Effects of neighbourhood-level educational attainment on HIV prevalence among young women in Zambia

Sexual and Gender-Based Violence and Vulnerability to HIV Infection in Uganda: Evidence from Multilevel Modelling of Population-Level HIV/AIDS Data

Background: Sexual and gender-based violence (SGBV) is highly prevalent in Uganda and its link with HIV infection and compromising access to HIV/AIDS services is known. However, current evidence is controversial. Most of the studies indicate a positive relationship but a few indicate otherwise. Moreover, there is no research examining the effects of community-level SGBV on HIV infection. Objectives: This research explores the association between SGBV and vulnerability to HIV infection. Methods: Multilevel binary logistic regression is applied to secondary data of Uganda AIDS Indicators Survey conducted in 2011. The survey data comprises 12,153 women and 9588 men. Results: SGBV significantly increases the likelihood of HIV infection, with victims having 34%, 1.34 [1.06–1.70] higher odds than non-victims. At the community level, wealth, and pre-sex alcohol abuse are important determinants. Conclusions: Vulnerability to the risk of HIV infection in Uganda is associated with individual-level and community factors. Effective HIV prevention policies need to pay attention to victims of SGBV using individual- and community-level strategies.

Examining the association between HIV prevalence and socioeconomic factors among young people in Zambia: Do neighbourhood contextual effects play a role?

Background

The study examined the association between HIV infection and individual and neighbourhood-level socioeconomic factors in Zambia.

Methods

We used multilevel mixed effects logistic regression to examine the association of individual and neighbourhood level variables on HIV prevalence based on data from the 2013–14 and 2018 Zambia Demographic and Health Surveys, population-based cross-sectional surveys. The analysis was restricted to young people (15–24 years) with HIV serostatus results (n = 11,751 and n = 10,154). HIV serostatus was the outcome variable and socioeconomic status was measured by wealth, education and employment.

Results

Overall, at individual level, education was associated with reduced odds of HIV infection among young women and men. Conversely, relative wealth was generally associated with increased odds of infection for both young women and men. Young, employed men were at reduced odds of HIV infection than the unemployed. Living in neighbourhoods with higher average level of education was associated with higher odds of HIV infection. In 2013–14, 13% and 11% of the variation in HIV infection among young men and women was attributed to neighbourhoods, while 20% and 11% variation was attributed to neighbourhoods in 2018. Inclusion of individual and neighbourhood variables in the full regression model accounted for 65.7% and 59.5% of explained variance in 2013–14 and 64.6% and 44.3% in 2018, for women and men, respectively. This reduced unexplained variance by an average of 56% in 2013–14 and 29% in 2018.

Conclusion

We found that HIV infection among young people in Zambia is more strongly associated with individual-level socioeconomic factors compared to neighbourhood factors. Individual-level education remains an important socioeconomic factor associated with reduced odds of HIV infection. This suggests that the HIV response in Zambia should still focus on individual level prevention strategies.

HIV Prevalence and Associated Factors Among Men in South Africa 30 Years into the Epidemic: The Fifth Nationwide Cross-Sectional Survey

We investigated HIV prevalence and associated factors among men ≥ 15 years in South Africa using data from a 2017 nationwide cross-sectional survey. HIV prevalence was 10.5% among 6 646 participants. Prevalence increased from 4.1% in the younger men (15-24 years), 12.5% in young men (25-34 years) to 12.7% in older men (≥ 35 years). Odds of being infected with HIV were lower among younger men who had secondary level education and those who reported poor/fair self-rated health. Young and older men of other race groups had lower odds of HIV infection. Odds of infection were lower among young men who had moderate/high exposure to HIV communication programmes. Men not aware of their HIV status had higher odds of HIV infection, including older men who never married. Improved access to education, behavioral change programmes, and awareness of HIV status are necessary to reduce the risk of HIV infection among Black African men.

Ending AIDS by 2030: the importance of an interlinked approach and meaningful youth leadership

Introduction

This commentary by authors from the Adolescent HIV Treatment Coalition calls for action to improve advocacy and service delivery for young people by leveraging the interlinkages between HIV and the broader development agenda. The 2030 Agenda for Sustainable Development includes target 3.3 on ending the AIDS epidemic by 2030, and along with the 2016 Political Declaration on HIV and AIDS, this has led to a global renewal of political commitment to the HIV response. However, young people are still being left behind, and to provide an equitable and sustainable response to HIV we must ensure that we are meeting the needs of the 3.9 million young people living with HIV, and the millions more at risk.

Discussion

While HIV has its own target within the 2030 Agenda, efforts to end AIDS are inextricable from other goals and targets, such as on poverty eradication, education, gender equality and peace. To tackle HIV we must work beyond target 3.3 and provide a comprehensive response that addresses the underlying structural inequalities that impact adolescents and young people, ensuring that we enable the meaningful engagement of youth and adolescents as partners and leaders of sustainable development and the HIV response. Finally, it is necessary to collect better disaggregated data and evidence on the HIV epidemic among adolescents, as well as on best practices for supporting them.

