Socioeconomic Predictors of Transactional Sex in a Cohort of Adolescent Girls and Young Women in Malawi: A Longitudinal Analysis

Initial Validity Evidence for a Measure of Transactional Sex in a U.S. College Student Sample

The current study provides initial validity evidence for a measure of Transactional Sex (TS). Participants (N = 269) were recruited from a Northeastern University in the United States and consisted of undergraduate and graduate students. Participants completed an online survey through QuestionPro that contained the Transactional Sex Measure (TSM) as well as measures of depression, anxiety, and stress, condom use negotiation self-efficacy and sexual risk, alcohol and drug use, and materialism. Construct and criterion validity were examined. Findings revealed that the TSM provided good criterion validity evidence but the construct validity evidence was minimal. Further studies on the conceptualization of TS and distribution of the TSM across a variety of diverse samples can provide more validity evidence.

Transactional sex and age-disparate sexual partnerships among adolescent girls and young women in Tanzania

Introduction

Adolescent girls and young women (AGYW) continue to experience a high incidence of HIV in southern and eastern Africa, even in the context of large-scale HIV prevention interventions. In Tanzania, AGYW account for the largest proportion of new infections and have a higher risk of HIV acquisition than males of comparable age.

Methods

We used routinely collected data from the PEPFAR/USAID-funded Sauti Project, a large combination HIV prevention program, to examine the relationship between transactional sex and sex with older partners among AGYW in Tanzania (2015-2020). Out-of-school AGYW 15-24 years completed a vulnerability index and were tested for HIV. We estimated weighted prevalence ratios (PR) and 95% confidence intervals (CI) for the associations of transactional sex (sex exchanged for money/services/gifts outside of sex work) and sex with older partners (≥5-years older, ≥10-years older) with prevalent HIV. Age cutoffs of 5 and 10 years were used to align partner age differences with age-disparate and intergenerational sex, respectively. We assessed potential synergism between exposures, and subgroup analyses explored associations among girls 15-19.

Results

Sixty seven thousand three hundred fifty seven AGYW completed the vulnerability index and 14,873 had captured HIV testing records. Median age was 20 years (IQR 18-22). Transactional sex and age-disparate sex were common (35% and 28%, respectively); 13% of AGYW reported both behaviors. HIV prevalence was associated with both transactional sex (PR: 1.28; 95% CI 1.00-1.63) and age-disparate sex (PR:1.26, 95% CI 0.99-1.60). In common referent analysis, transactional sex remained strongly associated with HIV, even in the absence of age-disparate sex (PR 1.41; 95% CI 1.02-1.94).

Discussion

Evidence of statistical synergism was not present, suggesting both transactional sex and age-disparate sex operate through similar pathways to increase HIV risk. Increased specificity within HIV prevention programs is needed to better meet the sexual and reproductive health needs of AGYW at high risk of HIV in Tanzania, including investment in tailored youth-friendly strategies for AGYW who have been marginalized from the current HIV response.

Experiences of Food Insecurity Among Pregnant Adolescents and Adolescent Mothers in Ghana: A Photovoice Method

Objectives: Food insecurity (FI) remains a major public health problem globally. However, there is limited information about adolescents' experiences. The current study explored FI experiences of pregnant adolescents and adolescent mothers in Cape Coast, Ghana using a Photovoice method. Methods: This study recruited 34 pregnant adolescents and adolescent mothers from communities in Cape Coast, Ghana. Each participated in a training session then was provided prompts to take photos that portrayed food access barriers, facilitators and coping strategies. In a debrief session, each participant selected two pictures they took and explained the image, followed by a group discussion of the selected photos. Debrief sessions were audio recorded and transcribed verbatim to develop themes using a theory-driven approach. Results: Most participants reported several or many experiences with FI (64.7%) in the previous month. Participants discussed money, unwanted pregnancy, and unstable work as barriers to obtaining food and working, selling goods, and family support as facilitators to obtaining food. Coping strategies mentioned include providing services to others, borrowing food and goods, meal stretching, pawning personal items and trading. Conclusion: The FI experience of this population is complex; interventions, including trade training or school retention, should be multifaceted.

