Structural determinants of adolescent girls’ vulnerability to HIV: Views from community members in Botswana, Malawi, and Mozambique

Advancing Adolescent and Young Adult HIV Prevention and Care and Treatment Through Use of Multi-level Theories and Frameworks: A Scoping Review and Adapted HIV Ecological Framework

While multi-level theories and frameworks have become a cornerstone in broader efforts to address HIV inequities, little is known regarding their application in adolescent and young adult (AYA) HIV research. To address this gap, we conducted a scoping review to assess the use and application of multi-level theories and frameworks in AYA HIV prevention and care and treatment empirical research. We systematically searched five databases for articles published between 2010 and May 2020, screened abstracts, and reviewed eligible full-text articles for inclusion. Of the 5890 citations identified, 1706 underwent full-text review and 88 met the inclusion criteria: 70 focused on HIV prevention, with only 14 on care and treatment, 2 on both HIV prevention and care and treatment, and 2 on HIV-affected AYA. Most authors described the theory-based multi-level framework as informing their data analysis, with only 12 describing it as informing/guiding an intervention. More than seventy different multi-level theories were described, with 38% utilizing socio-ecological models or the eco-developmental theory. Findings were used to inform the adaptation of an AYA World Health Organization multi-level framework specifically to guide AYA HIV research.

Age-disparate and intergenerational sex partnerships and HIV: the role of gender norms among adolescent girls and young women in Malawi

BACKGROUND

Age-mixing (age-disparate [5-9 years difference] and intergenerational [≥ 10 years difference]) partnerships are hypothesized drivers of HIV in adolescent girls and young women (AGYW; 15-24 years). These partnerships are often associated with increased gender inequities which undermine women's agency and assertiveness. We assessed whether age-mixing partnerships were associated with HIV in Malawi and if endorsement of inequitable gender norms modifies this relationship.

METHODS

We analyzed data from the Malawi Population-based HIV Impact Assessment, a nationally representative household survey conducted in 2015-2016. Participants underwent HIV testing and completed questionnaires related to actively endorsed gender norms and sexual risk behavior. We used multivariate logistic regression and multiplicative interaction to assess associations among AGYW who reported the age of their primary sex partner from the last year.

RESULTS

The analysis included 1,958 AGYW (mean age = 19.9 years, SD = 0.1), 459 (23.4%) and 131 (6.7%) of whom reported age-disparate and intergenerational partnerships, respectively. AGYW in age-mixing partnerships accounted for 13% of all AGYW and were older, more likely to reside in urban areas, to be married or cohabitating with a partner, and to have engaged in riskier sexual behavior compared with AGYW in age-concordant partnerships (p < 0.05). HIV prevalence among AGYW in age-disparate and intergenerational partnerships was 6.1% and 11.9%, respectively, compared with 3.2% in age-concordant partnerships (p < 0.001). After adjusting for residence, age, education, employment, wealth quintile, and ever been married or cohabitated as married, AGYW in age-disparate and intergenerational partnerships had 1.9 (95% CI: 1.1-3.5) and 3.4 (95% CI: 1.6-7.2) greater odds of HIV, respectively, compared with AGYW in age-concordant partnerships. Among the 614 (31% of the study group) who endorsed inequitable gender norms, AGYW in age-disparate and intergenerational partnerships had 3.5 (95% CI: 1.1-11.8) and 6.4 (95% CI: 1.5-27.8) greater odds of HIV, respectively, compared with AGYW in age-concordant partnerships.

CONCLUSIONS

In this Malawi general population survey, age-mixing partnerships were associated with increased odds of HIV among AGYW. These findings highlight inequitable gender norms as a potential focus for HIV prevention and could inform interventions targeting structural, cultural, and social constraints of this key group.

"I didn't support PrEP because I didn't know what it was": Inadequate information undermines male partner support for young women's pre-exposure prophylaxis use in western Kenya

The HIV infection rate is higher among adolescent girls and young women (AGYW) in Africa than men in the same age range. Pre-exposure prophylaxis (PrEP) can be used by women discreetly; however, for most AGYW, male partner approval is desired. We explored PrEP use in the context of relationship violence and power dynamics through focus group discussions and support club sessions with AGYW, in-depth interviews and male sensitisation sessions with male partners of AGYW, and joint sessions with AGYW and their male partners. Many male partners reported hesitancy in supporting partner's PrEP use without sufficient information; most of these became supportive following their engagement in study activities; and most preferred participation in decisions around PrEP use. For AGYW, male involvement minimised partner violence around their PrEP use. The findings support the need for correct PrEP information to be provided to male partners of AGYW and to involve them early on, in decision-making about PrEP use. This is likely to improve uptake of and adherence to PrEP.

Development of an Index to Measure the Exposure Level of UN Peacekeeper-Perpetrated Sexual Exploitation/Abuse in Women/Girls in the Democratic Republic of Congo

Sexual exploitation and abuse (SEA) of women and girls by United Nations (UN) peacekeepers is an international concern. However, the typical binary measurement of SEA (indicating that it occurred, or it did not) disregards varying exposure levels and the complex circumstances surrounding the interaction. To address this gap, we constructed an index to quantify the degree to which local women and girls were exposed to UN-peacekeeper perpetrated SEA. Using survey data (n = 2867) from the Democratic Republic of Congo (DRC), eight indicators were identified using a combination of qualitative (thematic analysis of narrative data) and quantitative variables. With further development, this index may offer a more comprehensive and nuanced perspective of peacekeeper-perpetrated SEA that can better inform SEA prevention and intervention efforts.

Associations between Home- and School-Based Violent Experiences and the Development of Sexual Behavior in Young Adolescent Girls in the Rural Southern Region of Malawi

Studies show that adolescent girls who experience violence grow up with fear and develop survival mechanisms that increase their susceptibility to sexually transmitted infections including HIV. However, the relationship between violence and the development of sexual behavior in young adolescent girls is under-investigated. We examined the Malawi Schooling and Adolescent Study data to explore the associations between home- and school-based violence and sexual behaviors in 416 young adolescent girls in rural Southern Malawi. Bivariate Logistic Regression analysis was applied to determine associations. Of 353 (84.9%) girls who had sex with a male partner, 123 (34.8%) experienced home-based violence, and 53 (15%) experienced school-based violence. The odds of girls who experienced home-based violence (OR = 2.46, 95% CI = 1.21, 5.01) and those who first experienced home-based violence between 13 and 14 years (OR = 2.78, 95% CI = 1.35, 5.74) were higher among girls who had multiple sexual partners than those with a single sexual partner. With school-based violence, sexual initiation, having multiple sexual partners, and not using protection were positively associated with experiencing teasing, sexual comments, punching, and touching in private areas in transit to school and by a teacher. These results suggest that home- and school-based violence should be essential components of research and biobehavioral interventions targeting the sexual behaviors of young adolescent girls.

“Alcohol is life, it’s part of us”: Examining the Everyday Experiences of Alcohol Use in Botswana

Efforts to control and regulate alcohol has recently gained steam in Botswana. Inspired by a public health perspective, the government of Botswana has recently increased the alcohol tax levy, reduced the hours of operation for bars and increased penalties for alcohol-related offences to control alcohol-related harm. While these reforms have been central to policymaking, and caused some controversy, not much is known about the everyday experiences of alcohol consumers in Botswana. Drawing from semi-structured interviews (n = 40) collected amongst drinkers over a five-year period, this paper examines the everyday use of alcohol in Botswana. The analysis demonstrates that alcohol use constitutes an important part of leisure and night-time economy (NTE) activities in Botswana. It is a functional social activity that is used by people to take time away from the routines and pressures of daily life. More importantly, it is pleasurable to people, enhances sociability, and partaken as a form of transaction between men and women in bars. There is need for policy makers to consider the embodied experiences of alcohol use when designing alcohol interventions in Botswana.

