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AbstractIntroductionWhile biomedical HIV prevention offers promise for preventing new HIV infections, access to and uptake of these technologies remain unacceptably low in some settings. New models for delivery of HIV prevention are clearly needed. This commentary highlights the potential of person‐centred programming and research for increasing the cultural relevance, applicability and use of efficacious HIV prevention strategies. It calls for a shift in perspective within HIV prevention programmes and research, whereby people are recognized for their agency rather than assumed to be passive beneficiaries or research participants.DiscussionPerson‐centred HIV prevention reorientates power dynamics so that individuals (rather than interventions) are at the centre of the response. Respecting personal choice and agency – and understanding how these are shaped by the context in which people exercise these choices – are critical dimensions of the person‐centred approach. Community‐based participatory research should be employed to inform and evaluate person‐centred HIV prevention. We argue that community‐based participatory research is an orientation rather than a method, meaning that it can be integrated within a range of research methods including randomized controlled trials. But embracing community‐based participatory approaches in HIV prevention research requires a systemic shift in how this type of research is reported in high impact journals and in how research impact is conceived. Community‐based organizations have a critical role to play in both person‐centred HIV prevention and research.ConclusionsHIV prevention is situated at the intersection of unprecedented opportunity and crisis. Person‐centred approaches to HIV prevention and research shift power dynamics, and have the potential to ensure a more sustainable response with each individual actively participating in their own care and meaningfully contributing to the production of knowledge on HIV prevention. This approach taps into the resourcefulness, resilience and knowledge of the person and their communities, to strengthen research and programmes, making them more relevant, appropriate and effective.

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.

AbstractIntroductionEfficacious antiretroviral treatment (ART) enables people to live long and healthy lives with HIV but young people are dying from AIDS‐related causes more than ever before. Qualitative evidence suggest that various forms of HIV‐related discrimination and resulting shame act as profound barriers to young people's engagement with HIV services. However, the impact of these risks on adolescent retention in HIV care has not been quantified. This study has two aims: (1) to examine whether and how different types of discrimination compromise retention in care among adolescents living with HIV in South Africa; and (2) to test whether internalized stigma mediates these relationships.MethodsBetween 2014 and 2017, adolescents living with HIV (aged 10 to 19) from 53 health facilities in the Eastern Cape, South Africa, were interviewed at baseline (n = 1059) and 18‐month follow‐up (n = 979, 92.4%), with responses linked to medical records. Data were analysed through multiple regression and mediation models.ResultsAbout 37.9% of adolescents reported full retention in care over the 2‐year period, which was associated with reduced odds of viral failure (OR: 0.371; 95% CI: .224, .614). At baseline, 6.9% of adolescents reported discrimination due to their HIV status; 14.9% reported discrimination due to HIV in their families and 19.1% reported discrimination in healthcare settings. Healthcare discrimination was associated with reduced retention in care both directly (effect: −0.120; CI: −0.190, −0.049) and indirectly through heightened internalized stigma (effect: 0.329; 95% CI: 0.129, 0.531). Discrimination due to family HIV was associated with reduced retention in care both directly (effect: −0.074, CI: −0.146, −0.002) and indirectly through heightened internalized stigma (effect: 0.816, CI: 0.494, 1.140). Discrimination due to adolescent HIV was associated with reduced retention in care only indirectly, through increased internalized stigma (effect: 0.408; CI: 0.102, 0.715).ConclusionsLess than half of adolescents reported 2‐year retention in HIV care. Multiple forms of discrimination and the resultant internalized stigma contributed to this problem. More intervention research is urgently needed to design and test adolescent‐centred interventions so that young people living with HIV can live long and healthy lives in the era of efficacious anti‐retroviral treatment.

AbstractIntroductionThe Sustainable Development Goals (SDGs) present a groundbreaking global development agenda to protect the most vulnerable. Adolescents living withHIVin Sub‐Saharan Africa continue to experience extreme health vulnerabilities, but we know little about the impacts ofSDG‐aligned provisions on their health. This study tests associations of provisions aligned with fiveSDGs with potential mortality risks.MethodsClinical and interview data were gathered from N = 1060 adolescents living withHIVin rural and urban South Africa in 2014 to 2015. AllART‐initiated adolescents from 53 government health facilities were identified, and traced in their communities to include those defaulting and lost‐to‐follow‐up. Potential mortality risk was assessed as either: viral suppression failure (1000+ copies/ml) using patient file records, or adolescent self‐report of diagnosed but untreated tuberculosis or symptomatic pulmonary tuberculosis.SDG‐aligned provisions were measured through adolescent interviews. Provisions aligned withSDGs 1&2 (no poverty and zero hunger) were operationalized as access to basic necessities, social protection and food security; AnSDG3‐aligned provision (ensure healthy lives) was having a healthy primary caregiver; AnSDG8‐aligned provision (employment for all) was employment of a household member; AnSDG16‐aligned provision (protection from violence) was protection from physical, sexual or emotional abuse. Research partners included the South African national government,UNICEFand Pediatric and Adolescent Treatment for Africa.Results20.8% of adolescents living withHIVhad potential mortality risk – i.e. viral suppression failure, symptomatic untreatedTB, or both. AllSDG‐aligned provisions were significantly associated with reduced potential mortality risk:SDG1&2 (OR0.599CI0.361 to 0.994);SDG3 (OR0.577CI0.411 to 0.808);SDG8 (OR0.602CI0.440 to 0.823) andSDG16 (OR0.686CI0.505 to 0.933). Access to multipleSDG‐aligned provisions showed a strongly graded reduction in potential mortality risk: Among adolescents living withHIV, potential mortality risk was 38.5% with access to noSDG‐aligned provisions, and 9.3% with access to all four.ConclusionsSDG‐aligned provisions across a range ofSDGs were associated with reduced potential mortality risk among adolescents living withHIV. Access to multiple provisions has the potential to substantially improve survival, suggesting the value of connecting and combiningSDGs in our response to paediatric and adolescentHIV.

