<strong>Background:</strong> Sub-Saharan Africa is home to 85% of the world's HIV-positive adolescents: an estimated 1.3-2.2 million 10-19 year olds. Adolescents living with HIV face multiple sexual and reproductive health risks: unwanted pregnancies and the risk of mother-to-child-transmission, risk of infecting partners, co-infection with other STIs, and the rising but undocumented risk of re-infection by potentially resistant HI-virus strains. Using contraception, especially condoms, is particularly challenging for all adolescents. It is even more difficult for HIV-positive adolescents due to HIV-related factors such as learning their HIV-positive status, withholding or disclosing their HIV-status to sexual partners, and accessing services in the home, clinics, and schools. This thesis aims to understand which factors shape sexual risk-taking among HIV-positive adolescents to inform the development of interventions that promote safe sexual practices in this population. <strong>Methodology:</strong> This thesis applies a socio-ecological model to investigate factors associated with sexual risk-taking among HIV-positive adolescents. It consists of three stand-alone papers: a systematic review and two quantitative papers based on a cross-sectional epidemiological and aetiological study of unprotected sex among HIV-positive adolescents and community controls in South Africa. Paper 1 is a systematic review of rates, correlates, and interventions to reduce sexual risk-taking among HIV-positive adolescents and youth in sub-Saharan Africa. Paper 2 looks at associations between HIV-status knowledge and disclosure and protective sexual practices in the cross-sectional study sample. Paper 3 explores the relationship between various social protection provisions and unprotected sex among HIV-positive adolescents. The candidate co-developed and conducted a community-traced study of adolescents in the Eastern Cape, in South Africa: 1,060 HIV-positive adolescents and 467 community controls. HIV-positive 10-19 year old adolescents were recruited from 53 government facilities in a health sub-district with antenatal HIV prevalence of over 30%. 90.1% of the eligible sample was traced, with only 4.1% refusing to take part. Community controls were neighbouring or co-habiting 10-19 year old adolescents, 92% of whom agreed to take part. Voluntary informed consent was obtained from adolescents and caregivers in the language of their choice: English or Xhosa. Questionnaires were administered by trained research assistants using mobile devices (tablets) with adolescent-friendly graphic content to ensure participant interest and reduce participant burden through skip-patterns. The systematic review (Paper 1) included studies located through electronic databases and grey literature. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Quantitative studies reporting on HIV-positive participants (10-24 year old) included data on at least one of eight outcomes (early sexual debut, inconsistent condom use, older sexual partner, transactional sex, multiple sexual partners, sex while intoxicated, sexually transmitted infections, and pregnancy). Only studies conducted in sub-Saharan Africa were included. The candidate and a second author independently piloted all processes, screened studies, extracted data independently, and resolved any discrepancies. Due to variance in reported rates and correlates, no meta-analyses was conducted. The systematic review informed the analyses conducted for the two quantitative papers. Analyses for Papers 2 and 3 used condom use at last sexual encounter (dichotomised either as safe sex/abstinence or unprotected sex) as the outcome, controlling for a series of covariates. Analyses used SPSS 22 and STATA 11. For each paper, the hypothesised factors were entered as independent variables in multivariate logistic regressions controlling for potential confounders. Based on the findings of the systematic review, gender moderation analyses was run entering a 2-way interaction term of gender*correlate in multivariate logistic regressions, controlling for covariates. Marginal effect models explored the effect of combinations of risk/ protective factors. Predicted probabilities for safe sex/ unprotected sex were computed for different two- and three-way combinations of the independent variables, controlling for covariates significantly associated with the outcome. Paper 2 tested the effect of three types of disclosure on protective sexual practices: (i) knowledge of one's own HIV-positive status, (ii) disclosing one's HIV-status to a partner, and (iii) knowing a partner's HIV-status. It compared HIV-positive status aware adolescents (n=794) with the rest of the sample (n=733). Paper 3 investigated associations between nine types of social protection provisions and unprotected sex. In line with UNICEF's definition, social protection was defined as any provision aimed at preventing, reducing and eliminating economic and social vulnerabilities to poverty and deprivation among HIV-positive adolescents. The nine social protection provisions tested by the analyses included ‘cash' and ‘care' factors accessed in the home, school, and community. <strong>Results: Paper 1 – ‘Sexual Risk-Taking among HIV-Positive Adolescents and Youth in Sub-Saharan Africa: A systematic review of prevalence rates, risk factors, and interventions.'</strong> The systematic review (Chapter 4) found that, despite their heightened vulnerabilities and high rates of sexual risk-taking, there is a dearth of evidence on interventions which may help HIV-positive adolescents engage in safe sexual practices. The review included 35 studies, four of which were interventions aiming to reduce sexual risk-taking. The quality of the included studies was low with most studies (k=31) reporting findings from cross-sectional data. HIV-positive adolescents and youth reported high rates of sexual risk-taking, however findings were inconsistent about potential factors associated with sexual risk-taking. Factors consistently associated with sexual risk-taking in multivariate analyses included: food insecurity, living alone, living with a partner, and gender-based violence. No significant associations were reported for: rural residence, informal housing, anxiety, religious guidance, STI prevention knowledge, poor birth outcomes, orphanhood, parental monitoring, having a supportive family, social support, maternal education level, poverty, disclosing one's HIV-status to a partner, time on ART, ART adherence, receiving care at a hospital, opportunistic infections. However, most of the above associations were reported by only one study, therefore further analyses is needed to build the evidence base on potential determinants of sexual risk-taking among HIV-positive adolescents and youth. The included interventions consist of three individual- and group-based psychosocial interventions evaluated in three small-scale trials (n<150) and one large trial of combination interventions for HIV-positive orphaned adolescent girls (n=710). Three of these interventions had positive effects in reducing sexual risk-taking: an individual based 18-session counselling intervention in Uganda, a support group intervention in South Africa, and a combination intervention in Zimbabwe. <strong>Quantitative data analyses of cross-sectional study data:</strong> Overall, adolescents in the full sample (n=1,527) reported high rates of sexual activity (34.9%) and high rates of unprotected sex (22%), with adolescent girls reporting higher rates of unprotected sex than boys (33% vs. 7%).

