Understanding high school students' risk behaviors to help reduce the HIV/AIDS epidemic in KwaZulu-Natal, South Africa

Prevalence and correlates of anal sex among secondary school students in Cape Town, South Africa

Research efforts have overlooked anal sex as a risk factor for adolescents' acquisition of HIV despite the high rates of HIV among South African youth. Here, we report findings from a survey conducted in 2012 among secondary school youth, ages 16-24, in Cape Town. 937 adolescents completed a pencil-and-paper survey. Eleven and 31% of female and male youth, respectively, reported ever having anal sex. By comparison, 59% and 78% of female and male youth reported ever having vaginal sex. The percentage of youth reporting lifetime rates of anal sex increased with age: 32% of 20-to-24 year olds had anal sex compared to 16% of 16-to-17-year olds. When the sample was stratified by sex, this difference appeared to be driven by older male, but not female, sexual behavior. Despite noted differences in prevalence rates by sex, both boys and girls who had anal sex were more likely than their same-sex peers who had vaginal sex to report sexual coercion victimization and perpetration experiences and inconsistent condom use. Interestingly, some differences in HIV motivation, information, and behavioral skills were noted for youth who had vaginal sex versus youth who had never had sex; scores were largely similar for youth who had anal sex versus youth who had never had sex however. Together, these findings suggest that anal sex is not uncommon and may be an important marker for other HIV risk behaviors in at least one lower income South African community. Anal sex needs to be explicitly discussed in adolescent HIV prevention and healthy sexuality programing, incorporating age-relevant scenarios about negotiating condoms and other healthy relationship behaviors (e.g., refusing sex when it is not wanted).

Rethinking HIV-prevention for school-going young people based on current behaviour patterns

The aim of the research was to gain increased knowledge regarding the sexual risk behaviour of school-going young people in South Africa after two decades of HIV-education in schools, to contribute to the development of improved HIV prevention strategies. In collaboration with the Department of Education, a sample of 5305 learners (between 10 and 18 years in Grades 5-12) from high-risk communities were identified. They completed a survey that assessed self-reported sexual risk behaviour and variables that potentially underlie sexual risk, such as attitudes towards preventive behaviour, perceived social norms and self-efficacy (based on the theory of planned behaviour [TPB]) and social factors like caregiver relationships and gender norms (based on the social ecological theory). Lifetime sex was reported by 49.4% of boys and 30.5% of girls in Grades 8-12, while 56% of the sexually active young people reported consistent condom use. Accurate knowledge about HIV transmission was low (37.8%). Regression analysis showed that risk behaviour was more prominent among older male youths, who perceived social norms as encouraging sexual activity, who use alcohol excessively, and who have negative attitudes towards abstinence. Perceived traditional community gender norms and negative relationships with caregivers were also associated with sexual risk behaviour. This research showed that the TPB can be used in planning HIV prevention interventions for young people. It also revealed that HIV-prevention strategies should focus beyond educating the individual, to address community factors such as improving caregiver relationships, the culture of substance abuse, peer group norms and inequality in community gender norms. These community processes influence young people's behaviour and need to be addressed to allow the youth to make healthy behavioural choices.

Teenage pregnancy rates and associations with other health risk behaviours: a three-wave cross-sectional study among South African school-going adolescents

BACKGROUND

Teenage pregnancy still remains high in low and middle-income countries (LMIC), as well as in high-income countries (HIC). It is a major contributor to maternal and child morbidity and mortality rates. Furthermore, it has social consequences, such as perpetuating the cycle of poverty including early school dropout by the pregnant adolescent, especially in sub-Saharan Africa (SSA). Few studies in SSA have investigated the trends in teenage pregnancy and the associated factors, while this is critical in fully understanding teenage pregnancy and for promotion of reproductive health among adolescents at large in SSA.

METHODS

To examine the trends in teenage pregnancy and to identify associations with other health risk behaviours in South Africa (SA), a total of 31 816 South African school-going adolescents between 11 to 19 years of age were interviewed in three cross-sectional surveys. Data from the first (2002, n = 10 549), second (2008, n = 10 270) and the third (2011, n = 10 997) nationally representative South African youth risk behaviour surveys (YRBS) were used for this study.

