The health research landscape in southern Africa is becoming increasingly complex as research efforts intensify to address the region's significant disease burden. The increasing volume and complexity of health research in low- and middle-income countries (LMICs) highlights the ongoing need for enhanced research ethics capacity. To supplement a review published in 2014, this paper provides an overview of research ethics capacity-building initiatives supported through substantive long-term competitive awards from the Fogarty International Center of the US National Institutes of Health between 2014 and 2024. These programs aimed to enhance the capabilities of research ethics committees (RECs) and strengthen research ethics capacity throughout Southern Africa, with broader benefits to the African continent and globally as collaborative health research increases. The programs have successfully developed and delivered comprehensive research ethics curricula tailored to research ethics concerns in the region. Trainees and graduates include clinicians, researchers, REC members, REC administrators, lawyers, and ethicists, with focused efforts to ensure gender parity. This increased representivity of scholars has improved the membership on RECs and in skilled research ethics leadership in the region. For the benefit of future planning, this paper also describes some of the many challenges faced in delivering on program goals - including COVID-19. We also describe innovative solutions developed to address these challenges and meet the needs of students, faculty and institutions, while cultivating excellence in health research ethics. The paper concludes by highlighting areas for future research, underscoring the importance of continued diverse global investment in research ethics capacity to protect research participants and maintain and improve ethical standards and practice in health research within the region and globally. This will enable the development of innovative evidence-based global health solutions based on ethical research.

This article critically examines the phenomenon of ‘blesser-blessee’ relationships – arrangements in which older, financially secure individuals (blessers) provide material support to younger individuals (blessees) in exchange for companionship or intimacy. While these relationships have become increasingly visible in South Africa, they are not typically classified as sex work, despite their transactional nature. The analysis is situated within the framework of the 2021 amendments to the Sexual Offences and Related Matters Amendment Act, which introduced a new category of ‘vulnerable persons’. This includes students and trainees <25 years old residing in institutional accommodation, raising complex legal questions about the potential criminalisation of blesser relationships. The article explores the implications of mandatory reporting obligations imposed on healthcare professionals and researchers, who are now required to report suspected sexual offences involving consenting adults. This may inadvertently encompass blesser-blessee relationships, particularly where the exchange of material benefits is interpreted as exploitative or coercive. The legal ambiguity surrounding these relationships is further compounded by the lack of clear statutory definitions, which risks conflating consensual arrangements with criminal conduct. We present a balanced discussion of the competing perspectives on criminalisation. Advocates argue that blesser relationships reinforce harmful gender norms and contribute to gender-based violence. In contrast, critics caution against overly broad interpretations of the law, noting that such relationships may also involve genuine emotional intimacy and mutual agency. Ultimately, the article concludes that while the legislative intent may not have been to criminalise blesser relationships per se, the imprecise drafting of the amendments creates a legal grey area. We call for clearer statutory guidance and interpretive direction from the Department of Justice and Constitutional Development to ensure that the law is applied consistently and justly.

In recent years there has been increasing concern about the various forms of abuse faced by birthing patients during labour and childbirth. Common examples include being scolded, slapped, pinched, stabbed with scissors or struck with a ruler or other instruments. This mistreatment is collectively termed obstetric violence.A growing body of literature examines legal responses to obstetric violence including the potential use of the criminal law. The present article explores whether, in South Africa, common-law crimes or statutory offences could be used to prosecute healthcare workers for the range of harms falling within the broad definition of obstetric violence. It does not question whether criminal law is an appropriate response in this instance.The article concludes that existing crimes are sufficient to address obstetric violence. It is clear that the common-law crimes of crimen iniuria, assault, assault with intention to commit grievous bodily harm and the statutory offence of involuntary sterilisation, could be used to address both physical and emotional forms of obstetric violence. It is submitted that they cater adequately for the broad range of conduct that potentially falls into the definition of obstetric violence. Further research is required in this area and it may mean that prosecutorial guidelines are needed.

