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Social protection can reduce HIV-risk behavior in general adolescent populations, but evidence among HIV-positive adolescents is limited. This study quantitatively tests whether social protection is associated with reduced unprotected sex among 1060 ART-eligible adolescents from 53 government facilities in South Africa. Potential social protection included nine ‘cash/cash-in-kind’ and ‘care’ provisions. Analyses tested interactive/additive effects using logistic regressions and marginal effects models, controlling for covariates. 18 % of all HIV-positive adolescents and 28 % of girls reported unprotected sex. Lower rates of unprotected sex were associated with access to school (OR 0.52 95 % CI 0.33–0.82 p = 0.005), parental supervision (OR 0.54 95 % CI 0.33–0.90 p = 0.019), and adolescent-sensitive clinic care (OR 0.43 95 % CI 0.25–0.73 p = 0.002). Gender moderated the effect of adolescent-sensitive clinic care. Combination social protection had additive effects amongst girls: without any provisions 49 % reported unprotected sex; with 1–2 provisions 13–38 %; and with all provisions 9 %. Combination social protection has the potential to promote safer sex among HIV-positive adolescents, particularly girls.
1060 HIV-positive adolescents (10–19 year olds) were recruited from a health district in the Eastern Cape province, South Africa. This was selected as a resource-limited setting with high HIV-prevalence rates [30]. The study was designed in collaboration with South African Departments of Health and Basic Education, UNICEF, PEPFAR-USAID, Pediatric AIDS Treatment for Africa (PATA) and local NGOs. Ethical approval for this study was provided by Research Ethics Committees at the Universities of Oxford (SSD/CUREC2/12-21) and Cape Town (CSSR 2013/4), Eastern Cape Departments of Health and Basic Education, and ethical review boards of participating hospitals. The study aimed to include all 10–19 year old adolescents within the health district who were eligible to initiate ART. First, all healthcare facilities providing ART were visited (n = 83): all facilities who reported more than five ART-eligible adolescents were included in the study (n = 39). As the study progressed, the South African Department of Health implemented a primary healthcare reengineering programme, as a result of which the adolescents receiving care in the initial 39 facilities were transferred to a total of 53 healthcare facilities including hospitals, community healthcare centres, and primary healthcare clinics. All 53 facilities were then included in the study. Adolescents were recruited at clinics where they were receiving antiretroviral treatment and care, or traced into their home communities for those not reachable at the clinics. All caregivers and adolescents participating in the study gave written informed consent prior to interviews, which took place in the language of their choice and lasted an average of 90 min. Of all study-eligible adolescents, n = 1060 (90.1 %) were interviewed, 4.1 % refused participation (either adolescent or caregiver), 0.9 % were excluded due to severe cognitive disability, 1.2 % were excluded due to living in very unsafe areas, and 3.7 % were untraceable. Participants who asked for help or disclosed abuse, neglect, defaulting from antiretroviral treatment or clinic care, severe hunger, or risk of significant harm were immediately assisted and linked to existing services (n = 66, 6.2 %). Due to high HIV-stigma rates, the study was presented in participating communities as a general study on adolescent access to health and social services. In order not to draw attention to HIV-affected families, when participants were traced and interviewed in communities, an additional n = 467 cohabitating or neighbouring age-peers were interviewed using a non HIV-specific version of the questionnaire (not included in this analysis). Quantitative and qualitative research were combined iteratively during the study: qualitative research guided the design and content of the quantitative data collection tools and processes, preliminary quantitative analysis provided themes to be further explored by qualitative research, and these in-depth explorations shaped quantitative analyses. Quantitative questionnaires used standardised scales and validated measures when available. Tools were translated into Xhosa and back-translated for improved conceptual validity [31], then piloted with 25 HIV-positive adolescents from rural and urban sites in the health district. Questionnaires included graphics, interactive games and vignettes to introduce questions around sensitive topics. Interviews were administered by trained research assistants or via tablet-assisted self-interviewing, based on the participants’ literacy levels. Unprotected sex at last sexual intercourse was measured as no condom use at most recent sexual encounter. It was dichotomised as: ‘1 = unprotected sex’ and ‘0 = abstinence or protected sex’. Adolescents were coded as STI symptomatic if they reported having at least one of the following four STI symptoms: genital sores/warts, burning whilst urinating, genital itching/redness, or anal itching/soreness/bleeding, in the last 6 months, following WHO guidelines for syndromatic diagnosis of STIs [32]. Adolescent pregnancy among girls was defined as ever having been pregnant before or during data collection, measured using an item from the National Survey of HIV and Risk Behaviour Amongst Young South Africans [33]. Socio-demographic characteristics (age, gender, home language, housing situation, urban/rural location) were measured using items from South Africa’s Census [34]. Housing was coded as 1 = informal if the adolescent lived in a hut, rondavel (traditional home), or a shack, and 0 = formal if they lived in a brick/concrete house or apartment. Orphanhood