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Since the adoption of the sustainable development goals (SDGs) by the United Nations (UN), the search has been on to identify interventions that have effects on multiple SDG-targets simultaneously. Like other developing countries, Ghana has a youthful population and would require creative, urgent, youth-focused interventions to be able to attain the SDGs by 2030. This paper describes the application of the accelerator model on data from a sample of Ghanaian adolescents to identify potential accelerators towards selected SDG targets involving youth. The data for 944 adolescents, 10-19 years (mean age 12.31 ± 3.51 years), extracted from two cross-sectional surveys on children and adolescents aged 6-19 years in Kumasi, Ghana, were analysed in this paper. Variables considered suitable proxies for SDG targets and potential accelerators were identified from the study instruments. Consequently, four aligned SDG targets (good mental health, access to ICT, school completion and no open defaecation) and five accelerators (cognitive stimulation, no relative poverty, low student-teacher ratio, high caregiver education and safe water) were extracted. Associations between accelerators and SDG targets were assessed using multivariable logistic regression adjusting for sociodemographic covariates and multiple testing. Cumulative effects were tested by marginal effects modelling. The three hypothesised accelerators identified were cognitive stimulation, low student-teacher ratio, and no relative poverty. A combination of all three accelerators was associated with a higher likelihood of adolescents having access to Information and Communication Technology (ICT) by +73% (CI 0.72-0.74), no open defecation by +44% (CI 0.43-0.46), school completion by +27% (CI 0.26-0.27) and good mental health by +9% (CI 0.08-0.10). Three hypothesized accelerators showed association across all four SDG aligned targets. The accelerator model has been further validated in this dataset from Ghana. Robust interventions designed around these accelerators may represent an opportunity for achieving the SDGs in Ghana.

Aim This study aims to investigate associations of formal childcare with maternal and child outcomes in a large sample of adolescent mothers. Background Forty percent of adolescent girls in Africa are mothers. Increasing evidence shows positive impacts of formal childcare use for adult women, but no known studies in the Global South examine associations for adolescent mothers and their children. Methods We interviewed 1046 adolescent mothers and completed developmental assessments with their children (n = 1139) in South Africa's Eastern Cape between 2017 and 2019. Questionnaires measured childcare use, maternal and child outcomes and socio-demographic background variables. Using cross-sectional data, associations between formal childcare use and outcomes were estimated in multivariate multi-level analyses that accounted for individual-level and family-level clustering. Results Childcare use was associated with higher odds of being in education or employment (AOR: 4.01, 95% CIs: 2.59–6.21, p Conclusions Adolescent mothers might benefit substantially from formal childcare, but causal links need to be explored further. Childcare use was also associated with improved parenting and better child development over time, suggesting positive pathways for children. At an average of $9 per month, childcare provisions for adolescent mothers may offer low-cost opportunities to achieve high returns on health and human capital outcomes in Sub-Saharan African contexts.

Background: Identifying risk and protective factors for adolescent antiretroviral therapy (ART) adherence is a public health priority, given high HIV-related mortality in this population. An area that merits further investigation is the relationship between bullying victimization, mental health problems, and ART non-adherence among adolescents living with HIV (ALHIV). However, no known studies assess effects of bullying on adolescent non-adherence, or risk and protective factors that could moderate this relationship. Setting: This study investigates a) the direct longitudinal relationship between bullying exposure and ART non-adherence, and the indirect relationship via psychological distress, and b) potential risk and modifiable protective factors moderating these pathways, among vertically and horizontally infected ALHIV who initiated treatment across 53 public healthcare facilities in a South African health district. Methods: Survey data was collected at two-time points, between 2014 and 2017, with 1046 ALHIV (94% retention). Various mediation and moderated mediation models were run as part of a staged analysis approach. Results: A significant longitudinal relationship was found between bullying victimization and non-adherence, operating indirectly via psychological distress (B= 0.07; 95%CI: [0.03, 0.13]). Moderation analyses indicated that older adolescents exposed to bullying are more at risk of non-adherence (B =0.52; 95%CI: [0.07, 0.97] p Conclusions: These findings underscore the importance of interventions that address bullying and psychological distress, and strengthen parental monitoring, particularly among older ALHIV.