RESULTS

The overall prevalence of having ever been pregnant among the combined 3-survey sample was self-reported to be 11.0 % and stable across the three surveys. Sexual intercourse among adolescents in SA has decreased from 41.9 % in 2002 to 36.9 % in 2011. However, pregnancy among girls who ever had sex increased from 17.3 % (95 % CI: 0.16-0.19) in 2002, to 23.6 % (95 % CI: 0.21-0.26) in 2008 and decreased to 21.3 % (95 % CI: 0.19-0.23) in 2011. The odds for ever been pregnant were higher for girls who had 2 or more sexual partners (OR: 1.250, 95 % CI: 1.039-1.503), girls who ever used alcohol before sex (OR: 1.373, 95 % CI: 1.004-1.878), practised binge-drinking during the last month (OR: 0.624, 95 % CI: 0.503-0.774), and girls who used mandrax (OR: 1.968, 95 % CI: 1,243-3.117). The odds for never been pregnant were lower for those who used condoms (OR: 0.462, 95 % CI: 0.309-0.691).

CONCLUSIONS

Girls continue to become pregnant at unacceptably high rates in SA. Sexual intercourse among adolescents in SA has decreased slightly. However, among those who are sexually active pregnancy prevalence rates have increased. More over, this is in the context of high prevalence of HIV and other STI. There is a need to address adolescents' sexual and reproductive health, and several health risk behaviours, including substance use, that are associated with teenage pregnancy in SA.

AIDS and hepatitis B and C high risk behaviors among 15 to 45 years old individuals in Bandar Abbas (Iran) in 2012

BACKGROUND

AIDS and hepatitis are two of the most important health issues in the world. Adolescents and individuals in their reproductive years are important population for interventions in order to reduce high risk behaviors for transmission of sexually transmitted disease. However the prevalence of AIDS and hepatitis B and C is high in Bandar Abbas, no study is available about high risk behaviors related to these diseases in Bandar Abbas. The aim of the current study was to investigate high risk behaviors related to AIDS and hepatitis B and C among 15- to 45 year old individuals in Bandar Abbas, Southern Iran.

METHOD

In this analytical study, 1938 participants between 15- and 45 years of age in Bandar Abbas in 2012 were selected to participate in this study. For each individual, the following information was sought: shared syringes, phlebotomy, tattoos, prisoning, drug abuse, amphetamine, alcohol, smoking, unsafe sexual contacts, as well as demographic information including age, sex, marital status, and education level. Data were analysed using SPSS version 16 (SPSS Inc. Chicago, Illinois, United States) using descriptive statistics and chi-square tests.

RESULTS

A total of 8.4% reported having had tattoos; 10.3% reported previous phlebotomy. Individuals with prison history included 7.3% of our study population and their mean age was 31.4 years. Unsafe sexual contact was reported in 10.7% of the study sample. High risk behaviors were more common among individuals with a low educational level, and in alcohol users and amphetamine users (P<0.05).

CONCLUSION

High risk behaviors are more common among individuals in their reproductive years. Increasing educational level and knowledge translation are effective in preventing AIDS and hepatitis high risk behaviors.

Identifying community risk factors for HIV among South African adolescents with mental health problems: a qualitative study of parental perceptions

High risk sexual behaviour, alcohol and drug use, and mental health problems combine to yield high levels of HIV-risk behaviour among adolescents with mental health problems. In South Africa, little research has been conducted on parental perspectives of HIV-risk among this population. We conducted a series of focus group discussions with 28 mothers of adolescents receiving services at two mental health clinics in South Africa to identify, from their perspectives, the key community problems facing their children. Participants indicated that HIV remained a serious threat to their adolescent children's well-being, in addition to substance abuse, early sexual debut, and teenage pregnancy. These social problems were mentioned as external to their household dynamics, and thus seemingly beyond the purview of the parent-adolescent relationship. These data have implications for the design of family-based interventions to ameliorate the factors associated with HIV-risk among youth receiving mental health services.

