“We will tell when we are ready”: perinatally HIV-infected adolescents and self-disclosure of their status in Eswatini

Access to antiretroviral therapy (ART) has promoted a significant decrease in mortality of vertically HIV-infected children. As a result, there has been an increasing growth of this population that reaches adolescence. These adolescents face problems such as self-disclosure and the stigma of the disease. This study aimed to determine the process followed by perinatally HIV-infected adolescents in self-disclosing their HIV status to significant others and the barriers and promoters of perinatally HIV-infected adolescents’ disclosure of their HIV status to others. Data were collected from 15–19-year-old adolescents through 23 in-depth individual interviews and three focus groups. For adolescents, a clear barrier to disclosure was being told when they were younger by a parent to keep their status secret from other people. Lack of trust and fear of breaches of confidentiality which would lead to stigma and discrimination also hindered disclosure. For those adolescents who disclosed, they did so face to face and through short text messages. Adolescents expressed the need to be capacitated to self-disclose and also called for HIV and AIDS education to the general public as a way of fighting stigma and discrimination in their communities and in society. For adolescents to be able to disclose, they have to work through issues of acceptance of their own HIV status first. This study is the first-ever study to document difficulties faced by adolescents in the self-disclosure of their status in Eswatini.


Introduction
Approximately 1.7 million adolescents of 10-19 years old are living with HIV globally, and out of this population of adolescents, 88% (1 496 000) live in sub-Saharan Africa (SSA) (UNAIDS, 2022).Eswatini, which is in the SSA region, is known to have the highest HIV prevalence in the world, at 24.8%, corresponding to approximately 185 000 adults living with HIV.Swati women continue to bear a higher HIV disease burden than men, with a prevalence rate of 30.4% versus 18.7% for men (Eswatini Government, 2022).Adolescents are also affected by this pandemic as HIV prevalence ranges from 5.6% among older adolescent girls from 15 to 19 years old versus 3.0% among older adolescent boys from 15 to 19 years old (Eswatini Government, 2022).More than half of the population is under the age of 20, and approximately 50% of the youth are considered to be at a higher risk of acquiring HIV (Belle & Gamedze, 2019).
The period of adolescence is regarded as a milestone where there is a shift from childhood to adulthood, and it brings about a lot of changes, such as a greater awareness of sexuality, sexual development, sexual debut and entry into relationships (Van Zantvliet et al., 2020;Bergam et al., 2022).This period is one of orientation and discovery as adolescents establish a sense of identity and independence.During this time, adolescents also become highly vulnerable as they negotiate friendships and gender identity (Loveday et al., 2022).Toska et al. (2015) assert that living with HIV is particularly challenging for adolescents because this phase of life is a formative period where identity is established and intimate sexual relationships are initiated.The quality of adolescents' future is shaped, to a large extent, by their ability to effectively negotiate this stage of life.This specifically affects adolescents living with HIV (ALHIV), who are more likely to experience stress that comes from contending with problems associated with disclosure (Jimu et al., 2021).
HIV-status self-disclosure is defined as a person autonomously sharing their HIV status with another person (Mugo et al., 2021) and has been known to enhance social support and adherence to ART (World Health Organization, 2016).Self-disclosure has public health benefits, especially for sexual partners, as it increases the likelihood of condom use and safer sex practices and prevents onward transmission of HIV (Thoth et al., 2014).Benefits of disclosure for people living with HIV (PLHIV) from past studies include enhanced self-esteem, building trust in relationships, promoting support for treatment adherence, improved access to care and viral suppression (Thoth et al., 2014;Gabbidon et al., 2020).
Establishing peer relationships during adolescence takes priority, and disclosure presents a possible threat that could destroy the relationships that are still being established (Hogwood et al., 2013).Self-disclosure is difficult for ALHIV, (Nöstlinger et al., 2015;Madiba & Mokgatle, 2016) since it is surrounded by fear of rejection and discrimination.It is also characterised by low self-efficacy to deal with negative reactions and poor communication skills (Mugo et al., 2021).
In Eswatini, ALHIV of 10 to 19 years old are enrolled in "teen clubs" which act as in-clinic support groups that give adolescents the opportunity to meet peers and further provide a platform where they can openly discuss their condition (Barker et al., 2019).These peer support groups also improve retention in care and adherence to antiretroviral therapy and are pivotal in decreasing stigma (Willis et al., 2018).Eswatini has not yet developed clear HIV self-disclosure guidelines for adolescents despite indications that they face challenges around disclosure and the distress it brings.Therefore, this article seeks to explore the process followed by adolescents in disclosing their HIV positive status to others in Eswatini and to inform the development of ALHIV self-disclosure guidelines.