Conclusions

Ending the AIDS epidemic among adolescents and young people (aged 10 to 24) by 2030 is possible. However, it requires an integrated, multi‐sectoral response to HIV which pays attention to the social determinants that put adolescents at risk and fuel the epidemic. Positioning efforts to end AIDS among young people within the broader 2030 Agenda and building youth leadership will contribute to building a more healthy, equitable and sustainable society for all.

A generation at risk: a cross-sectional study on HIV/AIDS knowledge, exposure to mass media, and stigmatizing behaviors among young women aged 15-24 years in Ghana

HIV/AIDS stigmatizing behaviors are a huge barrier to early detection and treatment of individuals with the AIDS virus. HIV/AIDS stigma and related consequences are debilitating, especially for vulnerable populations. This study sought to assess whether young women's HIV/AIDS knowledge levels and exposure to mass media (television and radio) have an influence on their stigmatizing behaviors and role as agents of stigma towards individuals living with HIV and AIDS. The data used for this study originated from the Ghana Multiple Indicator Cluster Survey 2011. Binary and multiple (stepwise) logistic regression analyses were used to examine the associations between HIV/AIDS knowledge, frequency of exposure to mass media, and HIV/AIDS stigmatizing behaviors among young women aged 15-24 years in Ghana. Of the 3573 young women, 80% of 15-19-year-olds and 76% of 20-24-year-olds had at least one stigmatizing behavior towards persons living with HIV/AIDS (PLHA). Young women with increased knowledge regarding HIV/AIDS and frequent exposure to mass media (television and radio) had lesser tendency to stigmatize or act as agents of stigma towards PLHA (proportion with at least one stigmatizing behavior per subgroup - HIV/AIDS knowledge: those with highest knowledge score 579 [70.1%], those with lowest knowledge score 28 [90.3%]; mass media: those with daily exposure 562 [73.4%], those not exposed at all 249 [89.2%]). There was a graded negative 'exposure-response' association between the ranked variables: HIV/AIDS knowledge, mass media, and HIV/AIDS stigmatizing behaviors. The significant inverse association between HIV/AIDS knowledge, frequency of exposure to mass media, and HIV/AIDS stigmatizing behaviors persisted even after adjusting for all other covariates in the multiple logistic regression models. It is extremely important to increase HIV/AIDS-related knowledge and reduce stigma among young women in Ghana through targeted HIV/AIDS factual knowledge transfer. The use of mass media for communication of issues regarding HIV/AIDS, its mode of transmission, and associated stigma should be emphasized among women in Ghana.

INDIVIDUAL- AND COMMUNITY-LEVEL DETERMINANTS OF ANTENATAL HIV TESTING IN ZIMBABWE

This study contributes to the dialogue on the prevention of mother-to-child HIV transmission (PMTCT) through the use of HIV and antenatal care (ANC) integrated services. The determinants of antenatal HIV testing in Zimbabwe were explored. Multilevel logistic regression models were applied to data for 8471 women from 406 clusters who gave birth in the 5 years preceding Zimbabwe Demographic and Health Surveys conducted in 2005/6 and 2010/11. The uptake of antenatal HIV testing was found to be determined by a wide range of individual-level factors relating to women's economic and demographic status, as well as HIV-related factors, including HIV awareness and stigma within the community. Important individual-level enabling and perceived need factors included high socioeconomic status, not having observed HIV-related stigma and knowledge of HIV status (based on a previous HIV test), such that these groups of individuals had a significantly higher likelihood of being tested for HIV during pregnancy than their counterparts of lower socioeconomic status, and who had observed HIV-related stigma or did not know their HIV status. The results further revealed that community HIV awareness is important for improving antenatal HIV testing, while stigma is associated with reduced testing uptake. Most contextual community-level factors were not found to have much effect on the uptake of antenatal HIV testing. Therefore, policies should focus on individual-level predisposing and enabling factors to improve the uptake of antenatal HIV testing in Zimbabwe.

Using multilevel models to evaluate the influence of contextual factors on HIV/AIDS, sexually transmitted infections, and risky sexual behavior in sub-Saharan Africa: a systematic review

PURPOSE

To describe the use of multilevel models (MLMs) in evaluating the influence of contextual factors on HIV/AIDS, sexually transmitted infections (STIs), and risky sexual behavior (RSB) in sub-Saharan Africa.

METHODS

Ten databases were searched through May 29, 2016. Two reviewers completed screening and full-text review. Studies examining the influence of contextual factors on HIV/AIDS, STIs, and RSB and using MLMs for analysis were included. The Quality Assessment Tool for Quantitative Studies was used to evaluate study quality.

RESULTS

A total of 118 studies met inclusion criteria. Seventy-four studies focused on HIV/AIDS-related topics; 46 focused on RSB. No studies related to STIs other than HIV/AIDS met the eligibility criteria. Of five studies examining HIV serostatus and community socioeconomic factors, three found an association between poverty and measures of inequality and increased HIV prevalence. Among studies examining RSB, associations were found with numerous contextual factors, including poverty, education, and gender norms.