Changing patterns of under- and over-nutrition in South African children—future risks of non-communicable diseases

Under- and over-nutrition in children in KwaZulu-Natal, South Africa was investigated comparing data collected from primary school children in a rural district (643 children aged 8-11 years in 1994) with secondary data from the National Schools Study (16,179 children, 4-11 years in 1994), the Vitamin A Consultative Group Study (408 children, 2-5 years in 1994) and the Income Dynamics Study (1,593 children, 2-11 years in 1998). Stunting and wasting (WHO/NCHS guidelines) and overweight and obesity (International Obesity Task Force guidelines) were retrospectively analysed from these studies and compared in the children aged 4-5 and 8-11 years. There was moderate stunting in 10-25%, wasting in 1-6%, 5-24% were overweight and 1-10% obese. Girls in the National Schools Study (p<0.005) and in the primary datasets (p=0.02) had a significantly higher prevalence of overweight than boys; girls (1.4%) were also more obese than boys (0.9%) in the Schools Study (p=0.002), and the boys significantly more stunted (p<0.005) and wasted (p<0.005). An increasing prevalence of overweight and obesity was seen in both the 4-5- and 8-11-year age-groups. The finding that moderate stunting co-exists with overweight and obesity suggests that patterns of under- and over-nutrition in South African children are changing and might indicate the early stages of a complex nutritional transition. Action is required to prevent the future risk of non-communicable diseases.

Gender, peer and partner influences on adolescent HIV risk in rural South Africa

BACKGROUND AND METHODS

In preparation for a school-based intervention in KwaZulu-Natal, South Africa, a cross-sectional survey of potential HIV risk factors in youth aged 14-17 (n=983) was conducted.

RESULTS

Boys were significantly more likely than girls to report lifetime sexual activity (37.7% v. 13.8%, P<0.01). Among boys and girls, 46.1% reported condom use at last sex. Discussion of condom use with a partner was the strongest predictor of condom use (boys, odds ratio (OR)=7.39; girls, OR=5.58, P<0.0001). Age was independently associated with sexual activity for boys (OR=1.49, P<0.0001) and girls (OR=1.74, P=0.02). For boys, perceptions of male peer behaviour were associated with both ever having participated in sexual activity (OR=1.48, P<0.01) and condom use at last sex (OR=1.79, P<0.01). Girls who equated condom use with having numerous partners were more likely to use them. Among boys, results challenged some expected gender beliefs: support for girls' initiative in relationship formation and refusal of sex were significant predictors of sexual activity. Among girls, higher pregnancy risk perception (OR=1.32, P=0.02) and knowledge (OR=4.85, P=0.055) were associated with sexual activity.

CONCLUSIONS

Creating more gender equitable norms can reduce HIV risk behaviours. HIV prevention interventions should build on existing gender equitable beliefs, and work to promote others, including sexual communication and negotiation skills, and modelling of positive peer norms.

Alcohol use and high-risk sexual behavior in Sub-Saharan Africa: a narrative review

Sub-Saharan Africa (SSA) contains 10% of the world's population and 60% of all people living with AIDS. Consequently, research investigating risk factors associated with HIV acquisition is a public health priority and one such risk factor is alcohol consumption. This article is a review of empirical studies on the association of alcohol and high-risk sexual behavior in SSA, with a focus on measurable outcomes generated from quantitative data. A critique of the literature is provided, with attention to methodological concerns. Empirically based theoretical orientations were used to interpret the reviewed research and to stimulate discussion about how to improve the state of the current literature. Based on this discussion, a model of alcohol and high-risk sexual behavior in an African context is proposed in order to integrate the existing literature and highlight areas in need of continued research.

Changing trends and the impact of alcohol on the HIV/AIDS epidemic in South Africa: review

The association between increased HIV infection and alcohol use has been extensively studied and is established. South Africa is among one of the sub-Saharan African countries with the highest prevalence and number of people living with HIV/AIDS in the world. Although recent evidence suggests that the epidemic has stabilised, infection rates remain unacceptably high. Alcohol use is on the increase, particularly in the groups most susceptible to HIV infection, namely women and young adults, and informs poor choices with respect to safer sexual practices. This paper reviews the association between alcohol and HIV. More specifically, however, it aims to explore the potential socio-politico-biological and cultural explanations as to the factors that intersect to drive these two epidemic diseases: alcoholism and HIV/AIDS in South Africa. Understanding some of the underlying factors will provide a framework to implement public health measures to curb HIV.

