A total of 557 (73.0%) of the 768 enrolled adolescents were surveyed at baseline and endline, including 301 (54.0%) females and 276 (46.0%) males. The median age was 14 years (IQR: 11–16) at baseline and 15 years (IQR: 12–17) at endline.

HIV testing increased from 315 (56.7%) at baseline to 557 (100%). The odds of undisclosed HIV status were 49% lower at endline adjusted OR (aOR) 0.51 (95% CI 0.92, 0.67; p<0.001). Status disclosure was nearly universal, with 557 (100%) at baseline and 556 (99.8%) at endline. Male adolescents aOR 0.77 (95% CI: 0.59, 0.99; p<0.04) and those cared for by their siblings or other relatives were less likely to know their HIV status (aOR 0.59; 95% CI: 0.41, 0.84; p<0.003).

We conducted a pre–post evaluation with surveys at baseline (December 2020) and at the endline (December 2022) to collect data on self-reported HIV testing and status and associated demographic variables. Adolescents from HIV-affected backgrounds were recruited in peer-led health clubs where they completed health education, including receiving HIV risk screening tools and referral for testing in health facilities. In addition, their caregivers received parenting training and financial literacy training.

The study was conducted in Nimule, a periurban town of South Sudan, which is located at the border between Uganda and South Sudan. The proximity of Nimule, a periurban town to the Ugandan border, makes it a refuge for thousands of internally displaced persons, leading to high population density and increased cross-border movement. Biobehavioural studies have revealed a high HIV prevalence among female sex workers in the area.19 Given the increased risk of HIV and other sexually transmitted infections among adolescents, this location was deemed suitable for this HIV prevention study.

We undertook a multifaceted intervention delivered using the OVC case management platform, where adolescents’ primary needs were assessed and intervention delivered based on their stratified individualised needs. Here, we used trained peer educators to deliver HIV risk education adapted from the South Sudan comprehensive sexuality education curriculum. Equally, their primary caregivers received parenting support training and financial literacy training and were provided business startup capital of US$200 disbursed in four quarterly payments of US$50 in 2021.

The study recruited young adolescents aged 10–17 years from four hundred HIV-affected households within seventeen neighbourhoods in Nimule periurban town. We considered adolescents from HIV-affected households for their study because of their increased vulnerability to HIV, as some of them were living with HIV, for those who did not know their HIV status, providing targeted health education combined with referrals for HIV testing increased their chances of acquiring HIV testing and status disclosure.

The primary outcome of this study was self-reported HIV testing and status disclosure to any trusted individual (caregiver, siblings or peer). Independent variables included age, gender, education and type of caregiver. Data collection took place at two points at baseline (December 2020) and endline (December 2022).

We used the WHO (1991) cluster sampling strategy20 for estimating a population proportion with specified relative precision. Assume 50% of adolescents at baseline tested for HIV and disclosed their HIV status, confidence level of 95% and a design effect of 2, the estimated sample size was 768 adolescents. Given the postconflict setting with high population movement, we anticipated a 15% attrition or refusal rate.

Adolescents were purposively recruited from households enrolled on the OVC programme. These households were first identified from the antiretroviral treatment therapy (ART) clinic in Nimule Hospital for people living with HIV on treatment. Trained case workers (research assistants) subsequently visited these households and recruited adolescents aged between 10 and 17 years after obtaining informed consent from both the caregiver and adolescents. This procedure was repeated until a total of 768 adolescents were recruited into the study from the 400 households.

Adolescents were assigned to 40 health clubs, each facilitated by a trained Peer educator. Before the first session, a baseline assessment was conducted using a survey questionnaire to obtain information on participation in sociodemographic factors and self-reported HIV testing and status disclosure. Using a standardised HIV health education manual adopted from the South Sudan MOH, peer educators delivered HIV risk education in their clubs for 4 months, with each group meeting twice a month. Members were recruited voluntarily and with consent from their caregivers. Supported by their peer educators, group members were consulted and decided on their meeting time, date and venues, which were all suitable for them.

