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In 2022, South Africa (SA) had the second-highest HIV incidence rate among adolescents worldwide. This study's participants were boys living in SA aged 15-19 years old, in a current dating or sexual relationship, and diagnosed with HIV before the age of 10. Despite the launch of campaigns to spread awareness of Undetectable equals Untransmittable (U = U), our findings showed that a significant number of adolescents living with HIV do not demonstrate an understanding of the concept. This highlights the importance of integrating U = U messaging in ongoing conversations with healthcare workers given the potential positive impact on adolescent wellbeing, transmission risk perception, and safer sexual practices., (© 2024. The Author(s).)

There are over 1.4 million adolescents living with HIV in sub-Saharan Africa, the majority of whom acquired the virus through perinatal transmission (PHIV). HIV stigma is particularly high among adolescents living with HIV and is associated with several outcomes that worsen health and increase the risk of onward HIV transmission. We tested associations between internalized HIV stigma and four of these outcomes over a one-year period among a sample of adolescent boys living with PHIV in Soweto, South Africa. Participants (N = 241) answered questions about internalized HIV stigma at baseline. They completed weekly mobile surveys over the following year to answer questions about their experiences with depression, binge drinking, medication adherence, and violence victimization. Using generalized linear mixed models, we found that baseline internalized HIV stigma was associated with increased odds of depression (OR 1.74), alcohol misuse (OR 2.09), and violence victimization (OR 1.44) and decreased odds of medication adherence (OR 0.60) over the course of a year. These outcomes negatively impact the health and wellbeing of adolescents living with PHIV and increase their risk of transmitting HIV to their partners in the future. Our findings provide novel, longitudinal evidence for the deleterious effects of HIV stigma. To improve health outcomes for adolescents with PHIV, it will be crucial to develop effective HIV stigma reduction interventions that address specific developmental, gendered, and cultural experiences., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Fewer adolescents achieve viral suppression compared to adults. One impediment may be a history of adverse childhood experiences (ACEs). To better develop targets and timeframes for intervention, this study created more robust estimates of the impact of cumulative adversity on viral suppression, tested whether the association is sensitive to the timing of adversity, and simultaneously tested several potential mechanisms. We focus on males, who have lower viral suppression than females and who may contribute to disproportionate incidence among young women. We recruited 251 male perinatally HIV-infected adolescents aged 15-19 from HIV clinics in Soweto, South Africa. Adversity was captured using the Adverse Childhood Experience - International Questionnaire (ACE-IQ). Viral load was measured using blood samples; viral suppression was defined as <20 copies/mL. Indicators of medication adherence, depression, post-traumatic stress disorder (, and substance misuse were captured. A series of pathway analysis were performed. Our sample experienced a median of 7 lifetime and 4 past-year adversities. Less than half (44%) exhibited viral suppression. Adversity demonstrated a significant association with suppression; depression mediated the association. Primary prevention of adversity among children living with HIV is paramount, as is addressing the subsequent mental and behavioral health challenges that impede viral suppression among adolescents.