Stakeholder acceptability of the risk reduction behavioural model [RRBM] as an alternative model for adolescent HIV risk reduction and sexual behavior change in Northern Malawi

We sought to assess stakeholder acceptability of a risk reduction behavioural model [RRBM] designed for adolescent HIV risk reduction and whose efficacy we tested in selected schools in Northern Malawi. We used qualitative procedures in sampling, data collection and data analysis. Our data collection instrument was the semi-structured interview and we applied thematic content analysis to establish stakeholder evaluations of the RRBM model. The study population included10 experts working within key organizations and teachers from two schools. The organizations were sampled as providers, implementers and designers of interventions while schools were sampled as providers and consumers of interventions. Individual study participants were recruited purposively through snowball sampling. Results showed consensus among participants on the acceptability, potential for scale up and likelihood of model sustainability if implemented. In essence areas to consider improving and modifying included: focus on the rural girl child and inclusion of an economic empowerment component to target the underlying root causes of HIV risk taking behavior. Stakeholders also recommended intervention extension to out of school adolescent groups as well as involvement of traditional leaders. Involvement of parents and religious leaders in intervention scale up was also highlighted. The study serves as a benchmark for stakeholder involvement in model and intervention evaluation and as a link between researchers and project implementers, designers as well as policy makers to bridge the research to policy and practice gap.

Feasibility, Acceptability and Preliminary Efficacy of Tikambisane ('Let's Talk to Each Other'): A Pilot Support Group Intervention for Adolescent Girls Living With HIV in Zambia

Background:

In Zambia, 84,959 adolescent girls and young women (AGYW) aged 15-24 are currently living with HIV. We explored the feasibility and acceptability of a 6-session, curriculum-based support group intervention designed to address key concerns of AGYW living with HIV.

Setting:

Urban Zambia

Methods:

Surveys and in-depth interviews were collected pre- and post-intervention from participants enrolled from 2 health facilities. Eight participant observations of sessions were conducted. Descriptive statistics at baseline were reported only for AGYW who participated in the intervention (N = 21), while analyses comparing baseline and endline outcome measures were restricted to participants who had data at both time points (N = 14).

Results:

Support groups were feasible to conduct and acceptable to participants. Co-facilitation by an adult counselor and peers living with HIV raised confidence about session content. Sessions on antiretroviral therapy (ART), disclosure and stigma, and grief and loss were most in demand. We did not observe significant differences in key outcome measures between baseline and follow-up. However, qualitative data supported the positive impact of the intervention on ART adherence and hope for the future following the intervention among our participants.

Conclusion:

A short-term, structured support group series holds promise for helping AGYW living with HIV safely navigate a complex time in their lives.

Adolescent condom use in Southern Africa: narrative systematic review and conceptual model of multilevel barriers and facilitators

BACKGROUND

Adolescent HIV and pregnancy rates in Southern Africa are amongst the highest in the world. Despite decades of sexual and reproductive health (SRH) programming targeting adolescents, recent trends suggest there is a continued need for interventions targeting condom use for this age group.

METHODS

This review synthesises evidence from qualitative studies that describe the determinants of condom use among adolescents in Southern Africa. We conducted systematic searches in four databases. Data were extracted, appraised for quality and analysed using a 'best-fit' framework synthesis approach.

RESULTS

We coded deductively findings from 23 original studies using an a priori framework and subsequently conducted thematic analysis. Synthesised findings produced six key themes relating to: 1) pervasive unequal gender norms and restrictive masculinities favouring male sexual decision-making and stigmatising condom use in committed relationships; 2) other social norms reflecting negative constructions of adolescent sexuality and non-traditional family planning; 3) economic and political barriers including poverty and a lack of policy support for condom use; 4) service-level barriers including a lack of youth-friendly SRH services and comprehensive sex education in schools; 5) interpersonal barriers and facilitators including unequal power dynamics in sexual partnerships, peer influences and encouraging condoning condom use, and inadequate communication about SRH from parents/caregivers; and 6) negative attitudes and beliefs about condoms and condom use among adolescents. A conceptual model was generated to describe determinants of condom use, illustrating individual-, interpersonal- and structural-level barriers and facilitating factors.

CONCLUSION

SRH programming targeting barriers and facilitators of condom use at multiple levels is recommended in Southern Africa. We present a multilevel integrated model of barriers and facilitators to guide adolescent SRH decision-making, programme planning and evaluation. Given the existence of multilevel barriers and facilitators, interventions should, likewise, take a multilevel approach that incorporates locally relevant understanding of the individual-, interpersonal- and structural-level barriers and facilitators to condom use among adolescents in the region.

Characterizing a sexual health and HIV risk stratification scale for sexually active adolescent girls and young women (AGYW) in Tanzania

Adolescent girls and young women (AGYW) aged 15 to 24 years face disproportionately high risks of acquiring HIV and other sexually transmitted infections (STIs). A sexual health risk stratification tool can support the development and implementation of tailored HIV and STI prevention services for sub-groups of at-risk AGYW. Data were collected among sexually active AGYW aged 15 to 24 years in Tanzania between April 2015 and March 2017. Exploratory and confirmatory factor analyses were conducted to construct and assess the latent structure of a ten-item scale for rapid assessment of sexual health risks. Items with high factor loadings and minimal cross loadings were retained in the final scale. Scale performance was appraised against condomless sex (defined as unprotected vaginal or anal intercourse) reported by AGYW for construct validity. A three-factor structure of vulnerability to HIV among AGYW was supported with subscales for socioeconomic vulnerability; lack of adult support; and sexual behavioral risks. The chi-square goodness-of-fit test, root mean square error of approximation, comparative fit index, and Tucker-Lewis index indicated a strong goodness-of-fit of the three-factor scale. Cronbach alphas (0.55 for socioeconomic vulnerability, 0.55 for lack of support, and 0.48 for sexual risk) indicated sub-optimal internal consistency for all sub-scales. The factor-item and factor-factor correlations identified in these analyses were consistent with the conceptual framework of vulnerability of HIV infection in AGYW, suggesting good construct validity. The scale also demonstrated a statistically significant association with condomless sex and could be potentially used for sexual health risk stratification (OR = 1.17, 95% CI: 1.12, 1.23). The sexual health and HIV risk stratification scale demonstrated potential in identifying sexually active AGYW at high risk for HIV and other STIs. Ultimately, all AGYW in Tanzania are not at equal risk for HIV and this scale may support directing resources towards those at highest risk of HIV.

'I married when I was 16… due to poverty, I had no other way': multi-level factors influencing HIV-related sexual risk behaviours among adolescent girls in Zambézia, Mozambique

This paper explores individual, interpersonal- and household-level factors influencing HIV-related sexual risk behaviour among adolescent girls who participated in an intervention to reduce HIV risk in a rural setting in Mozambique. Twenty-eight adolescent girls ages 13-19, 30 heads of household, and 53 influential men participated in in-depth interviews at two time points. Comparative analysis compared girls who reported reducing risk behaviours over time to girls who did not and identified factors that respondents described as influential to behaviour change. Among the twenty girls self-reporting sexual risk at the first time point, half had reduced these behaviours one year later. Changes in girls' behaviours were contingent upon household- and interpersonal-level factors, particularly households' economic stability and family members' financial support. Future interventions with adolescents in similar settings should evaluate and leverage household and family support to achieve sexual risk reduction.

Prevalence and correlates of HIV infection among adolescents and young people living in fishing populations along Lake Victoria Fishing Communities in Uganda

INTRODUCTION

fishing communities in Uganda are key populations for HIV, with persistently higher prevalence and incidence than the general population.