Food Insecurity and Engagement in Transactional Sex Among Female Secondary Students in Rwanda

The relationship between food insecurity and transactional sex is well recognized, but less is known about this relationship among adolescents. We analyzed cross-sectional baseline data from 3,130 female secondary students aged 12-19 enrolled in a three-arm, cluster randomized controlled trial to examine the association between food insecurity and transactional sex. The explanatory variable was food security and the outcome was ever engaging in transactional sex. Over one quarter (28.7%) reported any food insecurity and 1.9% of all participants (9.6% of sexually active participants) reported ever engaging in transactional sex. In adjusted models, ever experiencing any food insecurity was associated with a higher prevalence of ever transactional sex (PR: 1.60; 95% CI: 1.02, 2.49) compared to little to no food insecurity. These results provide insight into potential predictors of higher-risk sexual behavior in Rwanda; they also provide policy-makers with populations with whom to intervene on upstream determinants of transactional sex, notably poverty and food insecurity.

HIV Recent Infection and Past HIV Testing History Among Newly HIV-Diagnosed 15-24-Year-Olds in Malawi: An Analysis of 2019-2022 HIV Recent Infection Surveillance Data

Awareness of HIV status in Malawi is 88.3% and lowest among 15-24-year-olds (76.2%). There is a need to understand HIV testing history and transmission in this age group. We analyzed pooled HIV surveillance data to describe testing history and HIV recent infection among 8,389 HIV-positive 15-24-year-olds from 251 sites in Malawi between 2019 and 2022. Most HIV-positive 15-24-year-olds were female; aged 23-24 years; rural residents; and diagnosed at voluntary counseling and testing. No prior HIV testing was reported in 43.5% and 32.9% of 15-19-year-olds and males, respectively. Overall, 4.9% of HIV-positive diagnoses were classified as recent HIV infections, with the highest proportions among breastfeeding women (8.2%); persons tested at sexually transmitted infection clinics (9.0%); persons with a prior negative test within 6 months (13.0%); and 17-18-year-olds (7.3%). Tailored and innovative HIV prevention and testing strategies for young adolescents, young males, and pregnant and breastfeeding women are needed for HIV epidemic control.

Syndemic of factors that shape the early lives of women who enter into sex work: a qualitative methods study from Nairobi, Kenya

OBJECTIVE

To explore the structural and social co-factors that shape the early lives of women who enter sex work in Nairobi, Kenya.

DESIGN

Thematic analysis of qualitative data collected as part of the Maisha Fiti study among female sex workers (FSWs) in Nairobi.

PARTICIPANTS AND MEASURES

FSWs aged 18-45 years were randomly selected from seven Sex Workers Outreach Programme clinics in Nairobi and participated in baseline behavioural-biological surveys. Participants in this qualitative study were randomly selected from the Maisha Fiti study cohort and were interviewed between October 2019 and July 2020. Women described their lives from childhood, covering topics including sex work, violence and financial management.

RESULTS

48 out of 1003 Maisha Fiti participants participated in the in-depth qualitative interviews. FSWs described how physical and sexual violence, poverty and incomplete education in their childhood and adolescence intertwined with early pregnancy, marriage, intimate partner violence and relationship breakdown in their adolescence and early adulthood. The data analysis found clear syndemic relationships between these risk factors, particularly childhood violence, poverty and incomplete education and highlighted pathways leading to financial desperation and caring for dependents, and subsequent entry into sex work. Women perceived sex work as risky and most would prefer alternative work if possible, but it provided them with some financial independence and agency.

CONCLUSIONS

This is the first study in Kenya to qualitatively explore the early lives of sex workers from a syndemic perspective. This method identified the pivotal points of (1) leaving school early due to poverty or pregnancy, (2) breakdown of early intimate relationships and (3) women caring for dependents on their own. Complex, multi-component structural interventions before these points could help increase school retention, reduce teenage pregnancy, tackle violence, support young mothers and reduce entry into sex work and the risk that it entails by expanding livelihood options.

'I was in need of somewhere to release my hurt:' Addressing the mental health of vulnerable adolescent mothers in Harare, Zimbabwe, through self-help groups

Background

Adolescents experiencing multiple vulnerabilities, including poverty, curtailed education, transactional sex and early childbearing, are at risk of poor mental health. In Zimbabwe, girls who are pregnant or new mothers and involved in selling sex struggle to cope with the combined pressures of parenthood, financial insecurity, and social stigma. A pilot intervention brought such girls together into self-help groups to increase peer support, resources and skills.

Objective

This study aimed to explore whether and how participation in a self-help group intervention affected vulnerable young mothers’ experiences and perceptions of mental health stressors.

Methods

Self-help groups received 12 participatory sessions over 6 months. Eighteen semi-structured interviews and three focus group discussions were held with participants and drop-outs. Before and after the intervention, participants completed the locally validated 14-item Shona Symptom Questionnaire tool to indicate the probable prevalence of common mental health disorders.