Objective: To examine the relationship between hope, core self-evaluations, physical function, emotional well-being, health risk behaviors, and academic performance in freshman enrolled in their first year of college. Participants: Freshman (N = 495) attending a large public university in the Northeast completed an online survey between February 1 to February 13, 2017. Methods: Cross sectional descriptive survey. Linear regression, path analysis, and structural equation modeling procedures were performed. Results: Core self-evaluations mediated the relationship between hope and emotional well-being and academic performance. Contrary to the hypotheses, higher hope predicted more sexual risk taking behaviors and alcohol use. Conclusions: Core self-evaluations is an important component of hope theory. Hope Theory is useful for predicting emotional well-being, and academic performance, but not as useful for predicting drug use, alcohol use, and sexual risk taking. Hope and core self evaluations interventions are needed to improve academic performance and emotional well-being in university freshman.

<p>The overall aim of this thesis was to inestigate Swedish adolescents' perceptions and behaviours regarding sexual risk taking. Specific objectives were to explore teenagers' perceptions of contraceptive use, unintended pregnancy, and abortion; teenage girls' experiences of decision making process and support connected to abortion; and male adolescents' perceptions of sexual risk taking and barriers to practicing safe sex. Another objective was to evaluate the effect of advance provision of emergency contraceptive pills to teenage girls. The methodologies included focus group discussions, in-depth interviews, and a randomized controlled trial. </p><p>Among the adolescents in our studies, teenage parenthood was generally viewed as a "catastrophe", and the majority expressed supportive attitudes towards abortion (studies I-IV). Occasions of failure to use contraceptives were common, especially when sex was unplanned (studies I-V). Pregnancy prevention was perceived as the woman's responsibility. However, many girls were reluctant about using homonal contraceptives due to worries about negative side effects (I, III). Initiating condom use was difficult for girls, as well as for boys, for a number of reasons (I-IV): fear of ruining an intimate situation, associations with disease, distrust, pleasure reduction, and (for the boys) the fear of loosing one's erection. Males generally perceived personal and partner-related risks connected to unprotected intercourse as low. Few males were worried that an unintended pregnancy would be carried to term, and the majority would urge the girl towards abortion if she seemed ambivalent (II, IV). Girls viewed the abortion decision as a natural, yet difficult choice, strongly influenced by attitudes of partners, parents, peers and societal norms (III). Teenage girls provided with emergency contraceptive pills in advance used it more frequently and sooner after unprotected intercourse compared with controls, without jeopardising regular contraceptive use (V).</p>

The overall aim of this thesis was to inestigate Swedish adolescents' perceptions and behaviours regarding sexual risk taking. Specific objectives were to explore teenagers' perceptions of contraceptive use, unintended pregnancy, and abortion; teenage girls' experiences of decision making process and support connected to abortion; and male adolescents' perceptions of sexual risk taking and barriers to practicing safe sex. Another objective was to evaluate the effect of advance provision of emergency contraceptive pills to teenage girls. The methodologies included focus group discussions, in-depth interviews, and a randomized controlled trial. Among the adolescents in our studies, teenage parenthood was generally viewed as a "catastrophe", and the majority expressed supportive attitudes towards abortion (studies I-IV). Occasions of failure to use contraceptives were common, especially when sex was unplanned (studies I-V). Pregnancy prevention was perceived as the woman's responsibility. However, many girls were reluctant about using homonal contraceptives due to worries about negative side effects (I, III). Initiating condom use was difficult for girls, as well as for boys, for a number of reasons (I-IV): fear of ruining an intimate situation, associations with disease, distrust, pleasure reduction, and (for the boys) the fear of loosing one's erection. Males generally perceived personal and partner-related risks connected to unprotected intercourse as low. Few males were worried that an unintended pregnancy would be carried to term, and the majority would urge the girl towards abortion if she seemed ambivalent (II, IV). Girls viewed the abortion decision as a natural, yet difficult choice, strongly influenced by attitudes of partners, parents, peers and societal norms (III). Teenage girls provided with emergency contraceptive pills in advance used it more frequently and sooner after unprotected intercourse compared with controls, without jeopardising regular contraceptive use (V).

