BACKGROUND:Fathers are intricately bound to the experience of adolescent mothers and their children. Yet, fathers of children born to adolescent mothers, particularly within the context of HIV, remain neglected in the literature. These exploratory analyses provide insight into the characteristics of fathers of children born to adolescent mothers affected by HIV in South Africa. SETTING:Eastern Cape Province, South Africa. DESIGN:Cross-sectional data from a prospective cohort study. PARTICIPANTS:Young mothers (10-24 years of age) and their children (0-68 months). All mothers completed detailed study questionnaires, including standardised and study-specific measures, relating to their self, their children and the fathers of their children. Summary statistics are presented based on maternal self-report of father characteristics. χ2 tests and t-tests (Fisher's exact/Kruskal-Wallis tests, where appropriate) were additionally used to explore sample characteristics (including father characteristics, maternal experience and child characteristics) according to paternal age and father involvement in childcare (defined by responses to four maternal self-report questions). Father characteristics were also explored according to maternal HIV status and maternal mental health status. RESULTS:40% of fathers were adolescents (10-19 years) at the birth of their children. Overall, father involvement was low (19.5%). Compared with noninvolved fathers, involved fathers were more likely to be older when their child was born (21 years vs 20 years, t=4.30, p=0.04), to be in a relationship with the mothers of their children (74.8% vs 47.2%, χ2=40.8, p≤0.0001), to reside with their children and their mothers (14.7% vs 3.7%, χ2=49.3, p≤0.0001) and to attend the first antenatal appointment (4.3% vs 1.5%, χ2=5.21, p=0.02). A quarter (25.4%; 227/894) of the adolescent mothers in the sample were living with HIV. The prevalence of maternal HIV was found to be higher among adolescent mothers of children born to older fathers compared with adolescent fathers (31.7% vs 15.9%, χ2=28.3, p≤0.001). Likewise, depressive symptoms were more prevalent among adolescent mothers of children born to older fathers compared with adolescent fathers (9.9% vs 5.3%, χ2=6.08, p=0.01). Adolescent mothers reporting poor mental health were less likely to be in a relationship with the fathers of their children (41.8% vs 54.1%, χ2=7.32, p=0.03) and more likely to experience domestic violence perpetrated by the fathers of their children (8.2% vs 3.3%, χ2=6.07, p=0.01) and to engage in arguments about finances with the fathers of their children (30.0% vs 17.0%, χ2=10.8, p=0.001). While some differences in individual subscales were identified, overall composite scores of child cognitive development did not differ according to father age or father involvement. CONCLUSIONS:Analyses provide the first preliminary description of the fathers of children born to adolescent mothers affected by HIV in South Africa. Fathers are inherently tied to the experiences of adolescent mothers and their children. Father involvement with their children was low. Further research is required to explore the potential barriers to father involvement and pathways to overcome these. Efforts to bolster father engagement, such as the inclusion of fathers within maternal and child service provision, may have benefits for fathers, adolescent mothers and their children. There was a high prevalence of adolescent fatherhood in the study. Adolescent fathers may have specific needs requiring tailored intervention for adolescent parent families. The need for the inclusion of fathers within policy, programming and research remains.

