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Background Young people in sub-Saharan Africa (SSA) shoulder a disproportionate burden of global HIV. We conducted a scoping review to map the research on the experiences and perceptions of young people living with HIV (YPLHIV) on antiretroviral therapy (ART) in SSA to inform future research. Methods Following scoping review guidelines, we searched PubMed, Web of Science, EBSCOhost including Academic Search Complete, APA PsycInfo, Health Source: Nursing/Academic Edition, Medline with Full-text, Scopus and ScienceDirect for papers on YPLHIV adhering and not adhering to ART in SSA. We included literature published between 1 January 2010 and 30 September 2022. Search terms employed were adherence, non-adherence, and related synonyms. Bibliometric data and themes describing factors influencing the experiences and perceptions of ART adherence and non-adherence were extracted. Results Of the 2671 papers identified, 22 papers from 12 countries were included. Studies employed quantitative (3), mixed (6), and qualitative (13) methods. Most publications concentrated on barriers to adherence rather than enablers. Factors affecting ART adherence and non-adherence were psychosocial, emotional, self-management, support, financial and structural. YPLHIV also faced problems with the responsiveness of health services and access to information. Conclusions We identified multiple factors surrounding ART adherence and non-adherence impacting the health and wellbeing of YPLHIV. The review findings showed the importance of research to improve the understanding of the relationships that YPLHIV in SSA develop with ART in adolescence and factors that facilitate adherence. Psychosocial adherence support and patient-centred care approaches are required.

Background The last few decades have seen a demographic shift in the age of migrants with more young people involved, especially with regards to internal migration. Socio-economic deprivation, limited resources and adversities contribute to many young people leaving rural areas in low- and middle-income countries in search of a better life in urban settings. This move often requires an adaptation process and resilience to the adversities young people face while still in the challenging developmental life stage of adolescence, exposing them to health and physical risks. Methods As part of Lending a Hand support intervention, we conducted repeat in-depth interviews with 20 young people that had recently relocated from other rural villages to a peri-urban setting in uMkhanyakude district, KwaZulu-Natal in South Africa. Data were analysed thematically using inductive and deductive approaches and managed in NVivo software. Results The participants shared that there were alarming rates of teenage pregnancies in their local area and attributed this to younger girls dating older men for economic gain, which also exposed them to infectious diseases. Some vulnerabilities described by young people included coming from a single parent home, experiencing psychological distress, and living far away from the support of family. Other young people were able to use community-based resources as well as adaptive emotion regulation strategies that offered protective support such as church, school, and peer networks around them. Conclusions The accessibility and availability of protective resources offered support and provided strength to young people. This fostered resilience for these young people and in a way incorporated aspects of the collectivist communities they live in. Considering resources that are easily available in resource limited settings is important as young people may be more comfortable and confident to access and use. These protective factors may help curb some of the impact of the risks that they are exposed to.

ObjectivesWe evaluated whether implementation of lockdown orders in South Africa affected ambulatory clinic visitation in rural Kwa-Zulu Natal (KZN).DesignObservational cohortSettingData were analysed from 11 primary healthcare clinics in northern KZN.ParticipantsA total of 46 523 individuals made 89 476 clinic visits during the observation period.Exposure of interestWe conducted an interrupted time series analysis to estimate changes in clinic visitation with a focus on transitions from the prelockdown to the level 5, 4 and 3 lockdown periods.Outcome measuresDaily clinic visitation at ambulatory clinics. In stratified analyses, we assessed visitation for the following subcategories: child health, perinatal care and family planning, HIV services, non-communicable diseases and by age and sex strata.ResultsWe found no change in total clinic visits/clinic/day at the time of implementation of the level 5 lockdown (change from 90.3 to 84.6 mean visits/clinic/day, 95% CI −16.5 to 3.1), or at the transitions to less stringent level 4 and 3 lockdown levels. We did detect a >50% reduction in child healthcare visits at the start of the level 5 lockdown from 11.9 to 4.7 visits/day (−7.1 visits/clinic/day, 95% CI −8.9 to 5.3), both for children aged <1 year and 1–5 years, with a gradual return to prelockdown within 3 months after the first lockdown measure. In contrast, we found no drop in clinic visitation in adults at the start of the level 5 lockdown, or related to HIV care (from 37.5 to 45.6, 8.0 visits/clinic/day, 95% CI 2.1 to 13.8).ConclusionsIn rural KZN, we identified a significant, although temporary, reduction in child healthcare visitation but general resilience of adult ambulatory care provision during the first 4 months of the lockdown. Future work should explore the impacts of the circulating epidemic on primary care provision and long-term impacts of reduced child visitation on outcomes in the region.