METHODS

between March and August 2014, a cross sectional survey was conducted in 10 fishing communities of Lake Victoria in Uganda. Data was collected on socio-behavioural characteristics using interviewer administered questionnaires and venous blood collected for HIV testing. Prevalent HIV infections among adolescents and young people aged 13 to 24 years was estimated and the factors associated with those infections determined using multi variable logistic regression modelling.

RESULTS

HIV prevalence was 10.8% among the 630 (96.5%) who provided a blood sample. Females were 3.5 times as likely to have HIV infection as males (aOR=3.52, 95% CI: 1.34-9.22). Young people aged 20-24 years were twice as likely to be HIV infected as those aged 13-19 years (aOR=1.77, 95% CI: 0.05-2.10), participants without formal education or those who had studied up to primary level were more likely to be HIV infected than those who had post primary education ((aOR=2.45, 95% CI: 1.19-5.07) or (5.29 (1.35-20.71) respectively). Reporting more than one sexual partner in the past 6 months was associated with HIV prevalent infection than those reporting no sexual partners (aOR=6.44, 95% CI: 1.27-32.83).

CONCLUSION

adolescents and young people aged 13-24 years in fishing communities around Lake Victoria, Uganda, have a high HIV prevalence, with females having a three-fold higher level than males. These findings highlight-the need to improve HIV prevention among young females living in these fishing communities.

The extent of child sexual abuse in Botswana: hidden in plain sight

Introduction

Child Sexual Abuse (CSA) is a worldwide persisting public health problem which has generated interesting discussions within child protection scholarship. Globally as well as in Botswana, CSA estimates prove challenging to establish. This study sought to establish the extent of CSA in Botswana by use of existing data as well as narratives from key informants.

Methods

CSA existing data was extracted from the Botswana police services records and Botswana statistics for the year 2013, 2014, 2015 & 2016. In-depth interviews, semi-structured interviews, were used to collect data from policymakers, child protection practitioners, and caregivers respectively. The study sites were Gaborone city and Letlhakeng village. Qualitative data were analysed using NVivo qualitative data analysis computer software. Whereas the quantitative data I analysed using the excel Microsoft office 365.

Findings

According to CSA existing data, in 2013 defilement among children was 97 (0.2%). Whereas 901 children were reported pregnant in 2013, almost ten times more than defilement cases. In the same year, there was a high number (1058) of children who stayed away from school. Participants' narratives reported CSA to be an escalating problem in Botswana.

Conclusion

The finding that teenage pregnancy statistics are higher than defilement statistics needs further research to categorise and inform child sexual abuse programming in Botswana.

Botswana children's needs: orphans and vulnerable children dominated child welfare system

Children's needs in Botswana received considerable attention in the past three decades owing to the HIV/AIDS epidemic in the country. These decades of legal and policy practice processes focused on orphan and vulnerable children (OVC), ensured that the needs of the general population of Botswana children are grossly understudied, underestimated, and therefore, remain unaddressed. This study sought to determine the needs of the general population of children. Fifty-two visual arts, six semi-structured interviews, twenty-six in-depth interviews and two focus group discussions were conducted in two purposively selected sites with children, policy-makers, practitioners, community leaders and caregivers. The data were analyzed using deductive content analysis approach. Children expressed the need for basic, safety, love and belonging needs. Given some pockets of poverty that exists in Botswana, it is likely that children in the general population have needs similar to those of OVC. Therefore, child welfare program should also target children who are not considered OVC.

Key barriers and enablers associated with uptake and continuation of oral pre-exposure prophylaxis (PrEP) in the public sector in Zimbabwe: Qualitative perspectives of general population clients at high risk for HIV

Background

Understanding the perspectives and preferences of clients eligible for pre-exposure prophylaxis (PrEP) is essential to designing programs that meet clients’ needs. To date, most PrEP programs in limited-resource settings have been implemented by partner organizations for specific target populations, but the government of Zimbabwe aims to make PrEP available to the broader population at substantial risk in public sector clinics. However, there is limited information on general population perspectives about PrEP in Zimbabwe.

Methods

A qualitative study was conducted to explore clients’ motivation to take or decline PrEP and continue or discontinue PrEP. Through a PrEP pilot in one urban family planning clinic and one rural youth center in Zimbabwe, 150 HIV-negative clients screened as being at high risk of HIV and were offered PrEP between January and June 2018. Sixty semi-structured interviews were conducted with clients who agreed to follow-up (including 5 decliners, all from the rural youth center, and 55 accepters, with 42 from the rural youth center and 13 from the urban family planning clinic). Interviews were conducted after either the first or second PrEP follow-up appointment or after the client declined PrEP. Interviews were audio recorded, de-identified, transcribed, and coded thematically.

Results

PrEP uptake was driven by risk perception for HIV, and in many cases, that risk was introduced by the unsafe behavior or HIV-positive status of a partner. Among sero-discordant couples (SDCs), the desire to safely conceive a child was also cited as a factor in taking PrEP. Clients who opted for PrEP preferred it to other forms of HIV prevention. SDCs reported decreased condom use after PrEP initiation and in some cases were using PrEP while trying to conceive a child. After initiating PrEP, clients had more confidence in their sexual relationships and less stress associated with negotiating condom use. Family and partner support was critical to starting and continuing PrEP, but some clients stopped PrEP or missed appointments due to side effects or logistical challenges such as transportation.

Conclusions

Results of this study can be used to provide operational guidance for national public sector roll-out of PrEP as part of combination HIV prevention in Zimbabwe. Based on feedback and experiences of clients, the training materials for health workers can be refined to ensure that health workers are prepared to counsel clients on the decision to start and/or continue PrEP and answer common client questions. Program advertisements should also be targeted with key messages that speak to client experiences.

Trial registration

Clinical Trial Registry Number: PACTR201710002651160.

Preventing HIV and HSV-2 through knowledge and attitudes: A replication study of a multi-component community-based intervention in Zimbabwe

INTRODUCTION

Approximately two-thirds of HIV-infected individuals reside in sub-Saharan Africa. The region accounts for 68% of the new HIV infections occurring worldwide with almost one-half of these infections being among young adults aged 12-24 years. Cowan and colleagues conducted a community-based, multi-component HIV intervention aimed at youth in rural Zimbabwe. Despite some changes in knowledge and attitudes, the community-based intervention did not affect the prevalence of HIV or HSV-2. We selected this frequently cited study for replication since it incorporates individual-, community-, and structural- level intervention components that are often considered in global HIV/AIDS prevention programs. Additionally, the intervention could be easily scaled-up, which is especially important in the context of limited resources. Although this study indicated no intervention effects in reducing HIV, the authors acknowledged some key methodological challenges. Our replication analysis provided important insights regarding the impact of these challenges to the interpretation of the results of this study.

METHODS

Our replication study focused on replicating Cowan's findings and assessing the robustness of Cowan's results to alternative analytical models based on their study design. We determined how out-migration occurring during Cowan's study may have affected the population characteristics, the intervention exposure level, and the study findings. While the original intervention targeted knowledge and attitudes as a mechanism to decrease HIV/HSV-2, the Cowan study evaluated the intervention effects on knowledge, attitudes, and prevalence of HIV or HSV-2 separately. To better identify the pathway describing the interrelationship among the intervention and knowledge, attitudes, and prevalence of HIV or HSV-2, we assessed whether increases in knowledge or attitudes were associated with decreased HIV or HSV-2 prevalence.

