UNICEF-ESARO TP. Social cash transfers and children’s out-
comes: a review of evidence from Africa [internet]. 2015. https://
14. Fatti G, Shaikh N, Eley B, Jackson DJ, Grimwood A. Adolescent
and young pregnant women at increased risk of mother-to-child
transmission of HIV and poorer maternal and infant health out-
comes: a cohort study at public facilities in the Nelson Mandela
Bay Metropolitan district, Eastern cape, South Africa. S Afr Med
J. 2014;104:874–80.
15. Toska E, Cluver LD, Hodes RJ, Kidia KK. Sex and secrecy: how
HIV-status disclosure affects safe sex among HIV-positive ado-
lescents. AIDS Care. 2015;27(sup1):47–58.
16. Cluver LD, Hodes RJ, Toska E, Kidia KK, Orkin FM, Sherr L,
et al. HIV is like a tsotsi. ARVs are your guns’’: associations
between HIV-disclosure and adherence to antiretroviral treatment
among adolescents in South Africa. AIDS. 2015;29:S57–65.
17. Test FS, Mehta SD, Handler A, Mutimura E, Bamukunde AM,
Cohen M. Gender inequities in sexual risks among youth with
HIV in Kigali, Rwanda. Int J STD AIDS. 2012;23(6):394–9.
18. Obare F, Van Der Kwaak A, Birungi H. Factors associated with
unintended pregnancy, poor birth outcomes and post-partum
contraceptive use among HIV-positive female adolescents in
Kenya. BMC Womens Health. 2012;12(34):1–8.
19. CluverLD,HodesRJ,SherrL,OrkinFM,MeinckF,LimPLAK,etal.
Social protection: potential for improving HIV outcomes among
adolescents. J Int AIDS Soc [internet]. 2015;18(Suppl 6):202–607.
20. Devereux S, Sabates-Wheeler R. Editorial introduction: debating
social protection. IDS Bull. 2007;38(3):1–7.
21. Toska E, Gittings L, Cluver LD, Hodes RJ, Chademana E,
Gutierrez VE. Resourcing resilience: social protection for HIV
prevention amongst children and adolescents in Eastern and
Southern Africa. Afr J AIDS Res. 2016;15(2):123–40.
22. The African Child Policy Forum (ACPF). Social protection that
benefits children: a moral imperative and viable strategy for
growth and development. Addis Ababa: The African Child Policy
Forum (ACPF); 2014.
23. Cluver LD, Orkin FM, Yakubovich AR, Sherr L. Combination
social protection for reducing HIV-risk behavior amongst ado-
lescents in South Africa. J Acquir Immune Defic Syndr.
24. Cluver LD, Orkin FM, Boyes ME, Sherr L. Cash plus care: social
protection cumulatively mitigates HIV-risk behaviour among
adolescents in South Africa. AIDS. 2014;28(Suppl 3):S389–97.
25. Handa S, Halpern CT, Pettifor AE, Thirumurthy H. The gov-
ernment of Kenya’s cash transfer program reduces the risk of
sexual debut among young people age 15–25. PLoS One.
2758 AIDS Behav (2017) 21:2746–2759
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
26. Lightfoot MA, Kasirye R, Comulada WS, Rotheram-Borus MJ.
Efficacy of a culturally adapted intervention for youth living with
HIV in Uganda. Prev Sci. 2007;8:271–3.
27. Snyder K, Wallace M, Duby Z, Aquino LDH, Stafford S, Hosek
S, et al. Preliminary results from Hlanganani (coming together): a
structured support group for HIV-infected adolescents piloted in
Cape Town, South Africa. Child Youth Serv Rev.
28. Senyonyi RM, Underwood LA, Suarez E, Musisi S, Grande TL.
Cognitive behavioral therapy group intervention for HIV trans-
mission risk behavior in perinatally infected adolescents. Health.
29. Parker L, Maman S, Pettifor AE, Chalachala JL, Edmonds A,
Golin CE, et al. Adaptation of a U.S. evidence-based positive
prevention intervention for youth living with HIV/AIDS in Kin-
shasa, Democratic Republic of the Congo. Eval Program Plan.
30. Department of Health. The 2011 national antenatal sentinel HIV
and syphilis prevalence survey in South Africa. Pretoria:
Department of Health; 2012.
31. Brislin RW. Back-translation for cross-cultural research. J Cross
Cult Psychol. 1970;1(3):185–216.
32. World Health Organization (WHO). Guidelines for the manage-
ment of sexually transmitted infections [internet]. World Health
Organization; 2004. p. 88.
33. Pettifor AE, Rees HV, Steffenson A, Madikizela-Hlongwa L,
Macphail C, Kleinschmidt I. HIV and sexual behaviour among
young South Africans: a national survey of 15–24 year olds.
Johannesburg: University of Witswatersrand; 2004.
