Understanding Caregiver-Adolescent Communication About Sex in South Africa: a Qualitative Study

Introduction: Adolescents living with HIV in South Africa are a vulnerable population with high prevalence rates of HIV and low retention in care, requiring greater focus and attention. Adolescents living with HIV are at elevated risk for experiencing negative consequences associated with the normative onset of sexual activity during this period, including the risk of transmitting HIV to their sexual partners or co-infection with other sexually transmitted infections.School-based sex education alone has limited impact, and caregiver-adolescent communication about sex can be a protective factor in reducing sexual risk-taking and increasing safe sex practices. Much research has been done examining caregiver-adolescent communication about sex globally, with extensive research in high-income countries. Yet, the nature of caregiver-adolescent communication about sex for adolescents living with HIV in sub-Saharan Africa is poorly understood. The current study aims to develop a greater understanding of the timing, content, and perceptions of communication about sex among adolescents living with HIV and their caregivers in Cape Town, South Africa.

Methods: We conducted semi-structured, in-depth interviews with adolescents living with HIV, their caregivers, and community stakeholders. Adolescents and their caregivers were recruited from the waiting room at a local HIV clinic in Cape Town. Community stakeholders were recruited from local organizations serving adolescents living with HIV. The interviews were thematically analyzed utilizing inductive and deductive approaches.Results: Twenty adolescents, 19 caregivers, and 20 stakeholders participated in the study. There was unanimous agreement that communication about sex was important and should be comprehensive, including topics such as condom use, education about how HIV and STIs are spread, and preventing unwanted pregnancies. Conversations about sex should include information about the positive aspects of sex (e.g., pleasure) and negative consequences (e.g., STIs and unwanted pregnancy). Participants believed that communication about sex should occur often and be normalized, with most suggesting that these conversations should occur around the age of 13 years. Parents were seen as primarily responsible for teaching youth about sex, and school was seen as a secondary source. Notably, few participants discussed the role of adolescent's HIV status in communication about sex.

Conclusion: The study provides insight into caregiver-adolescent communication about sex for youth living with HIV. Conversations were similar to those that caregivers of youth without HIV have. Adults expressed a responsibility to teach adolescents living with HIV about sex and ensure they have lifesaving knowledge to practice safe sex. Conversations about sex were challenging to initiate and perceived as awkward or embarrassing. Despite these barriers, they were described as essential and necessary.