RESULTS

We replicated the original findings with minor discrepancies during the pure replication. Our additional analyses revealed that the study population characteristics changed over time in ways that may have affected outcomes. These changes also affected the levels of intervention exposure, with 48.7% males and 75.5% females of the intervention group receiving low-level exposure. Both genders with higher level intervention exposure experienced higher increments in multiple knowledge, attitude, and sexual risk behavior outcomes. Unfortunately, these did not translate to a significant reduction in HIV or HSV-2 regardless of the level and combination of knowledge and attitude domains. However, males receiving high-level intervention exposure compared to control indicated significantly lower odds of having HIV or HSV-2 under a Bayesian modeling paradigm.

CONCLUSIONS

Our findings suggest a more robust conclusion on the study intervention effects. Further study based on a design that more consistently maximizes the exposure level of the intervention is necessary and should ideally be an evaluated goal in similar studies. Evaluation of the intervention impact for key subgroups of the target population is important and would better advise the use and scale-up of the evaluated interventions in various contexts. Our observation of a consistent lack of relationship between knowledge/attitudes and HIV/HSV-2 suggests a need to explore and include relevant additional and or complementary interventions, e.g., promoting effective skills in reducing risky sexual behaviors and addressing cultural and structural bottlenecks that may reduce HIV/HSV-2 risk among youth.

A longitudinal qualitative evaluation of an economic and social empowerment intervention to reduce girls' vulnerability to HIV in rural Mozambique

PURPOSE

An intervention including business training and health education was implemented in Mozambique, where girls are at elevated risk for acquiring HIV. As part of a mixed-methods evaluation, we describe perceived effects of the intervention on girls' sexual behavior and school attendance.

METHODS

We conducted 49 in-depth interviews (IDIs) with girl intervention participants (ages 13-19), 24 IDIs with heads of girls' households, 36 IDIs with influential males identified by girls, and 12 focus group discussions with community members after the intervention ended and one year later.

RESULTS

Informants said the primary intervention benefit was realized when girls had money to stay in or return to school and/or to buy necessities for themselves and their households-reducing their need for transactional or intergenerational sex. However, some girls did not make a profit and some businesses were not sustainable. Sometimes the intervention appeared to be implemented in a way to reinforce inequitable gender norms resulting in some girls feeling shame when they reengaged in risky sex after their businesses failed.

CONCLUSIONS

Earning money enabled girls to potentially reduce their vulnerability to HIV. We offer recommendations for future multi-sector interventions, including the need to address potential harms in programs serving vulnerable girls.

Quasi-experimental evaluation using confirmatory procedures: A case study of an economic and social empowerment intervention to reduce girls' vulnerability to HIV in rural Mozambique

PURPOSE

Our goal was to determine whether an economic and social empowerment intervention implemented in Zambézia Province, Mozambique reduced girls' vulnerability to HIV. We use this experience to discuss challenges of evaluating real-world interventions.

METHODS

Two rounds of data were collected from 885 girls, 13-19 years, for this clustered, non-equivalent (two-stage) cohort trial. We used multi-level exact matching and difference-in-differences estimation to estimate intervention effects on two outcomes: girls' knowledge of gender-based violence and school attendance.

RESULTS

Estimates of two outcomes analysed indicated no statistically significant intervention effects. Preliminary analysis of data from the intervention group revealed this study was unable to obtain accurate measures for five outcomes related to HIV vulnerability.

CONCLUSIONS

Although our study did not find evidence of impact on the a priori selected outcomes, we report on our experience implementing this robust methodologic design and describe how the challenges encountered in this program setting affected our ability to attain results. We recommend prospective evaluation designs with random allocation be accommodated early during planning. When not possible, quasi-experimental studies should collect data from large samples. To reduce measurement bias, biological endpoints such sexually transmitted infections should serve as primary outcomes for programs intending to reduce sexual behaviors.

Narrating the Transition to Adulthood for Youth in Uganda: Leaving School, Mobility, Risky Occupations, and HIV

School enrollment, mobility, and occupation are each important factors to consider when examining HIV (human immunodeficiency virus) infection risk among youth in sub-Saharan Africa. Through an analysis of narrative life histories from 30 HIV-positive and 30 HIV-negative youth (aged 15-24 years), matched on gender, age, and village and purposively selected and interviewed from the Rakai Community Cohort Study, this article shows the complex connection between leaving school, mobility, and occupation with implications for HIV risk. We identified a pattern of risk factors that was present in many more HIV-positive than HIV-negative youth life stories. These HIV-positive youth shared a similar pathway during their transition to adulthood: After leaving school, they moved in search of occupations; they then engaged in risky occupations before eventually returning to their home village. Linking the lines of inquiry on school enrollment, mobility, and risky occupations, our findings have important implications for adolescent health research, practice, and policy in Uganda and across sub-Saharan Africa and the developing world.

Clustered risk: An ecological understanding of sexual activity among adolescent boys and girls in two urban slums in Monrovia, Liberia

Many young people experience sexual debut before they are able to manage risk in order to avoid adverse consequences. Gender norms, social position, and power can undermine an adolescent's ability to exercise agency in their first sexual encounters and negotiate safer sexual behavior. This study examines the intersection of psychosocial and interpersonal factors with the social and physical environment to form an ecological understanding of how the determinants that shape sexual activity differ between boys and girls in two urban slums in Monrovia, Liberia. This study focuses on three different levels: 1) intrapersonal and psychosocial factors, 2) the role of the family and other interpersonal relationships, and 3) the overall community structure. Fifty-three adolescents aged 15-17 years (27 males and 26 females) were recruited to participate in a concept mapping exercise. Concept mapping is a participatory research method that uses both qualitative and quantitative approaches through 1) group discussion, 2) brainstorming, 3) sorting factors into meaningful clusters, and 4) interpretation of the results to create a visual map. Cluster maps include both positive and negative factors that participants believe to influence adolescent sexual activity in their communities, including parental pressure, transactional sex, family status, goals and aspirations, and poverty. The influence of these factors diverged according to participant gender. Participants described how psychosocial, interpersonal, family, and community factors interact with economic and social forces to influence their sexual experience and combine to exacerbate the prevalence of transactional and forced sex. The results highlight the need for multi-level interventions to shape adolescent sexual and reproductive health in positive, rather than harmful, ways.

Effects of adolescent exposure to behaviour change interventions on their HIV risk reduction in Northern Malawi: a situation analysis

Understanding adolescents’ translation of HIV and AIDS-related behaviour change interventions (BCI) knowledge and skills into expected behavioural outcomes helps us appreciate behaviour change dynamics among young people and informs evidence-based programming. We explored the effects of adolescents’ exposure to BCI on their HIV risk reduction in selected schools in Nkhatabay and Mzimba districts and Mzuzu city in Northern Malawi. The study used questionnaires as instruments. Data were collected between January and April 2017. Adolescent boys and girls [n = 552], ages 11–19 were randomly sampled to participate. Data analysis was through multiple regression and content analysis. Respondents included 324 female [58.7%] and 228 male [41.3%]. Multiple regression analysis indicated that exposure to BCI did not affect risk reduction in the study area. The best stepwise model isolated sexual experience ([Beta = .727, p = .0001, p < .05]) as having the strongest correlation with the dependent variable – risk reduction. BCI exposure was stepwise excluded ([Beta = −.082, p = .053, p > .05]). There was therefore no evidence against the null hypothesis of no relationship between adolescent exposure to BCI and their HIV risk reduction. Overall there was limited BCI knowledge and skills translation to behavioural risk reduction. The study points to the need to evaluate and redesign adolescent BCI in line with current behavioural dynamics among young people in Malawi. The findings have been used to inform the design and programming of a model to be tested for feasibility through a quasi-experiment in the second phase of our project.