34. Statistics South Africa (SSA). Census 2011 methodoloy and
highlights of key results. 2011.
35. Joint United Nations Programme on HIV/AIDS (UNAIDS),
(UNICEF) TUNCF, (USAID) TUSA for ID. Children on the
brink 2004 [internet]. New York; 2004.
36. Evans D, Menezes C, Mahomed K, Macdonald P, Untiedt S,
Levin L, et al. Treatment outcomes of HIV-infected adolescents
attending public-sector HIV clinics across Gauteng and Mpu-
malanga, South Africa. AIDS Res Hum Retrovir.
37. Ferrand RA, Corbett EL, Wood R, Hargrove J, Ndhlovu CE,
Cowan FM, et al. AIDS among older children and adolescents in
Southern Africa: projecting the time course and magnitude of the
epidemic. AIDS. 2009;23(15):2039–46.
38. World Health Organization (WHO). Technical and operational
considerations for implementing HIV viral load testing: interim
technical update [internet]. Geneva: World Health Organization;
2014. p. 28.
39. Labadarios D, Steyn NP, Maunder EMW, MacIntryre U, Gericke
G, Swart R, et al. The national food consumption survey (NFCS):
South Africa, 1999. Public Health Nutr. 2005;8(5):533–43.
40. Pillay U, Roberts B, Rule SP. South African social attitudes:
changing times, diverse voices. Cape Town: HSRC Press; 2006.
p. 391.
41. Elgar FJ, Waschbusch DA, Dadds MR, Sigvaldason N. Devel-
opment and validation of a short form of the Alabama parenting
questionnaire. J Child Fam Stud. 2007;16(2):243–59.
42. Eshleman SH, Hudelson SE, Ou SS, Redd AD, Swanstrom R,
Porcella SF, et al. Treatment as prevention: characterization of
partner infections in the HIV prevention trials network 052 trial.
J Int AIDS Soc. 2015;18(Supplement 4):18.
43. Wood K, Jewkes RK. Blood blockages and scolding nurses:
barriers to adolescent contraceptive use in South Africa. Reprod
Health Matters. 2006;14(27):109–18.
44. Cluver LD, Boyes ME, Orkin MF, Pantelic M, Molwena T, Sherr
L. Child-focused state cash transfers and adolescent risk of HIV
infection in South Africa: a propensity-score-matched case-con-
trol study. Lancet Glob Health. 2013;1(6):e362–70.
AIDS Behav (2017) 21:2746–2759 2759
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... Free schooling was associated with reduced incidence of transactional sex for females (sex in return for in-kind or financial support by older male partners) (51). Similarly, Toska et al. (52) investigated how combined social protection interventions can affect sexual risk taking in South Africa among female adolescents aged between 16-19. Cash-in-kind transfers as access to school, parental supervision and adolescent-sensitive clinic care were associated with lower rates of unprotected sex (52). ...
... Similarly, Toska et al. (52) investigated how combined social protection interventions can affect sexual risk taking in South Africa among female adolescents aged between 16-19. Cash-in-kind transfers as access to school, parental supervision and adolescent-sensitive clinic care were associated with lower rates of unprotected sex (52). A recent qualitative study done in South Africa also supports the influence of positive caregiving relations (family support and cohesion, emotional connection with caretakers) and cash transfer programmes, in a cash plus model, can reduce adolescent sexual risktaking (53). ...
Full-text available
Social protection is a human right and a key intervention in protecting against poverty and enabling sustainable growth. As new social protection instruments are designed for new challenges, such as external shocks (climate events, natural disasters, pandemics, wars/conflicts, displacement), there is a need to understand programmes better, and to consider gender implications. This scoping review aimed to review knowledge regarding how social protection is implemented to address gender equality and external shock in Africa and what should be considered in the expansion of these programmes.
... 15 Combination service delivery models like DREAMS also offer promising returns on investments-by packaging individual interventions into a streamlined service delivery platform, they can magnify the expected benefits of these same interventions delivered independently, optimizing cost-effectiveness. [16][17][18] Nevertheless, relative to standalone HIV initiatives, combination HIV prevention programs like DREAMS require innovation, flexibility, and integration-characteristics that pose unprecedented challenges to intervention fidelity and sustainability. Given the unique service delivery and implementation context in which DREAMS is situated, implementation science research offers a useful paradigm for examining the implementation trajectory of complex initiatives like DREAMS. ...