South African law provides that children under 18 years old can self-consent to medical treatments and terminations of pregnancy.An article published by van Heerden et al. in the South African Journal of Child Health in 2020 found that children 12 years and olderwere able to give informed consent to medical procedures because they were able to make a treatment choice, comprehend information, weigh options and provide reasons for their decision. However, only children older than 14 years possessed actual understanding of more abstract concepts. This paper considers whether the law is consistent with empirical data on child capacity. It does so by examining the evolution of laws regarding child capacity, interrogating current legal standards on capacity and ultimately evaluating whether the law reflects current empirical knowledge. We conclude that the law on medical treatment is not in conflict with the findings of van Heerden et al. However, there is less synergy between law and empirical data regarding terminations of pregnancy for children under 14 years old.Parliament placed an emphasis on access to health services and did not want age or parental consent to act as a barrier to adolescentsgetting medical assistance; however, data show that children younger than 14 years old struggle with more complex and abstract medical choices. We suggest that the recommendations in the Choice Act for counselling in terminations of pregnancy by children under the age of 14 years need to be more fully operationalised through the issuing of regulations or a national policy.Keywords. consent; medical treatment; capacity; law.

Mandatory reporting of various forms of abuse, from violence to corruption, is an attempt by the state to intervene in circumstances where there is a public or a private interest that ought to be protected. This intrusion of the state into what is often a very personal space, such as the home, is largely justified on the basis of the need to provide protection to prevent further harm, and in services to vulnerable populations such as children, the disabled or the elderly. In some instances, researchers and other members of the study team may encounter reportable information requiring the consideration of mandatory reporting in the design, implementation and review of health research. This is not simple. There are complex and competing interests at play, particularly as there are differing approaches in law and ethical guidelines. This article aims to describe the mandatory reporting obligations in South African law, discussing the ways in which these provisions apply within the context of health research, and to propose some factors that could be used to determine whether it is ethical or not to report information.

Background In response to the COVID-19 pandemic, South Africa implemented a national lockdown including a ban on the sale of alcohol. This paper describes adults’ perspectives on this alcohol ban, focusing on whether they support or oppose this regulation.Methods As part of a longitudinal study that documents South African’s experiences of the COVID-19 lockdown, qualitative data were collected from 49 adults and analyzed thematically.Results Perspectives are framed around the overarching theme of “lives versus livelihoods,” presented as support and/or opposition to the ban. Participants who endorsed the ban, as preserving “lives,” thought that it facilitated social distancing and therefore limited the spread of COVID-19. Those who opposed the ban suggested that it undermined the “livelihoods” of South Africans, in the context of an already-strained economy.Conclusion Our findings show that decisions around whether to support or oppose the alcohol ban were informed by critical reflections on the wider socio-behavioral and health implications of such regulations. Further implications are discussed.

Background Literature on issues relating to comprehension during the process of obtaining informed consent (IC) has largely focused on the challenges potential participants can face in understanding the IC documents, and the strategies used to enhance comprehension of those documents. In this review, we set out to describe the factors that have an impact on comprehension and the strategies used to enhance the IC process in sub-Saharan African countries. Methods From November 2021 to January 2022, we conducted a literature search using a PRISMA tool. We searched electronic databases (PubMed, EMBASE, EBSCOHOST) to identify relevant peer reviewed studies. We then reviewed the references of these articles to find additional literature that might have been missed through the initial search. We were particularly interested in full text articles in English that focused on the IC process in SSA published between 2006 and 2020. We included systematic reviews, and studies from Western and Asian countries that included data about SSA. We excluded articles that focused on medical interventions and studies that did not require IC. Results Out of the 50 studies included most were multi-country ( n = 13) followed by single country studies in South Africa ( n = 12); Kenya, Tanzania, Uganda ( n = 5) each; Gambia, Ghana and Nigeria ( n = 2)each ; and one each for Botswana, Malawi, Mali, Mozambique. We identified three areas of focus: (1) socio-cultural factors affecting IC; (2) gaps in the ethical and legal frameworks guiding the IC process; and (3) strategies used to improve participants’ understanding of IC. Conclusion Our review showed wide recognition that the process of achieving IC in SSA is inherently challenging, and there are limitations in the strategies aimed at improving comprehension in IC. We suggest that there is a need for greater flexibility and negotiation with communities to ensure that the approach to IC is suited to the diverse socio-cultural contexts. We propose moving beyond the literal translations and technical language to understanding IC comprehension from the participants’ perspectives and the researchers’ views, while examining contextual factors that impact the IC process.