Young people's health service utilisation (the number accessing a facility) has been the focus of guidelines and health systems strengthening policies. This is due to young people being at an increased health risk because of inequitable access and utilisation of health services, which is more pronounced in rural settings with limited service availability. This is a major concern as globally, youth constitute a considerable and increasing part of the population in Sub-Saharan Africa. The objective of this paper is to present a comprehensive approach for the exploration of health service utilisation by young people in rural KwaZulu-Natal, South Africa. We examined barriers and facilitators conceptualised by the constructs of the Theory of Planned Behaviour, framed within a socio-ecological model. Data were collected in January to June 2017 from two sites using in-depth interviews, spiral transect walks and community mapping with young people (aged 10 to 24 years), primary care health providers, school health professionals, community stakeholders and young people's parents. Socio-ecological and behavioural factors influenced young people's intention to use services. Barriers included perceived negative attitudes of health providers and perceived poor staff competencies. Facilitators included an appreciation of receiving health education and assumed improved health. At social and community levels, normative beliefs hindered young people from utilising services as they feared stigmatisation and gossip. At a public policy level, structural elements had a disempowering effect as the physical layout of the clinics hindered utilisation, limited resources influenced staffing, and facility opening times were not convenient for school goers. We suggest that to fully appreciate the complexity of health service utilisation, it is necessary to not only consider factors and processes relevant to the individual, but also acknowledge and act upon, the disjuncture between community level cultural values, norms and national policies.

Background We use the ‘candidacy framework’ to describe adolescents’ and young people’s (AYP) experiences of health services in a rural KwaZulu-Natal district, South Africa. Methods A qualitative approach was used including group discussions, in-depth and key informant interviews with a purposive sample of AYP ( n  = 70), community leaders ( n  = 15), school health teams ( n  = 10), and health service providers ( n  = 6). Results Findings indicate tacit understanding among AYP that they are candidates for general health services. However, HIV stigma, apprehensions and misconceptions about sexual and reproductive health, and socio-cultural views which disapprove of AYP pre-marital sex undermine their candidacy for sexual and reproductive services. Conclusion Consideration and understanding of the vulnerabilities and reasons AYP exclude themselves will inform interventions to address their health needs. AYP’s participation in the design of health services will increase their acceptability and encourage uptake of services.

A link between adversity, including low socio-economic status, and behaviours which carry health risks, such as alcohol consumption, has often been observed. The causes of this link are, however, poorly understood, making it difficult to explain why the association is often not linear and why there is so much variability between groups and individuals facing similar adversity. We investigate the use of the concept of emergent properties in explaining the link and its non-linear nature. `Emergent properties' arise from the interaction of factors or items in a high-level system which, as a result, has qualities possessed by none of the individual factors. We apply a mixed methods approach to examine the association of an example emergent property, hope, and alcohol consumption among adolescents in a rural South African site. We found that among adolescents living in similar contexts, there was enough variance in reported levels of hope, that an association with alcohol use could be identified. This result is cause for optimism regarding the potential use of emergent properties in explaining variations in risk behaviour. Improving our measurement of emergent properties is perhaps the biggest challenge facing this approach. More work is needed to take further the task of identifying emergent properties capable of distilling the influence of lower level variables into single measures useful for analysis and policy purposes.

Background South Africa is committed to achieving Sustainable Development Goal 3 (SDG 3), which aims to ensure health and well-being for all. However, in rural provinces like KwaZulu-Natal, structural inequalities, socio-cultural challenges, and environmental stressors hinder progress. This study synthesises findings from qualitative research conducted at the Africa Health Research Institute (AHRI) to explore the challenges and opportunities in meeting SDG 3 targets.  Methods An integrative literature review was conducted, analysing studies from 2015 to 2024 that focused on SDG 3related topics, including HIV/AIDS, tuberculosis, maternal and child health, sexual and reproductive health, and the impact of climate change. A framework analysis approach was applied to identify common themes, opportunities and challenges to achieving SDG 3 in rural KwaZulu-Natal. Results and discussion Key challenges to achieving SDG 3 include limited access to healthcare, socio-cultural norms that influence health-seeking behaviours, climate-related stressors, and gender disparities. Studies highlighted poor maternal immunisation uptake due to traditional beliefs, stigma-related challenges in HIV prevention, and climate-induced economic hardships affecting treatment adherence. Gendered challenges were prominent, with men’s healthcare engagement being hindered by masculinity norms and adolescent girls facing restricted access to sexual health services. The COVID-19 pandemic further disrupted access to healthcare, particularly for older adults. Despite these challenges, opportunities exist for progress. Community-driven interventions such as DREAMS and MTV-Shuga improved adolescent engagement with sexual health education. Male-focused interventions like Stepping Stones and Creating Futures increased men’s involvement in HIV care. Additionally, integration of climate adaptation strategies into health systems could mitigate environmental health risks.  Conclusion This study provides critical insights for policymakers to enhance the progress towards achieving SDG 3. To do so policymakers should focus on addressing systemic healthcare challenges, integrating gender-responsive interventions, and strengthening community-based health initiatives. Climate-resilient healthcare infrastructure and policies are crucial to ensuring sustained progress. Future efforts should focus on expanding youth-friendly services, enhancing male engagement in healthcare, and leveraging local partnerships to improve health outcomes in rural communities.