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Objective: To identify solutions to the implementation challenges with the DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe women) Partnership in Zambia, this study examines the rollout and evolution of the DREAMS Partnership's implementation. Methods: In September-October 2018, implementing partner (IP) staff (n=15) and adolescent girls and young women (AGYW) participating in DREAMS programming (n=32) completed in-depth interviews exploring early rollout and scale-up of DREAMS, experiences with program participation, and shifting service delivery approaches in response to emerging implementation challenges. Inductive and deductive thematic analysis of 47 interviews uncovered salient service delivery facilitators and barriers in the first 2 years of DREAMS implementation, which were subsequently mapped onto the following domains: reach, effectiveness, adoption, implementation, and maintenance. Results: Key implementation successes identified by IP staff included using standardized recruitment and risk assessment tools across IP organizations, using a mentor model for delivering program content to AGYW, and offering centralized service delivery at venues accessible to AGYW. Implementation challenges identified early in the DREAMS Partnership's lifecycle were rectified through adaptive service delivery strategies. Monthly in-person coordination meetings were established to resolve IP staff jurisdictional disputes over recruitment and target setting. To address high participant attrition, IP staff adopted a cohort approach to sequentially recruit AGYW who enrolled together and provided social support to one another to sustain involvement in DREAMS programming. Prominent barriers to implementation fidelity included challenges recruiting the highest-risk AGYW (e.g., those out of school), limited resources to incentivize participation by young women, and inadequate planning to facilitate absorption of individual DREAMS interventions by the public sector upon project conclusion. Conclusions: Delivering multisectoral HIV prevention programs like DREAMS with fidelity requires a robust implementation infrastructure (e.g., adaptable workplans and harmonized record management systems), early coordination between IP organizations, and sustained financial commitments from donors.
... Lastly, our findings reaffirm several suggestions that have emerged from the literature on adolescent HIV and SRH care, both prior to and during the pandemic (Denno et al., 2021;Grimsrud & Wilkinson, 2021;Huber et al., 2021;Khan et al., 2021;Toska et al., 2017). While this analysis has enabled us to triangulate data from HCWs and AYP themselves in a specific South African district during a time of uncharacteristic stress, it also reasserts key practical actions that should be taken, at scale, to improve quality of care and promote better adolescent HIV and SRH outcomes. ...
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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.
... This group had engaged in a series of advisory and research activities over the prior 12 years, including policy engagement, research design and arts and games-based activities, described elsewhere (Cluver et al., 2021). They also informed the design of a number of large, mixed-methods longitudinal cohorts: a national survey of adolescents (Meinck et al., 2015), a cohort of adolescents living with and without HIV (Toska et al., 2017), a cohort of adolescent mothers and their children (Toska, 2020), randomized controlled trials of parenting support programmes , and research to identify development accelerators for adolescents in Africa (Cluver et al., 2019). ...
Full-text available
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.
The DREAMS (Determined, Resilient, Empowered, AIDS-Free, Mentored, and Safe) Partnership, a public-private partnership launched by the United States President's Emergency Plan for AIDS Relief (PEPFAR), represents the largest investment in comprehensive HIV prevention for adolescent girls and young women (AGYW) ever made in a single global initiative. This paper describes the evolution of programming over time using the triangulation of multiple data sources to develop and refine an impactful program, as well as to improve efficacy and resource investment. Methods of analysis used to evolve this programming include reviews of literature on behavioral, biomedical and structural interventions, and HIV vulnerability; PEPFAR program data; external implementation science and impact studies;observations from site visits; in-depth reviews of program materials; and inputs from AGYW and other stakeholders. Key program improvements made in response to this real-time data use are described, including the rationale for programmatic changes and the evidence base for continual program refinements. This review emphasizes the importance and process of implementing the most effective combination of structural and biomedical HIV prevention programming, based on the best available science, while also adapting to local context in a way that does not compromise effectiveness or violate core implementation principles. Data from research and evaluation are critical to move the HIV prevention field toward more impactful and efficient programming responsive to the lived realities of AGYW. A central tenant to using these data sources effectively is the inclusion of AGYW in decision-making throughout the planning and implementation of programming.
The Philippine HIV crisis disproportionately affects young Filipino men who have sex with men (MSM). MSM accounted for about 80% of all new infections. Hence, this study explored the sociodemographic characteristics, sexual orientation, living arrangements, and mental health conditions that may influence HIV sexual risk behaviors among them. A survey questionnaire was administered to 119 young adult Filipino MSM. It found that the average annual number of sexual partners and instances of unprotected anal intercourse among the respon- dents were 13 and 6, respectively. Living with one’s partner and depression correlated with a higher number of sexual partners and unprotected anal intercourse (p<.05). Contrastingly, these sexual behaviors did not correlate with age, education, employment, income, sexual orientation, anxiety, and alcohol use. These may be due to the negative effect of depression on one’s judgment as well as the limited sex education, con- dom use stigma, gender-based discrimination, and communi- cation difficulty in MSM romantic relationships in the Philippines. Thus, sex education, safe sex practices, PrEP availability, gender equality, and mental health and sexual behavior screening must be strengthened to address the HIV disparity among young Filipino MSM.