Background:Adolescents are a unique population with significant unmet health needs. They are often excluded from research that may benefit them as they are perceived as vulnerable and needing protection from research participation. For Research Ethics Committees, conflicting positions in statutes, regulations and ethical guidelines about who provides informed consent for adolescent involvement in health research can be a significant barrier to approving adolescent research. For researchers, the requirement for parental/guardian proxy consent or prolonged approval processes may potentially result in the exclusion of those adolescents most vulnerable and at risk, particularly if issues such as gender-based violence, gender identity, sexuality and sexual practices are in question.Objectives:To describe the challenges to adolescent research and suggest strategies to address these.Method:We consider the legal and ethical framework in South Africa regarding the consenting age for adolescents in research, outline the challenges and, using examples of best practices, suggest strategies to address the current conundrum.Results:We suggest three principles to guide Research Ethics Committees on their approach to reviewing health research involving adolescents. Strategies to develop ethically acceptable approaches to adolescent research and consent processes are described, which include community involvement. We elaborate on examples of nuanced approaches to adolescent research.Conclusion:The inclusion of adolescents in research is critical in informing appropriate and effective health services for this vulnerable population, whilst providing an opportunity to link them into care and services where relevant.

Crime and punishment have always gone hand in hand. Over the centuries, courts have struggled with the difficult task of finding appropriate sentences. In doing so, they have had to deal with moral, social and other issues whilst striving to find a balance between society’s right to have justice done, and the offender’s right not to face an unnecessarily harsh sentence (S v Calitz 2003 1 SACR 116 SCA 121I-J). The rationale behind any particular sentence has historically been retributive (the court in pronouncing a sentence and imposing it, exacts the community’s lust for “revenge” in a legally sanctioned manner); preventative (once removed from free society,the offender is prevented from continuing to behave in the socially reprehensible manner for which he or she was convicted); reformative (once in custody of the correctional service authorities, the offender will be given the opportunity to reform, returning to society as a better citizen); and deterrent (the sentence imposed upon the offender discourages others from embarking on the criminal path (S v Khumalo 1984 3 SA 327 (A) 330D-E ). In a recent decision by the Supreme Court of Appeal, S v Magida (2005 2SACR 591 (SCA)), the court held that the appellant was entitled to a lesser sentence because she was HIV-positive, had developed full-blown AIDS and could die soon (par 21). This case is significant as it is the first time the Supreme Court of Appeal has dealt with the circumstances in which HIV status ought to be a mitigating factor in sentencing. Whilst it is argued that the court’s decision is correct, it is regrettable that the court glossed over the complexities relating to HIV status as a mitigating factor.

Background The South African legal framework requires mandatory parental/legal guardian consent for all research with children. Ethics guidelines provide some reprieve by allowing RECs to grant waivers of parental or guardianship consent in certain defined circumstances. In the first instance, consent may be provided by a proxy when parents or guardians are unavailable, for example with orphaned children. In the second instance, guidelines permit adolescent self-consent when the nature of the study justifies this approach, for example, research on sensitive issues like sexual behaviour or substance use. Discussion South African guidelines set several conditions that must be met for waivers to be granted. These norms overlap with those in international guidelines. However, the ethical norms, especially related to self-consent are sometimes vague. This article critically evaluates the consent norms in the national ethics guidelines and makes recommendations for reform to ethics guidelines in a way that recognises the value of child participation in research, their evolving decision-making capacity and their best interests. Conclusion Recommendations are made to harmonise ethics guidelines and law in a way that promotes child participation in research, to ensure additional protections for adolescents when self-consent is allowed, and to withdraw procedural requirements for the community endorsement of self-consent strategies.

