Abstract

Globally, an estimated 2.38 million children and adolescents (0–19 years) are living with HIV, with 80% residing in sub-Saharan Africa. In Uganda, adolescents remain at high risk, with approximately 6,600 new infections among 10–19-year-olds in 2023. Despite expanded access to antiretroviral therapy (ART), adolescents Living with HIV (ALHIV) continue to experience poor outcomes, including low viral suppression and high mortality, largely driven by non-adherence. However, ART adherence represents only one dimension of their lived experience. ALHIV must also navigate intersecting adversities, including poverty, stigma, orphanhood, and exposure to sexual and gender-based violence, while meeting academic expectations, particularly in boarding school settings. Limited research has examined how these adolescents cope with such cumulative challenges, or the broader supports needed to promote their well-being and educational outcomes. Guided by coping and stress theory, cumulative risk theory, and resilience theory, this dissertation examines how co‑occurring risks and protective processes shape school enrollment and school satisfaction among ALHIV, and how a multilevel intervention (M‑Suubi) mitigates these challenges. Using data from a longitudinal randomized controlled trial (N=833 ALHIV aged 10-17 in southern Uganda), the study integrates clinic-clustered survey data at baseline and 12 months with in-depth qualitative interviews. Aim 1 assessed associations between cumulative risk (CRT) and school enrollment and life satisfaction (SLS). Mixed-effects models showed that higher cumulative risk was significantly associated with lower baseline school life satisfaction (B = −1.30, p < .001) and with declines over 12 months (B = −0.67, p < .001), even after adjusting for covariates. The M-Suubi intervention did not produce significant short-term effects on school life satisfaction, nor did it moderate the effects of cumulative risk. Mixed-effects logistic regression further indicated that age was the only significant predictor of school enrollment, with older adolescents being less likely to remain enrolled (B = −0.41, p < .001). Aim 2 tested whether protective factors, such as self-esteem, family cohesion, and social support, mediated the associations between cumulative risk and school enrollment and school satisfaction. Cumulative risk had a significant negative total effect on changes in school life satisfaction (B = −0.59, p < .001), with partial mediation observed; the direct effect remained significant (B = −0.41, p = .002). Similarly, age retained a strong negative association with school enrollment in both total and direct effects, suggesting that the mediators did not explain age-related disparities in school retention. Aim 3 used thematic analysis to examine adolescents’ coping strategies. Findings revealed multilevel coping processes, including individual strategies (e.g., spiritual reliance, selective avoidance, academic focus, treatment adherence), family support (financial assistance, encouragement), peer collaboration, and school-level supports (fee flexibility, mentorship). These narratives highlight how adolescents actively mobilize resources across ecological levels, though their efforts are constrained by broader structural conditions. Overall, this dissertation makes a clear contribution by demonstrating that cumulative risk is a central and persistent determinant of school retention and satisfaction among ALHIV, while commonly targeted protective factors provide only partial and insufficient buffering. The absence of short-term effects from the M-Suubi intervention, coupled with persistent age-related disparities in school enrollment, highlights a critical gap in current intervention approaches. These findings advance the field by showing that improving outcomes for ALHIV requires moving beyond single focus adherence models toward sustained, multilevel strategies that simultaneously address structural constraints, developmental transitions, and interconnected psychosocial risks. The results provide strong empirical justification for designing and scaling longer-term, ecologically grounded interventions that integrate family, school, and community systems to more effectively support both educational attainment and overall well-being among ALHIV.

Committee Chair

Mary McKay

Committee Members

Fred Ssewamala; Mary McKay; Massy Mutumba; Proscovia Nabunya; Shenyang Guo

Degree

Doctor of Philosophy (PhD)

Author's Department

Social Work

Author's School

Brown School

Document Type

Dissertation

Date of Award

8-3-2026

Language

English (en)

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