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Introduction: Tremendous progress has been made in the global fight against HIV. However, the impact of HIV interventions among adolescent girls and young women is not clear. We aimed to explore the impact of biomedical, behavioural and structural interventions targeted at adolescent girls and young women on HIV incidence and other biomedical, behavioural and structural outcomes in sub-Saharan Africa. Methods: We conducted a systematic review. An online search of various databases such as PsycARTICLES, Embase, Global Health, MEDLINE, and PsycINFO, PubMed, CINAHL, ProQuest, and WHO Afro Library, the Cochrane and Campbell databases and the PROSPERO register of systematic reviews was conducted for studies reporting HIV interventions and outcomes for adolescent girls and young women aged 15-24 years in sub-Saharan Africa. Given the heterogeneity in interventions in terms of context, study group, implementation type, study design, sample size and characteristics, outcome indicators, analysis methods, variations in conditions and geography, it was difficult to compare outcomes across contexts and the studies in this systematic review. The intervention summaries instead highlight patterns within these characteristics but do not seek to explicitly compare the studies. Findings: 73 studies were identified from twelve countries in sub-Saharan Africa, with most interventions taking place in Southern and Eastern Africa. Few studies measured biomedical and/or structural outcomes, while most focused on self-reported behavioural outcomes. Seven biomedical, 31 behavioural and 35 structural interventions were included in this systematic review. Biomedical interventions: Some biomedical interventions have been shown to reduce the transmission of HIV. However, others have had no to little impact on reduction in HIV risk for women due to lack of efficacy, varied uptake and low adherence to pre-exposure prophylaxis, biologic factors, and concerns of potential side effects of the intervention. Implementers must understand the target population requirements, their motivation for enrolling in the study and perceptions of potential benefits. Implementation of multilevel interventions focusing on HIV testing for couples and not only adolescent girls and young women is critical. There must be plans in place to achieve high adherence outside clinical-trial settings, such as the introduction of less user-dependent pre-exposure prophylaxis formulations that do not require daily use. In terms of scaling up, HIV prevention technologies must be accessible, affordable and easy to use and adhere to. Behavioural change interventions: Interventions included in this review had impact on more than one self-reported behavioural and structural outcome. While behavioural change interventions are extremely critical in HIV prevention among adolescent girls and young women, their success is largely dependent on a number of aspects such as: access to financial and human resources; logistical, theoretical and methodological factors; dealing with competing health priorities; and the suitability of the programme to the local context. There is need for evidence-based, contextually specific and cost-effective approaches. Interventions must avoid isolated focus on adolescent girls and young women to include other population groups. Implementers must deal with challenges of self-reports and social desirability by implementing combination prevention interventions. Structural interventions: Most of the evidence on the structural HIV prevention interventions for adolescent girls and young women focused on self-reported behavioural and structural outcomes, with few measuring biomedical outcomes, with current evidence on the impact of conditional incentives mixed. There is need for further research on the mechanism driving divergent results on financial incentives for HIV risk reduction and to understand mechanisms for attaining sustained responses after interventions end. Implementers need to respond to issues around the complexity and costs associated with structural interventions in terms of implementation, policing conditions, feasibility, sustainability, and cost-effectiveness of incentive programmes in resource-constrained countries with limited administrative capacity. It is also critical to address the ethical concerns about removing sources of income from poor adolescent girls and young women in periods of acute vulnerability, such as HIV diagnosis. Conclusions: There has been some success in combating the generalised HIV epidemic. However, adolescent girls and young women in sub-Saharan Africa remain highly vulnerable to HIV infection. We argue for the design of combination prevention strategies, which are contextual, feasible, effective, acceptable and scalable. HIV prevention interventions for adolescent girls and young women need to be informed by the socioecological model of development, which consider childhood factors, individual’s relationship and interaction with their family, peers, sexual and social networks and community and cultural contexts.
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Background Adolescents living with HIV (ALHIV) 15-19 years of age are a growing proportion of all people living with HIV globally and the population includes adolescents with vertically acquired HIV (AVH) and behaviorally acquired HIV (ABH).Methods We conducted a survey to measure sociodemographic characteristics, educational status, health history, and antiretroviral therapy (ART) adherence among a convenience sample of ALHIV at three government health facilities in 2019 in Nampula, Mozambique. ALHIV 15-19 years on ART, including females attending antenatal care, were eligible. Routine HIV care data were extracted from medical charts. Classification of ALHIV by mode of transmission was based on medical charts and survey data. ALHIV who initiated ART
Technical Report
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This is a systematic review that focuses on the impact of HIV prevention interventions targeted at adolescent girls and young women (AGYW) on HIV incidence and other biomedical, behavioural and structural outcomes in sub-Saharan Africa.