Research design
A qualitative exploratory design was used in the study.Such a design is predominantly used where those directly experiencing the phenomenon under study have to provide information (Bradshaw et al., 2017), and it further permits the researchers the opportunity to explore a topic which has not been deeply studied previously, allowing the participants to contribute to the development of new knowledge in that area (Hunter et al., 2018).This approach was regarded as appropriate for the study because there is no sufficient inquiry on self-disclosure of HIV status by adolescents in Eswatini.First author, Baliwe Dlamini, had planned that for every facility, adolescents who agreed to be part of the study would participate in interviews first and then form a focus group.So, all focus groups were made up of adolescents from the same facility.Individual interviews were used to better understand individual participant's unique perspectives about living with HIV, being aware of HIV status and of being on treatment.Focus group discussions (FDGs) were utilised to get further clarification on data that emerged during interviews and to capture participants' ideas and attitudes as they evolved through group interaction.All participants completed a short questionnaire to capture demographic information before the individual interviews and FDGs started.

Research setting
The study was conducted at four facilities; Mkhuzweni Health Centre, Nhlangano Health Centre, Siteki Public Health Unit and Aids Healthcare Foundation clinic, widely known as Lamvelase.One facility was chosen from each of the four regions of Eswatini; Hhohho, Shiselweni, Lubombo and Manzini.All these facilities provide paediatric and adult HIV care services.

Participants and recruitment strategy
A total of 23 adolescents from 15 to 19 years old who already knew their HIV statuses were purposively recruited for the study (Table 1).The inclusion criteria for the study for all participants were being adolescents of 15-19 years old, being aware of their own HIV status for a period of at least six months and on ART for at least six months.This was to ensure that participants were accustomed to living with HIV and what taking treatment requires, as they would find it easier to reflect and share their experiences than those who had just learnt of their status and started on treatment.Younger adolescents from 10 to 14 years old were excluded from the study for ethical reasons as they were deemed not suitable for this type of research.The final sample size was determined by data saturation.
To recruit participants, Dlamini first went to the medical officer or sister in charge of each facility and introduced the study.This person then assigned a liaison person who helped Dlamini go through the register to identify eligible adolescents to recruit.Dlamini was then given a date by the liaison person on which adolescents would come during the weekends to refill their medication.Dlamini was available on Saturdays to give information about the study to the prospective participants when they came for their medication refills and "teen club" meetings.All adolescents recruited in this study were part of the teen club.Teen club meetings are held once a month and it is where ALHIV meet for peer-topeer support which includes education about how to maintain a healthy lifestyle living with HIV and the benefits of adhering to treatment.The Saturdays were chosen for adolescents to hold their meetings and refill their medications to avoid disrupting their school classes.Together with the prospective participants, Dlamini went through the information sheet and explained the purpose of the study, voluntary participation, including their rights as prospective participants, and they were thereafter given parental consent forms to complete at home.The next time the adolescents came for the teen club meeting, they brought the signed parental consent forms if they were under 18 years old and provided assent before data was collected on the same day.18-and 19-year-old adolescents signed their own consent forms to participate in the study on the same day.The duration of time from the introduction of the study to data collection was 30 days.The age of consent to make autonomous decisions and at which a person is considered legally competent in Eswatini is 18 years old, and for adolescents below the age of 18, parents or caregivers provided written consent for the adolescents to participate in the study.

Data collection
Data were collected from October 2022 to January 2023 using individual semi-structured interviews and focus group interviews.To promote privacy, interviews were conducted in a quiet room allocated to Dlamini, and they were conducted in the participants' home language of siSwati to ensure they understood all the questions clearly.Interviews lasted about 30 minutes.A semi-structured interview guide containing open-ended questions was used to guide the discussion, and probes were used to elicit more information from the participants.The broad opening question was "how do you feel about sharing your HIV status with others?"Furthermore, a total of three focus group discussions were conducted by Dlamini, who acted as the moderator.The FDGs also lasted around 30 minutes, and each FDG was made up of five to six participants.Data collection was stopped after saturation was reached with 23 interviews and three FDGs.There was no new data that emerged to add any further insights, but there was information redundancy.