Adolescence is defined by significant socio-emotional changes and vulnerability. Adolescents and youth living with HIV (AYLHIV) experience worse clinical HIV outcomes—adherence, retention and viral load suppression—compared to adults [1]. Novel approaches to implement evidence-based interventions to address their unique needs and life-stage are needed. Undetectable = Untransmittable (U = U) is important in the comprehensive care of AYLHIV [2, 3]. U = U is a community-driven, evidence-based movement embodying the message that a person living with HIV who has reached and sustained an undetectable viral load (<200 copies/ml) will not transmit HIV to a sexual partner [4, 5]. As AYLHIV navigate friendships, sexual and romantic relationships, and parenthood, U = U may be a powerful tool for safe relationships and motivation for maintaining viral suppression [6]. Limited U = U interventions exist for AYLHIV, especially in Eastern and Southern Africa, where nearly 80% of AYLHIV reside. Promoting U = U to address self-stigma and accurate knowledge sharing between sexual partners has the power to shape AYLHIV's ability to live full and healthy lives [3]. Despite global support and conclusive evidence for U = U, varying levels of awareness, reception and integration in standard clinical practice remain [7]. There is a critical gap in the literature and knowledge regarding how to message and use U = U to empower AYLHIV across sub-Saharan Africa (SSA). We embarked on creating a tool to address this gap and subsequently aimed to understand how this tool is being used and whether it is relevant to AYLHIV around U = U. The Elizabeth Glaser Pediatric AIDS Foundation's (EGPAF) Committee of African Youth Advisors (CAYA) developed an innovative U = U tool in partnership with researchers at the University of Cape Town. CAYA engages 15- to 29-year-old youth from 11 SSA countries. CAYA identified U = U as a priority in their 2022 prioritization survey. Members completed initial surveys on U = U knowledge and awareness, informing skill-building sessions. CAYA previously developed cartoon-based tools on HIV-treatment literacy, which are routinely used in AYLHIV programming and positively received [8]. In discussions on format, CAYA preferred the tool to be visually appealing, relevant, youth-friendly and use simple language. CAYA, therefore, decided to create a U = U graphic novel. Graphic novels and comic books can be effective in delivering clinical information to youth and can be integrated into individual/group-based programming [9]. A graphic novel, compared to a video, can be utilized in various ways—role plays, individual/group reads, play-acting and so on, for participatory-based learning [9]. Paper-based tools are useful as not all health facilities and adolescents have access to reliable technology or connectivity for standardized use of video-based learning. We conducted several discussions with CAYA to identify relevant U = U scenarios for youth. The three main scenarios identified included U = U in the context of romantic partnerships (heterosexual and same-sex) and pregnant young women. CAYA reflected on characters for each scenario and developed character profiles for each story. We iteratively developed the stories and worked with local African artists for illustration. Lira and Obi: A young man and woman in a new relationship navigating HIV disclosure Martha and Ibrahim: A sero-discordant married couple, Martha is newly pregnant Tambo and Junior: Two young men as a couple navigating disclosure and prevention of HIV EGPAF Lesotho implements youth-responsive HIV services supported by youth ambassadors (YA). U = U messaging is included in national guidelines on HIV treatment and prevention. YA are trained peers who facilitate all AYLHIV peer support groups (PSGs), conduct individual counselling and support health services at adolescent corners and other facilities. Utilizing YA to implement the tool was logical as the tool was designed for use with AYLHIV in individual and group settings supported by capacitated peers. YA were introduced to the U = U graphic novel and oriented on how to integrate it into programming during a training in December 2022. YA facilitate PSGs for different ages 10−14, 15−19, 20−24 and groups including pregnant and breastfeeding girls. Twenty-seven YA support 238 PSGs and 75 Ariel Clubs across eight districts. YA facilitate PSGs on weekends at facilities ranging in size between 40 and 60 AY. At the end of 2023, 5300 AY were actively participating in PSGs facilitated by YA. In August 2023, we sought to understand how YA use the tool and their feedback on its use. We developed an e-survey with questions focused on how the tool is used, the stories used in what different settings (PSGs, individual counselling, etc.), perceptions of the usefulness and relevance, confusions raised on U = U and suggestions on improving the tool. EGPAF Lesotho staff shared an English