This report summarises the study findings and impact of a research project implemented jointly by the Universities of Oxford and Cape Town: Pathways to survival: identifying psychosocial, family and service mechanisms to improve anti-retroviral adherence amongst HIV-positive adolescents in Southern Africa (hereafter: Mzantsi Wakho – Your South Africa – its locally used name). The core source of funding for this high-impact and successful study came from the Nuffield Foundation. This study was also supported by supplementary co-funding. This study was the first to systematically examine potential causes of ART non-adherence and non-retention in HIV care amongst adolescents (10-19 years old) in Sub-Saharan Africa. Through additional funding awarded to the research team, additional research aims were also examined. The research project was implemented by a team of more than 50 researchers, including capacity-building for early-career academics and students in South Africa and the UK. In July 2015 – March 2018, this multi-disciplinary, mixed-methods team engaged with over 1,600 adolescents, 100 caregivers, and 120 healthcare providers through participatory workshops, in-depth interviews, ethnographic research, and three waves of quantitative surveys. In parallel, a clinic team engaged with over 79 public health facilities collecting data from clinic managers, healthcare providers, and patient files (with appropriate consent). With the essential support of the Nuffield Foundation, this study became the world’s largest longitudinal cohort of adolescents living with HIV. Mzantsi Wakho’s research team successfully followed up and maintained high retention rates across three time points, as research participants transitioned from early adolescence into youth. The study has already had major impact on policy, UN guidelines and programming for adolescents living with HIV.