status was coded as death of either mother or father or both [35]. Mode of infection was assessed following similar studies and modelling from Southern Africa [36, 37]: adolescents were coded as vertically-infected if they had started ART prior to age 12 or if they had been on treatment for more than 5 years, based on the year of widely available ART access in the study area. Adolescent’s knowledge of their own HIV-positive status was determined through a stepwise process: initially healthcare providers’ report, followed by confirmation by caregiver during the consent process. Additional checks on adolescent knowledge of own HIV-status were conducted using a screening on recent health and medication-taking histories to avoid unintentional disclosure. Adolescents who did not know their own HIV-positive status responded to a questionnaire on ‘illness’ and ‘medication’ instead of ‘HIV’ and ‘antiretrovirals’, respectively. Most recent viral loads were extracted from patient records for a random sub-sample (n = 266, 25 %). Participants with viral load counts >1000 copies/ml were coded as reporting virological failure using WHO standards [38]. ‘Cash/cash-in-kind’ provisions of social protection included the following: Social cash transfers referred to participants’ household receiving at least one of South Africa’s five social welfare grants: child support grant, foster child grant, pension, disability or care dependency. Past-week food security, defined as at least two meals daily for the past week, was measured through items from the National Food Consumption Survey [39]. Access to school was defined as access to free schooling or ability to afford school fees, uniform and equipment. School feeding referred to receiving at least one free meal at school daily. Sufficient clothing was measured using an item from the South African Social Attitudes Survey [40]. Psychosocial ‘care’ provisions included: Positive parenting—including items on praise and positive reinforcement from caregiver—and good parental supervision—including monitoring of adolescent social activities and home rule-setting—measured using two sub-scales of the Alabama Parenting Questionnaire [41]. Attending an HIV-support group was measured as past-month attendance at either a youth-focused or general HIV-support group. Adolescent-sensitive care at clinics was measured through two items asking adolescents about their experience obtaining contraception at the clinic: whether they felt disrespected or were scolded. These items were developed based on extensive qualitative research and consultations with HIV-positive adolescents in the study’s teen advisory group [15]. Data analysis consisted of five steps: first, the included sample (90.1 %) was compared to the rest of the eligible sample across available key demographics (age, gender and residential location) to check for any differences. Descriptive statistics of socio-demographic characteristics, access to each social protection provision, and rates of unprotected sex were calculated for the full included sample and by gender. Covariates and social protection provisions were excluded from further analysis if sub-group sizes were too small for reliable analysis (cut-off n < 100 in the full sample, n < 50 per gender). To check the extent of risk for onwards HIV-transmission, we tested whether unprotected sex was associated with virological failure, a marker of high HIV-transmission risk through unprotected sex [42]. Second, validation checks for self-reported unprotected sex were conducted by testing associations between a) unprotected sex and STI symptomology (full sample) and b) unprotected sex and pregnancy (females only). These used multivariate logistic regression models controlling for all potential covariates. Third, we tested potential associations of unprotected sex and seven social protection provisions: three ‘cash-in-kind’ and four ‘care’, using a multivariate logistic regression model, controlling for covariates. Covariates entered included: adolescent age, gender, language, housing type, residential location, maternal and paternal orphanhood, living with biological caregiver, mode of infection, and knowledge of own HIV-positive status. Fourth, we tested whether gender acted as a moderator for each social protection provision. Moderator analyses were conducted using logistic regression models with two-way interaction terms of gender and each social protection provisions entered in separate models, controlling for covariates found significant in the above step. Subsequently, based on existing literature suggesting different social protection provisions may work for adolescent boys and girls, and because a moderator effect was found, multivariate logistic regressions were run separately for HIV-positive girls and boys. Fifth, effects of combinations of social protection provisions on unprotected sex were tested for the full and then gender-disaggregated samples. To check for potential interaction effects, all significant social protection variables, covariates and interaction terms from stage 3 above (p < .05) were added in a stepwise multivariate logistic regression model, following processes applied by similar studies [23]. Step 1—all covariates significant from the model in stage 3, step 2—all significant social protection variables, step 3—all two-way interaction terms of significant social protection variables, step 4—all three-way and higher order interaction terms of significant social protection variables. Subsequently, marginal effect analysis in STATA tested potential additive effects of significant social protection provisions by computing predicted probabilities of unprotected sex under each potential combination of significant social protection provisions, with all significant covariates held at mean values.
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