and Sesotho survey link via email and on WhatsApp to the 27 YA. No personal identifiable data were collected, and all responses were anonymized. Twenty (74%) YA completed the survey. Eighty percent (16/20) reported having used one or more of the U = U stories. YA reported using the tool in different ways: 65% (13/20) used it in PSGs with AYLHIV; 45% (9/20) used it in one-on-one counselling with AYLHIV; and 35% (7/20) used it personally. All three stories were used. Ten YA reported using Lira and Obi in putting U = U in context for sexually active young people, those in relationships and navigating disclosure. Five YA utilized the Martha and Ibrahim story to support AY navigating disclosure, address misconceptions about pregnancy, process acceptance of their status and empower pregnant girls in pregnancy peer support settings. Six YA used the Tambo and Junior story as they support all AYLHIV regardless of identity and gender and to discuss disclosure and U = U with sexually active youth. Table 1 depicts themes on the usefulness and relevance of the tools, and clarifications raised on U = U while using the tool. YA who identified the tool as useful (n = 14) cited reasons including it facilitated the sharing of personal stories, it provided avenues to connect adherence with living a healthy positive life and it showcased helpful context around how to disclose. The format was described as simple to use and enjoyable. Three YA described the tools as somewhat useful indicating other life experiences may not be depicted. No YA reported the tool as not useful. Usefulness 80% of youth ambassadors described the graphic novel tool as useful (n = 13 very useful; n = 3 somewhat useful) Relevance 80% of youth ambassadors described the graphic novel tool as relevant (n = 10 as very relevant; n = 6 as somewhat relevant) Confusions and clarifications 40% of youth ambassadors reported questions on U = U raised while using the tool (n = 8) Many YA (n = 10) identified the tool as very relevant because it explained adherence and viral suppression; it motivated youth to get virally suppressed; and it mirrored similar situations young people experience. The imagery and storylines were described as relevant and relatable. Six YA found the tool somewhat relevant, noting more difficulty in use with large groups, omission of other lifestyle barriers and the need for translation into Sesotho. Eight YA shared a range of clarifications/questions raised when using the tool with AYLHIV ranging from U = U and safe sex to U = U and gender/sexual identity. YA shared the tool helped AYHLIV see life is still possible when living with HIV. Most YA respondents indicated nothing was missing from the tool. Suggestions for improvements included translating the stories into Sesotho, implementing more training on its use, digitizing the stories and adding a story depicting a young person who thinks reaching undetectable is being cured. Other suggestions included developing accompanying demonstration tools, adding more diversity in stories including elements from rural settings, and exploring options for use in school settings. The experience of implementing this tool reveals the practicality and promise of a narrative, youth-friendly graphic novel tool on a topic like U = U. The authors declare no competing interests. CL, TR, ET, AT, MM and CAYA conceptualized the project. Data tools were designed by CL, TR and MM with inputs from CAYA, ET and AT. Data collection was facilitated by TR and MM. Data analysis was led by CL. The draft was jointly constructed by all authors and reviewed by all authors. The authors would like to sincerely thank all members of the Committee of African Youth Advisors for their invaluable contributions, ideas and leadership in the development and use of the U = U graphic novel. CAYA members include: Chadrack Mudikisi, Chams Mwinyi, Patrick Banda, Deborah Simbeye, Elcina Joao Manhiqu, Elves Moralino, Ismail Harlemana, Agaba Frank, Manzi Jim, Saline Awuor Mboya, Emish Ondiek, Kandida Paul Kisanji, Kelvin Josiah Benjamin, Sylvia Thadei Masawe, Lebohang Khaahloe, Sebuoeng Lekanyane, Siboniso Mamba, Temlandvo Mhlanga, Achu Eric, Lionelle Deborah, Ihunwo Victor Ibuchim, Denis Angela La'azeye, Joshua Ochieng, Mthobisi Simelane and Ismail Harlemana. We would also like to thank the youth ambassador cadres in Lesotho for their invaluable insights for this project as well as their ongoing efforts in supporting adolescents and youth. ET/AT were funded by the Fogarty International Center, National Institute on Mental Health, National Institutes of Health [K43TW011434] and UKRI GCRF Accelerating Achievement for Africa's Adolescents (Accelerate) Hub (ES/S008101/1). The content is solely the responsibility of the authors and does not represent the official views of the National Institutes of Health. Data sharing is not applicable to this article as no datasets were generated or analysed during the current study.