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Adolescents are the only age group with growing AIDS-related morbidity and mortality in Eastern and Southern Africa, making HIV prevention research among this population an urgent priority. Structural deprivations are key drivers of adolescent HIV infection in this region. Biomedical interventions must be combined with behavioural and social interventions to alleviate the socio-structural determinants of HIV infection. There is growing evidence that social protection has the potential to reduce the risk of HIV infection among children and adolescents. This research combined expert consultations with a rigorous review of academic and policy literature on the effectiveness of social protection for HIV prevention among children and adolescents, including prevention for those already HIV-positive. The study had three goals: (i) assess the evidence on the effectiveness of social protection for HIV prevention, (ii) consider key challenges to implementing social protection programmes that promote HIV prevention, and (iii) identify critical research gaps in social protection and HIV prevention, in Eastern and Southern Africa. Causal pathways of inequality, poverty, gender and HIV risk require flexible and responsive social protection mechanisms. Results confirmed that HIV-inclusive child-and adolescent-sensitive social protection has the potential to interrupt risk pathways to HIV infection and foster resilience. In particular, empirical evidence (literature and expert feedback) detailed the effectiveness of combination social protection particularly cash/in-kind components combined with “care” and “capability” among children and adolescents. Social protection programmes should be dynamic and flexible, and consider age, gender, HIV-related stigma, and context, including cultural norms, which offer opportunities to improve programmatic coverage, reach and uptake. Effective HIV prevention also requires integrated social protection policies, developed through strong national government ownership and leadership. Future research should explore which combinations of social protection work for sub-groups of children and adolescents, particularly those living with HIV.
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Introduction: Advances in biomedical technologies provide potential for adolescent HIV prevention and HIV-positive survival. The UNAIDS 90-90-90 treatment targets provide a new roadmap for ending the HIV epidemic, principally through antiretroviral treatment, HIV testing and viral suppression among people with HIV. However, while imperative, HIV treatment and testing will not be sufficient to address the epidemic among adolescents in Southern and Eastern Africa. In particular, use of condoms and adherence to antiretroviral therapy (ART) remain haphazard, with evidence that social and structural deprivation is negatively impacting adolescents' capacity to protect themselves and others. This paper examines the evidence for and potential of interventions addressing these structural deprivations. Discussion: New evidence is emerging around social protection interventions, including cash transfers, parenting support and educational support ("cash, care and classroom"). These interventions have the potential to reduce the social and economic drivers of HIV risk, improve utilization of prevention technologies and improve adherence to ART for adolescent populations in the hyper-endemic settings of Southern and Eastern Africa. Studies show that the integration of social and economic interventions has high acceptability and reach and that it holds powerful potential for improved HIV, health and development outcomes. Conclusions: Social protection is a largely untapped means of reducing HIV-risk behaviours and increasing uptake of and adherence to biomedical prevention and treatment technologies. There is now sufficient evidence to include social protection programming as a key strategy not only to mitigate the negative impacts of the HIV epidemic among families, but also to contribute to HIV prevention among adolescents and potentially to remove social and economic barriers to accessing treatment. We urge a further research and programming agenda: to actively combine programmes that increase availability of biomedical solutions with social protection policies that can boost their utilization.
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HIV-positive adolescents who engage in unsafe sex are at heightened risk for transmitting or re-acquiring HIV. Disclosure of HIV-status to sexual partners may impact on condom use, but no study has explored the effects of (i) adolescent knowledge of one's HIV-status, (ii) knowledge of partner status and (iii) disclosure to partners, on safer sex behaviour. This study aimed to identify whether knowledge of HIV-status by HIV-positive adolescents and partners was associated with safer sex. Eight fifty eight HIV-positive adolescents (10–19 years old, 52% female, 68.1% vertically infected) who had ever initiated antiretroviral treatment in 41 health facilities in the Eastern Cape, South Africa, were interviewed using standardised questionnaires. Quantitative analyses used multivariate logistic regressions, controlling for confounders. Qualitative research included interviews, focus group discussions and observations with 43 HIV-positive teenagers and their healthcare workers. N = 128 (14.9%) of the total sample had ever had sex, while N = 109 (85.1%) of sexually active adolescents had boy/girlfriend. In total, 68.1% of the sample knew their status, 41.5% of those who were sexually active and in relationships knew their partner's status, and 35.5% had disclosed to their partners. For adolescents, knowing one's status was associated with safer sex (OR = 4.355, CI 1.085–17.474, p = .038). Neither knowing their partner's status, nor disclosing one's HIV-status to a partner, were associated with safer sex. HIV-positive adolescents feared rejection, stigma and public exposure if disclosing to sexual and romantic partners. Counselling by healthcare workers for HIV-positive adolescents focused on benefits of disclosure, but did not address the fears and risks associated with disclosure. These findings challenge assumptions that disclosure is automatically protective in sexual and romantic relationships for HIV-positive adolescents, who may be ill-equipped to negotiate safer sex. There is a pressing need for effective interventions that mitigate the risks of disclosure and provide HIV-positive adolescents with skills to engage in safe sex.
