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BACKGROUND: Mental health problems may impact adherence to anti-retroviral treatment, retention in care, and consequently the survival of adolescents living with HIV. The adolescent-caregiver relationship is an important potential source of resilience. However, there is a lack of longitudinal research in sub-Saharan Africa on which aspects of adolescent-caregiver relationships can promote mental health among adolescents living with HIV. We draw on a prospective longitudinal cohort study undertaken in South Africa to address this question. METHODS: The study traced adolescents aged 10–19 initiated on antiretroviral treatment in government health facilities (n = 53) within a health district of the Eastern Cape province. The adolescents completed standardised questionnaires during three data collection waves between 2014 and 2018. We used within-between multilevel regressions to examine the links between three aspects of adolescent-caregiver relationships (caregiver supervision, positive caregiving, and adolescent-caregiver communication) and adolescent mental health (depression symptoms and anxiety symptoms), controlling for potential confounders (age, sex, rural/urban residence, mode of infection, household resources), n=926 adolescents. RESULTS: Improvements in caregiver supervision were associated with reductions in anxiety (0.98, 95% CI 0.97–0.99, p=0.0002) but not depression symptoms (0.99, 95% CI 0.98–1.00, p=.151), while changes in positive caregiving were not associated with changes in mental health symptoms reported by adolescents. Improvements in adolescent-caregiver communication over time were associated with reductions in both depression (IRR=0.94, 95% CI 0.92–0.97, p<.0001) and anxiety (0.91, 95% CI 0.89–0.94, p<.0001) symptoms reported by adolescents. CONCLUSIONS: Findings highlight open and supportive adolescent-caregiver communication and good caregiver supervision as potential factors for guarding against mental health problems among adolescents living with HIV in South Africa. Several ...

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 take into account 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. ...

In order to respond more effectively to the health of young people in South Africa, in 2017 the National Department of Health of South Africa released the National Adolescent & Youth Health Policy. The Policy focused on a range of health problems and recommended interventions for delivery through multiple settings and government departments. It also included specific recommendations to empower and involve young people in policy and programme implementation. Adaptation of a short course on adolescent health in lowand middle-income countries, organized annually by the London School of Hygiene and Tropical Medicine and the World Health Organization, was piloted in 2017 as one means of contributing to the implementation of the Policy. The Adolescent & Youth Health Policy short course was subsequently offered in 2018 and 2019, attracting 96 participants working on adolescent health in various organizations at national and provincial levels throughout the country. Most participants (75%) successfully completed the course, as assessed by the completion criteria that had been defined. The range of topics for the assignments selected by the participants over the 3 years reflected both the content and intent of the Policy. The evaluations of the short course indicate that it helped to create legitimacy and strengthen the capacity of various constituencies, both of which are important prerequisites for policy implementation.

OBJECTIVE: Adolescent antiretroviral treatment (ART) adherence remains critically low. We lack research testing protective factors across both clinic and care environments. DESIGN: A prospective cohort of adolescents living with HIV (sample n = 969, 55% girls, baseline mean age 13.6) in the Eastern Cape Province in South Africa were interviewed at baseline and 18-month follow-up (2014–2015, 2015–2016). We traced all adolescents ever initiated on treatment in 52 government health facilities (90% uptake, 93% 18-month retention, 1.2% mortality). METHODS: Clinical records were collected; standardized questionnaires were administered by trained data collectors in adolescents' language of choice. Probit within-between regressions and average adjusted probability calculations were used to examine associations of caregiving and clinic factors with adherence, controlling for household structure, socioeconomic and HIV factors. RESULTS: Past-week ART adherence was 66% (baseline), 65% (follow-up), validated against viral load in subsample. Within-individual changes in three factors were associated with improved adherence: no physical and emotional violence (12.1 percentage points increase in adjusted probability of adherence, P < 0.001), improvement in perceived healthcare confidentiality (7.1 percentage points, P < 0.04) and shorter travel time to the clinic (13.7 percentage points, P < 0.02). In combination, improvement in violence prevention, travel time and confidentiality were associated with 81% probability of ART adherence, compared with 47% with a worsening in all three. CONCLUSION: Adolescents living with HIV need to be safe at home and feel safe from stigma in an accessible clinic. This will require active collaboration between health and child protection systems, and utilization of effective violence prevention interventions.

Abstract
Background
With 60% of Africa's population under the age of 25 years, investing in youth will accelerate progress towards achieving the Sustainable Development Goals (SDGs). The United Nations concept of 'Development Accelerators' is operationalized by examining factors associated with multiple SDGs among adolescents in Nigeria.

Methodology
Through data collected on the health of 1800 adolescents in Southwest Nigeria (Ibadan), ten SDG targets were identified. Accelerator protective factors that could lead to the attainment of two or more SDG targets were identified. Associations were assessed using multivariable logistic regression adjusting for sociodemographic covariates and multiple testing. Cumulative effects were tested by marginal effects modelling.