Purpose: The Adverse Childhood Experiences (ACE) cohort of the Malawi Longitudinal Study of Families and Health (MLSFH-ACE) is a study of adolescents surveyed during 2017-2021. It provides an important opportunity to examine the longitudinal impact of ACEs on health and development across the early life course. The MLSFH-ACE cohort provides rich data on adolescents, their children and adult caregivers in a low-income, high-HIV-prevalence context in sub-Saharan Africa (SSA)., Participants: The MLSFH-ACE cohort is a population-based study of adolescents living in three districts in rural Malawi. Wave 1 enrolment took place in 2017-2018 and included 2061 adolescents aged 10-16 years and 1438 caregivers. Wave 2 took place in 2021 and included data on 1878 adolescents and 208 offspring. Survey instruments captured ACEs during childhood and adolescence, HIV-related behavioural risk, mental and physical health, cognitive development and education, intimate partner violence (IPV), marriage and aspirations, early transitions to adulthood and protective factors. Biological indicators included HIV, herpes simplex virus and anthropometric measurements., Findings to Date: Key findings include a high prevalence of ACEs among adolescents in Malawi, a low incidence of HIV and positive associations between ACE scores and composite HIV risk scores. There were also strong associations between ACEs and both IPV victimisation and perpetration., Future Plans: MLSFH-ACE data will be publicly released and will provide a wealth of information on ACEs and adolescent outcomes in low-income, HIV-endemic SSA contexts. Future expansions of the cohort are planned to capture data during early adulthood., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Adverse childhood experiences have been robustly associated with poor sexual health in later life. In low-income countries, there is growing evidence that children experience greater adversity than those in higher income countries. Research suggests this may contribute to later sexual risk taking and HIV infection, though most studies to date have been cross-sectional., Design: We use longitudinal data on adolescents to examine the temporal relationship between adversity and HIV-related behavioral and biological outcomes., Methods: We interviewed 1878 adolescents living in Malawi in 2017-2018 (age 10-16) and again in 2021 (age 13-20). Adolescents completed the Adverse Childhood Experience - International Questionnaire. HIV-risk was assessed through both behavioral (e.g. condom use) and biological (HIV and herpes simplex virus 2 [HSV2] infection) outcomes. ordinary least squares (OLS) and logistic multivariate regression models are used to explore associations between adversity and HIV risk., Results: In longitudinal analyses, adverse childhood experiences (ACEs) were significantly associated with intimate partner violence and girls' behavioral risk scores only. HIV incidence was too low to model; there were no significant associations with HSV2. In cross-sectional analyses, ACEs were additionally associated with an early sexual debut, lack of condom use, a greater number of sexual partnerships, and sexually transmitted infection symptoms., Conclusions: Our findings emphasize the importance of collecting prospective data: results from longitudinal and cross-sectional analyses drew qualitatively different conclusions. Cross-sectional analyses may not be accurate representations of longitudinal processes. However, they suggest that recent adversity and distress drives HIV-related behavior, perhaps more than early adversity. Interventions that combat emotional abuse or peer violence during adolescence could potentially reduce HIV risk., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Over three million youth live with HIV worldwide. Very little is known about whether youth disclose their HIV status to family, friends or sexual partners, and what risks and benefits may accrue from doing so. This study characterizes HIV disclosure among 250 youth with perinatally-acquired HIV (PHIV; age 13-24 years) living in Soweto, South Africa. A third had self-disclosed their HIV status to at least one person; similarly, only a third of sexually-active PHIV had disclosed their HIV status to their most recent partner. It is not clear whether HIV disclosure alone leads to positive impact: we found perceived social support from the family was negatively associated with disclosure (aOR 0.81, 95% 0.70-0.94). PHIV who spoke to a provider about disclosure were more likely to share their HIV status with a sexual partner (aOR 2.48; 95% CI 1.28-4.81). However, those PHIV who disclosed their status were no more likely to use a condom. The World Health Organization recommends that health providers advise adolescent patients on safe disclosure, but we still lack evidence on the consequences for young people and effective tools to help them weigh benefits and risks.

Over a third of new HIV infections occur in adolescents aged 10-19 globally. Pre-exposure prophylaxis (PrEP) could be a powerful tool for prevention. Understanding more about the drivers of PrEP interest could inform implementation strategies among this age group. Moreover, family dynamics may play a uniquely critical role for this younger age group, thus it is important to gauge whether caregivers would support their children's use of PrEP. We surveyed 2,089 adolescents (aged 10-16) and their caregivers in Malawi during 2017-2018. Data were collected on PrEP interest, factors that may facilitate PrEP use, and preferences for PrEP modality. We used multivariate logistic regression to estimate the association between the above characteristics and PrEP interest. We find that young adolescents are engaging in behaviors that would put them at substantial risk of acquiring HIV, would likely benefit from PrEP, are largely (82%) interested in using such, would prefer to get an injection over taking a daily pill, and are considerably discouraged by the prospect of side effects. Endorsement by caregivers was even greater (87%). Our findings demonstrate initial support for adolescent PrEP, and suggest parents may be a surprising advocate.