Peer educators used various interactive approaches including short presentations (30–40 min), followed by question-and-answer sessions, and breakaway sessions with games, plays, singing and storytelling to enhance engagement. Using the HIV risk screening tool (online supplemental appendix 2), peer educators screened the participants for risk of HIV (ever had sex), referred them for HIV testing and encouraged them to disclose their test results to trusted individuals. Additionally, caregivers were engaged in positive parenting and Village, Lending and Savings Association groups, where they received US$50 quarterly for the first year as seed capital. These interventions were aimed at empowering caregivers in providing nurturing, responsive parenting and confidently discussing sexuality education, generating income and meeting the cost of basic needs such as education, healthcare and food, as well as their capacity to manage HIV status disclosure among adolescents. After 2 years and the closure of the OVC programme, an endline survey was conducted using a standardised survey questionnaire (online supplemental appendix 1). We measured rates of self-reported HIV testing by asking adolescents at baseline and endline whether or not they had ever tested for HIV and what their test results were.

The study held stakeholder engagement meetings at the national and state levels involving the MOH, South Sudan HIV and AIDS Commission and partners to discuss the indicators to be measured, including the selection of study sites and targeted adolescent groups. This guided the choice of the indicators, target age groups and study site. In addition, caregivers and adolescents were also consulted to decide on how they wanted to get involved in the study activities, expectations and what their contribution would be to the study. This helped in identifying the appropriate meeting times, venues and dates for caregivers and adolescents.

No identifiable information, aside from the voices of participants, was recorded. Each participant was assigned a unique subject ID number to assist the study team in tracking notes. Data were reported only in aggregate form, and personal identifiers were not collected. All notes and paper-based materials were securely stored in locked cabinets at the study sites, accessible only to investigators, research assistants and data analysts. After data collection, paper forms were stored securely and transferred to the OVC programme Management for storage within 60 days. Data were archived at the Head Office of the Centre for Research and Development in Population Health (CRDPH) in Juba. Disposition of confidential HIV information would be done by the designated Monitoring and Evaluation (M&E) team according to the MOH data disposition guideline. The Unique Personal Identifier Code was securely kept by the PI and not shared with anyone outside the study team.

Routine survey monitoring and close field supervision were conducted by supervisors, data managers and coinvestigators to ensure that the survey team did not deviate from the survey protocol and standard operating procedures and to help maintain data integrity. The following measures were undertaken to safeguard data integrity and mitigation of biases:

To minimise transcription errors, the principal investigator (PI), research coordinator and M&E officer provided training and technical supervision during data collection and reviewed data completeness and consistency. The M&E officer conducted a data quality assessment by verifying 10% of questionnaires with respective respondents before data entry and exporting to STATA for analysis. In addition, incomplete data due to non-responses or participant transferring out of the study area were removed from the endline dataset before analysis was performed.

To prevent enrolment of ineligible participants, research assistants were trained on identification and enrolment based on eligibility criteria with close supervision from the M&E officer.

Non-responses, due to refusal to answer all or part of the questionnaire and transfer out of the study area, were anticipated to occur. To account for this, the sample size was adjusted by 15%.

Awareness of the study objectives and research question by the research team would likely influence the alteration and omission of participants’ responses to the questionnaire. To mitigate this bias, the study objectives and research questions were concealed from data collectors. In addition, data collection at both the baseline and endline was done by different groups of data collectors. Additionally, the PI was not directly involved in the day-to-day implementation of planned activities and data collection.

A data governance document outlined the rights of each investigating institution regarding data, the roles and responsibilities of each partner for data stewardship, the membership of the data governance body, and the process by which this body would communicate decisions on data handling and access. The governance body approved the data management plan, granting the release of data and certifying the finalisation of data at the end of the survey. The data governance agreement covered the period from the start of survey data collection to the release of the survey report and dataset-associated documentation. The CRDPH implementing the programme was the primary owner of the data, having real-time, unimpeded access to the de-identified data for data monitoring, data analysis and report/manuscript development, as well as all coinvestigators.

Deidentified data were owned by CRDPH and co-owned by the MOH under a written agreement. Data were made available to the researchers and subject to an approved concept sheet that has been reviewed and cleared by the data study oversight committee. Researchers who did not participate in the survey would be granted access to deidentified data sets, survey documentation, code books and questionnaires upon reasonable request to survey investigators.

Data were captured in Microsoft Excel and exported into STATA V.16 for cleaning and analysis (online supplemental file 4). The datasets were merged to enable comparisons at baseline and endline. Descriptive statistics were used to summarise the sociodemographic characteristics of the study populations at baseline and endline.

We assessed the distribution of the data using histograms and the Shapiro-Wilk test for normality. We also tested for multicollinearity among independent variables using correlation matrices and the variance inflation factor.