"Too Much Sex and Alcohol": Beliefs, Attitudes, and Behaviors of Male Adolescents and Young Men Who have Sex with Men in Ghana

Background

Research suggests that men who have sex with men (MSM) often engage in high-risk sex and use illicit substances.

Objective

To increase understanding of HIV knowledge and vulnerability among adolescent and young adult MSM, with a focus on alcohol and drug use and transactional sex.

Methods

We conducted in-depth interviews and Focus Group Discussions (FGDs) with adolescent (aged 15-17 years) and young adult (aged 18-29 years) MSM in Kumasi, Ghana. MSM who reported recent alcohol and/or substance use or engagement in transactional sex were eligible. Questions covered HIV-related knowledge, experiences with substance-use and transactional sex, and attitudes regarding sexual risk-taking and HIV-related services. Data were analyzed thematically using NVivo 10.0 software.

Results

Ninety-nine MSM participated in 44 interviews and 8 FGDs. Most were attending or had completed secondary school. HIV knowledge was high, but with major gaps. Most consumed alcohol; one-fourth used drugs. Alcohol and substances were consumed to enhance pleasure during sex with another man. Transactional sex was common and positively viewed. Half of the participants used condoms inconsistently or never, and self-perceived HIV risk was high. Nearly half faced stigma-related barriers to accessing HIV-related services.

Conclusion

As Ghana strives to achieve the UNAIDS's 90-90-90 global targets (90% of people living with HIV know their status, 90% who know their status are on sustained treatment, and 90% of those on treatment are virally suppressed), we recommend enhancing MSM-targeted prevention programs, improving care options, and increasing use of critical clinical HIV-services by ensuring that MSM receive unbiased, confidential care.

Food insecurity, sexual risk taking, and sexual victimization in Ghanaian adolescents and young South African adults

OBJECTIVES

The objectives of this study were to examine whether food insecurity is associated with sexual risk taking and victimization in young people (aged 16-24); and to investigate whether the relationship of food insecurity with sexual risk taking and victimization is moderated by gender.

METHODS

Cross-sectional data were obtained in 2014 from a sample of Ghanaian adolescents (n = 773) and in 2015 from young South African adults (n = 823). We used multilevel logistic regression given the study's binary outcome and clustered data. We tested a moderation effect of gender by including an interaction between gender and food insecurity.

RESULTS

Food insecurity was highly prevalent (72% in Ghana and 83% in South Africa). Food insecurity was significantly associated with unwanted sexual contact among Ghanaian adolescents (OR 1.05, 95% CI 1.02, 1.08) and age-disparate sex among young South African adults (OR 1.03, 95% CI 1.00, 1.06). Results indicated no moderating effect of gender.

CONCLUSIONS

Our findings underscore the importance of food access on young people's sexual health, regardless of gender. Prevention efforts may be more relevant when integrated with food security interventions that target vulnerable adolescents and young adults, irrespective of gender.

HIV/AIDS National Strategic Plans of Sub-Saharan African countries: an analysis for gender equality and sex-disaggregated HIV targets

National Strategic Plans (NSPs) for HIV/AIDS are country planning documents that set priorities for programmes and services, including a set of targets to quantify progress toward national and international goals. The inclusion of sex-disaggregated targets and targets to combat gender inequality is important given the high disease burden among young women and adolescent girls in Sub-Saharan Africa, yet no comprehensive gender-focused analysis of NSP targets has been performed. This analysis quantitatively evaluates national HIV targets, included in NSPs from eighteen Sub-Saharan African countries, for sex-disaggregation. Additionally, NSP targets aimed at reducing gender-based inequality in health outcomes are compiled and inductively coded to report common themes. On average, in the eighteen countries included in this analysis, 31% of NSP targets include sex-disaggregation (range 0–92%). Three countries disaggregated a majority (>50%) of their targets by sex. Sex-disaggregation in data reporting was more common for targets related to the early phases of the HIV care continuum: 83% of countries included any sex-disaggregated targets for HIV prevention, 56% for testing and linkage to care, 22% for improving antiretroviral treatment coverage, and 11% for retention in treatment. The most common target to reduce gender inequality was to prevent gender-based violence (present in 50% of countries). Other commonly incorporated target areas related to improving women’s access to family planning, human and legal rights, and decision-making power. The inclusion of sex-disaggregated targets in national planning is vital to ensure that programmes make progress for all population groups. Improving the availability and quality of indicators to measure gender inequality, as well as evaluating programme outcomes by sex, is critical to tracking this progress. This analysis reveals an urgent need to set specific and separate targets for men and women in order to achieve an equitable and effective HIV response and align government planning with international priorities for gender equality.

Socio-demographic, Marital, and Psychosocial Factors Associated with Condom Use Negotiation Self-Efficacy Among Mozambican Women at Risk for HIV Infection

PURPOSE

In Mozambique, women are the most affected by HIV/AIDS. Self-efficacy is one of the main predictors of effective use of a condom. Therefore, it is essential to identify the factors that influence condom-use negotiation self-efficacy in vulnerable women. The aim of this paper is to identify socio-demographic, marital, and psychosocial factors associated with condom-use negotiation self-efficacy among Mozambican women at risk for HIV infection.

METHODS

Participants were women (173) who were patients at the Gynecology Department of the Central Hospital of Beira, Mozambique, and at risk for HIV infection. Women completed measures of condom-use negotiation self-efficacy, HIV prevention knowledge, and perceived barriers against safer sex.

RESULTS

The results showed that demographic and marital variables are associated with condom-use negotiation self-efficacy, namely, those having more than 9 years of education, who are younger and not living with a partner, and who talk about AIDS with partners report higher condom-use negotiation self-efficacy. Regarding psychosocial factors, higher HIV prevention knowledge and fewer perceived barriers to safer sex predict higher condom-use negotiation self-efficacy.

CONCLUSION

These results can contribute to sexual health promotion and HIV/AIDS prevention in Mozambican women because they identify at-risk groups and marital and psychosocial malleable factors that can be targeted in AIDS prevention among at-risk Mozambican women.

Economic Context and HIV Vulnerability in Adolescents and Young Adults Living in Urban Slums in Kenya: A Qualitative Analysis Based on Scarcity Theory

Urban slum adolescents and young adults have disproportionately high rates of HIV compared to rural and non-slum urban youth. Yet, few studies have examined youth's perceptions of the economic drivers of HIV. Informed by traditional and behavioral economics, we applied a scarcity theoretical framework to qualitatively examine how poverty influences sexual risk behaviors among adolescents and young adults. Focus group discussions with one hundred twenty youth in Kenyan's urban slums were transcribed, coded, and analyzed using interpretive phenomenology. Results indicated that slum youth made many sexual decisions considered rational from a traditional economics perspective, such as acquiring more sex when resources were available, maximizing wealth through sex, being price-sensitive to costs of condoms or testing services, and taking more risks when protected from adverse sexual consequences. Youth's engagement in sexual risk behaviors was also motivated by scarcity phenomena explained by behavioral economics, such as compensating for sex lost during scarce periods (risk-seeking), valuing economic gains over HIV risks (tunneling, bandwidth tax), and transacting sex as an investment strategy (internal referencing). When scarcity was alleviated, young women additionally described reducing the number of sex partners to account for non-economic preferences (slack). Prevention strategies should address the traditional and behavioral economics of the HIV epidemic.

The Incidence Patterns Model to Estimate the Distribution of New HIV Infections in Sub-Saharan Africa: Development and Validation of a Mathematical Model

BACKGROUND

Programmatic planning in HIV requires estimates of the distribution of new HIV infections according to identifiable characteristics of individuals. In sub-Saharan Africa, robust routine data sources and historical epidemiological observations are available to inform and validate such estimates.