Objectives: To investigate whether adverse childhood experiences are important determinants of sexual debut and HIV testing., Design: Adolescents (age 10-16; N = 2089) from rural Malawi were interviewed in 2017-2018 for the baseline wave of a longitudinal study of childhood adversity and HIV risk., Methods: Respondents were interviewed in their local language. Surveys captured 13 lifetime childhood adversities (using the Adverse Childhood Experience - International Questionnaire); sexual debut; and previous HIV testing. We used multivariate regression models to test whether adversity, measured both cumulatively and separately, predicted HIV risk., Results: For each additional adversity, there was a significant rise in the odds of sexual debut (odds ratio 1.13, confidence interval 1.07-1.20) and HIV testing (odds ratio 1.10, confidence interval 1.04-1.16)., Conclusion: Preventing HIV among all young people necessitates a paradigm shift that recognizes the importance of early life social determinants in structuring HIV risk.

A growing population of youth who acquired HIV from their mothers are surviving into adulthood. This group is unique in that they experience both internalized stigma (due to their HIV status) and associative stigma (due to their mothers' HIV status). Results of a cross-sectional survey of 250 perinatally HIV-infected South African youth suggests that internalized stigma is associated with greater risk of depression, and associative stigma is associated with greater risk of depression and substance use problems. Interventions currently focus on internalized stigma; this study highlights the importance of also addressing associative stigma to improve outcomes among perinatally HIV-infected youth.

Repeated exposure to childhood adversity (abuse, neglect and other traumas experienced before age 18) can have lifelong impacts on health. For HIV-infected adolescents and youth, such impacts may include onward transmission of HIV. To evaluate this possibility, the current study measured the burden of childhood adversity and its influence on risky health behaviors among perinatally-infected adolescents and youth. We surveyed 250 perinatally-infected adolescents and youth (13-24 years) receiving care in Soweto, South Africa. Both male and female participants reported on childhood adversity (using the ACE-IQ), sexual behavior, and psychosocial state. Viral load was also abstracted from their charts. We used logistic regressions to test the association between cumulative adversity and behavioral outcomes. Half the sample reported eight or more adversities. Overall, 72% experienced emotional abuse, 59% experienced physical abuse, 34% experienced sexual abuse, 82% witnessed domestic violence, and 91% saw someone being attacked in their community. A clear gradient emerged between cumulative adversities and behavioral risk. Having experienced one additional childhood adversity raised the odds of risky sexual behavior by almost 30% (OR 1.27, 95% CI 1.09-1.48). Viral suppression was poor overall (31% had viral loads >400 copies/ml), but was not related to adversity. Adversity showed a robust relationship to depression and substance abuse. Childhood adversity is common, influences the current health of HIV-positive adolescents and youth, and puts their sexual partners at risk for HIV infection. Greater primary prevention of childhood adversity and increased access to support services (e.g., mental health) could reduce risk taking among HIV-positive adolescents and youth., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: As perinatal HIV-infected youth become sexually active, the potential for onward transmission becomes an increasing concern. In other populations, intimate partner violence (IPV) is a risk factor for HIV acquisition. We build on this critical work by studying the role of IPV in facilitating onward transmission among HIV-infected youth-an important step toward effective intervention., Setting: Soweto, South Africa., Methods: Self-report surveys were completed by 129 perinatal HIV-infected female youth (aged 13-24 years). We calculated the IPV prevalence and used logistic models to capture the association between IPV and health outcomes known to facilitate onward HIV transmission (eg, risky sex, poor medication adherence, depression, and substance abuse)., Results: A fifth of perinatal HIV-infected participants reported physical and/or sexual IPV in the past year; one-third reported lifetime IPV. Childhood adversity was common and positively associated with IPV. Past-year physical and/or sexual IPV was positively correlated with high-risk sex [odds ratio (OR) = 8.96; 95% confidence interval (CI): 2.78 to 28.90], pregnancy (OR = 6.56; 95% CI: 1.91 to 22.54), poor medication adherence to antiretroviral therapy (OR = 5.37; 95% CI: 1.37 to 21.08), depression (OR = 4.25; 95% CI: 1.64 to 11.00), and substance abuse (OR = 4.11; 95% CI: 1.42 to 11.86). Neither past-year nor lifetime IPV was associated with viral load or HIV status disclosure to a partner., Conclusions: We find that IPV may increase risk for onward HIV transmission in perinatal HIV-infected youth by both increasing engagement in risky sexual behaviors and lowering medication adherence. HIV clinics should consider integrating primary IPV prevention interventions, instituting routine IPV screening, and collocating services for victims of violence.