Data analysis
The recordings were transcribed verbatim and then translated into English.Initially open coding was done where transcripts were read until Dlamini got a sense of the data.The transcripts were read line by line, and key phrases were identified and highlighted to uncover the participants' thoughts, ideas and meanings (Corbin & Strauss, 2015).Thereafter concepts that were similar or related in meaning were grouped together into categories and subcategories in terms of their properties and dimensions.Emergent categories were then closely examined and compared for similarities and differences.Axial coding followed where relationships among categories was looked at to discover how categories relate to each other to form more specific and complete explanations of how they crosscut and link (Corbin & Strauss, 2015).Selective coding, the final step, followed with the most significant and frequent codes being identified, leading to the integration and refinement of categories.Finally three categories with nine subcategories emerged.

Ethical considerations
The study was conducted after getting ethical clearance from the University of KwaZulu-Natal Higher Degrees Ethics Committee (BREC/00002527/2021) and the Eswatini Health and Human Research Review Board (EHHRRB064/2021), as well as permission from the respective institutions and facilities where data were collected.Confidentiality, privacy and anonymity were respected during the data collection process.During data collection, the adolescents were not required to write their names on the demographic forms so that their identity was protected.Demographic forms are currently kept in a lockable cabinet in Dlamini's office.Written consent was also sought for audio recording of the interviews and FGDs before the data collection began.

Demographic characteristics of participants
Twenty-three adolescents of between 15 and 19 years old participated in this study; four were 15 years old, two were 16, three were 17, seven were 18 and another seven were 19 years old.There were more females (13/23) than males (10/23).Their mean age was 17 years old.Twenty-one of the particpants were attending school: two were in primary school, nine were in secondary school (Grade 8-10), ten were in high school (Grade 11-12) and two were out of school.Eight adolescents only had their mothers as the surviving parent, while another eight had both parents alive, one had the father as the surviving parent, and six were orphans (Table 1).
Eleven of the adolescents were disclosed to by their mothers, one was disclosed to by their father, one was disclosed to by both maternal and paternal grandmothers, six were disclosed to by the nurse, two were disclosed to by the doctor and another one was disclosed to by the nurse (Table 2).Disclosure to adolescents occurred at different ages, starting from 5 to 15 years old, and the mean age of disclosure was 10 years.For one adolescent, their HIV status was a self-discovery through education at the teen club.With regard to onward self-disclosure, only eight out of the 23 adolescents (35% of this study's sample) had disclosed their HIV status; five had disclosed to friends, and only three had disclosed to their romantic partners.Participants disclosed to their friends because they felt ready to do so, and the belief that the other person had a right to know prompted disclosure to romantic partners.

Categories
After data analysis, three categories with subcategories emerged (Table 3): (1) Approaches to self-disclosure, with subcategories, no need to disclose, testing the waters and disclosure event; (2) Factors influencing disclosure, with subcategories, enablers of disclosure, obstacles to disclosure, acceptance of HIV status and the possibility of onward transmission of HIV; and (3) Empowerment, with subcategories, need for support on how to disclose and education to the general public.

Approaches to self-disclosure
Findings revealed that adolescents have different approaches when it comes to the issue of self-disclosure.
Fifteen participants felt no need to disclose, three wanted to first test the waters before disclosing and five initiated disclosure directly.

No need to disclose
Adolescents stated that they felt they need not disclose their status to friends or romantic partners as they believed that their HIV status was confidential just like any other ailment.They also asserted that they were told from a young age that they should not tell anyone about it as it was their secret.Not being sexually active in their romantic relationships also made participants feel that there was no reason to disclose since there was no risk of HIV transmission.

Testing the waters
To be able to disclose, participants first rehearsed an occasion in their minds when they would initiate a discussion on views about HIV infection in a way that would give them a clue about whether they would get a positive or negative response to disclosing their status to the person they planned to disclose to, be it a friend or romantic partner.
If they got a positive reaction, they were encouraged to continue with disclosure, but a negative reaction served as a deterrent.Other participants would ask the friend if they were living with HIV first, and if the answer was yes, they stated that they would then also disclose their own status.
Other adolescents revealed medicines they took as a way of prompting their friends or romantic partners to ask them about their status, in which case they would then disclose.
I then asked him how he would feel if he were to find out that I also had HIV.He said that wouldn't be an issue for him, and we would continue with our relationship as normal as long as we adhered to the precautions.He also said that things were much better now since there were also things like PrEP.I then related the story of how I got it because I feel that is important; you shouldn't tell a person that you have HIV and then leave him hanging (P16, IDI).
I would first ask her if she ever goes to the hospital and how many times she does per year.I would then ask her if she does have HIV, and when she says she is HIV positive, I would then tell her that I am also HIV positive, but I was scared to tell her (P21, IDI).
I would tell them the truth if they asked -that these are my pills.They've already seen the pills anyway, and they know what those pills are for.I'm not worried about anything whatsoever.My mind is free, and so is my heart (P17, IDI).