METHODS AND FINDINGS

We developed a predictive model, the Incidence Patterns Model (IPM), representing populations according to factors that have been demonstrated to be strongly associated with HIV acquisition risk: gender, marital/sexual activity status, geographic location, "key populations" based on risk behaviours (sex work, injecting drug use, and male-to-male sex), HIV and ART status within married or cohabiting unions, and circumcision status. The IPM estimates the distribution of new infections acquired by group based on these factors within a Bayesian framework accounting for regional prior information on demographic and epidemiological characteristics from trials or observational studies. We validated and trained the model against direct observations of HIV incidence by group in seven rounds of cohort data from four studies ("sites") conducted in Manicaland, Zimbabwe; Rakai, Uganda; Karonga, Malawi; and Kisesa, Tanzania. The IPM performed well, with the projections' credible intervals for the proportion of new infections per group overlapping the data's confidence intervals for all groups in all rounds of data. In terms of geographical distribution, the projections' credible intervals overlapped the confidence intervals for four out of seven rounds, which were used as proxies for administrative divisions in a country. We assessed model performance after internal training (within one site) and external training (between sites) by comparing mean posterior log-likelihoods and used the best model to estimate the distribution of HIV incidence in six countries (Gabon, Kenya, Malawi, Rwanda, Swaziland, and Zambia) in the region. We subsequently inferred the potential contribution of each group to transmission using a simple model that builds on the results from the IPM and makes further assumptions about sexual mixing patterns and transmission rates. In all countries except Swaziland, individuals in unions were the single group contributing to the largest proportion of new infections acquired (39%-77%), followed by never married women and men. Female sex workers accounted for a large proportion of new infections (5%-16%) compared to their population size. Individuals in unions were also the single largest contributor to the proportion of infections transmitted (35%-62%), followed by key populations and previously married men and women. Swaziland exhibited different incidence patterns, with never married men and women accounting for over 65% of new infections acquired and also contributing to a large proportion of infections transmitted (up to 56%). Between- and within-country variations indicated different incidence patterns in specific settings.

CONCLUSIONS

It is possible to reliably predict the distribution of new HIV infections acquired using data routinely available in many countries in the sub-Saharan African region with a single relatively simple mathematical model. This tool would complement more specific analyses to guide resource allocation, data collection, and programme planning.

Effectiveness of Community Dialogue in Changing Gender and Sexual Norms for HIV Prevention: Evaluation of the Tchova Tchova Program in Mozambique

Structural HIV prevention interventions have gained prominence as ways to address underlying social and cultural factors that fuel the HIV epidemic. Identifying theories that explain how structural interventions are expected to change such factors can substantially increase their success. The Tchova Tchova community dialogue program, a theory-based intervention implemented in 2009-2010 in the provinces of Zambezia and Sofala, Mozambique, aimed to change gender and sexual norms for HIV prevention. Through facilitated sessions, the program sparked critical thinking and open dialogue among participants. This article measures the program's effectiveness based on a sample of 462 participants and 453 nonparticipants. The results show that the program was successful in producing changes in three of the underlying structural factors of HIV: gender attitudes, gender roles, and HIV stigma. The program was also successful in changing other factors associated with HIV infection, including HIV prevention knowledge, discussion of HIV between sex partners, and having multiple sex partners.

VULNERABILIDADES DE GÊNERO, PRÁTICAS CULTURAIS E INFECÇÃO PELO HIV EM MAPUTO

RESUMOA construção social do gênero feminino em Moçambique está baseada na submissão ao homem, influenciando a vulnerabilidade de gênero à infecção pelo HIV. Objetivou-se analisar a percepção de pessoas vivendo com HIV/aids (PVHA) e de profissionais de saúde (PS), da cidade de Maputo, em relação à vulnerabilidade de gênero e infecção pelo HIV. Participaram 33 PVHA e 15 PS, selecionados por conveniência, mediante a realização de grupos focais e de entrevistas semiestruturadas. Dois eixos temáticos nortearam a análise: vulnerabilidade de gênero e práticas culturais tradicionais. A análise de conteúdo dos relatos verbais permitiu concluir que a vulnerabilidade feminina é maior, segundo a quase totalidade dos participantes, delineando categorias como submissão da mulher, dificuldade para negociar o uso do preservativo e influência das práticas culturais. O estudo possibilitou compreender melhor o contexto de vulnerabilidades que afetam cidadãos de Maputo, em especial as mulheres, em um país de prevalência elevada da epidemia.

Multilevel Analysis of Childbearing in Childhood in Tanzania's Rufiji District

OBJECTIVES

To examine levels, trends and correlates of childbearing in childhood (CiC) in the Rufiji district of Tanzania from 2002 to 2010.

METHODS

Using longitudinal data collected in, and by, the Rufiji health and demographic surveillance system in Tanzania from 2002 to 2010, all women who initiated childbearing in this period (n = 5491) were selected for analysis. CiC was defined as childbearing initiation before age 18. Data analysis involved one-way tabulations of each variable-most of which were socio-demographic-to obtain frequency distributions, cross-tabulations of CiC and each of the independent variables with a Chi square test for associations, and multivariate analysis using multilevel logistic regression to examine covariates of CiC.

RESULTS

CiC was 44 % and remained constant over the 2002-2010 period (P = 0.623). The relative odds of CiC was significantly reduced by 83 percent among women with secondary or higher educational attainment relative to CiC among uneducated women (OR = 0.17, CI 0.12-0.23). Moreover, the odds of CiC significantly declines monotonically as relative household wealth increases by quintile (OR = 0.70, CI 0.57-0.86). CiC also declines significantly with employment and marital status of the respondent.

CONCLUSIONS

CiC represents a challenging social and health problem. Forty-four percent of first time mothers in Rufiji district of Tanzania are of childhood age, and this has not changed over the past 9 years since 2002. Prioritizing girls' formal education-especially up to secondary level or higher-as well as devising some economic empowerment modalities, may be worthwhile measures towards curbing CiC in the study area.

Inequalities in addressing the HIV epidemic: the story of the Indonesian Ojek community

Purpose

– The purpose of this paper is to identify the potential socio-cultural determinants contributing to inequalities and the susceptibility of the Ojek to Human Immunodeficiency Virus (HIV) infection.

Design/methodology/approach

– In 2010 a qualitative enquiry was employed to collect data concerning the susceptibility of the Ojek to HIV infection. Both one-on-one open-ended in-depth interviews and focus group discussions were employed. Participants included Ojek (hired motorcycle drivers), religious and community leaders, staff from the HIV/Acquired Immune Deficiency Syndrome (AIDS) Commission of Belu and staff from two HIV/AIDS non-governmental organisations. A thematic analysis and a framework approach were used to analyse the data.

Findings

– The findings showed four socio-cultural determinants of susceptibility to HIV infection within the Ojek community. These included: first, mobility and migration; second, patterns of sexual behaviours, sexual networks and sexual incentives; third, cultural norms and social interactions; and fourth, the lack of resources, knowledge and awareness of HIV/AIDS. Underpinned by these factors, the main determinant of HIV susceptibility for the Ojek is an individual’s engagement in sexual intercourse with multiple sex partners, including female commercial sex workers (FCSWs).

Social implications

– There is a need to disseminate HIV/AIDS information and education throughout the Ojek communities, and to engage the general population in the promotion of sexual behavioural change among the Ojek in Belu. Empowerment strategies should also be employed to empower the general community, the Ojek and FCSWs in order to address HIV/AIDS transmission.

Originality/value

– This paper provides evidence of the socio-cultural determinants of HIV inequalities within the Ojek community in Indonesia. An understanding of these determinants would enable the planning, implementation and application of a holistic approach addressing the determinants of HIV in Belu and other similar settings. Additionally, knowledge of such determinants would provide an understanding of the role of inter-sectoral collaboration and community participation in tackling the susceptibility to HIV infection within the Ojek community.