Purpose: Why do orphans have higher rates of HIV infection than nonorphaned peers? Research consistently assumes that orphans acquire HIV primarily through sexual behavior, but infections may instead be due to maternal transmission. Although these two pathways have very different implications for HIV programs and policies, their relative contribution has not been previously examined. In this research, we compare the contribution of maternal and sexual transmission to HIV infection among orphans in Africa., Methods: We use Demographic and Health Survey data for 21,463 women and 18,359 men from 17 countries. We propose a conceptual framework linking orphanhood to HIV, and use mediation analysis and structural equation modeling to compare the potential contribution of maternal transmission (measured through direct pathways from orphanhood to HIV) and sexual transmission (measured through reports of risky sexual behavior) to orphan HIV infection., Results: Our results suggest that maternal transmission is the predominant pathway of HIV infection among orphaned adolescents: there is strong evidence for a direct pathway from maternal (odds ratio [OR]: 2.45; 95% confidence interval [CI]: 1.72-3.51 for females and OR: 2.45; 95% CI: 1.53-3.90 for males) and double orphanhood (OR: 2.69; 95% CI: 1.97-3.66 and OR: 2.53; 95% CI: 1.68-3.82, respectively) to HIV; greater excess HIV risk in maternal versus paternal orphans. The contribution of sexual behavior is largely not significant. We do not observe correspondingly high orphan disparities in other sexually transmitted diseases., Conclusions: Maternal transmission is a more likely explanation than sexual transmission for heightened HIV infection among orphans. These results suggest that programs designed to address HIV infection among adolescents should focus on reducing maternal transmission and on identifying and testing undiagnosed HIV among orphans., (Copyright © 2017 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Despite extensive resources and numerous programmes directed towards orphans in sub-Saharan Africa, evidence of their disadvantage is surprisingly limited. While initial research suggests that orphans are at greater risk of being HIV-positive, the evidence is limited in geographic scope., Methods: To rigorously test disparities in HIV prevalence related to orphanhood and parental HIV status in sub-Saharan Africa, we used Demographic and Health Survey data from 19 countries in sub-Saharan Africa. We conducted pooled multilevel logistic regression on adolescents aged 15-17 years with HIV test results (N=22 837 girls and 20 452 boys)., Results: Regardless of their gender, orphans who lost their mother, lost both parents or had an HIV-infected mother were two to three times more likely to test positive for HIV infection (ORs 1.87-3.17). The loss of a father was also associated with HIV infection risk for females, but of slightly lower magnitude (OR 1.63)., Conclusions: To better inform interventions, future research is needed to quantify the relative contribution of perinatally-acquired and sexually-acquired infections, and to investigate the specific mechanisms that may account for disparities in the latter. In the meantime, programmes serving HIV-infect adults as well as those serving orphaned and vulnerable children should invest in family-based HIV testing in order to identify adolescents in need of treatment., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