Inconsistencies in self-reporting of sexual activity among young people in Nairobi, Kenya

PURPOSE

Accurate and reliable data on the prevalence of adolescents' sexual behavior are paramount for effective sexual and reproductive health intervention. Adolescents' sexual behavior has been widely studied. However, scholars have raised concerns about the accuracy and reliability of self-reported sexual behavior by adolescents. Previous research shows high levels of adolescent sexual activity in urban informal settlements; yet, the accuracy of self-reported sexual experience in these settings is understudied.

METHODS

The objective of this article is to assess consistency of self-reported sexual activity among 2324 adolescents living in slum and nonslum settlements in Nairobi, Kenya. We examine two forms of inconsistencies, namely, what we term "reborn virgins" and inconsistent timing of sexual debut, during two rounds of survey. Factors influencing inconsistent reporting are explored through logistic regression.

RESULTS

A total of 469 (20%) adolescents gave inconsistent information on whether they have ever had sex (n = 190) or timing of first intercourse (n = 279). Males, slum residents, and adolescents attending school were more likely to give inconsistent sexual information. Among inconsistent reporters, slum residents, adolescents reporting substance use, and those with secondary (vs. primary) education were more likely to reclaim virginity status than to misreport the timing of first sex. However, older adolescents were less likely to reclaim virginity status.

CONCLUSIONS

We found significant differences between adolescents who provide consistent reports and those who misreport sexual behavior data. We argue that researchers should account for biases stemming from misreporting of sensitive information among young people and, in particular, should be cognizant of how reporting quality may vary across demographic groups.

Correlates of condom use among male high school students in Nairobi, Kenya

BACKGROUND

Correct and consistent condom use is an effective strategy to reduce the risk of sexually transmitted infections (STIs). This study examines sociodemographic, behavioral, and psychosocial characteristics of 3 groups of adolescent males: consistent, sporadic, and non-condom users.

METHODS

The sample consisted of 931 sexually experienced male high school students in Nairobi, Kenya. Cross tabulations and general linear models were used to test the relation between each explanatory variable and condom user group.

RESULTS

Fifty-three percent of respondents reported having used condoms. Compared with nonusers and sporadic users, consistent users engaged in sexual intercourse for the first time at an older age and reported higher condom use self-efficacy, more positive peer attitudes toward safe sex, and stronger attitudes toward condom use. Compared with sporadic and consistent users, nonusers reported fewer sexual partners, less substance use, and more frequent intercourse with non-romantic partners. Sporadic users, compared with the other 2 groups, had more sexual partners and stronger attitudes that support that males and females have separate roles. The 3 groups did not differ in HIV/AIDS knowledge. On average, respondents responded correctly to two thirds of the questions. All groups perceived their risk of contracting an STI as low, and this perception did not differ by condom use. Differences in participants' age by group were minimal.

CONCLUSIONS

The study supports the need for interventions that target specific condom use groups.

Gender factors associated with sexual abstinent behaviour of rural South African high school going youth in KwaZulu-Natal, South Africa

The cross-sectional study investigated South African rural high school learners' choice of sexual abstinence in order to be able to develop tailored health education messages. All Grade 9 learners from one class at each of 10 randomly selected rural high schools participated. The Integrated Model for Motivational and Behavioural Change was used to elicit attitudes, social influences, self-efficacy and intentions towards sexual abstinence. Chi-square and t-tests were used for bivariate analysis. In total, 454 learners, mean age 16.7 years (standard deviation 1.41) range 14-20 years, participated, of whom 246 (54.2%) were female. When comparing learners reporting abstinence (n=252) with those not abstinent (n=202), abstinent learners were significantly more often females (P<0.005), younger (16.5 years versus 17.1 years, P<0.005) and drank less alcohol (P<0.005). Abstaining girls believed that their friends and parents think that they should abstain from sex, that their friends abstained from sex and that abstinence helped them to mature emotionally. Abstinent boys expressed intentions to abstain from sex until marriage. Targeted intervention research is required to encourage South African rural high school learners to delay their sexual initiation to reduce their risk of human immunodeficiency virus infection. Different abstinent messages are needed for boys and girls to address the different patterns of behaviour observed.