Who speaks?For whom? Where?And why?-Conceptual, methodological, and

Background: While growing evidence has documented risks and resilience to HIV and poor sexual and reproductive health (SRH) among young women, young mothers' abilities to respond to and overcome challenges have been understudied. Developing appropriate methodologies to measure resilience in the context of HIV, especially among young mothers, is a critical first step to filling this gap. We aimed to improve the relevance, and comprehensibility of an open-access resilience measure for use among young mothers living in HIV-endemic communities in South Africa. This paper summarizes a two-stage study that was carried out in the Eastern Cape, South Africa.Methods: First, n = 9 cognitive interviews were conducted to inform the adaptation of the Child and Youth Resilience Measure Revised (CYRM-R) for use among young mothers (n = 7 living with HIV). The adapted measure was applied in remote interviews with 892 adolescent mothers during the COVID-19 pandemic (December 2021-April 2023). We investigated the basic psychometric properties of the adapted measure using STATA16.Results: Cognitive interviews offered unique perspectives on how to modify items in English and isiXhosa, including items that had similar understandings and responses, with new probes and additional key words added to seven items. Participants' understanding of item wording and the translation of items resulted in word changes or substitution to maximise participants' understanding of eight out of 17 items. The utilization of vignettes proved to be useful in engaging participants to reflect on their experiences. The revised scale had moderate psychometric properties. The EFA confirmed a two-factor structure, and the internal consistency of the CYRM-R was moderate (alpha = 0.75; omega = 0.75).Conclusion: Cognitive interviews supported the adaptation of a resilience measure for adolescent mothers affected by HIV in South Africa. Initial psychometric properties highlight possible further adaptations needed, potentially due to the unique population of adolescent mothers.

Growing evidence documents the effects of the COVID-19 pandemic on adolescents in East and Southern Africa. We present and explore the longitudinal health and development-related priorities and challenges of adolescent advisors in South Africa and Kenya, including prior to, and during the COVID-19 pandemic. Findings were co-generated with adolescent advisors in the Eastern Cape Province of South Africa (n=15, ages 18-22 in 2019) and Kisumu, Kenya (n=16, ages 10-14 in 2020). Prior to COVID-19, adolescent advisors engaged in a participatory exercise to share and explore their health and development-related priorities and challenges in 2019 and 2020. During the COVID-19 pandemic in 2020 and 2021, members of the same groups shared their experiences, challenges and coping strategies in semi-structured telephone interviews (Eastern Cape: n=14, aged 19-23; Kisumu n=12, aged 11-16) and group-based remote participatory social media activities (n=27 activities with n=12 advisors, Eastern Cape). We thematically analysed COVID-19 activities, considering them alongside pre-pandemic priorities and challenges. Many of the health and development-related priorities and challenges identified prior to COVID-19 remained issues of concern during COVID-19. These included education; victimization and violence; teenage pregnancy; substance use; household tension, conflict and inadequate family and caregiver support; health and medication concerns (South Africa) and water and food shortages (Kenya). Other issues such as financial insecurity, mental health, and crime were strong themes that emerged during COVID-19, which were not directly reported as priorities prior. Although almost all of adolescent advisors' most pressing pandemic-related challenges were also priorities for them prior to COVID-19, these issues were often discussed as new, and caused by the onset of COVID-19. While demonstrating how COVID-19 has exacerbated pre-existing vulnerabilities, we also suggest that the pandemic may have brought about a new way for adolescents to make sense of, and articulate pre-existing challenges.