Results

Adolescent girls described mutually reinforcing stressors in their lives and reported low self-esteem and anxiety. Key themes emerging from qualitative data centred around girls’ struggles with adverse life events, the burden of new motherhood, social isolation related to sex work and self-help groups as a source of hope. Participants joined groups to obtain support and felt their mental well-being improved due to new social networks, feelings of solidarity with peers, and increased confidence for positive action, that is, seeking health services for themselves and their babies. Prior to enrolment 16% showed signs of possible common mental disorders falling to 2% at follow-up.

Conclusions

Participants believed involvement in interactive self-help groups improved their mental health by strengthening peer support and engendering hope for the future. Although reduced mental distress cannot be attributed to the programme, the pilot intervention offers a low-cost approach that could be rigorously tested and adapted to a wide range of community settings.

Impact of Family-Based Economic Empowerment Intervention, Suubi+Adherence (2012-2018) on Multidimensional Poverty for Adolescents Living with HIV (ALWHIV) in Uganda

Children growing up in poverty are disproportionately affected by diseases, including HIV. In this study, we use data from Suubi+Adherence, a longitudinal randomized control trial (2012-2018) with 702 adolescents living with HIV (ALWHIV), to examine the effectiveness of a family-based multifaceted economic empowerment (EE) intervention in addressing economic instability and multidimensional poverty among ALWHIV in Southern Uganda. We constructed a Multidimensional Poverty Index of individual and household indicators, including health, assets, housing and family dynamics. We computed the proportion of multidimensionally poor children (H), estimated poverty intensity (A) and adjusted headcount ratio (M₀). Using repeated measures at five-time points (baseline, years 1, 2, 3 and 4-post baseline) across two study arms: treatment (receiving the EE intervention) vs. control arm (not receiving EE), we find that both the incidence and proportion of multidimensional poverty decreased in the treatment arm vs. the control arm. Given that there is a direct link between economic instability and poor health outcomes, these findings are informative. They point to the potential for family EE interventions to decrease multidimensional poverty among vulnerable children, including ALWHIV, impacting their overall wellbeing and ability to meet their treatment needs and improve HIV care continuum outcomes.

Food Insecurity and Risky Sexual Behaviors among University Students in KwaZulu-Natal, South Africa

Objective: Risky sexual behavior (RSB) is associated with increased rates of sexually transmitted infections (STIs), Human Immunodeficiency Virus (HIV) infection, and unwanted pregnancies among university students. In view of its global impact on public health, the potential association between food insecurity and RSBs among university students requires investigation. This study aimed to determine the association between food security status and the likelihood to engage in RSBs amongst university students in KwaZulu-Natal (KZN), South Africa (SA). Methods: This cross-sectional study was conducted at four public sector higher educational institutions (HEIs) in KZN. A convenience sampling strategy was used to recruit participants (N = 375). All data were analyzed using STATA version 15 software. Results: Our data shows that food insecurity increased the odds of students engaging in transactional sex for "money" or "to meet basic material needs." Participants who were food insecure were two times more likely to have multiple sexual partners. Conclusions: Our findings demonstrate a significant association between food insecurity and RSBs. It is recommended that interventions targeting the alleviation of food insecurity, should be developed and implemented by HEIs to reduce RSB participation.

From a drought to HIV: An analysis of the effect of droughts on transactional sex and sexually transmitted infections in Malawi

Each year there are over 300 natural disasters globally with millions of victims that cost economic losses near USD$100 billion. In the context of climate change, an emerging literature linking extreme weather events to HIV infections suggests that efforts to control the HIV epidemic could be under threat. We used Demographic and Health Survey (DHS) data collected during the 2015-2016 harsh drought that affected several areas of Malawi to provide new evidence on the effect of an unanticipated economic shock on sexual behaviours of young women and men. We find that amongst women employed in agriculture, a six-months drought doubles their likelihood of engaging in transactional sex compared to women who were not affected by the drought and increases their likelihood of having a sexually transmitted infections (STI) by 48% in the past twelve months. Amongst men employed outside of agriculture, drought increases by 50% the likelihood of having a relationship with a woman engaged in transactional sex. These results suggest that women in agriculture experiencing economic shocks as a result of drought use transactional sex with unaffected men, i.e. men employed outside agriculture, as a coping mechanism, exposing themselves to the risk of contracting HIV. The effect was especially observed among non-educated women. A single drought in the last five years increases HIV prevalence in Malawi by around 15% amongst men and women. Overall, the results confirm that weather shocks are important drivers of risky sexual behaviours of young women relying on agriculture in Africa. Further research is needed to investigate the most adequate formal shock-coping strategies to be implemented in order to limit the negative consequences of natural disasters on HIV acquisition and transmission.

