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AbstractIntroduction: Internalized HIV stigma is a key risk factor for negative outcomes amongst adolescents living with HIV (ALHIV), including non‐adherence to anti‐retroviral treatment, loss‐to‐follow‐up and morbidity. This study tested a theoretical model of multi‐level risk pathways to internalized HIV stigma among South African ALHIV.Methods: From 2013 to 2015, a survey using total population sampling of ALHIV who had ever initiated anti‐retroviral treatment (ART) in 53 public health facilities in the Eastern Cape, South Africa was conducted. Community‐tracing ensured inclusion of ALHIV who were defaulting from ART or lost to follow‐up. 90.1% of eligible ALHIV were interviewed (n = 1060, 55% female, mean age = 13.8, 21% living in rural locations). HIV stigma mechanisms (internalized, enacted, and anticipated), HIV‐related disability, violence victimization (physical, emotional, sexual abuse, bullying victimization) were assessed using well‐validated self‐report measures. Structural equation modelling was used to test a theoretically informed model of risk pathways from HIV‐related disability to internalized HIV stigma. The model controlled for age, gender and urban/rural address.Results: Prevalence of internalized HIV stigma was 26.5%. As hypothesized, significant associations between internalized stigma and anticipated stigma, as well as depression were obtained. Unexpectedly, HIV‐related disability, victimization, and enacted stigma were not directly associated with internalized stigma. Instead significant pathways were identified via anticipated HIV stigma and depression. The model fitted the data well (RMSEA = .023; CFI = .94; TLI = .95; WRMR = 1.070).Conclusions: These findings highlight the complicated nature of internalized HIV stigma. Whilst it is seemingly a psychological process, indirect pathways suggest multi‐level mechanisms leading to internalized HIV stigma. Findings suggest that protection from violence within homes, communities and schools may interrupt risk pathways from HIV‐related health problems to psychological distress and internalized HIV stigma. This highlights the potential for interventions that do not explicitly target adolescents living with HIV but are sensitive to their needs.

AbstractResearch in high‐income countries has identified an array of risk factors for youth antisocial behavior. However, in low‐ and middle‐income countries, despite higher prevalence of offending and antisocial behavior, there is a paucity of prospective, longitudinal evidence examining predictors. South Africa is a middle‐income country with high rates of violence and crime, and a unique social context, characterized by striking income and gender inequality, and increasing number of children orphaned by AIDS. We tested predictors of antisocial behavior at community, family, and individual levels over four years. One thousand and twenty five adolescents from poor, urban South African settlements were assessed in 2005 (50 percent female; M = 13.4 years) and followed up in 2009. The sample analyzed consisted of the 723 youth (71 percent) assessed at both time points. We employed sociodemographic questionnaires and standardized scales. Validity of our antisocial behavior measure was supported by cross‐sectional associations with well‐evidenced concomitants of youth antisocial behavior, including drug taking and truancy. Regression analysis indicated that male gender and experience of community violence, but not poverty or abuse, predicted antisocial behavior. Despite many South African youth experiencing abuse and poverty at the family level, our findings suggest that high levels of violence in communities may be a more important factor contributing to the development of antisocial behavior, particularly among males.

IntroductionSocial protection is high on the HIV‐prevention agenda for youth in sub‐Saharan Africa. However, questions remain: How do unconditional cash transfers work? What is the effect of augmenting cash provision with social care? And can "cash plus care" social protection reduce risks for adolescents most vulnerable to infection? This study tackles these questions by first identifying mediated pathways to adolescent HIV risks and then examining potential main and moderating effects of social protection in South Africa.MethodsThis study was a prospective observational study of 3515 10‐to‐17‐year‐olds (56.7% female; 96.8% one‐year retention). Within randomly selected census areas in four rural and urban districts in two South African provinces, all homes with a resident adolescent were sampled between 2009/2010 and 2011/2012. Measures included 1) potential structural drivers of HIV infection such as poverty and community violence; 2) HIV risk behaviours; 3) hypothesized psychosocial mediating factors; and 4) types of social protection involving cash and care. Using gender‐disaggregated analyses, longitudinal mediation models were tested for potential main and moderating effects of social protection.ResultsStructural drivers were associated with increased onset of adolescent HIV risk behaviour (p<0.001, B=0.06, SE=0.01), fully mediated by increased psychosocial problems. Both cash and care aspects of social protection were associated with reductions in HIV risk behaviour and psychosocial deprivations. In addition, cash social protection moderated risk pathways: for adolescent girls and boys experiencing more acute structural deprivation, social protection had the greatest associations with HIV risk prevention (e.g. moderation effects for girls: B=−0.08, p<0.002 between structural deprivation and psychosocial problems, and B=−0.07, p<0.001 between psychosocial problems and HIV risk behaviour).ConclusionsAdolescents with the greatest structural deprivation are at higher risk of HIV, but social protection has the greatest prevention effects for the most vulnerable. Social protection comprising unconditional cash plus care was associated with reduced risk pathways through moderation and main effects, respectively. Our findings suggest the importance of social protection within a combination package of HIV‐prevention approaches.

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 ...

Purpose: Violence against children increases in adolescence, but there is a research and practice gap in research-supported child abuse prevention for the adolescent years. A pilot program for low-resource settings was developed in collaboration with nongovernmental organizations, government, and academics in South Africa, using research-supported principles. Method: This study used a pre-post design to test initial effects of a 10-session parenting program with 60 participants (30 caregiver–adolescent dyads) in high-poverty rural South Africa. Areas requiring further testing and adaptation were also identified. Results: Pre-post findings show medium to large program effects in reducing child abuse and adolescent problem behavior, as well as large effects in improvements of positive parenting, and perceived parent and adolescent social support. Discussion: There is potential to reduce child abuse, improve parenting, and reduce adolescent problem behavior in rural South Africa through parenting programs. Further development, testing and longer term follow-up are required to ascertain potential for scale-up.