Univariate analysis described the distribution of our variables across baseline and endline. McNemar’s test was used to examine changes over time for paired data. For associations between sociodemographics and outcomes, we used the χ² test for categorical data.

To examine independent associations, we built multivariate models using a stepwise approach, including variables associated with the outcome at p<0.25 from the bivariate analysis. The Akaike information criterion (AIC) was used to select the most appropriate model, with lower AIC values indicating a better fit. Adjusted ORs (aORs) and corresponding p values (with p<0.05 considered statistically significant) were reported to represent findings from the multivariate analysis.

Of the 768 adolescents enrolled from 400 households, 211 (27.5%) were lost to follow-up primarily due to displacement caused by conflict, leading them to flee to Uganda as refugees. This reduced the total number of participants to 557 (73.0%) at the endline survey. More than half of the adolescents, 301 (54%) were female. The median age was 14 (IQR 11–16) at baseline with over 76% of adolescents enrolled in school both at baseline and endline survey. The majority, 462 (82.9%), were cared for by their parents with none reporting being married. Additionally, a substantial proportion, 430 (77.2%), reported having worked for pay in both cash and in-kind (table 1).

There was an increase in the proportion of adolescents who self-reported that they had ever tested for HIV (p<0.001) from 315 (56.7) at baseline to 557 (100.0) at endline, and those who knew their HIV status also increased from 316 (56.7) at baseline to 398 (71.5) at endline HIV testing and known status disclosure at baseline and endline (table 2).

In bivariate analyses, the participant’s employment status and reading proficiency were the only sociodemographic characteristics that were significantly associated with known HIV status. The odds of unknown HIV status were 58%, cOR 1.58 (95% CI 1.06, 2.35) higher among unemployed participants compared with the employed, and about 62% 0.62 (95% CI 0.39, 0.97) lower among participants who could read a whole sentence compared with those who could not read any sentence (table 3).

The odds of unknown HIV status were 49% lower at the endline vs baseline (aOR 0.51; (95% CI: 0.92, 0.67). Male participants had significantly lower odds of unknown HIV status compared with females (aOR 0.77 (95% CI: 0.60, 0.99), while respondents who were caretaken by a non-parent had lower odds of unknown HIV status compared with those under their parents’ care (aOR 0.59; 95% CI: 0.41, 0.84). The age of the respondents was not associated with awareness of their HIV status (aOR 1.05, 95% CI: 0.77, 1.43) (table 4).

Consent obtained from parent(s)/guardian(s).

The study was granted ethical approval by the South Sudan Ministry of Health Research and Ethics Review Board (MOH/RERB/24/2020) and Strathmore University Institutional Ethics and Research Committee (SU-IERC1287/22). All participants provided informed assent, and participation was voluntary with assurance of confidentiality and privacy throughout the study. For minors (10–14), verbal consent was granted by their caregivers, and for emancipated minors (15–17) consent was granted by themselves. Caregivers and emancipated adolescents aged 15–17 were provided detailed information regarding the purpose of the study, procedures involved, benefits, risks associated, rights to participate and withdraw consent at any time, and privacy and confidentiality. All participants at the baseline assessment gathered informed consent (online supplemental appendix 3) before gathering any data. A session was held to explain all the procedures outlined in the consent/assent forms. The procedure included (1) oral and written information to consider participation and (2) a variant for illiterate participants, who may give consent through the signature of a literate witness (not a member of the research team). Full information on the study was provided before obtaining consent (written or oral, as described above) from each participant. To illiterate participants, the information was read out in the presence of an independent witness not affiliated with the study to ensure that potential participants fully understood what it meant to participate and that they could withdraw their consent at any time without having to explain. It was also made clear that refusal to participate would not have an impact on any type of support they receive. The research assistants allowed adequate time to address all questions and concerns of participants. The informed consent procedure for the participation of children (10–14 years of age) followed a two-stepped process: First, caregiver consent was obtained for their child to participate in the study as part of their informed consent process, involving the same caregivers and process as outlined above. Second, if consent from the caregiver was obtained, verbal assent to participate in the study would be obtained from children before tool administration. This study adhered to ethical principles stipulated in the Declaration of Helsinki of 1964, as amended in 2024. In this regard, the study ensured that the health and well-being of the adolescents and their caregivers involved in the study were safe from any harm. Before the study, the research assistants signed a confidentiality agreement and child safeguarding policy statement. Any breach of confidentiality and abuse of children was monitored during the study by the principal investigator.