"A man without money getting a sexual partner? It doesn't exist in our community": male partners' perspectives on transactional sexual relationships in Uganda and Eswatini

Research on transactional sexual relationships has largely focused on women's perspectives. Better understanding the men's views-especially regarding relationships with adolescent girls and young women-can inform HIV prevention efforts. In 2017, 134 in-depth interviews were conducted with the male partners of girls and young women aged 19-47 years, 94 in Uganda and 40 in Eswatini. Respondents were recruited at venues such as bars where men and potential partners meet and through other young women. Most respondents believed that providing money/gifts was the way to establish relationships with women in their communities, a context that some found undesirable. Young women were mainly perceived as actively pursuing transactional sex for material goods, but respondents also described economically impoverished women who were manipulated into relationships. Men described conflict with longer term partners as a driver to seeking younger partners, who were more compliant. Transaction dominates the male partners of adolescent girls and young women's understanding of sexual relationships, and inequitable power dynamics are reinforced by seeking younger partners. However, some respondents' discontent with this dynamic suggests an opportunity for change. HIV prevention programmes should directly address the underlying drivers of transactional relationships (e.g. gender norms) and work with men who question the practice.

Assessing layered HIV prevention programming: optimizing outcomes for adolescent girls and young women

OBJECTIVE

To assess how exposure to multiple, layered interventions predicts HIV-related outcomes among adolescent girls (15-19 years) and young women (20-24 years) in Kenya.

DESIGN

Survey data from adolescent girls and young women (n = 736) with 14-16 months of engagement with DREAMS, a comprehensive HIV prevention program that provides a range of health education, life skills, social protection, and social and behaviour change interventions.

METHODS

Nonparametric recursive partitioning technique - classification and regression tree (CART) - to identify the best predictors (DREAMS interventions) for achieving the desired HIV-related outcomes (consistent condom use and no transactional sex or sexual violence).

RESULTS

Among adolescent girls, schooling support reduced the likelihood of engaging in transactional sex, whereas schooling support and exposure to parenting program reduced the likelihood experiencing sexual violence. Likelihood of consistent condom use increased among adolescent girls with exposure to preexposure prophylaxis (PrEP), schooling support, and the violence prevention programming. Among young women, multiple pathways reduced the likelihood of engaging in transactional sex: exposure to the male sexual partner program; exposure to the youth fund program; exposure to the violence prevention program; or exposure/engagement with schooling support, parenting programming, and the youth fund program. For young women, consistent condom use increased with schooling support and male partner engagement. Additionally, engagement in violence prevention program and male partner engagement increased the likelihood of not experiencing sexual violence among young women.

CONCLUSION

Exposure to a combination of DREAMS interventions predicted outcomes that can reduce HIV risk among AGYW, though the pathways differed by outcome and age group.

Individual and Relationship-Level Correlates of Transactional Sex Among Adolescent Girls and Young Women in Malawi: A Multilevel Analysis

Transactional sex increases HIV risk among adolescent girls and young women (AGYW). Understanding the individual and dyadic nature of transactional sex may provide evidence for risk reduction interventions. Multilevel logistic regression was used to cross-sectionally examine correlates of transactional sex among AGYW in Lilongwe, Malawi. Participants (N = 920) reported 1227 relationships. Individual-level associations were found between being divorced/widowed (AOR 5.07, 95% CI 1.93, 13.25), married (AOR 0.26, 95% CI 0.09, 0.72), or unstably housed (AOR 7.11, 95% CI 2.74, 18.47) and transactional sex. At the relationship-level, transactional sex occurred in relationships with: non-primary primary partners (AOR 4.06, 95% CI 2.37, 6.94), perceived partner concurrency (AOR 1.85, 95% CI 1.11, 3.08), and feared violence with couples HIV testing (AOR 2.81, 95% CI 1.26, 6.29), and less likely to occur in relationships with children (AOR 0.15, 95% CI 0.06, 0.38). Multiple co-occurring social and structural vulnerabilities increase transactional sex engagement warranting the need for social protection and gender transformative approaches.

Gifting Relationships and School Dropout in Rural Malawi: Examining Differences by Gender and Poverty Level

Research from sub‐Saharan Africa has shown the heightened likelihood of dropping out of school for students in sexual relationships, particularly girls. However, our knowledge is limited as to whether the risk of school dropout is exacerbated by the exchange of gifts in the relationship as well as students’ poverty level. Drawing on longitudinal survey data from rural Malawi, this study explores these questions, examining differences by gender and poverty level in the association between being in a sexual relationship in which gifts are exchanged and school dropout for adolescents in primary school. Our findings show that for both boys and girls, being in a gifting relationship heightens the risk of school dropout and eliminates the protective advantages of being nonpoor on dropout. However, non‐gifting sexual relationships also erase the protective advantage of being nonpoor for girls, but not for boys. These results point to the value of examining poverty–gender interactions to gain a more nuanced understanding of the impact of sexual relationships on adolescent trajectories.