2006 was the tenth anniversary of the development of the International Guidelines on HIV/AIDS and Human Rights and to celebrate this occasion the AIDS and Rights Alliance of Southern Africa (ARASA) commissioned research into the extent to which these Guidelines have been used and implemented in the Southern African Development Community (SADC) region. This article examines the findings of this research on the three guidance points related to developing a legal and policy framework. It finds that although reforms are taking place within the SADC region and many are aimed at ensuring that responses to HIV are based on human rights, there is an uneven approach, with a number of countries failing to meet the basic requirements described in the Guidelines. There are also a number of regional human rights issues that need to be addressed as a matter of urgency. These include the continued testing and exclusion of HIV-positive recruits from the military, the criminalisation of same-sex relationships and the lack of legal protection for women.

HIV remains a leading cause of death globally, with adolescents continuing to be one of the most at-risk population groups. Effective public health responses require an enabling legal environment to facilitate adolescent access to HIV prevention tools. South Africa (SA) is a good case study of a country with legislative reforms supporting public health HIV prevention programmes. A desktop review was conducted of relevant SA laws compared with key international norms such as age of independent consent and the right to confidentiality. This article reflects on whether the SA legal framework is a facilitator or barrier to adolescent access to key HIV prevention services such as HIV testing and HIV education. The findings indicate a clear recognition of evolving capacity and the inclusion of protections aimed at enhancing decisionmaking. International legal norms are, however, scattered, and not comprehensive enough to inform certain national policy choices. As such, developing a coherent approach to the evolving capacity and protection relating to age-appropriate decision-making can be a challenge for states legislating on adolescent access to HIV prevention interventions. This article highlights the fact that SA has largely created an enabling legal environment for adolescent access to HIV prevention. Nevertheless, there are a number of weaknesses in the SA legal framework, such as the divergent approaches between criminal and civil law regarding sexual activity among adolescents. It is recommended that further research be conducted on legal reform toward a coherent approach to support adolescent access to HIV prevention services.

It is uncontroversial that no form of treatment, including a surgical operation, can be undertaken without the consent of the patient/proxy. The Children’s Act deals expressly with consent to ‘surgical operations’ on children. Section 129 creates a framework based on the principles of child participation and protection. Nevertheless, obtaining consent from children remains complex: firstly, children are legal minors and have limited capacity to act independently. Secondly, there may be risks or longer-term consequences of surgery that distinguish it from medical treatment. Third, a child’s capacity to understand risks is not static: it evolves with age, and limited tools exist to access capacity. Fourth, there are at least three parties to the consent procedure – the child, the parent/guardian and the medical practitioner, all of whom may have different interests. Fifth, in some instances there is the added complication of child parents who need to provide consent for their own child. This article aims to provide guidance to surgeons and other medical practitioners performing surgery on children. It does this through setting out the legal norms relating to child consent to an operation. It critically examines the pro forma consent forms (forms 34 and 35) found in the regulations issued in terms of the Children’s Act that are to be used to document the consent process, and identifies key gaps and weaknesses. It concludes with recommendations for the adaptation of these forms through the use of a checklist to ensure that all the requirements for valid consent are documented, protecting children and medical practitioners.

Violence against women (VAW) is a human rights violation under international law, and human immunodeficiency virus (HIV) is regarded as a global public health concern necessitating a human rights response. In the Kingdom of Eswatini (formerly Swaziland), violence and HIV infection are higher among women. In this chapter, the link between VAW and HIV as it affects HIV-positive women in Eswatini is investigated. Many countries have enacted legislation that invokes criminal and civil law to address intimate partner violence (IPV)—including Eswatini through the recent enactment of the Sexual Offences and Domestic Violence Act of 2018. Although there is much literature on the use of the criminal law to punish people who infect others, there is a minimal discussion on the use of the criminal justice system to address violence against HIV-positive women, in particular, violence that interrupts their access to medical treatment. There is also very little discussion in Eswatini on violence against HIV-positive women by healthcare workers. This chapter answers the questions: What obstacles do HIV-positive women face in getting a protection order against a partner who throws away her antiretroviral treatment in Eswatini and what are the remedies for an HIV-positive woman who has been sterilised without informed consent. The study found that HIV-positive women seldom use legal remedies or turn to the criminal justice system. They are largely distrusting of these systems and see them as ineffective. The study is necessitated by the fact that the abuse of women living with HIV inhibits their rights to health, life, and bodily integrity, and the scant attention given to violence that interrupts treatment. This chapter adopts a qualitative methodology comprising of empirical and desktop research methods.