Disclosure event
A total of five participants disclosed their status to friends and three disclosed to romantic partners and used different modalities to do this.Others opted to disclose face-to-face, even though it was not easy.They felt that the other person had a right to know the status of the person they were in a relationship with, and being ready to disclose also made them decide to do so.We dated for a while, after which I then decided to tell him.I did have it in me that you have to tell your partner.I felt that it is his right to know and not make him do things without knowing the whole story behind it.Then there came the time when I felt I was ready because for disclosure to go well, you need to satisfy yourself that you are ready… (P16, IDI).Some participants decided to use short text messages to disclose because that seemed easier for them to relay the message than face-to-face interactions.
I then sent a short text message disclosing my status to him, after which I turned off my phone.He then called me through my sister's number and asked me why I didn't tell him all along.He said sorry and cut off the call.We didn't communicate for about two

Obstacles to disclosure
Lack of trust in the other person's ability to keep things confidential after being disclosed to made it difficult to disclose.People who were not well informed about HIV made it difficult to disclose because they lacked understanding.The main worry was the person being unable to maintain confidentiality which would lead to stigma and discrimination.Being young also made it difficult to disclose because it meant the current relationships were probably not going to be lifelong.So if there was disclosure with every relationship, this meant that by the time the adolescents settle down, they would have disclosed to a lot of people.
In turn, what they feared was there would be ex-friends or partners whose confidentiality could not be guaranteed such that through gossip many more people would get to know their status.The other obstacle was that disclosing one's status ultimately discloses the parents' status, which breached their wish for confidentiality, which would not be the intention of the participant disclosing.The stigma is still a major challenge; we are still not able to stand up to it, especially when it touches on our parents.For instance, if I say I am living with HIV and I was born with it, it automatically discloses my mother's and father's HIV status.Therefore, my disclosure involves a lot of people, even though that would not be the intention (P3, FGD1).
What scares us most as teenagers is the likelihood of being stigmatised by people we disclose to.We worry about how we will cope with a situation where the person we may disclose to starts telling other people about our status.Would I be able to survive in an environment where everyone knows my HIV status? (P14, FGD3).

Acceptance of HIV status
Acceptance of a positive HIV status is important before the individual can be free to share the status with another person.Participants suggested that it was difficult for them to accept their status, and for some, they were still trying to come to terms with it.Therefore, they found it difficult to disclose when they were still struggling with accepting their own status.
The way people describe someone with HIV… Even now, I haven't fully accepted that I have HIV.
If I haven't accepted it myself, then how can I tell someone else about it?(P6, IDI).
When I found out, I was 10, I didn't know all along, I hadn't known and when they told me, I stopped taking the medication.Mom had to bring me back here to the hospital where they explained that if I don't take the medication, I will die.They actually confused me… (P4, IDI).
I couldn't believe it.Even today, I haven't accepted, and it is not acceptable.No matter how much counselling I get, it is still difficult (P12, IDI).

Possibility of onward transmission of HIV
Some of the adolescents do not use precautions every time with their romantic partners when engaging in sex, which poses a risk for onward transmission of HIV.They use a condom; however, they are not consistent, and they also find themselves pressured by their romantic partners not to use it because of perceptions that it interferes with the act.Yes, we do use it as much as it is possible, but the two girlfriends I've had don't want protection; they say the condom hurts them and minimises pleasure…I put it aside, but I try to make sure there is no mixing of blood (P3, IDI).
We use the condom sometimes, it depends; we don't always carry condoms because we haven't planned on doing anything (P1, IDI).

Empowerment
Need for support on how to disclose Adolescents expressed the need to be supported on how to disclose because they lacked the necessary skills required for self-disclosure and did not know how to start talking about something they regarded as difficult to talk about.It also emerged that they felt they should be told about the importance of disclosure from a young age so that they grow up knowing that they have to disclose.They further reiterated that their parents should also be taught about the importance of self-disclosure so that they could instil it in them at a younger age.
We would have to be taught that this is how you tell someone your status, and you tell that person your status when you are prepared and have enough information because you can't just say that I am taking treatment (P8, IDI).