Rethinking HIV prevention to prepare for oral PrEP implementation for young African women

INTRODUCTION

HIV incidence remains high among young women in sub-Saharan Africa in spite of scale-up of HIV testing, behavioural interventions, antiretroviral treatment and medical male circumcision. There is a critical need to critique past approaches and learn about the most effective implementation of evidence-based HIV prevention strategies, particularly emerging interventions such as pre-exposure prophylaxis (PrEP).

DISCUSSION

Women in sub-Saharan Africa are at increased risk of HIV during adolescence and into their 20s, in part due to contextual factors including gender norms and relationship dynamics, and limited access to reproductive and sexual health services. We reviewed behavioural, behavioural economic and biomedical approaches to HIV prevention for young African women, with a particular focus on the barriers, opportunities and implications for implementing PrEP in this group. Behavioural interventions have had limited impact in part due to not effectively addressing the context, broader sexual norms and expectations, and structural factors that increase risk and vulnerability. Of biomedical HIV prevention strategies that have been tested, daily oral PrEP has the greatest evidence for protection, although adherence was low in two placebo-controlled trials in young African women. Given high efficacy and effectiveness in other populations, demonstration projects of open-label PrEP in young African women are needed to determine the most effective delivery models and whether women at substantial risk are motivated and able to use oral PrEP with sufficient adherence to achieve HIV prevention benefits.

CONCLUSIONS

Social marketing, adherence support and behavioural economic interventions should be evaluated as part of PrEP demonstration projects among young African women in terms of their effectiveness in increasing demand and optimizing uptake and effective use of PrEP. Lessons learned through evaluations of implementation strategies for delivering oral PrEP, a first-generation biomedical HIV prevention product, will inform development of new and less user-dependent PrEP formulations and delivery of an expanding choice of prevention options in HIV prevention programmes for young African women.

Risky sexual behaviors among female youth in Tiss Abay, a semi-urban area of the Amhara Region, Ethiopia

BACKGROUND

Little is known about sexual risks and associated factors about female youths in semi-urban areas of Ethiopia. This study aimed to describe the nature and magnitude of risky sexual behaviors, and the socio-demographic and behavioral determinants among female youths in Tiss Abay, a semi-urban area on the outskirts of Bahir Dar City of the Amhara Region in northern Ethiopia.

METHODS

A cross-sectional census type study was conducted among female youths who were unmarried and aged 15-29 years in September 2011.

RESULTS

711 female youths participated in the study, with the mean age of initiation of sex of 78.6% being16.73±2.53 years. Only 52(9.3%) used condom during the first sex. Within the last 12 months, 509(71.6%) had sexual intercourse and 278(54.6%) had two or more sex partners, and 316(62.1%) did not use condom during their last sex. Sex under the influence of substances was reported by 350(68.8%), and a third of the recent sexes were against the will of participants. One or more risky sexual practices were reported by 503(70.3%) participants, including: multiple sexual partnerships, inconsistently using or not using condoms, sex under the influence of alcohol and/or sex immediately after watching pornography. Age group, current marital status, drinking homemade alcohol, chewing 'khat', watching pornography and using any form of stimulant substances were the predictors of risky sexual behavior. Watching pornography before sex and sex for transaction were the predicators of not using condom during most recent sex.

CONCLUSIONS

Risky sexual behaviors were very common among the female youths in Tiss Abay. Initiation of context-based interventions, such as raising awareness about the risks, safer sex practices, condom promotion and integration of gender issues in the programs are recommended.

Programa Geração Biz, Mozambique: how did this adolescent health initiative grow from a pilot to a national programme, and what did it achieve?

Adolescent sexual and reproductive health gained particular traction in Mozambique following the 1994 International Conference on Population and Development leading to the inception of Programa Geração Biz (PGB), a multi-sectoral initiative that was piloted starting in 1999 and fully scaled-up to all provinces by 2007. We conducted a systematic review of the literature to gather information on PGB and analyzed how it planned and managed the scale-up effort using the WHO-ExpandNet framework. PGB’s activities comprised a clear and credible innovation. Appropriate resource and user organizations further facilitated national scale-up. Challenges relating to the complex nature of the multi-sectoral approach and resistance due to norms about adolescent sexual and reproductive health hindered scaling-up in some geographic areas. The national government exhibited commitment and ownership to PGB through budgetary support and integration into multiple policies. This study adds to the documentation of successful scaling-up strategies that can provide guidance for policy makers and programme managers.

Predictors of sexual risk behaviour among adolescents from welfare institutions in Malaysia: a cross sectional study

BACKGROUND

In welfare institutions, it is essential to address the health-related needs of adolescent populations who often engage in sexual activities. This study examines the association between individual and interpersonal factors concerning sexual risk behaviour (SRB) among adolescents in welfare institutions in Malaysia.

METHODS

Data were derived from a cross-sectional study of 1082 adolescents in 22 welfare institutions located across Peninsular Malaysia in 2009. Using supervised self-administered questionnaires, adolescents were asked to assess their self-esteem and to complete questions on pubertal onset, substance use, family structure, family connectedness, parental monitoring, and peer pressure. SRB was measured through scoring of five items: sexual initiation, age of sexual debut, number of sexual partners, condom use, and sex with high-risk partners. Multivariate logistic regression analysis was used to examine the various predictors of sexual risk behaviour.

RESULTS

The study showed that 55.1% (95%CI = 52.0-58.2) of the total sample was observed to practice sexual risk behaviours. Smoking was the strongest predictor of SRB among male adolescents (OR = 10.3, 95%CI = 1.25-83.9). Among females, high family connectedness (OR = 3.13, 95%CI = 1.64-5.95) seemed to predict the behaviour.

CONCLUSION

There were clear gender differences in predicting SRB. Thus, a gender-specific sexual and reproductive health intervention for institutionalised adolescents is recommended.

Strengthening nonrandomized studies of health communication strategies for HIV prevention

BACKGROUND

There is growing interest in impact evaluations of health communication (HC) interventions for HIV prevention. Although cluster randomized trials may be optimal in terms of internal validity, they are often unfeasible for political, practical, or ethical reasons. However, a common alternative, the observational study of individuals who do and do not self-report HC intervention exposure, is prone to bias by confounding. Cluster-level quasi-experimental study designs offer promising alternatives to these extremes.

METHODS

We identified common rollout strategies for HC initiatives. We mapped these scenarios against established quasi-experimental evaluation designs. We identified key issues for implementers and evaluators if these designs are to be more frequently adopted in HC intervention evaluations with high internal validity.

RESULTS

Stronger evaluations will document the planned intervention components in advance of delivery and will implement interventions in clusters according to a predefined systematic allocation plan. We identify 4 types of allocation plan and their associated designs. Where some places get the HC intervention, whereas others do not, a nonrandomized controlled study may be feasible. Where HC is introduced everywhere at a defined point in time, an interrupted time series may be appropriate. Where the HC intervention is introduced in phases, a nonrandomized phased implementation or stepped-wedge design may be used. Finally, where there is variation in strength of implementation of HC, a nonrandomized, dose-response study can be planned.

DISCUSSION

Our framework will assist teams planning such evaluations by identifying critical decisions for the implementers and for the evaluators of HC interventions.