Results
Participants' mean age was 15.02 years (SD = 2.27). Family (parenting support), environmental (no survival work and food security) and school (safe schools) related factors emerged as development accelerators. For seven of the identified SDG-aligned targets, a combination of two or more accelerator factors showed cumulative positive associations, suggesting accelerator synergies with a combination of three accelerators showing the greatest increase. For instance, perceiving the school environment as safe, being food secure and having optimal mental health was associated with an 67% chance of not using psychoactive substances. While with safe school alone it was 39% (29%-51%), with food security alone it was 42% (31%-54%) and with optimal mental health alone it was 54% (42%-66%).

Conclusion
Several development accelerators related to family, environmental and school factors can have additive effects on the attainment of the SDGs amongst adolescents in Nigeria. This has practical and policy utility in the fastest growing economy in Africa.

Recent data protection regulatory frameworks, such as the Protection of Personal Information Act (POPI Act) in South Africa and the General Data Protection Regulation (GDPR) in the European Union, impose governance requirements for research involving high-risk and vulnerable groups such as children and adolescents. Our paper's objective is to unpack what constitutes adequate safeguards to protect the personal information of vulnerable populations such as children and adolescents. We suggest strategies to adhere meaningfully to the principal aims of data protection regulations. Navigating this within established research projects raises questions about how to interpret regulatory frameworks to build on existing mechanisms already used by researchers. Therefore, we will explore a series of best practices in safeguarding the personal information of children, adolescents and young people (0-24 years old), who represent more than half of sub-Saharan Africa's population. We discuss the actions taken by the research group to ensure regulations such as GDPR and POPIA effectively build on existing data protection mechanisms for research projects at all stages, focusing on promoting regulatory alignment throughout the data lifecycle. Our goal is to stimulate a broader conversation on improving the protection of sensitive personal information of children, adolescents and young people in sub-Saharan Africa. We join this discussion as a research group generating evidence influencing social and health policy and programming for young people in sub-Saharan Africa. Our contribution draws on our work adhering to multiple transnational governance frameworks imposed by national legislation, such as data protection regulations, funders, and academic institutions.

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

AbstractIntroductionAdolescent girls and young women, including adolescent mothers, in Southern Africa have high HIV seroconversion and transmission. We need to know which risks drive HIV infections, and what can reduce these risks.MethodsWe interviewed 1712 adolescent girls and young women (11–23 years), including 1024 adolescent mothers who had conceived before age 20 and had a living child, from two health municipalities of South Africa's Eastern Cape Province between March 2018 and July 2019. Recruitment was through multiple community, school and health facility channels. Associations between adolescent motherhood and seven HIV risk behaviours (multiple sexual partners, transactional sex, age‐disparate sex, condomless sex, sex on substances, alcohol use and not in education or employment) were investigated using the generalized estimating equations method for multiple outcomes specified with a logit link and adjusting for nine covariates. Using the same model, we investigated associations between having enough food at home every day in the past week (food security) and the same seven HIV risk behaviours. When we found evidence of moderation by HIV status, we report stratum‐specific odds ratios.ResultsMean age was 17.51 years (SD: 2.54), 46% participants were living with HIV. Compared to non‐mothers, adolescent mothers had lower odds of alcohol use (AOR = 0.47, 95% CI = 0.29–0.75), but higher odds of multiple sexual partners (AOR = 1.93, 95% CI = 1.35–2.74), age‐disparate sex (HIV‐uninfected AOR = 1.73, 95% CI = 1.03–2.91; living with HIV AOR = 5.10, 95% CI = 2.98–8.73), condomless sex (AOR = 8.20, 95% CI = 6.03–11.13), sex on substances (AOR = 1.88, 95% CI = 1.10–3.21) and not in education/employment (HIV‐uninfected AOR = 1.83, 95% CI = 1.19–2.83; living with HIV AOR = 6.30, 95% CI = 4.09–9.69). Among non‐mothers, food security was associated with lower odds of multiple sexual partners (AOR = 0.45, 95% CI = 0.26–0.78), transactional sex (AOR = 0.32, 95% CI = 0.13–0.82) and not in education/employment (AOR = 0.48, 95% CI = 0.29–0.77). Among adolescent mothers, food security was associated with lower odds of transactional sex (AOR = 0.17, 95% CI = 0.10–0.28), age‐disparate sex (AOR = 0.66, 95% CI = 0.47–0.92), sex on substances (AOR = 0.51, 95% CI = 0.32–0.82), alcohol use (AOR = 0.45, 95% CI = 0.25–0.79) and not in education/employment (AOR = 0.56, 95% CI = 0.40–0.78).ConclusionsAdolescent motherhood is associated with multiple vulnerabilities to HIV infection and transmission. Social protection measures that increase food security are likely to reduce HIV risk pathways for adolescent girls and young women, especially adolescent mothers.