Early adolescent pregnancy increases risk of incident HIV infection in the Eastern Cape, South Africa: a longitudinal study

Incident HIV during pregnancy and early postpartum period: a population-based cohort study in a rural area in KwaZulu-Natal, South Africa

BACKGROUND

The evidence on the effect of pregnancy on acquiring HIV is conflicting, with studies reporting both higher and lower HIV acquisition risk during pregnancy when prolonged antiretroviral therapy was accessible. The aim of this study was to assess the pregnancy effect on HIV acquisition where antiretroviral therapy was widely available in a high HIV prevalence setting.

METHODS

This is a retrospective cohort study nested within a population-based surveillance to determine HIV incidence in HIV-uninfected women from 15 to 49 years from 2010 through 2015 in rural KwaZulu-Natal. HIV incidence per 100 person-years according to pregnancy status (not pregnant, pregnant, to eight weeks postpartum) were measured in 5260 HIV-uninfected women. Hazard ratios (HR) were estimated by Cox proportional hazards regression with pregnancy included as a time varying variable.

RESULTS

Overall, pregnancy HIV incidence was 4.5 per 100 person-years (95% CI 3.4-5.8), higher than non-pregnancy (4.0; 95% CI 3.7-4.3) and postpartum incidences (4.2 per 100 person-years; 95% CI 2.3-7.6). However, adjusting for age, and demographic factors, pregnant women had a lower risk of acquiring HIV (HR 0.4; 95% CI 0.2-0.9, P = 0.032) than non-pregnant women; there were no differences between postpartum and non-pregnant women (HR 1.2; 95% CI 0.4-3.2; P = 0.744). In models adjusting for the interaction of age and gravidity, pregnant women under 25 years with two or more pregnancies had a 2.3 times greater risk of acquiring HIV than their older counterparts (95% CI 1.3-4.3; P = 0.008).

CONCLUSIONS

Pregnancy had a protective effect on HIV acquisition. Elevated HIV incidence in younger women appeared to be driven by those with higher gravidity. The sexual and biological factors in younger women should be explored further in order to design appropriate HIV prevention interventions.

Love grows with sex: teenagers negotiating sex and gender in the context of HIV and the implications for sex education

How do teenagers located in the KwaZulu-Natal province of South Africa, the epicentre of the HIV pandemic, give meaning to sexuality? This paper examines teenage black Africans investments in sex and sexuality and the gendered dynamics through which sexuality is articulated. Whilst unequal gender relations of power continue to feature prominently within relationship dynamics fuelling the gendering of HIV, attention to the micro-processes through which relationships are forged remain significant in illustrating the complex connections between love, sex and gender. Drawing on empirical findings with teenagers between the ages of 16 and 17 years old, the paper shows how relationships are conceptualised based on discourses of love. Love is inextricably bound up with sex and when teenagers talk about love and sex they also talk about condom use, multiple sexual partners and gender inequalities. What teenagers were interested in for their sexual relationships was not raised in sex education programmes at school. Implications for addressing teenage constructions of sexuality are discussed in the conclusion.

Combination Social Protection for Reducing HIV-Risk Behavior Among Adolescents in South Africa

BACKGROUND

Social protection (ie, cash transfers, free schools, parental support) has potential for adolescent HIV prevention. We aimed to identify which social protection interventions are most effective and whether combined social protection has greater effects in South Africa.

METHODS

In this prospective longitudinal study, we interviewed 3516 adolescents aged 10-18 between 2009 and 2012. We sampled all homes with a resident adolescent in randomly selected census areas in 4 urban and rural sites in 2 South African provinces. We measured household receipt of 14 social protection interventions and incidence of HIV-risk behaviors. Using gender-disaggregated multivariate logistic regression and marginal effects analyses, we assessed respective contributions of interventions and potential combination effects.

RESULTS

Child-focused grants, free schooling, school feeding, teacher support, and parental monitoring were independently associated with reduced HIV-risk behavior incidence (odds ratio: 0.10-0.69). Strong effects of combination social protection were shown, with cumulative reductions in HIV-risk behaviors. For example, girls' predicted past-year incidence of economically driven sex dropped from 11% with no interventions to 2% among those with a child grant, free school, and good parental monitoring. Similarly, girls' incidence of unprotected/casual sex or multiple partners dropped from 15% with no interventions to 10% with either parental monitoring or school feeding, and to 7% with both interventions.

