Mthiyane, Thandiwe Nondumiso; (2025) The effect of multi-level HIV prevention interventions on non-HIV outcomes among adolescents and young adults in rural South Africa. Doctoral thesis (Ph.D), UCL (University College London).

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Abstract

By 2030, the number of adolescents and young people aged 10-24 in Africa is projected to increase by 42% and they face multiple challenges that render them vulnerable to both HIV and mental health problems. Poor mental health among young people in high HIV prevalence settings may detrimentally affect the success of HIV prevention programs. Therefore, sustainable and scalable interventions are needed that can address mental health issues while reducing HIV risk in young people. This dissertation aimed to understand how multi-level HIV prevention interventions delivered at the community, family and individual (behavioural or biological) levels, affect mental health outcomes in adolescents and young adults in uMkhanyakude district, KwaZulu-Natal, South Africa. Specifically, I utilised the delivery of the Determined, Resilient, Empowered, AIDS-free, Motivated, Safe (DREAMS) Partnership in a health and demographic survey site, to study the effect of multi-level HIV prevention interventions on common mental disorders. I hypothesised that combining individual-level interventions with family-focused or community-based interventions would have a greater impact on mental health compared to no intervention or single-level interventions. Multi-level interventions were defined as combinations of individual-level and community-level (including family) interventions. First, I conducted a systematic review to investigate the effect of multi-level interventions on mental health outcomes among adolescents and young adults aged 10-24 in sub-Saharan Africa. Second, I analysed data (N=5248) from two cohort studies evaluating the impact of DREAMS in uMkhanyakude to describe and quantify adolescents' and young adults' exposure to different aspects of multi-level HIV prevention interventions, and to evaluate the effect of this exposure on common mental disorders (CMD). Lastly, I used literature and young people’s opinions to construct a conceptual framework explaining the pathways through which multi-level interventions affect mental health in adolescents and young adults. The evidence from the systematic review suggests that multi-level interventions, including economic empowerment, cognitive behavioural therapy, and peer support, are effective in reducing common mental disorders. Findings from the analysis of HIV prevention intervention uptake show that the majority of adolescents received multi-level interventions, with the most common combination including cash transfers, school-based HIV education, and HIV testing and counselling. Exposure to these combined interventions was positively associated with subsequent voluntary medical male circumcision (VMMC), whereas participation in community-level interventions only, such as cash transfers and school-based HIV education, was associated with higher odds of reporting no condomless sex. In contrast, participation in healthcare interventions such as HIV testing, contraception, and condom promotion was associated with reduced condom use. In causal analysis using inverse probability of treatment weighting (IPTW), exposure to multi-level HIV prevention interventions relative to no intervention did not reduce CMD in young people. However, among adolescent girls and young women (AGYW), participation in community-level interventions only compared to multi-level interventions, was protective against CMD. Using participatory workshops, I developed a conceptual framework describing how social and behavioural factors interact and affect young people’s mental health. Behavioural factors such as romantic relationships and alcohol use, influenced by peer pressure, were identified as coping mechanisms that young people use to manage social challenges such as unemployment and violence. The conceptual framework highlights interventions such as economic empowerment and family support aimed at promoting social protection and protective coping mechanisms that enhance resilience, helping young people adapt to and manage stressful events leading to mental health problems. My research demonstrates that multi-level interventions have the potential to improve mental health among adolescents and young adults. Social factors such as poverty and violence were identified as primary contributors not only to poor mental health but also to risky behaviours. Therefore, social protection interventions addressing these social and community factors should be central to multi-level interventions aimed at preventing mental disorders and HIV in young people.

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