I really don't know how to, unless it's someone who sees me taking the pills. I'd compose myself and tell him that I have HIV, but it does not mean that I'm dying (P12, IDI).
I think it would be best that we are taught at a younger age the importance of disclosure because if I am told you don't talk about it, then I will listen to that, even when I am old.Even our parents should be educated because I think that would make it easier… (P2, FGD1).

Education to the general public
The general public still needs to be educated about HIV for them to understand that individuals living with HIV are the same as them, and they deserve to be treated like everybody else.Educating the public would also make it easier for adolescents because, by the time they choose to disclose, they would find that the person they are disclosing to is well-informed about HIV and this would make it easier.Peers of adolescents also need to be educated so that they stop stigmatising them simply because they think they brought it on themselves and acquired the disease behaviourally instead of perinatally.
Educating everyone about HIV, not just us, because they would understand it better and also people should move around and see how other people live outside of themselves (P20, IDI).
These teachings must get to the schools because at one time the teacher had to intervene at the assembly because some students were discriminating against a child simply because of losing weight (P4, FGD2).
Everyone, whether living with HIV or not, should be educated about HIV and make people aware that people living with HIV are still human and deserve to be treated right because they cannot change anything (P7, FGD1).
I feel that the public should be educated more and that more community outreach programmes be rolled out to help the public be more informed that HIV is not that bad, but rather a virus one can live a normal life with.This is so that when the time comes for us to disclose our statuses, the person we disclose to already has a clue as to what we are talking about and is more informed about it.That way, things are easier (P11, IDI).
They first need to understand that we didn't do this to ourselves; we are not to blame because the stigmatisation may come from them thinking for themselves how I got the sickness.Just a Swati mindset…just difficult… (P3, FGD2).
With my peers that I went to school with, I think the best way to understand it would be if they are in the same situation as me, then they would know this is real, and they would stop stigmatising us because you can't understand it just by talking about it (P5, FGD1).