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WHO guidelines recommend disclosure to HIV-positive children by school age in order to improve antiretroviral therapy (ART) adherence. However, quantitative evidence remains limited for adolescents. This study examines associations between adolescent knowledge of HIV-positive status and ART-adherence in South Africa. A cross-sectional study of the largest known community-traced sample of HIV-positive adolescents. Six hundred and eighty-four ART-initiated adolescents aged 10-19 years (52% female, 79% perinatally infected) were interviewed. In a low-resource health district, all adolescents who had ever initiated ART in a stratified sample of 39 health facilities were identified and traced to 150 communities [n = 1102, 351 excluded, 27 deceased, 40 (5.5%) refusals]. Quantitative interviews used standardized questionnaires and clinic records. Quantitative analyses used multivariate logistic regressions, and qualitative analyses used grounded theory for 18 months of interviews, focus groups and participant observations with 64 adolescents, caregivers and healthcare workers. About 36% of adolescents reported past-week ART nonadherence, and 70% of adolescents knew their status. Adherence was associated with fewer opportunistic infection symptoms [odds ratio (OR) 0.55; 95% CI 0.40-0.76]. Adolescent knowledge of HIV-positive status was associated with higher adherence, independently of all cofactors (OR 2.18; 95% CI 1.47-3.24). Among perinatally infected adolescents who knew their status (n = 362/540), disclosure prior to age 12 was associated with higher adherence (OR 2.65; 95% CI 1.34-5.22). Qualitative findings suggested that disclosure was undertaken sensitively in clinical and family settings, but that adults lacked awareness about adolescent understandings of HIV status. Early and full disclosure is strongly associated with improved adherence amongst ART-initiated adolescents. Disclosure may be an essential tool in improving adolescent adherence and reducing mortality and onwards transmission.
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Background: South Africa (SA) has the highest burden of childhood HIV infection globally, and has high rates of adolescent and youth pregnancy. Objective: To explore risks associated with pregnancy in young HIV-infected women, we compared mother-to-child transmission (MTCT) of HIV and maternal and infant health outcomes according to maternal age categories. Methods: A cohort of HIV-positive pregnant women and their infants were followed up at three sentinel surveillance facilities in the Nelson Mandela Bay Metropolitan (NMBM) district, Eastern Cape Province, SA. Young women were defined as 24 years old and adolescents as 19 years. The effect of younger maternal age categories on MTCT and maternal and child health outcomes was assessed using log-binomial and Cox regression controlling for confounding, using women aged > 24 years as the comparison group. Results: Of 956 mothers, 312 (32.6%) were young women; of these, 65 (20.8%) were adolescents. The proportion of young pregnant women increased by 24% between 2009/10 and 2011/12 (from 28.3% to 35.1%). Young women had an increased risk of being unaware of their HIV status when booking (adjusted risk ratio (aRR) 1.37; 95% confidence interval (CI) 1.21 - 1.54), a reduced rate of antenatal antiretroviral therapy (ART) uptake (adjusted hazard ratio 0.46; 95% CI 0.31 - 0.67), reduced early infant HIV diagnosis (aRR 0.94; 95% CI 0.94 - 0.94), and increased MTCT (aRR 3.07; 95% CI 1.18 - 7.96; adjusted for ART use). Of all vertical transmissions, 56% occurred among young women. Additionally, adolescents had increased risks of first presentation during labour (aRR 3.78; 95% CI 1.06 - 13.4); maternal mortality (aRR 35.1; 95% CI 2.89 - 426) and stillbirth (aRR 3.33; 95% CI 1.53 - 7.25). Conclusion: An increasing proportion of pregnant HIV-positive women in NMBM were young, and they had increased MTCT and poorer maternal and infant outcomes than older women. Interventions targeting young women are increasingly needed to reduce pregnancy, HIV infection and MTCT and improve maternal and infant outcomes if SA is to attain its Millennium Development Goals.
