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Globally over 2.8 million children aged between 0-18 years were living with HIV in 2019. ART substantially reduces mortality but the pre-requisite step for accessing treatment is HIV diagnosis. Coverage of HIV treatment in children has lagged behind when compared to adults largely because of delayed diagnosis. Children experience unique challenges to access HIV testing. Existing strategies for paediatric HIV testing, which largely are similar to those used for adults, have not been effective in addressing the HIV diagnosis gap in children. Index-linked HIV testing (HIV testing offered to household members and sexual contacts of individuals living with HIV) for children and adolescents may improve HIV testing uptake and have high HIV yield. Offering index-linked HIV testing for children and adolescents in both facility and community settings may be an effective strategy to help bridge the HIV testing gap. The aim of this research was to evaluate facility and community-based approaches for index-linked HIV testing for children and adolescents aged 2-18 years in Zimbabwe. This PhD combined mixed methods research in the city of Bulawayo and in Matabeleland South province between January 2018 and May 2019. Overall, 2870 index patients had 6062 children who were eligible for HIV testing in their households. Indexes were offered a choice of facility-based or community-based HIV testing (either home-based HIV testing by a health provider or an oral mucosal transudate (OMT) HIV test kit given to a caregiver to test their child(ren)). HIV testing was accepted for 5326 (87.9%) children, and 3638 children were tested (60.0% HIV testing uptake). The HIV prevalence and yield were 1.1% and 0.6% respectively. Older children and adolescents were less likely to be tested when compared to children aged 2-5 years. Children had increased odds of being tested if community-based HIV testing was chosen over facility based HIV testing. There was inadequate emphasis on paediatric HIV in routine HIV care which had a negative impact on subsequent uptake of HIV testing for children. Once the decision to test had been made, access to facilities was sometimes challenging and alleviated by community-based HIV testing. OMT tests, although previously validated for HIV testing in adults and widely used in HIVST for adults had not been validated for HIV testing in children < 12 years. In this research, OMT sensitivity was 100% [97.5% CI: 94.9% to 100%]) and specificity was 99.9% [95% CI: 99.6% to 100.0%] among children aged 2-18 years when compared to national HIV testing algorithms. A further application of OMT testing evaluated as part of this research was caregiver's ability to test their children for HIV and interpret test results. Overall, most caregivers correctly collected oral fluid (87.1% without provider demonstrations and 96.8% with demonstrations from a provider, p=0.002). The HIV yield was low when compared with blanket HIV testing approaches in similar settings. There is a need to improve messaging on the importance of HIV testing for children and adolescents and to provide support to caregivers and their families in order to increase HIV testing uptake. Addressing access barriers through the provision of community-based HIV testing can optimise index-linked HIV testing. Caregiver-provided testing using OMTs is a feasible and accurate HIV testing strategy for children and can also be used to improve uptake of HIV testing for children.

Cyclic environmental events, such as the El Niño Southern Oscillation (ENSO / El Niño) phenomenon may add to the development or worsening of mental disorders and may have a negative psychosocial impact. Little is known of the effects of El Niño on the mental health of residents from historically vulnerable zones, such as the northern coast of Peru. Community-based strategies, such as those based in theories of Social Capital (SC), may increase mutual cooperation and lower the risk for mental disorders, increasing post-disaster resilience. Using a mixed-methods approach this thesis aimed to understand the effects of El Niño-related events on mental health of affected residents of Tumbes, Peru, explore their perceptions on their mental well-being and identify resilience strategies that would help them to overcome future El Niño events. First, through a systematic review I identified quasi- experimental studies, randomised controlled trials and pilot studies that evaluated interventions with SC components to improve mental health outcomes. Second, I explored whether time trends of mild depression rates changed by exposure to the El Niño 2015-2016 event, through a secondary data analysis. After adjusting for an a priori set of confounders I linked individual and ecological-level data, from participants of a three-year pragmatic stepped-wedge cluster randomized-trial conducted in Tumbes. Finally, through qualitative research methods, I explored the perceived effect of the occurrence of the El Niño events of 2015-2016 and 2017 on residents’ mental well-being, the individual and community responses, availability and access to support systems and community resilience strategies. I found that communities with chronic exposure to El Niño events may not have a high prevalence of a mental disorder, such as depression, but they are affected from prior trauma, through relived personal disturbing experiences, relentless distress associated to scarcity, hopelessness related to authorities’ neglect and lack of community resilience. I recommend that policy should include a two-level (individual and community) approach, with greater emphasis on psychosocial and community empowerment support, nested within and alongside structural interventions that improve survivors’ social and material reconstruction of their livelihoods and fragmented social bonds.