Discussion
The study sought to determine the process followed by ALHIV in self-disclosing their HIV status to friends and romantic partners and to determine the barriers and promoters of ALHIV disclosure of their HIV status to others.For adolescents, a clear barrier to disclosure was having been told when younger by a parent to keep their status secret from other people.This made them grow up with the belief that it was a subject never to be discussed with anyone.These findings are consistent with other studies (Filho et al., 2020;Kidman & Violari, 2020) where participants specified that they consider information about their HIV serostatus to be a private matter.By keeping their HIV status a secret, adolescents wish to safeguard and preserve their relationships with their peers because, at this stage, peer acceptance and a sense of normalcy are important (Okawa et al., 2017).Findings in our study on fear of stigma, discrimination and being abandoned agree with findings that have been reported in other studies (Galano et al., 2017;Jimu et al., 2021).Some participants in the study did not have the courage to disclose, and therefore they used different strategies that would eventually help them to disclose.Sending short text messages helped them to disclose as they could not do it face to face.A study conducted by Mlilo et al. (2020) found that adolescents in Zimbabwe used the same strategy of disclosing through short text and WhatsApp messages.For those participants who disclosed, the right of the other person to know compelled them to disclose as well as being ready for disclosure without feeling coerced.According to Olumide and Owoaje (2020), adolescents prefer to reveal their status to others on their own terms, that is, when they are actually ready to disclose and to someone they regard as close to them.
The study also revealed that having a long-term relationship served as an enabler of disclosure due to participants thinking they would have gained trust in the person they were disclosing to.Rich et al. (2022) assert that due to the nature of HIV, there is an expected difficulty in disclosing, which can, however, be overcome once trust and a long-term partnership have been established.Adolescents stated that they could disclose more easily if they had the assurance that the people they are disclosing to, people in their communities and the general public, had sufficient knowledge about HIV.This would ensure that they would not be subjected to stigma and discrimination caused by people lacking appropriate knowledge.
Our study revealed that a fear of breaches of confidentiality once a status has been disclosed made it difficult for participants to disclose because the ALHIV has no control over how that individual decides to treat information about their status.These findings agree with those from a study by Loveday et al. (2022) that adolescents, like adults, struggle to self-disclose and worry about the negative consequences after having done so.Automatic disclosure of parents' HIV status was also an obstacle in this study.Adolescents felt that by disclosing their status and saying they were born with it, they were ultimately disclosing the status of their parents even though that was not their wish, and these findings agree with a South African study by Kidman and Violari (2020).
The findings also reveal that it was not easier for ALHIV to accept their status, and some of them were still struggling with acceptance.Therefore, they did not feel they were at a stage where they could disclose since they had not reached the stage of acceptance.Adolescents with perinatally acquired HIV do not fully accept living with HIV but alternate between episodes of acceptance and moments of distress.In a previous study conducted in Eswatini (Nsibandze et al., 2020) adolescents expressed difficulty in coming to terms with their status, but were trying to move on and live their lives.The societal belief that HIV is like any other disease has had a great influence on adolescents expressing that they have come to an acceptance of their status (Maseko & Madiba, 2020).The reality of adolescents is that they fluctuate between periods of acceptance and periods of non-acceptance.
In this study, there was the possibility of onward transmission of HIV to uninfected sexual partners because condoms were not consistently used.According to Otieno and Obuya (2019), adolescents have challenges talking about HIV/AIDS generally and especially their HIV status.This leads to the non-disclosure of a positive HIV status to romantic partners, which heightens the risk of engaging in unprotected sex, resulting in new infections (Okawa et al., 2018).This is evident in the fact that while there has been a reduction in new HIV infections among all the other populations, there has been a marked escalation in HIV incidence among adolescents, accounting for 37% of all new infections (UNICEF, 2019).
Participants in the study also asserted that they were unable to disclose because they lacked the required skills that would make it easier.These findings agree with other studies (e.g.Madiba & Mokgatle, 2016;Mugo et al., 2021) where adolescents lacked the self-efficacy to disclose and are, therefore, a critical group to target for assisted disclosure (Dalal et al., 2017).The World Health Organization recommends that ALHIV be educated so they know the right time for disclosure, as this will greatly reduce new infections.Caregivers of adolescents also need to be taught the importance of instilling in the adolescents the importance of disclosure as they grow up instead of reinforcing that they should keep it secret because adolescents then think that is how it should always be, even when they start engaging in romantic relationships.Nabunya et al. (2020) emphasise that programmes aimed at improving HIV care for children and adolescents should consider integrating approaches that will strengthen family communication, especially around HIV knowledge, disclosure, stigma and social support to the betterment of HIV health-related outcomes.
Adolescents in our study called for massive HIV education campaigns to the general public because they felt the public still lacked basic information about HIV, which then perpetuated stigma and discrimination.In studies conducted in Zimbabwe (Mlilo et al., 2020;Jimu et al., 2021), participants in those studies felt that the public does not have adequate knowledge about HIV and AIDS, and this was evident in the stigmatisation of people living with HIV.Therefore, tailor-made interventions to fight against stigma and create protective environments for ALHIV are necessary.HIV education should not focus mainly on adolescents but also their communities where stigma and discrimination exist.
According to the participants in the study, HIV and AIDS education must also be offered at schools because their peers also exhibited stigma and discrimination.Schools are important for rolling out interventions and programmes that target stigma reduction among ALHIV.Most adolescents, whether infected or not, are found in school, and if these programmes are implemented in schools, there would be increased coverage because such places bring together students who would otherwise not be reached through community interventions (Nabunya et al., 2020).

Conclusion and recommendations
This study explored the challenges for ALHIV in disclosing their serostatus to others.Adolescents reported difficulty in disclosing their status to significant others, especially romantic partners.The main findings from the study are pertinent issues reported by ALHIV that they should be educated and supported on how to disclose, and furthermore be allowed to exercise their autonomy in deciding when to disclose.For adolescents to be able to disclose, they have to work through issues of acceptance of their own HIV status first, that they are living with a chronic condition and be encouraged to continue attending teen club meetings which act as a support group as they share experiences with people similar to them and better understand how they feel.In addition, programmes aimed at supporting and strengthening caregiver communication with ALHIV should be made a priority.Evidence from this study supports the opinion that HIV education and mental and social support are important in reducing stigma and discrimination in communities.To the best of our knowledge, the unique contribution of this study is that it is the first-ever study to document difficulties faced by adolescents in the self-disclosure of their status in Eswatini.It also raises the need to explore further initiatives that will empower adolescents and give them a voice in developing custommade interventions.

Study limitations
The study has certain limitations.The findings cannot be generalised because a small sample was used, and the study population is not representative of all ALHIV.Furthermore, the study also relied on self-reported narratives.

Table 2 :
Person who disclosed to adolescent and self-disclosure by adolescent

Table 3 :
Categories and subcategories I wouldn't tell him initially, but I would see how far we have been in a relationship, maybe some years, then I could decide because with a boyfriend there is a possibility you can split, and I wouldn't know what he would say to other people about me… (P10, IDI).