A third of adolescent girls in South Africa become pregnant before the age of 20, despite contraception being free and mostly accessible. This qualitative study was undertaken in Limpopo Province in 1997 on the barriers to adolescent girls accessing clinic services for contraception. Thirty-five in-depth interviews and five group discussions were conducted with girls aged 14—20, and interviews with nursing staff at 14 clinics. Many of the girls described pressure from male partners and family members to have a baby or prove their fertility. Other barriers to sustained contraceptive use included medically inaccurate notions about how conception occurs and fears about the effects of contraception on fertility and menstruation, which were not taken seriously by nurses. Nurses' attempts to stigmatise teenage sexuality, their scolding and harsh treatment of adolescent girls, and their unwillingness to acknowledge adolescents' experiences as contraceptive users, undermined the effective use of contraception by girls. Youth need better information on reproductive physiology and sexual health, and detailed information on contraception. Tools to enhance the accuracy and availability of knowledge in the clinic setting have a role, but need to be introduced along with initiatives to ensure that services are adolescent-friendly and do not stigmatise adolescent sexual activity. Résumé En Afrique du Sud, un tiers des adolescentes sont enceintes avant l'âge de 20 ans, malgré la gratuité et l'accessibilité de la contraception. Cette étude qualitative, réalisée dans la province de Limpopo en 1997, a analysé les obstacles empêchant les adolescentes d'accéder aux services de contraception. Elle a mené 35 entretiens et 5 discussions de groupe avec des jeunes filles de 14 à 20 ans, et des entretiens avec des infirmières dans 14 dispensaires. Beaucoup d'adolescentes ont décrit les pressions de leurs partenaires et des membres de la famille qui les incitent à avoir un bébé ou à prouver leur fécondité. L'utilisation suivie de contraceptifs était aussi entravée par des notions erronées sur la conception et des craintes quant aux conséquences de la contraception sur la fécondité et les menstruations, que les infirmières ne prenaient pas au sérieux. Les tentatives des infirmières de stigmatiser la sexualité des jeunes, leurs réprimandes, leur brusquerie et leur refus de tenir compte des expériences des adolescentes comme utilisatrices de contraceptifs contrariait l'utilisation efficace de la contraception chez les adolescentes. Les jeunes doivent être mieux informés de la physiologie reproductive, de la santé génésique et de la contraception. Des outils pour améliorer la fiabilité et la disponibilité de connaissances dans les dispensaires jouent un rôle, mais doivent être introduits parallèlement à des initiatives pour que les services soient adaptés aux adolescents et ne stigmatisent pas l'activité sexuelle des adolescents. Resumen Una tercera parte de las adolescentes en Sudáfrica quedan embarazadas antes de cumplir los 20 años, pese a que los anticonceptivos son gratis y accesibles. Este estudio cualitativo sobre las barreras que enfrentan las adolescentes al intentar acceder a los servicios clínicos de anticoncepción, se llevó a cabo en la Provincia Limpopo, en 1997. Se realizaron 35 entrevistas a profundidad y cinco discusiones en grupo con mujeres jóvenes entre 14 y 20 años, así como entrevistas con el personal de enfermería de 14 consultorios. Muchas de las jóvenes informaron presión de sus parejas y familiares para tener un bebé. Otras barreras al uso sostenido de anticonceptivos fueron: creencias erróneas sobre cómo ocurre la anticoncepción y temores sobre los efectos de anticonceptivos en la fertilidad y la menstruación, las cuales las enfermeras no tomaron en serio. Los efectos de los intentos de las enfermeras de estigmatizar la sexualidad de las jóvenes, sus regaños y trato duro de las mismas, y su renuencia a reconocer las experiencias de éstas como usuarias de anticonceptivos, debilitaron el uso eficaz de la anticoncepción por parte de las jóvenes. La juventud necesita mejor información sobre la fisiología reproductiva y la salud sexual, y datos detallados sobre los anticonceptivos. Las herramientas para mejorar la exactitud y disponibilidad del conocimiento en el ámbito clínico desempeñan un papel, pero se deben introducir junto con iniciativas para garantizar que los servicios sean amigables a las adolescentes y no estigmaticen su actividad sexual.
With increased access to HIV treatment throughout Africa, a generation of HIV positive children is now transitioning to adulthood while living with a chronic condition requiring lifelong medication, which can amplify the anxieties of adolescence. This qualitative study explored how adolescents in Tanzania with HIV experience their nascent sexuality, as part of an evaluation of a home-based care programme. We interviewed 14 adolescents aged 15–19 who had acquired HIV perinatally, 10 of their parents or other primary caregivers, and 12 volunteer home-based care providers who provided support, practical advice, and referrals to clinical services. Adolescents expressed unease about their sexuality, fearing that sex and relationships were inappropriate and hazardous, given their HIV status. They worried about having to disclose their status to partners, the risks of infecting others and for their own health. Thus, many anticipated postponing or avoiding sex indefinitely. Caregivers and home-based care providers reinforced negative views of sexual activity, partly due to prevailing misconceptions about the harmful effects of sex with HIV. The adolescents had restricted access to accurate information, appropriate guidance, or comprehensive reproductive health services and were likely to experience significant unmet need as they initiated sexual relationships. Care programmes could help to reduce this gap by facilitating open communication about sexuality between adolescents and their caregivers, providers, and HIV-positive peers. Résumé Grâce à l'accès élargi au