Role of community-level factors across the treatment cascade: a critical review

Addressing community-level factors (CLFs) is integral to the ongoing effort to design multilevel, effective, and sustainable interventions to address each element of the HIV/AIDS treatment cascade. This review, the first critical review of this topic, identified 100 articles that (1) assessed CLFs in relation to the HIV/AIDS treatment cascade, (2) had been peer-reviewed, and (3) were based on studies conducted in low- or middle-income countries. Social support and social networks, cultural norms, gender norms, and stigma were the key CLFs associated with treatment and care. This extensive review found only 5 evaluations of interventions designed to affect CLFs, reflecting a major gap in the literature. All were communication interventions designed to create a more positive environment for HIV testing and access to treatment and care, thus pointing to some of the potential extraindividual effects of communication interventions. The qualitative data are rich and vital for understanding the context; yet, more quantitative analysis to provide evidence regarding the distribution of these factors is essential, as only 19 of the studies were quantitative. There is a pressing need to (1) collect community-level data, (2) validate social and gender norm scales, and (3) better use available data regarding social norms, gender norms, and other CLFs. These data could be aggregated at the cluster, neighborhood, or community levels and incorporated into multilevel analysis to help clarify the pathways to enhanced outcomes across the treatment cascade and thereby mitigate HIV sequelae.

Co-occurring psychosocial problems and HIV risk among women attending drinking venues in a South African township: a syndemic approach

BACKGROUND

In South Africa, women comprise the majority of HIV infections. Syndemics, or co-occurring epidemics and risk factors, have been applied in understanding HIV risk among marginalized groups.

PURPOSE

The purposes of this study are to apply the syndemic framework to examine psychosocial problems that co-occur among women attending drinking venues in South Africa and to test how the co-occurrence of these problems may exacerbate risk for HIV infection.

METHOD

Five hundred sixty women from a Cape Town township provided data on multiple psychosocial problems, including food insufficiency, depression, abuse experiences, problem drinking, and sexual behaviors.

RESULTS

Bivariate associations among the syndemic factors showed a high degree of co-occurrence and regression analyses showed an additive effect of psychosocial problems on HIV risk behaviors.

CONCLUSIONS

These results demonstrate the utility of a syndemic framework to understand co-occurring psychosocial problems among women in South Africa. HIV prevention interventions should consider the compounding effects of psychosocial problems among women.

Gendered norms, sexual exploitation and adolescent pregnancy in rural Tanzania

Adolescent pregnancy places girls at increased risk for poor health and educational outcomes that limit livelihood options, economic independence, and empowerment in adulthood. In Tanzania, adolescent pregnancy remains a significant concern, with over half of all first births occurring before women reach the age of 20. A participatory research and action project (Vitu Newala) conducted formative research in a rural district on the dynamics of sexual risk and agency among 82 girls aged 12-17. Four major risk factors undermined girls' ability to protect their own health and well-being: poverty that pushed them into having sex to meet basic needs, sexual expectations on the part of older men and boys their age, rape and coercive sex (including sexual abuse from an early age), and unintended pregnancy. Transactional sex with older men was one of the few available sources of income that allowed adolescent girls to meet their basic needs, making this a common choice for many girls, even though it increased the risk of unintended (early) pregnancy. Yet parents and adult community members blamed the girls alone for putting themselves at risk. These findings were used to inform a pilot project aimed to engage and empower adolescent girls and boys as agents of change to influence powerful gender norms that perpetuate girls' risk.

Factors associated with the utilization of maternal health care services among adolescent women in Malawi

The poor maternal health care service utilization among adolescent women remains an intimidating challenge in Malawi. This study examines the factors associated with the utilization of selected maternal health care services among married adolescent women (aged 15-19 years) using data from the Malawi Demographic and Health Survey, 2010. Maternal age, household economic status, and status of the child were found to be significant factors associated with at least four antenatal care visits; whereas personal barriers, birth order and interval, religion, and ethnic group explain the variation in the utilization of postnatal care within 42 days of delivery.

Reducing HIV and AIDS in adolescents: opportunities and challenges

Adolescents are critical to efforts to end the AIDS epidemic. Few national AIDS strategies explicitly program for children in their second decade of life. Adolescents (aged 10-19 years) are therefore largely invisible in global, regional, and country HIV and AIDS reports making it difficult to assess progress in this population. We have unprecedented knowledge to guide investment towards greater impact on HIV prevention, treatment, and care in adolescents, but it has not been applied to reach those most vulnerable and optimize efficiency and scale. The cost of this is increasing AIDS-related deaths and largely unchanged levels of new HIV infections in adolescents. An AIDS-free generation will remain out of reach if the global community does not prioritize adolescents. National AIDS responses must be accountable to adolescents, invest in strengthening and monitoring protective and supportive laws and policies and access for adolescents to high impact HIV interventions.

Making a difference in adult-child relationships: evidence from an adult-child communication intervention in Botswana, Malawi, and Mozambique

Girls are vulnerable to HIV in part because the social systems in which they live have failed to protect them. This study evaluates a program aimed at strengthening adult-child relationships to reduce girls' vulnerability to HIV in Botswana, Malawi, and Mozambique. In addition to an extensive process evaluation, a cross-sectional post-intervention survey was conducted in the three countries. The total sample size was 1418 adolescent girls (ages 11-18). Bivariate and multilevel, multivariate analyses were conducted to assess the association between adult program exposure and adult-child relationship improvement. In Botswana, Malawi, and Mozambique, girls whose mothers and fathers participated in the program, as compared to those whose parents did not participate in the program, were significantly more likely to report that their relationships with their parents had improved. Research has shown the important role that adults can play in the mitigation of youth risk taking behavior.

Nothing as Practical as a Good Theory? The Theoretical Basis of HIV Prevention Interventions for Young People in Sub-Saharan Africa: A Systematic Review

This paper assesses the extent to which HIV prevention interventions for young people in sub-Saharan Africa are grounded in theory and if theory-based interventions are more effective. Three databases were searched for evaluation studies of HIV prevention interventions for youth. Additional articles were identified on websites of international organisations and through searching references. 34 interventions were included; 25 mentioned the use of theory. Social Cognitive Theory was most prominent (n = 13), followed by Health Belief Model (n = 7), and Theory of Reasoned Action/Planned Behaviour (n = 6). These cognitive behavioural theories assume that cognitions drive sexual behaviour. Reporting on choice and use of theory was low. Only three articles provided information about why a particular theory was selected. Interventions used theory to inform content (n = 13), for evaluation purposes (n = 4) or both (n = 7). No patterns of differential effectiveness could be detected between studies using and not using theory, or according to whether a theory informed content, and/or evaluation. We discuss characteristics of the theories that might account for the limited effectiveness observed, including overreliance on cognitions that likely vary according to type of sexual behaviour and other personal factors, inadequately address interpersonal factors, and failure to account for contextual factors.

Age-disparate relationships and implications for STI transmission among young adults in Cape Town, South Africa

OBJECTIVES

To estimate the prevalence of age-disparate (AD) relationships among young black and coloured adults in Cape Town (South Africa) and determine socio-demographic predictors and individual and relationship characteristics of women in these relationships.

METHODS

A secondary analysis of the Cape Area Panel Study (N = 1960) data was conducted. Descriptive statistics were used to quantify the age-mixing pattern and logistic regression was used to identify significant socio-demographic and behavioural correlates of AD relationships.

RESULTS

Prevalence of AD relationships was high in both black (36%) and coloured (28%) women. The average age difference between male respondents and their partners increased with age. Young, black women who spent fewer nights under the same roof in one week, had a deceased parent, and were not currently attending classes were more likely to be in an AD relationship. Reports of sexually-transmitted infection (STI) symptoms in the last month and unprotected sex were more common among women in AD relationships.

CONCLUSIONS

AD relationships are common among young women in Cape Town. Home and family stability is preventative of young women engaging in AD relationships. Therefore, holistic, societal interventions may reduce AD relationships, which are a risk factor for STIs.