CONCLUSION

In real world, high-epidemic conditions, "combination social protection," shows strong HIV prevention effects for adolescents and may maximize prevention efforts.

Intimate partner violence as a factor associated with risky sexual behaviours and alcohol misuse amongst men in South Africa

Globally intimate partner violence (IPV) is a public health problem that can be perpetrated by both males and females, although males are more likely to inflict severe IPV-related injuries on their female partners. In low- and middle-income countries like South Africa, few studies have conducted research to determine whether IPV perpetration by men may be a risk factor for engaging in other risk behaviours. The aim of this study is to determine whether IPV perpetration by men is a risk factor for engaging in other risk behaviours with a particular focus on risky sexual behaviours and alcohol misuse. The data for this study were drawn from a multilevel intervention study, which addressed the nexus of alcohol abuse and HIV prevention among men in South Africa. Men were screened and recruited from informal drinking places within 12 communities situated in one of the oldest, predominantly Xhosa-speaking African townships in Cape Town. Univariate and multivariate logistic regression models were used to analyse the associations between IVP and potential explanatory variables. Of the 975 men included in the survey, 39.9% reported to have been involved in Intimate Partner Violence. IPV perpetration was significantly more likely among men who reported having a child [OR 1.51 (1.07-2.14) p = .019], having a casual sexual partner [OR 1.51 (1.11-2.05) p = .008], and those with possible alcohol dependence [OR 3.46 (1.17-10.20) p = .024]. IPV was significantly less likely among men with matric educational qualification than those with no education [OR 0.30 (95% CI: 0.09-1.02) p = .053] and among those who reported using a condom at last sex [OR 0.69 (0.50-0.97) p = .034]. We therefore recommend that interventions aimed at reducing IPV need to address risky sexual and drinking behaviours amongst men simultaneously, while also focusing on intimate relationship power dynamics and gendered norms amongst couples.

Factors that Influence Teenage Antenatal Care Utilization in John Taolo Gaetsewe (JTG) District of Northern Cape Province, South Africa: Underscoring the Need for Tackling Social Determinants of Health

BACKGROUND AND OBJECTIVES

In resource-limited settings, the uptake of antenatal care visits among women, especially teenage pregnant women, is disturbingly low. Factors that influence the uptake of ANC services among teenage women is largely understudied and poorly understood in John Taolo Gaetsewe (JTG), a predominantly rural and poor district of South Africa. The aim of this study was to determine the factors that influence uptake of ANC services among teenage mothers in JTG district.

METHODS

A cross-sectional health facility-based study utilising mixed method was conducted in all public health facilities (n=44) at JTG district. Mother-infant pairs (n=383) who brought their infants for six-week first DPT immunisation during the study period were enrolled in the study. Structured questionnaires were used to collect data on demographic, socio-economic and uptake of ANC indicators.

RESULTS

Out of 272 respondent mothers, 18.68% were adolescent mothers (13-19 years). The logistic regression analysis shows that mother's age (OR=2.11; 95%CI = 1.04 - 4.27); distance to the nearest health facility (OR=3.38; 95%CI = 1.45-7.87); and client service satisfaction (OR=8.58; 95%CI =2.10-34.95 are significantly associated with poor uptake of ANC services.

CONCLUSION AND GLOBAL HEALTH IMPLICATIONS

There is a need to improve the quality of adolescent reproductive health services tailored to their health and developmental needs. Moreover, addressing the social determinants of health that affect individual's healthy life style and health seeking behavior is critical.

Sustained High HIV Incidence in Young Women in Southern Africa: Social, Behavioral, and Structural Factors and Emerging Intervention Approaches

Young women in southern Africa experience some of the highest incidence rates of HIV infection in the world. Across southern Africa, HIV prevalence among women increases rapidly between the teenage years and young adulthood. Adult HIV prevalence is 16.8 % in South Africa, 23 % in Botswana, 23 % in Lesotho, and 26.5 % in Swaziland. Existing research has illuminated some of the key social, behavioral, and structural factors associated with young women's disproportionate HIV risk, including gendered social norms that advantage male power in sexual relationships and age disparities in relationships between younger women and older male partners. Important structural factors include the region's history of labor migration and legacy of family disruption, and entrenched social and economic inequalities. New interventions are emerging to address these high levels of HIV risk in the key population of young women, including structural interventions, biomedical prevention such as PrEP, and combined HIV prevention approaches.