traitement du VIH en Afrique, une génération d'enfants séropositifs entre maintenant dans l'âge adulte tout en vivant avec une affection chronique qui demande une médication tout au long de la vie, ce qui peut amplifier les angoisses de l'adolescence. Cette étude qualitative s'est demandé comment les adolescents avec le VIH vivent leur sexualité naissante en Tanzanie, dans le cadre de l'évaluation d'un programme de soins à domicile. Nous avons interrogé 14 adolescents âgés de 15 à 19 ans contaminés par le VIH durant la période périnatale, 10 de leurs parents ou autres responsables principaux et 12 bénévoles prestataires de soins à domicile qui leur apportaient un soutien et des conseils pratiques, et les aiguillaient vers des services cliniques. Les adolescents ressentaient un malaise à propos de leur sexualité et craignaient que les rapports sexuels soient inappropriés et risqués, compte tenu de leur séropositivité. Ils appréhendaient de devoir révéler leur statut aux partenaires, s'inquiétaient du risque d'infection et craignaient pour leur propre santé. Beaucoup prévoyaient donc de reporter indéfiniment ou d'éviter les rapports sexuels. Les proches et les prestataires de soins à domicile renforçaient les idées négatives sur l'activité sexuelle, en partie du fait des préjugés dominants sur les conséquences néfastes de la sexualité avec le VIH. Les adolescents disposaient d'un accès restreint à des informations exactes, à des conseils adaptés ou à des services complets de santé génésique et risquaient de connaître d'importants besoins non satisfaits au moment où ils deviendraient sexuellement actifs. Les programmes de soins pourraient combler ces manques en facilitant une communication ouverte sur la sexualité entre les adolescents et les personnes qui s'occupent d'eux, les prestataires de soins et les pairs séropositifs. Resumen Con mayor acceso al tratamiento del VIH en toda Ãfrica, una generación de niños VIH-positivos ahora está pasando a la adultez a la vez que vive con una enfermedad crónica que requiere medicamentos de por vida, lo cual puede amplificar las ansiedades de la adolescencia. En este estudio cualitativo en Tanzania se exploró cómo la adolescencia con VIH experimenta su sexualidad incipiente, como parte de una evaluación de un programa de cuidados domiciliarios. Entrevistamos a 14 adolescentes de 15 a 19 años de edad, que habían adquirido el VIH por transmisión perinatal, 10 de sus padres u otros cuidadores principales y 12 voluntarios proveedores de cuidados domiciliarios, quienes brindaron apoyo, consejos prácticos y referencias a servicios clínicos. Los adolescentes expresaron inquietud respecto a su sexualidad, por temor de que el sexo y las relaciones fueran inapropiados y peligrosos, en vista de su estado de VIH. Se preocupaban por tener que revelar su estado a sus parejas, por los riesgos de infectar a otras personas y por su propia salud. Por ello, muchos de ellos previeron tener que aplazar o evitar las relaciones sexuales por tiempo indefinido. Los cuidadores y prestadores de servicios domiciliarios reforzaron los puntos de vista negativos sobre la actividad sexual, en parte debido a ideas erróneas imperantes respecto a los efectos dañinos de tener sexo con VIH. Los adolescentes tenían acceso limitado a información exacta, orientación correspondiente, o servicios integrales de salud reproductiva y probablemente tenían una importante necesidad insatisfecha según iniciaban sus relaciones sexuales. Los programas de tratamiento del VIH podrían ayudar a llenar esta brecha al facilitar comunicación abierta sobre la sexualidad entre adolescentes y sus cuidadores, prestadores de servicios de salud y pares VIH-positivos.
HIV Prevention Trials Network (HPTN) 052 demonstrated that antiretroviral therapy (ART) prevents HIV transmission in serodiscordant couples. HIV from index-partner pairs was analyzed to determine the genetic linkage status of partner infections. Forty-six infections were classified as linked, indicating that the index was the likely source of the partner's infection. Lack of viral suppression and higher index viral load were associated with linked infection. Eight linked infections were diagnosed after the index started ART: four near the time of ART initiation and four after ART failure. Linked infections were not observed when the index participant was stably suppressed on ART.
Background: Social protection (ie, cash transfers, free schools, parental support) has potential for adolescent HIV prevention. We aimed to identify which social protection interventions are most effective and whether combined social protection has greater effects in South Africa. Methods: In this prospective longitudinal study, we interviewed 3516 adolescents aged 10-18 between 2009 and 2012. We sampled all homes with a resident adolescent in randomly selected census areas in 4 urban and rural sites in 2 South African provinces. We measured household receipt of 14 social protection interventions and incidence of HIV-risk behaviors. Using gender-disaggregated multivariate logistic regression and marginal effects analyses, we assessed respective contributions of interventions and potential combination effects. Results: Child-focused grants, free schooling, school feeding, teacher support, and parental monitoring were independently associated with reduced HIV-risk behavior incidence (odds ratio: 0.10-0.69). Strong effects of combination social protection were shown, with cumulative reductions in HIV-risk behaviors. For example, girls' predicted past-year incidence of economically driven sex dropped from 11% with no interventions to 2% among those with a child grant, free school, and good parental monitoring. Similarly, girls' incidence of unprotected/casual sex or multiple partners dropped from 15% with no interventions to 10% with either parental monitoring or school feeding, and to 7% with both interventions. Conclusion: In real world, high-epidemic conditions, "combination social protection," shows strong HIV prevention effects for adolescents and may maximize prevention efforts.