Abstract Background Transgender women have a disproportionately high HIV prevalence compared to cisgender women and men who have sex with men, which puts them at risk of HIV-related stigma (Baral SD et al., Lancet Infect Dis, 13;3, 2013). People whose gender identities are in tension with dominant social norms (including transgender women) often also experience gender identity-related stigma. There has been increasing attention to transgender people in HIV research and interventions. However, very little research has been done in sub-Saharan African countries. Methods We conducted a qualitative cohort study which included eight transfeminine and/or gender diverse women (four living with HIV) in Western Cape, South Africa, for a follow-up period of 12–18 months. Using a narrative analysis approach, we set out to understand how transfeminine and gender diverse participants in the cohort anticipated, experienced and internalised HIV stigma and gender identity stigma, and how these stigmas affected HIV service access. Result We found that participants reported anticipated, experienced, and internalised stigma relating both to their gender identity and to living with HIV. Participants reported inconsistent uptake of antiretroviral therapy (ART) services (including ART initiation and adherence) that they linked to stigma. We also found that gender diverse women and transfeminine women are challenged with other stigmatising social identities, like being a sex worker, drug user and/or a man (or assigned male sex at birth) who have sex with men (MSM). We use the terms ‘transfeminine’ and ‘gender diverse’ as terms that are inclusive of gender variant people who were all assigned male sex at birth and identify as women in some or all aspects of their lives. The persons in our study also showed gender identifications that were fluid and sometimes varied in different contexts and situations, therefore gender identity and sexual identity were often conflated for these individuals. Participants managed high levels of reported stigma by drawing on social support networks like families, friends and peers. Conclusion Our study provides exploratory work on how stigma may affect HIV services uptake amongst gender diverse women and transfeminine women in South Africa. We recommend future studies to further explore the unique HIV risks of gender diverse individuals. Trial registration DOH-27-0513-4253 .

INTRODUCTION:Population distributions, family and household compositions, and people's sense of belonging and social stability in southern Africa have been shaped by tumultuous, continuing large-scale historical disruptions. As a result, many people experience high levels of geographic and social fluidity, which intersect with individual and population-level migration patterns. We describe the complexities of household fluidity and HIV service access in South Africa and Zambia to explore implications for health systems and service delivery in contexts of high household fluidity.METHODS:HPTN 071 (PopART) is a three-arm cluster randomized controlled trial implemented in 21 peri-urban study communities in Zambia and South Africa between 2013 and 2018. A qualitative cohort nested in the trial included 148 purposively sampled households. Data collection was informed by ethnographic and participatory research principles. The analysis process was reflexive and findings are descriptive narrative summaries of emergent ideas.RESULTS:Households in southern Africa are extremely fluid, with people having a tenuous sense of security in their social networks. This fluidity intersects with high individual and population mobility. To characterize fluidity, we describe thematic patterns of household membership and residence. We also identify reasons people give for moving around and shifting social ties, including economic survival, fostering interpersonal relationships, participating in cultural, traditional, religious, or familial gatherings, being institutionalized, and maintaining patterns of substance use. High fluidity disrupted HIV service access for some participants. Despite these challenges, many participants were able to regularly access HIV testing services and participants living with HIV were especially resourceful in maintaining continuity of antiretroviral therapy (ART). We identify three key features of health service interactions that facilitated care continuity: disclosure to family members, understanding attitudes among health services staff including flexibility to accommodate clients' transient pressures, and participants' agency in ART-related decisions.CONCLUSIONS:Choices made to manage one's experiential sense of household fluidity are intentional responses to livelihood and social support constraints. To enhance retention in care for people living with HIV, policy makers and service providers should focus on creating responsive, flexible health service delivery systems designed to accommodate many shifts in client circumstances.