Factors associated with sexual activity among high-school students in Nairobi, Kenya

The high level of HIV infection in sub-Saharan Africa has led to an increased interest in understanding the determinants of sexual activity among young people, who are at high risk of sexually transmitted infections. The present study examined sociodemographic, behavioral, and psychosocial factors associated with heterosexual activity among a sample of 3556 male and female high-school students in Nairobi, Kenya. Approximately 50% of the males and 11% of females reported having had sexual intercourse at least once in their lifetime with a significant proportion reporting multiple sexual partnerships. Sexual activity was associated with various factors including religiosity, perceived parental attitudes towards sex, living arrangements, and school characteristics. However, the pattern of association differed for males and females. Results suggest that adolescents may benefit from sex education programs addressing multiple factors that may predispose adolescents to sexual activity, and that take into account gender differences.

Substance use and sexual risk prevention in Cape Town, South Africa: an evaluation of the HealthWise program

Sexual behavior and substance use represent major threats to the health and well-being of South African adolescents, especially in light of the high prevalence of HIV infection in this population. However, there is currently a lack of evidence-based school programs designed to address health risk behaviors. The current study details the evaluation of HealthWise South Africa, a leisure, life skills, and sexuality education intervention for eighth and ninth grade students. We hypothesized that, compared to controls, HealthWise participants would have delayed sexual initiation, reduced rates of current sexual activity, increased use of and perceived access to condoms, and lower rates of lifetime and past use of multiple substances. Longitudinal data were analyzed using logistic regression of multiply imputed data. Results indicate that HealthWise was effective in increasing the perception of condom availability for both genders (OR = 1.6). As compared to HealthWise participants, control participants also had steeper increases in recent and heavy use of alcohol (OR = 1.4 [95% C.I. = 1.1-1.8], 1.6 [1.2-2.2], respectively) and recent and heavy cigarette use (OR = 1.4 [1.1-1.7], 1.4 [1.1-1.8], respectively). There were also several significant gender by treatment interactions, which are discussed. These results suggest that HealthWise is a promising approach to reducing multiple health risk behaviors among the population of school-going South African adolescents.

Reasons for inconsistent condom use by rural South African high school students

AIM

To describe the condom use practices of high school students, compare the beliefs of students who used condoms with those who did not, investigate gender differences in condom use and identify factors that prevent condom use.

METHOD

Cross sectional descriptive study of sexually active grade 10 students at 28 rural high schools who completed a self-reporting structured questionnaire.

RESULTS

Of n = 353 students, mean age 17.50 y (SD 1.40), n = 249 (70.5%) males and n = 104 (29.5%) females (p < 0.005), n = 136 (38.5%) had used a condom at last sex. Students who used condoms differed from non-condom users in their beliefs that use of condoms did not imply lack of trust (p = 0.03), supported girls' requesting that their partners use condoms (p = 0.002), perceived greater social support (p < 0.005), and had more self-efficacy (p < 0.005). In the model, condom use at last sex was significantly associated with males (p = 0.03), age at first sex (p = 0.02), knowing a person infected with HIV/AIDS (p = 0.03), and condom use self-efficacy (p = 0.001).

CONCLUSION

The low rate of condom use amongst these students during the AIDS epidemic is influenced by students' condom use self-efficacy, emphasizing the need for skills' training. The increasing mortality due to HIV/AIDS may be a cue that encourages condom use.

Alcohol use and sexual risks for HIV/AIDS in sub-Saharan Africa: systematic review of empirical findings

Alcohol consumption is associated with risks for sexually transmitted infections (STI), including HIV/AIDS. In this paper, we systematically review the literature on alcohol use and sexual risk behavior in southern Africa, the region of the world with the greatest HIV/AIDS burden. Studies show a consistent association between alcohol use and sexual risks for HIV infection. Among people who drink, greater quantities of alcohol consumption predict greater sexual risks than does frequency of drinking. In addition, there are clear gender differences in alcohol use and sexual risks; men are more likely to drink and engage in higher risk behavior whereas women's risks are often associated with their male sex partners' drinking. Factors that are most closely related to alcohol and sexual risks include drinking venues and alcohol serving establishments, sexual coercion, and poverty. Research conducted in southern Africa therefore confirms an association between alcohol use and sexual risks for HIV. Sexual risk reduction interventions are needed for men and women who drink and interventions should be targeted to alcohol serving establishments.

