Early adolescents (13-15 years) are an ideal target for preventive interventions targeting healthy sexual and mental behaviors. Engaging families in adolescent prevention is developmentally appropriate for early adolescents (13-15 years). However, few family-based adolescent HIV interventions have been empirically tested in South Africa and few HIV interventions take an integrated HIV-mental health approach.
We describe a set of preliminary studies in South Africa and the existing literature documented the intersections between poor mental health and HIV risk. We then describe preliminary qualitative work conducted to inform the design of a resilience-focused family preventive intervention targeting prevention of adolescent HIV risk and depression. This intervention is derived from the integration and adaptation of two existing best-evidence models for HIV risk reduction and prevention of depression. Adaptation needs were assessed utilizing k=8 focus groups with Xhosa-speaking mixed gender adolescents and parents or guardians and n=25 interviews with HIV and mental health experts. Qualitative data were recorded, transcribed verbatim, translated from Xhosa to English, and analyzed in NVivo using a thematic analysis. Respondents identified social and contextual challenges for HIV prevention including age disparate sexual relationships driven by economic needs, adolescent gang violence, and sexual violence. Respondents described aspects of family interactions that presented both challenges and opportunities for family-based adolescent HIV prevention. Parent-child communication on mental health and sexual topics were taboo, with these conversations perceived as an invitation for children to engage in HIV risk behavior. Parents experienced social sanctions for discussing sex and animosity towards children who asked about sex. However, respondents also identified unique cultural conceptions of family resilience that could be leveraged to increase intervention engagement, including family meetings and communal parenting. Qualitative findings guided alteration of existing intervention content, and the addition of new content, topics, and delivery modalities for South Africa. This included a strengthened emphasis on family resilience; how mental health affects sexual decision making; parental monitoring, positive parenting; and building efficacy around parent-adolescent communication on the topics of sex and mental health are important target foci for a family-based intervention. The adapted family intervention will be tested in a randomized pilot trial in 2015-2016.