Social support among HIV-positive and HIV-negative adolescents in Umlazi, South Africa: changes in family and partner relationships during pregnancy and the postpartum period

Background

Pregnancy is common among adolescents in South Africa, yet the social experiences of adolescents during the pregnancy and postpartum period remain understudied in this context. We aimed to explore how adolescent women’s discovery and disclosure of both their pregnancy and HIV status affected their relationships with family members and sexual partners, with a particular focus on whether and how support changed throughout this time period.

Methods

We conducted in-depth semi-structured interviews with 15 HIV-positive and HIV-negative adolescent women who were either pregnant or had delivered in the last 18 months from one urban clinic in Umlazi, South Africa. Interviews were audiotaped, transcribed, translated, and coded for analysis.

Results

Young women described stress and instability in their relationships with family and partners during pregnancy and the postpartum period, though prior to and during HIV-status disclosure women generally experienced less stress than in disclosing their pregnancy to family members and partners. After a destabilizing period immediately following pregnancy disclosure, families became and remained the primary source of material and emotional support for the young women. Women discussed heightened closeness with their partners during pregnancy, but few women had close relationships with their partners postpartum. Support experiences did not differ by HIV status.

Conclusion

Programs should be aware of the relative importance of pregnancy-related concerns over HIV-related concerns in this population of young women. Engaging family members is critical in ensuring social support for this population of young pregnant women, and in encouraging timely initiation of antenatal care.

Risk factors for unplanned and unwanted teenage pregnancies occurring over two years of follow-up among a cohort of young South African women

BACKGROUND

Although teenage pregnancies in South Africa have declined, the short and longer term health and social consequences are a potential public health concern. This longitudinal study aimed to describe the range of risk and protective factors for incident unwanted and unplanned pregnancies occurring over 2 years of follow-up among a cohort of adolescent women in the Eastern Cape, South Africa. It also investigated the relationship between gender inequality and gender-based violence and subsequent unplanned and unwanted pregnancies among the cohort.

OBJECTIVE

Teenage girls, aged 15-18 years (n=19), who were volunteer participants in a cluster randomized controlled trial and who had data from at least one follow-up were included in this analysis. To assess risk and protective factors for incident unwanted or unplanned pregnancies, we constructed multivariate polytomous regression models adjusting for sampling clusters as latent variables. Covariates included age, having a pregnancy prior to baseline, education, time between interviews, study intervention arm, contraceptive use, experience of intimate partner violence, belief that the teenage girl and her boyfriend are mutual main partners, and socioeconomic status.

RESULTS

Overall, 174 pregnancies occurred over the 2-year follow-up period. Beliefs about relationship control were not associated with unwanted and unplanned pregnancies, nor were experiences of forced first sex or coerced sex under the age of 15. Hormonal contraception was protective against unplanned pregnancies (OR 0.40; 95% CI 0.21-0.79); however, using condoms was not protective. Physical abuse (OR 1.69; 95% CI 1.05-2.72) was a risk factor for, and having a pregnancy prior to baseline was protective against an unwanted pregnancy (OR 0.25; 95% CI 0.07-0.80). Higher socioeconomic status was protective for both unplanned and unwanted pregnancies (OR 0.69; 95% CI 0.58-0.83 and OR 0.78; 95% CI 0.64-0.96). Believing that the teenage girl and her boyfriend were mutual main partners doubled the odds of reporting both an unplanned and unwanted pregnancy (OR 2.58 95% CI 1.07-6.25, and OR 2.21 95% CI 1.13-4.29).

CONCLUSION

Although some of the measures of gender inequity were not associated with unplanned and unwanted pregnancies, there is evidence of the role of both gender power and socioeconomic status. This was evident in teenage girls who experienced physical violence being more likely to have an unwanted pregnancy. Interventions to prevent teenage pregnancies need to be tailored by socioeconomic status because some teenagers may see having a pregnancy as a way to have a more secure future. Interventions that engage with relationship dynamics of teenagers are essential if unwanted and unplanned pregnancies are to be prevented.