Condom use among South African adolescents: developing and testing theoretical models of intentions and behavior

We developed and tested models of intentions and behavior among adolescents from Cape Town, South Africa. Data from 261 participants who completed an initial measure of attitudes, beliefs, and prior behavior were used to develop a model of intentions to use condoms based on the Theory of Planned Behavior (TPB) and additional constructs found to be important in previous research with adolescents. Of the initial sample, 227 (87%) completed a behavioral follow-up 4 months later, and approximately one-third of those (n=72; 44 boys and 30 girls) reported having had sex in the prior 4 months. Data from this smaller sample were used to develop a model of condom use behavior based on intentions (as per the TPB) and the additional sub-population relevant constructs. Analyses generally supported the validity of the TPB in this context for predicting intentions and behavior. HIV knowledge and positive outlook (self-esteem and future optimism) were significantly related to TPB predictors of intentions. Intentions, acceptance of sexuality, and gender were significant predictors of behavior. Implications for the status of the TPB and the design of interventions for South African adolescents are discussed.

Alcohol abuse, gender-based violence and HIV/AIDS in Botswana: establishing the link based on empirical evidence

The existence of gender-based violence has been a source of concern within the public and private sectors as well as civil society organisations in Botswana. The present study investigated the link between alcohol abuse, gender-based violence and HIV/AIDS. Further, it attempted to unravel the often unquestioned assumption that gender-based violence is perpetuated by cultural practices. Case study qualitative methodology was used to gather data for the study. A sample of 20 cases was selected purposively from five women's non-governmental organisations. In addition, in-depth interviews were conducted with agency coordinators, social workers, police commanders and police officers. The findings of the study revealed a relationship between alcohol abuse and gender-based violence, which makes victims vulnerable to HIV infection. From the findings, it is recommended that gender-based programmes be established to sensitise people about the link between alcohol abuse, gender-based violence and HIV/AIDS.

HIV Knowledge and Practices Among Rural South Africans

PURPOSE

To explore the knowledge and practices related to HIV/AIDS by rural South Africans in Limpopo Province.

DESIGN AND METHODS

Qualitative research methods were used. Twenty-eight key and general informants participated in individual interviews in summer 2001. The setting was a hospital-based HIV clinic in rural Limpopo Province.

FINDINGS

All participants were members of a support group, and they had basic knowledge about HIV/AIDS; however, participants indicated that they lacked basic knowledge of HIV/AIDS until they joined the support group.

CONCLUSIONS

Support groups were effective in educating people about HIV/AIDS.

National cross sectional study of views on sexual violence and risk of HIV infection and AIDS among South African school pupils

OBJECTIVE

To investigate the views of school pupils on sexual violence and on the risk of HIV infection and AIDS and their experiences of sexual violence.

DESIGN

National cross sectional study.

SETTING

5162 classes in 1418 South African schools.

PARTICIPANTS

269,705 school pupils aged 10-19 years in grades 6-11.

MAIN OUTCOME MEASURE

Answers to questions about sexual violence and about the risk of HIV infection and AIDS.

RESULTS

Misconceptions about sexual violence were common among both sexes, but more females held views that would put them at high risk of HIV infection. One third of the respondents thought they might be HIV positive. This was associated with misconceptions about sexual violence and about the risk of HIV infection and AIDS. Around 11% of males and 4% of females claimed to have forced someone else to have sex; 66% of these males and 71% of these females had themselves been forced to have sex. A history of forced sex was a powerful determinant of views on sexual violence and risk of HIV infection.

CONCLUSIONS

The views of South African youth on sexual violence and on the risk of HIV infection and AIDS were compatible with acceptance of sexual coercion and "adaptive" attitudes to survival in a violent society. Views differed little between the sexes.