In the wake of the HIV/AIDS epidemic, caregivers are struggling to support HIV-affected children. For reasons of equity and efficiency, their needs can be best met through strong social protections and policies. This paper presents a conceptual framework to help address the needs of HIV-affected caregivers and to prioritize policies. We describe the needs that are common across diverse caregiving populations (e.g., economic security); the needs which are intensified (e.g., leave to care for sick children) or unique to providing care to HIV-affected children (e.g., ARV treatment). The paper then explores the types of social policies that would facilitate families meeting these needs. We outline a basic package of policies that would support HIV-affected families, and would meet goals agreed to by national governments. We examine the availability of these policies in 25 highly affected countries in sub-Saharan Africa. The majority of countries guarantee short-term income protection during illness, free primary school, and educational inclusion of children with special needs. However, there are significant gaps in areas critical to family economic security and healthy child development. Fewer than half of the countries we analyzed guarantee a minimum wage that will enable families to escape poverty; only six have eliminated tuition fees for secondary school; and only three offer paid leave to care for sick children. Filling these policy gaps, as well as making mental health and social services more widely available, is essential to support caregiving by families for HIV-affected children. As part of the HIV agenda, the global community can help national governments advance towards their policy targets. This would provide meaningful protection for families affected by HIV, as well as for millions of other vulnerable families and children across the region.

HIV places acute stressors on affected children and families; especially in resource limited contexts like sub-Saharan Africa. Despite their importance, the epidemic's potential consequences for family dynamics and children's psychological health are understudied. Using a population-based sample of 2,487 caregivers and 3,423 children aged 8-14 years from the Central Province of Kenya, analyses were conducted to examine whether parental illness and loss were associated with family functioning and children's externalizing behaviors. After controlling for demographics, a significant relationship between parental illness and externalizing behaviors was found among children of both genders. Orphan status was associated with behavioral problems among only girls. Regardless of gender, children experiencing both parental loss and illness fared the worst. Family functioning measured from the perspective of both caregivers and children also had an independent and important relationship with behavioral problems. Findings suggest that psychological and behavioral health needs may be elevated in households coping with serious illness and reiterate the importance of a family-centered approach for HIV-affected children.

Children and families affected by HIV are at considerable risk for psychological distress. Community-based home visiting is a common mechanism for providing basic counseling and other services to HIV-affected families. While programs emphasize home visitor training and compensation as means to promote high-quality service delivery, whether these efforts result in measurable gains in beneficiaries' well-being remains largely unanswered. This study employs a longitudinal quasi-experimental design to explore whether these kinds of investments yield concomitant gains in psychological outcomes among beneficiaries. Baseline and follow-up data were collected over a two-year period from children aged 10-17 at the time of program enrollment and their caregivers, with 80% retention. In this sample of 1487 children and 918 caregivers, the psychological health outcomes of those enrolled in programs with home visitors who receive intensive training, organizational support, and regular compensation (termed "paraprofessional") were compared to those enrolled in programs offering limited home visiting services from lay volunteers. Applying multilevel logistic regression, no measurable improvements were found among paraprofessional enrollees, and three outcomes were significantly worse at follow-up regardless of program model. Children's behavior problems became more prevalent even after adjusting for other factors, increasing from 29% to 35% in girls and from 28% to 43% in boys. Nearly one-quarter of girl and boys reported high levels of depression at follow-up, and this was a significant rise over time for boys. Rates of poor family functioning also significantly worsened over time, rising from 30% to 59%. About one-third of caregivers reported high levels of negative feelings at follow-up, with no improvements observed in the paraprofessional group. Results highlight that children's and caregivers' psychological outcomes may be relatively impervious to change even in paraprofessional home visiting models. Findings underscore the need for programs serving HIV-affected families to add focused evidence-based psychological interventions to supplement traditional home visiting.