Introduction: Qualitative data are lacking on the impact of mobility among people living with HIV (PLHIV) and their decision-making around anti-retroviral treatment (ART). We describe challenges of juggling household responsibility, livelihood mobility and HIV management for six PLHIV in urban Zambia. Methods: Six PLHIV (three men and three women, aged 21 to 44) were recruited from different geographic zones in one urban community drawn from a qualitative cohort in a social science component of a cluster-randomized trial (HPTN071 PopART). Participants were on ART (n = 2), not on ART (n = 2) and had started and stopped ART (n=2). At least two in-depth interviews and participant observations, and three drop-in household visits with each were carried out between February and August 2017. Themed and comparative analysis was conducted. Results: The six participants relied on the informal economy to meet basic household needs. Routine livelihood mobility, either within the community and to a nearby town centre, or further afield for longer periods of time, was essential to get by. Although aware of ART benefits, only one of the six participants managed to successfully access and sustain treatment. The other five struggled to find time to access ART alongside other priorities, routine mobility and when daily routines were more chaotic. Difficulty in accessing ART was exacerbated by local health facility factors (congestion, a culture of reprimanding PLHIV who miss appointments, sporadic rationed drug supply), stigma and more limited social capital. Conclusions: Using a time-space framework illustrated how household responsibility, livelihood mobility and HIV management every day were like spinning plates, each liable to topple and demanding constant attention. If universal lifelong ART is to be delivered, the current service model needs to adjust the limited time that some PLHIV have to access ART because of household responsibilities and the need to earn a living moving around, often away from home. Practical strategies that could facilitate ART access in the context of livelihood mobility include challenging the practice of reprimand, improving drug supply, having ART services more widely distributed, mapped and available at night and weekends, and an effective centralized client health information system.

HIV prevalence and incidence in South Africa remain high, making HIV a part of everyday life. Community narratives on HIV treatment and prevention are important and influence official and unofficial health messaging and community perceptions and understandings of HIV. We explore how contributors and the columnist of an agony aunt column position HIV relative to choices made about love, partnership, and sex over three years. We analysed all columns of an agony aunt series (Antie Mona) published between December 2012 and November 2015. The column is published in a South African, Afrikaans-language newspaper "Son", prioritising sensationalist news items. Trends were identified through narrative analysis. Data were managed in ATLAS.ti and inductive, iterative coding conducted. It was found that letters to the agony aunt rarely refer to HIV directly (less than 7%). Euphemisms such as diseases of the flesh and the great flu were more commonly used instead of HIV or AIDS. Letters addressed HIV in three ways: direct references to experiences living with HIV; direct questions about HIV prevention; and scenarios where HIV could (from a public health perspective) have been the main concern, but everyday issues took precedence. The majority of letters fell into this latter category where the writers focused on the immediate concerns of good sexual relations, problems related to love and romantic relationships, good moral behaviour of others, and issues of oppressive life conditions rather than on HIV directly. The findings illustrate that informal, public contributions to health information, such as agony aunts, are important narratives that inform popular perspectives on HIV and health. A better appreciation of this context would allow health implementers to ensure that these role players receive updated health messaging to avoid the risk of HIV-related stigma where HIV is used as a moral rod to punish perceived moral transgressions.

The development of methodologies, techniques, and tools for analysis and simulation of stage separation is critically needed for successful design and operation of next-generation reusable launch vehicles. As a part of this activity, the ConSep simulation tool is being developed, which is a MATLAB-based front and back end to the commercially available ADAMS solver, an industry standard package for solving multibody dynamic problems. This paper discusses the application of ConSep to the simulation and analysis of staging maneuvers of two-stage-toor-bit bimese reusable launch vehicles, one staging at Mach 3 and the other at Mach 6. The proximity and isolated aerodynamic database were assembled using available wind-tunnel test data. The effects of parametric variatibns in mass, inertia, flight path angle, and altitude from their nominal values at staging were evaluated. Monte Carlo runs were performed for Mach 3 staging to evaluate the sensitivity to uncertainties in aerodynamic. coefficients.

NASA has initiated a comprehensive stage separation tool development activity to address the technology needed for successful development and operation of next generation reusable launch vehicles. As a part of this activity, ConSep simulation tool is being developed. This paper discusses the application of this tool to the staging maneuvers of two-stage-to-orbit (TSTO) vehicles. Simulation and analyses are performed for two bimese TSTO concepts, one staging at Mach 3 and the other at Mach 6. The TSTO bimese vehicles used in this study are sized for international space station class payload. The proximity and isolated aerodynamic databases used in the simulation were generated using the data from wind tunnel tests conducted at NASA Langley Research Center. ConSep is a MATLAB-based front end to the commercially available ADAMS solver, an industry standard package for solving multi-body dynamic problems.