Temporal shifts in HIV-related risk factors among cohorts of adolescent girls and young women enrolled in DREAMS programming: evidence from Kenya, Malawi and Zambia

OBJECTIVES

To assess temporal shifts in HIV risk factors among adolescent girls (AG, aged 15-19 years) and young women (YW, aged 20-24 years) in Kenya, Malawi and Zambia.

DESIGN

Prospective cohorts with two time points (Kenya: 2016/2017, 2018; Malawi: 2017, 2018; Zambia: 2016/2017, 2018) SETTING: Community-based programming.

PARTICIPANTS

1247 AG (Kenya: 389, Malawi: 371, Zambia: 487) and 1628 YW (Kenya: 347, Malawi: 883, Zambia: 398) INTERVENTION: Determined, Resilient, Empowered, AIDS-free, Mentored and Safe (DREAMS), a multisectoral approach to reduce AGYW's HIV vulnerability by delivering a package of tailored, multilayered activities and services.Primary and secondary outcome measures: HIV testing, sexually transmitted infection (STI) symptom experience, number of sexual partners, condom use (consistently, at last sex), transactional sex, experience of physical violence (from intimate partners) and sexual violence (from intimate partners and strangers/non-partners).

RESULTS

Changes in HIV-related risk behaviours among DREAMS participants varied by age group and country. Among AG, HIV testing increased (Kenya and Zambia) and sexual violence from partners (in Kenya and Malawi) and non-partners (in Malawi) decreased. Among YW, HIV testing increased and STI experience decreased in Malawi; consistent condom use decreased in Kenya; transactional sex increased in Kenya and Zambia; and physical violence (in Malawi) and sexual violence from partners (in Kenya and Malawi) and non-partners (all three countries) decreased over time.

CONCLUSIONS

Improvements in HIV testing and reductions in experiences of sexual violence were coupled with variable shifts in HIV-related risk behaviours among DREAMS participants in Kenya, Malawi and Zambia. Additional consideration of AGYW's risk circumstances during key life transitions may be needed to address the risk heterogeneity among AG and YW across different contexts.

Impact of Women's Home Environment on Use of the Dapivirine Vaginal Ring for HIV Prevention in Sub-Saharan Africa

The monthly dapivirine vaginal ring has proven efficacious in reducing HIV incidence in two Phase 3 clinical trials. When considering the potential future availability of the ring to the public, key questions remain about the feasibility of integrating the ring as an HIV prevention intervention into women's lives. We conducted qualitative mapping interviews (n = 66) among women enrolled in MTN-025/HOPE, an open-label trial conducted in Malawi, South Africa, Uganda and Zimbabwe, to examine how home environments influenced use of the dapivirine vaginal ring. Most women had secure places to store their rings including wardrobes, suitcases, and bags. The primary concerns for ring storage were potential tampering from children or rodents. Household overcrowding limited the privacy some women had which made removal and insertion of vaginal rings challenging. Despite these challenges, ring storage, insertion, and removal was feasible across social and living contexts.

Intersections of financial agency, gender dynamics, and HIV risk: A qualitative study with adolescent girls and young women in Zambia

Objectives: Recent research demonstrates that economic interventions may positively effect HIV risk among adolescent girls and young women (AGYW) in sub-Saharan Africa. Some evidence reveals potential associations between financial decision-making and bargaining power in sexual relationships. However, this evidence is mixed, nuanced, and limited. This paper explores how AGYW in Zambia understand financial agency and its effect on intimate relationships. Methods: In-depth qualitative interviews were conducted with 30 females aged 15-24 years residing in Kalingalinga, a low income, high-density residential area in Lusaka. Data were analysed using thematic content analysis. Results: Participants spoke of the ability to earn and spend money as reality for some and aspirational for many others, intrinsic to cultural and religious caveats influencing perceptions of agency for women. The transfer of financial independence to sexual agency within relationships was viewed as a mechanism for HIV risk reduction; however, male sexual privilege was an obstacle irrespective of financial decision-making. Conclusions: Programmes aiming to enhance financial agency for AGYW have the potential to reduce HIV sexual risk. Yet, to be most effective, integration with gender-transformative programmes is needed to address norms of male dominance that keep AGYW in positions of vulnerability.