“I am not shy anymore”: A qualitative study of the role of an interactive mHealth intervention on sexual health knowledge, attitudes, and behaviors of South African adolescents with perinatal HIV

South African adolescents with perinatally-acquired HIV (APHIV)—teenagers who were born with HIV—lack access to sexual and reproductive health (SRH) education specific to their HIV status.

Ineffective SRH education often leads to risky behaviors (such as unprotected sex), teenage pregnancy, and the spread of HIV.

Mobile health (mHealth) interventions, such as phone apps, can help improve adolescent SRH knowledge and decision-making.

In this study, we evaluate how a WhatsApp-based intervention—Interactive Transition Support for Adolescents Living with HIV (InTSHA)—influences SRH attitudes and behaviors of APHIV.

InTSHA involved long-term, weekly group chats of APHIV, run by trained facilitators, that included two modules discussing SRH.

This study analyzes in-depth interviews we conducted with adolescents who completed InTSHA, asking them about their SRH knowledge and behaviors before and after the intervention.

The interviews took place in a government-supported clinic in an urban township of KwaZulu-Natal.

Interviews were recorded, transcribed, translated, coded, and analyzed.

Of 21 participants, 13 were female and the average age was 16.6 years.

Most participants reported first learning about SRH as young teenagers in school, through peers, or on the internet, rather than through healthcare workers or family members.

Participants reported that InTSHA provided a comfortable platform to discuss relationships, gender, and sexuality as APHIV.

Adolescents enjoyed giving and receiving information from peers in a moderated setting.

They reported that InTSHA built their confidence, decision-making skills, and communication with partners and caregivers.

South African SRH education for APHIV can be supplemented by targeted mHealth interventions.

Background South Africa has one of the highest burdens of adolescents with perinatally-acquired HIV (APHIV) in the world.

APHIV in South Africa have limited access to sexual and reproductive health (SRH) education and services specific to their HIV status.

When lacking comprehensive SRH education, APHIV are prone to sexual risk behaviors that can lead to unintended pregnancy, sexually transmitted infections, and HIV transmission.

The use of mHealth interventions has been shown to deliver information, foster social support, and improve decision-making skills.

In this study, we evaluate how an mHealth intervention influences sexual health knowledge and behaviors in APHIV.

Methods We purposively enrolled adolescents from the intervention arm of a randomized clinical trial assessing a multi-module, moderated WhatsApp-based intervention—Interactive Transition Support for Adolescents Living with HIV (InTSHA)—within a government supported clinic in KwaMashu, an urban township of KwaZulu-Natal, South Africa.

We conducted in-depth interviews based on World Health Organization guidelines for asking adolescents about SRH.

We thematically analyzed data through an iterative, team-based coding approach combining deductive and inductive elements to contextualize SRH attitudes, knowledge, and behaviors before and after receiving the InTSHA intervention.

Results Of the 21 participants, 13 (61.9%) were female and the mean age was 16.6 years.

Most participants reported first learning about SRH as young teenagers in school through non-targeted and negative ways, seeking clarification through peers and the internet rather than clinicians or caregivers.

Participants reported that InTSHA provided a holistic perspective on relationships, gender, and sexuality specific to growing up with HIV in South Africa.

They praised the ability to give and receive information from peers in a moderated setting through the mHealth intervention, building their confidence, decision-making skills, and communication with partners and caregivers throughout their everyday lives.

Despite reporting some technological challenges, adolescents agreed that InTSHA was convenient, confidential, and user-friendly.

Conclusions South African APHIV receive incomplete and conflicting sexual education from peers, caregivers, teachers, and technology that can be supplemented by mHealth curricula targeted for the unique needs of APHIV.

Future, scaled-up mHealth interventions can lower SRH stigma by expanding access to sexual education and peer support, supplementing adolescents’ existing SRH education.