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Bakgrund: Tonårsperioden är en avgörande tid för unga. Ungdomars utsatthet för våld utgör en väsentlig folkhälsofråga globalt och nationellt. Vid mötet med ungdomar kan barnmorskor på ungdomsmottagningar ta upp ämnen som relationer, livsstil och sexuellt beteende. Västra Götalandsregionen har utvecklat SEXIT, en metod som kan bidra till att identifiera ungdomars sexuella risker och våldsutsatthet.   Motiv: Ungdomars sexuella och reproduktiva hälsa och rättigheter behöver förbättras. Genom att kartlägga ungdomars självrapporterade sexuella beteende och erfarenheter av våldsutsatthet kan en bättre uppfattning om vilka risker som de utsätter sig eller andra för nås.    Syfte: Att via SEXIT kartlägga ungdomars sexuella beteende och deras utsatthet för våld samt att utforska eventuella skillnader mellan ålder och kön.   Metod: Stickprovsundersökning med 284 ungdomar vid en ungdomsmottagning i Norrland under 2022, som besvarat SEXIT enkäten som innehöll bakgrundsfrågor, våldsutsatthet och sexuella riskbeteenden. 96 sorterades bort, 188 deskriptiva statistiska analyser utfördes i statistikprogrammet Jamovi 2.4.8.0., med uppdelning i ungdomar och unga vuxna samt jämförelser mellan våldsutsatthet, sexuellt risktagande, ålder och kön.   Resultat: En hög andel ungdomar och unga vuxna rapporterade utsatthet för fysiskt, psykiskt och sexuellt våld. Fler kvinnor uppger att de blev pressade till sex (kvinnor 22%, män 3%). Mer än en tredjedel (34%) av kvinnor rapporterade utsatthet för psykiskt våld och motsvarande siffra för män är 38%. Unga vuxna män angav att de oftare har blivit utsatt för fysiskt våld jämfört med unga vuxna kvinnor (p=0.018). Mer än hälften av kvinnor (60%), rapporterade att de hade utsatts för oönskade handlingar mot sin vilja. 15% använde sex som en strategi för att hantera känslomässiga svårigheter eller en form av självskada.  Konklusion: En betydande andel ungdomar rapporterade att de utsatts för psykiskt, fysiskt och sexuellt våld, och de tar stora sexuella risker. Tillgängliga ungdomsmottagningar är väsentligt för deras hälsa. / Background: Adolescence is a crucial period for youth. Youth exposure to violence is a public health issue globally and nationally. Midwives at youth clinics adress topics such as relationships, lifestyle and sexual behaviour. Västra Götaland Region has developed SEXIT, method to identify youth’s sexual risks and experiences of violence.  Motive: Adolescents' sexual and reproductive health needs to be improved and their rights strengthened. By mapping young people's sexual behavior and experiences of violence, we can see what risks they expose themselves to or expose others to.  Aim: to map adolescens´ sexual behavior and their exposure to violence through SEXIT and to explore potential differenses between age and gender.  Method: Survey with 284 youths at a youth clinic in Norrland during 2022, responding to the SEXIT questionnaire containing background questions,exposure to violence, and sexual risk behaviors. 96 were excluded, and 188 analyses were conducted using the statsistical software Jamovi 2.4.8.0, categorized by youths and young adults, including comparisions between exposure to violence, sexual risk-taking, age and gender.   Results: A high proportion of adolescents and young adults reported exposure to physical, psychological and sexual violence. More women state that they are pressured into sex (women 22%, men 3%). Over a third(34%) of women report exposure to psychological violence, corresponting to men who report 38%. Young adult men indicated that they have often been exposed to physical violence compared to young adult women (p=0.018)  More than half of women reported experiencing unwanted actions against their will. 15% used sex as a strategy to cope with emotional difficulties or as a form of self-harm.   Conclusion: A significant proportion of youths report exposure to psychological, physical and sexual violence, and they take substantial sexual risks. Accessible youth clinics are crucial for their health.