Discussion
We used an evidence-based, iterative process to develop a novel intervention designed to support treatment uptake among adolescents and young adults newly diagnosed with HIV. Participant feedback in field testing was positive and emphasized the importance of peer support from other youth with HIV as well as the motivation they derived from these peers and the facilitator. This feedback confirmed similar findings from our formative qualitative work as well as our model of behavior change. It also builds on a small but growing number of HIV program acceptability studies with adolescents and young adults in sub-Saharan Africa [In addition to peer support and motivation within a stigma-free environment, field testing participants appreciated the educational content related to HIV and ART. Research to promote ART initiation among adolescents and young adults has largely focused on the psychosocial and structural challenges known to create barrires to care, including mental health challenges and a perceived lack of adolescent-friendly and confidential services in health facilities [Participant feedback highlighted that mental health concerns remain challenges for young people. Research has shown that adolescents living with HIV are at heightened risk for mental health challenges as compared to their peers, which may negatively impact HIV care outcomes [Some participants raised the importance of refreshments and reimbursements for travel in our intervention. Food insecurity remains a major issue in some communities in South Africa and has a negative impact on HIV treatment engagement, such as declining free ART in South Africa for fear of taking ART on an empty stomach [Training programs for facilitators involved in HIV interventions have emphasized building skills in peer support and self-care, as well as becoming comfortable understanding and delivering essential knowledge [SAT guided both our qualitative analyses as well as our intervention development process by shaping our understanding of the multi-level factors which influence young people’s engagement in care. We originally hypothesized that Yima Nkqo would address address barriers to HIV care and facilitate behavior change through each SAT domain, including peer support and participant confidentiality (social regulation), a youth-friendly community space (contextual influences), and facilitator support to improve coping skills (self-regulation). Our data show that each intervention component did not solely address a single domain, as hypothesized, but rather there was inherent overlap and interplay between domains. For example, an important role of the facilitator was to help participants to develop positive coping skills and to share knowledge with them, which contributed to participants’ self-regulation processes. However, facilitators also played a role in setting a positive and supportive tone to create a space that felt stigma-free, which enabled participants to share confidential challenges comfortably (social regulation).We were limited by scheduling difficulties given participants’ varied school, work, and family schedules, which could create barriers to participation. However, our facilitator contacted every participant before each session to ensure attendance, and all participants in our field testing came for each session. Additionally, themes discussed during the intervention sessions may elicit strong emotions, which can be challenging for the facilitator and the participants. We trained the facilitator to recognize and support participants at these times as well as recognize when referral to a mental health professional would be necessary. Finally, given that this intervention was iteratively developed for a specific population and context, it may not be generalizable. At the same time, we did observe consistency in parts of our intervention that resonated with participants and with what has been shown to be effective in HIV interventions in other contexts, e.g., peer support.