Background: Sub-Saharan Africa is home to 85% of the world’s HIV-positive adolescents: an estimated 1.3-2.2 million 10-19 year olds. Adolescents living with HIV face multiple sexual and reproductive health risks: unwanted pregnancies and the risk of mother-to-child-transmission, risk of infecting partners, co-infection with other STIs, and the rising but undocumented risk of re-infection by potentially resistant HI-virus strains. Using contraception, especially condoms, is particularly challenging for all adolescents. It is even more difficult for HIV-positive adolescents due to HIV-related factors such as learning their HIV-positive status, withholding or disclosing their HIV-status to sexual partners, and accessing services in the home, clinics, and schools. This thesis aims to understand which factors shape sexual risk-taking among HIV-positive adolescents to inform the development of interventions that promote safe sexual practices in this population. Methodology: This thesis applies a socio-ecological model to investigate factors associated with sexual risk-taking among HIV-positive adolescents. It consists of three stand-alone papers: a systematic review and two quantitative papers based on a cross-sectional epidemiological and aetiological study of unprotected sex among HIV-positive adolescents and community controls in South Africa. Paper 1 is a systematic review of rates, correlates, and interventions to reduce sexual risk-taking among HIV-positive adolescents and youth in sub-Saharan Africa. Paper 2 looks at associations between HIV-status knowledge and disclosure and protective sexual practices in the cross-sectional study sample. Paper 3 explores the relationship between various social protection provisions and unprotected sex among HIV-positive adolescents. The candidate co-developed and conducted a community-traced study of adolescents in the Eastern Cape, in South Africa: 1,060 HIV-positive adolescents and 467 community controls. HIV-positive 10-19 year old adolescents were recruited from 53 government facilities in a health sub-district with antenatal HIV prevalence of over 30%. 90.1% of the eligible sample was traced, with only 4.1% refusing to take part. Community controls were neighbouring or co-habiting 10-19 year old adolescents, 92% of whom agreed to take part. Voluntary informed consent was obtained from adolescents and caregivers in the language of their choice: English or Xhosa. Questionnaires were administered by trained research assistants using mobile devices (tablets) with adolescent-friendly graphic content to ensure participant interest and reduce participant burden through skip-patterns. The systematic review (Paper 1) included studies located through electronic databases and grey literature. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Quantitative studies reporting on HIV-positive participants (10-24 year old) included data on at least one of eight outcomes (early sexual debut, inconsistent condom use, older sexual partner, transactional sex, multiple sexual partners, sex while intoxicated, sexually transmitted infections, and pregnancy). Only studies conducted in sub-Saharan Africa were included. The candidate and a second author independently piloted all processes, screened studies, extracted data independently, and resolved any discrepancies. Due to variance in reported rates and correlates, no meta-analyses was conducted. The systematic review informed the analyses conducted for the two quantitative papers. Analyses for Papers 2 and 3 used condom use at last sexual encounter (dichotomised either as safe sex/ abstinence or unprotected sex) as the outcome, controlling for a series of covariates. Analyses used SPSS 22 and STATA 11. For each paper, the hypothesised factors were entered as independent variables in multivariate logistic regressions controlling for potential confounders. Based on the findings of the systematic review, gender moderation analyses was run entering a 2-way interaction term of gender*correlate in multivariate logistic regressions, controlling for covariates. Marginal effect models explored the effect of combinations of risk/ protective factors. Predicted probabilities for safe sex/ unprotected sex were computed for different two- and three-way combinations of the independent variables, controlling for covariates significantly associated with the outcome. Paper 2 tested the effect of three types of disclosure on protective sexual practices: (i) knowledge of one’s own HIV-positive status, (ii) disclosing one’s HIV-status to a partner, and (iii) knowing a partner’s HIV-status. It compared HIV-positive status aware adolescents (n=794) with the rest of the sample (n=733). Paper 3 investigated associations between nine types of social protection provisions and unprotected sex. In line with UNICEF’s definition, social protection was defined as any provision aimed at preventing, reducing and eliminating economic and social vulnerabilities to poverty and deprivation among HIV-positive adolescents. The nine social protection provisions tested by the analyses included ‘cash’ and ‘care’ factors accessed in the home, school, and community. Results: Paper 1 – ‘Sexual Risk-Taking among HIV-Positive Adolescents and Youth in Sub-Saharan Africa: A systematic review of prevalence rates, risk factors, and interventions.’ The systematic review (Chapter 4) found that, despite their heightened vulnerabilities and high rates of sexual risk-taking, there is a dearth of evidence on interventions which may help HIV-positive adolescents engage in safe sexual practices. The review included 35 studies, four of which were interventions aiming to reduce sexual risk-taking. The quality of the included studies was low with most studies (k=31) reporting findings from cross-sectional data. HIV-positive adolescents and youth reported high rates of sexual risk-taking, however findings were inconsistent about potential factors associated with sexual risk-taking. Factors consistently associated with sexual risk-taking in multivariate analyses included: food insecurity, living alone, living with a partner, and gender-based violence. No significant associations were reported for: rural residence, informal housing, anxiety, religious guidance, STI prevention knowledge, poor birth outcomes, orphanhood, parental monitoring, having a supportive family, social support, maternal education level, poverty, disclosing one’s HIV-status to a partner, time on ART, ART adherence, receiving care at a hospital, opportunistic infections. However, most of the above associations were reported by only one study, therefore further analyses is needed to build the evidence base on potential determinants of sexual risk-taking among HIV-positive adolescents and youth. The included interventions consist of three individual- and group-based psychosocial interventions evaluated in three small-scale trials (n Quantitative data analyses of cross-sectional study data: Overall, adolescents in the full sample (n=1,527) reported high rates of sexual activity (34.9%) and high rates of unprotected sex (22%), with adolescent girls reporting higher rates of unprotected sex than boys (33% vs. 7%). In univariate ANOVA, rates of unprotected sex among those sexually-active were lower amongst ART-eligible HIV-positive adolescents (p±.001) compared to community controls, adolescent boys compared to girls (p±.001), and HIV-positive adolescents who knew their status compared to the rest of the sample (p±.001). Among sexually-active HIV-positive adolescents who knew their status, horizontally-infected adolescents reported more unprotected sex (64% vs. 44%, p±.001). Paper 2 ‘Is Knowledge Power? HIV-status disclosure and protective sexual practices among adolescent girls and boys in South Africa.’ In Paper 2 (Chapter 6), analyses of the full sample of adolescents (n=1,527) found that knowing one’s own HIV-positive status was associated with more safe sex (OR1.88, CI1.35-2.63, p±0.001), knowledge of a sexual/ romantic partner’s HIV-status (positive or negative) was associated with less safe sex (OR0.45 CI0.29-0.69, p±0.001), while disclosing one’s HIV-status to a partner was not associated with safe sex. Gender did not moderate the relationship between HIV-status knowledge and disclosure, and protective sexual practices. Among female adolescents (N=843), the patterns of association between disclosure (to and from) and safe sex were the same: HIV-positive status-aware adolescent girls were more likely to report safe sex than the rest of adolescent girls (OR1.86 CI1.26-2.74, p=0.002). When combinations of disclosure were considered, knowing one’s own HIV-positive status was associated with higher rates of protective sexual practices, but it was not sufficiently protective when HIV-positive adolescents also disclosed to their partners or knew their partner’s HIV-status. Paper 3 ‘School, Supervision, and Adolescent-Sensitive Clinic Care: Combination social protection and reduced unprotected sex among HIV-positive adolescents in South Africa.’ Analyses in Paper 3 (Chapter 7) tested associations between social protection provisions accessed by HIV-positive adolescents in the home, school and clinics (n=1,060). Participants reported lower rates of unprotected sex if they received strong parental supervision (OR0.54, CI0.33-0.90, p=0.019), had free access to school (OR0.52, CI0.33-0.82, p=0.005), and received adolescent-sensitive care when accessing sexual health services (OR0.43, CI0.25-0.73, p=0.002). Gender acted as a moderator for the positive effect of adolescent-sensitive clinic care: the association between reduced reports of unprotected sex and better clinic care was stronger for girls than boys. Gender-disaggregated regression models confirmed these findings. Analyses then checked for multiplicative or additive effects: whether receiving more than one social protection provision had a greater effect on rates of unprotected sex. No multiplicative effects were found. In marginal effect models, receiving more than one social protection intervention had an additive effect on predicted probabilities of unprotected sex rates, controlling for covariates. This effect was even stronger among adolescent girls: without any social protection, 49% were likely to report unprotected sex; with 1-2 of the interventions 13-38%; and with all interventions only 9%. Conclusion: This thesis provides new evidence on what may support HIV-positive adolescents engage in safe sexual practices. The findings suggest that some factors may strongly support safe sex: knowledge of own HIV-positive status, good caregiver supervision, access to schools, and adolescent-sensitive sexual healthcare at clinics. These factors are located in various levels of the socio-ecological model, supporting the application of this theoretical model to understand the sexual health of HIV-positive adolescents in South Africa. These findings also highlight the greater vulnerability of adolescent girls, even when they are already HIV-positive, and propose potential interventions that may have positive effects in reducing these vulnerabilities: supported disclosure of their HIV-positive status, access to schools, good parental supervision, and adolescent-sensitive clinic care. By identifying key HIV-specific and HIV-inclusive programmes that may support safe sex, this thesis contributes to the problem theory for the sexual and reproductive health of HIV-positive adolescents.