IntroductionAdolescents living with HIV (ALHIV) are an extremely vulnerable population, with the burden of mental health problems carefully documented together with the constraints for receiving timely and adequate management of the problems, especially in rural settings. Problem Management Plus (PM+) is a scalable psychological intervention for individuals impaired by distress in communities exposed to adversity. Initially developed for adult populations, few studies have assessed its potential to address adolescent distress. This study aims to co-adapt PM+ with an adherence component (PM+Adherence) for ALHIV and to evaluate its acceptability and feasibility in rural Kwa-Zulu Natal Province, South Africa.Methods and analysisWe will use a mixed-methods approach over three phases. The first phase will include a realist synthesis and collection of formative data from up to 60 ALHIV, caregivers and healthcare providers to inform the adaptation of WHO PM+, including the components of an adherence module. During the second phase, we will undertake the cultural adaptation of the PM+Adherence intervention. The third phase will involve a hybrid type 3 implementation strategy among ALHIV aged 16–19 years (n=50) to implement and evaluate the feasibility of the culturally co-adapted PM+Adherence. The feasibility indicators to be evaluated include reach, adoption, attrition, implementation and acceptability of the adapted intervention, which will be assessed qualitatively and quantitatively. In addition, we will assess preliminary effectiveness using an intention-to-treat approach on HIV-related indicators and mental health outcomes at baseline, end intervention, 2-month follow-up during the 6-month implementation.DiscussionWe expect that the PM+Adherence will be acceptable and can feasibly be delivered by lay counsellors in resource-limited rural KwaZulu-Natal.Ethics and disseminationEthical clearance has been obtained from the University of KwaZulu-Natal Biomedical Research Ethics Committee, (BREC/00005743/2023). Dissemination plans include presentations at scientific conferences, peer-reviewed publications and community level.

Background The COVID-19 pandemic forced governments, multilateral public health organisations and research institutions to undertake research quickly to inform their responses to the pandemic. Most COVID-19-related studies required swift approval, creating ethical and practical challenges for regulatory authorities and researchers. In this paper, we examine the landscape of ethics review processes in Africa during public health emergencies (PHEs). Methods We searched four electronic databases (Web of Science, PUBMED, MEDLINE Complete, and CINAHL) to identify articles describing ethics review processes during public health emergencies and/or pandemics. We selected and reviewed those articles that were focused on Africa. We charted the data from the retrieved articles including the authors and year of publication, title, country and disease(s) reference, broad areas of (ethical) consideration, paper type, and approach. Results Of an initial 4536 records retrieved, we screened the titles and abstracts of 1491 articles, and identified 72 articles for full review. Nine articles were selected for inclusion. Of these nine articles, five referenced West African countries including Liberia, Guinea and Sierra Leone, and experiences linked to the Ebola virus disease. Two articles focused on South Africa and Kenya, while the other two articles discussed more general experiences and pitfalls of ethics review during PHEs in Africa more broadly. We found no articles published on ethics review processes in Africa before the 2014 Ebola outbreak, and only a few before the COVID-19 outbreak. Although guidelines on protocol review and approval processes for PHEs were more frequently discussed after the 2014 Ebola outbreak, these did not focus on Africa specifically. Conclusions There is a gap in the literature about ethics review processes and preparedness within Africa during PHEs. This paper underscores the importance of these processes to inform practices that facilitate timely, context-relevant research that adequately recognises and reinforces human dignity within the quest to advance scientific knowledge about diseases. This is important to improve fast responses to PHEs, reduce mortality and morbidity, and enhance the quality of care before, during, and after pandemics.

In 2016, the Lancet Commission on Adolescent Health defined adolescence universally as ‘a critical phase in life for achieving human potential; where an individual acquires the physical, cognitive, emotional, social and economic recourses that are the foundation for later life health and well-being’.1 The aim of this paper is to explore the extent to which concepts of adolescence from the Global North are appropriate for health interventions in Africa. Importantly, it is during this phase of the life course that reproductive potential is achieved, which is critical for the survival of the human race. Experimentation and risk-taking during adolescence are associated with many behaviours such as sexual behaviour, alcohol, smoking and substance use, which in turn are risk factors for some of the leading causes of morbidity and mortality later in the life-course worldwide, for example, HIV and cardiovascular disease. [...]a specific focus on addressing these behaviours during adolescence is key to improving health both immediately and later in life. Table 1 Legal ages for voting, marriage and drinking in five countries Zimbabwe Argentina Iraq France Canada Boys Girls Boys Girls Boys Girls Boys Girls Boys Girls Legal voting age* 18 18 16 16 18 18 18 18 18 18 Legal drinking age† 18 18 18 18 21 21 18 18 18 18 Legal age for Marriage‡ 18 18 18 16 18 18 18 18 18 18 *Lowering the Voting Age.