AbstractIntroductionThere are two million HIV‐positive adolescents in southern Africa, and this group has low retention in care and high mortality. There is almost no evidence to identify which healthcare factors can improve adolescent self‐reported retention. This study examines factors associated with retention amongst antiretroviral therapy (ART)‐initiated adolescents in South Africa.MethodsWe collected clinical records and detailed standardized interviews (n = 1059) with all 10‐ to 19 year‐olds ever initiated on ART in all 53 government clinics of a health subdistrict, and community traced to include lost‐to‐follow‐up (90.1% of eligible adolescents interviewed). Associations between full self‐reported retention in care (no past‐year missed appointments and 85% past‐week adherence) and health service factors were tested simultaneously in sequential multivariate regression and marginal effects modelling, controlling for covariates of age, gender, urban/rural location, formal/informal housing, maternal and paternal orphanhood, vertical/horizontal HIV infection, overall health, length of time on ART and type of healthcare facility.ResultsAbout 56% of adolescents had self‐reported retention in care, validated against lower detectable viral load (AOR: 0.63, CI: 0.45 to 0.87, p = 0.005). Independent of covariates, five factors (STACK) were associated with improved retention: clinics Stocked with medication (OR: 3.0, CI: 1.6 to 5.5); staff with Time for adolescents (OR: 2.7, CI: 1.8 to 4.1); adolescents Accompanied to the clinic (OR: 2.3, CI: 1.5 to 3.6); enough Cash to get to clinic safely (OR: 1.4, CI: 1.1 to 1.9); and staff who are Kind (OR: 2.6, CI: 1.8 to 3.6). With none of these factors, 3.3% of adolescents reported retention. With all five factors, 69.5% reported retention.ConclusionsThis study identifies key intervention points for adolescent retention in HIV care. A basic package of clinic and community services has the potential to STACK the odds for health and survival for HIV‐positive adolescents.

INTRODUCTION: There are two million HIV-positive adolescents in southern Africa, and this group has low retention in care and high mortality. There is almost no evidence to identify which healthcare factors can improve adolescent self-reported retention. This study examines factors associated with retention amongst antiretroviral therapy (ART)-initiated adolescents in South Africa. METHODS: We collected clinical records and detailed standardized interviews (n = 1059) with all 10- to 19 year-olds ever initiated on ART in all 53 government clinics of a health subdistrict, and community traced to include lost-to-follow-up (90.1% of eligible adolescents interviewed). Associations between full self-reported retention in care (no past-year missed appointments and 85% past-week adherence) and health service factors were tested simultaneously in sequential multivariate regression and marginal effects modelling, controlling for covariates of age, gender, urban/rural location, formal/informal housing, maternal and paternal orphanhood, vertical/horizontal HIV infection, overall health, length of time on ART and type of healthcare facility. RESULTS: About 56% of adolescents had self-reported retention in care, validated against lower detectable viral load (AOR: 0.63, CI: 0.45 to 0.87, p = 0.005). Independent of covariates, five factors (STACK) were associated with improved retention: clinics Stocked with medication (OR: 3.0, CI: 1.6 to 5.5); staff with Time for adolescents (OR: 2.7, CI: 1.8 to 4.1); adolescents Accompanied to the clinic (OR: 2.3, CI: 1.5 to 3.6); enough Cash to get to clinic safely (OR: 1.4, CI: 1.1 to 1.9); and staff who are Kind (OR: 2.6, CI: 1.8 to 3.6). With none of these factors, 3.3% of adolescents reported retention. With all five factors, 69.5% reported retention. CONCLUSIONS: This study identifies key intervention points for adolescent retention in HIV care. A basic package of clinic and community services has the potential to STACK the odds for health and survival for HIV-positive adolescents. ; ISI

AbstractIntroductionDespite the widely recognized ethical and practical benefits of community engagement in HIV research, epistemic injustice persists within the field. Namely, the knowledge held by communities disproportionately affected by HIV is systematically afforded less credibility than that of more privileged academic researchers. In order to illustrate what this looks like in practice, we synthesized the extent of reporting on community engagement within recent high‐impact HIV intervention research papers. However, we also posit that the HIV research sector has the potential to devise and showcase world‐leading examples of equitable research‐community partnerships and suggest actionable key steps to achieving this goal.DiscussionIn the absence of reporting requirements within the publishing process, it is difficult to infer whether and how the community have been consulted in the design, implementation, analysis and/or interpretation of findings. As an illustrative exercise, we offer a rapid synthesis of the extent of reporting on community engagement in HIV research from 2017 to 2019, which highlighted sporadic and very low rates of reporting of community engagement in recent high‐impact HIV intervention studies. Of note is that none of the included studies reported on community engagement through all stages of the research process. There were also discrepancies in how community involvement was reported. We provide three actionable recommendations to enhance reporting on community engagement in HIV research: (1) community‐led organizations, researchers and scientific journals should band together to develop, publish and require adherence to standardized guidelines for reporting on community involvement in HIV research; (2) research funders should (continue to) require details about how relevant communities have been engaged prior to the submission of funding requests; and (3) researchers should take proactive measures to describe their engagement with community organizations in a clear and transparent manner.ConclusionsThere is a clear and urgent need for guidelines that facilitate transparent and consistent reporting on community engagement in HIV intervention research. Without standardized reporting requirements and accountability mechanisms within the research sector, the extent of meaningful community engagement cannot be established and may remain a catchphrase rather than reality.