Toska, E., Gittings, L., Hodes, R., Cluver, L. D., Govender, K., Chademana, K. E., & Gutiérrez, V. E. (2016). Resourcing resilience: Social protection for HIV prevention amongst children and adolescents in Eastern and Southern Africa. African Journal of AIDS Research, 15(2), 123–140. http://dx.doi.org/10.2989 /16085906.2016.1194299Acknowledgement — Additional support for Lesley Gittings was provided by the South African Social Science and HIV Programme (SASH), funded by NIH Grant R24HD077976 and the South African National Research Foundation.

This is a story that is often told: a young woman from a poor family has had a baby so that she can access the child support grant. Then, instead of spending the money on her family, she dumps the baby with her mother or aunt. She uses the grant to buy trendy clothes, beauty treatments and booze. The state has provided this young mother with money to care for her child, but she is wasting it on selfish luxuries. Among nurses and social workers, alarm about the misuse of social grants is growing. For many health and social workers, it appears that young people are increasingly using grants for income, as a substitute for formal employment.

In selected cases of endoscopic surgery of bladder cancer, in order to reach an oncologic radicality, the resection of the ureteral ostium affected by the disease is required. Although infrequent, a possible complication of this manoeuvre is represented by the complete obliteration of theresected ostium. Literature suggests that the traditional "open" surgery and the latest "laparoscopic" surgery are effective in the resolution of this complication, in contrast with the techniques of endourological and uro-interventional radiology which, although minimally invasive, do not appear to be completely appropriate in the treatment of this condition. We believe that an innovative, minimally invasive anterograde trans-nephrostomic and retrograde endoscopic combined approach can be decisive in restoring complete patency of the neo-ostium.