CONCLUSIONS

Studies using MLMs indicate that several contextual factors, including community measures of socioeconomic status and educational attainment, are associated with a number of outcomes related to HIV/AIDS and RSB. Future studies using MLMs should focus on contextual-level interventions to strengthen the evidence base for causality.

The role of partners' educational attainment in the association between HIV and education amongst women in seven sub-Saharan African countries

INTRODUCTION

Individuals' educational attainment has long been considered as a risk factor for HIV. However, little attention has been paid to the association between partner educational attainment and HIV infection.

METHODS

We conducted cross-sectional analysis of young women (aged 15-34) in 14 Demographic and Health Surveys from seven sub-Saharan Africa (SSA) countries with generalized HIV epidemics. We measured the degree of similarity in educational attainment (partner homophily) in 75,373 partnerships and evaluated the correlation between homophily and female HIV prevalence at the survey cluster level. We then used logistic regression to assess whether own and partner educational attainment was associated with HIV serostatus amongst 38,791 women.

RESULTS

Educational attainment was positively correlated within partnerships in both urban and rural areas of every survey (Newman assortativity coefficients between 0.09 and 0.44), but this correlation was not ecologically associated with HIV prevalence. At the individual level, larger absolute differences between own and partner educational attainment were associated with significantly higher HIV prevalence amongst women. This association was heterogeneous across countries, but not between survey waves. In contrast to other women, for those aged 25-34 who had secondary or higher education, a more-educated partner was associated with lower HIV prevalence.

CONCLUSIONS

HIV prevalence amongst women in SSA is associated not only with one's own education but also with that of one's partner. These findings highlight the importance of understanding how partners place individuals at risk of infection and suggest that HIV prevention efforts may benefit from considering partner characteristics.

Strong effects of home-based voluntary HIV counselling and testing on acceptance and equity: a cluster randomised trial in Zambia

Home-based voluntary HIV counselling and testing (HB-VCT) has been reported to have a high uptake, but it has not been rigorously evaluated. We designed a model for HB-VCT appropriate for wider scale-up, and investigated the acceptance of home-based counselling and testing, equity in uptake and negative life events with a cluster-randomized trial. Thirty six rural clusters in southern Zambia were pair-matched based on baseline data and randomly assigned to the intervention or the control arm. Both arms had access to standard HIV testing services. Adults in the intervention clusters were offered HB-VCT by local lay counsellors. Effects were first analysed among those participating in the baseline and post-intervention surveys and then as intention-to-treat analysis. The study was registered with www.controlled-trials.com, number ISRCTN53353725. A total of 836 and 858 adults were assigned to the intervention and control clusters, respectively. In the intervention arm, counselling was accepted by 85% and 66% were tested (n = 686). Among counselled respondents who were cohabiting with the partner, 62% were counselled together with the partner. At follow-up eight months later, the proportion of adults reporting to have been tested the year prior to follow-up was 82% in the intervention arm and 52% in the control arm (Relative Risk (RR) 1.6, 95% CI 1.4-1.8), whereas the RR was 1.7 (1.4-2.0) according to the intention-to-treat analysis. At baseline the likelihood of being tested was higher for women vs. men and for more educated people. At follow-up these differences were found only in the control communities. Measured negative life events following HIV testing were similar in both groups. In conclusion, this HB-VCT model was found to be feasible, with a very high acceptance and to have important equity effects. The high couple counselling acceptance suggests that the home-based approach has a particularly high HIV prevention potential.

College graduation reduces vulnerability to STIs/HIV among African-American young adult women

African-American women are disproportionately affected by sexually transmitted infections (STIs), including HIV. The Theory of Gender and Power (TGP) posits that socioeconomic exposures, including educational attainment, place women at increased risk for STIs/HIV. This study examined the association between educational attainment and vulnerability to STIs/HIV, as well as potential TGP-driven mediators of this association, among African-American women. Baseline data were assessed from an STI/HIV prevention intervention for African-American women (n = 848) aged 18 to 29 recruited from three Kaiser Permanente Centers in Atlanta, Georgia. Data collection included a survey of demographic, psychosocial, and behavioral measures and self-collected, laboratory-confirmed vaginal swabs for STIs (trichomoniasis, chlamydia, gonorrhea, and human papillomavirus). Multiple regression analyses and multivariate mediation analyses were used to examine the association between educational attainment with a laboratory-confirmed STI and potential TGP mediators. Controlling for age and receipt of public assistance, the odds of an STI diagnosis were 73% lower among participants with a college degree or greater compared with participants who had not completed high school. There were also significant associations between educational attainment and multiple TGP mediators from the sexual division of power and the structure of cathexis. TGP constructs did not mediate the association between educational attainment and laboratory-confirmed STI. The current study suggests that graduating from college may lead to a beneficial reduction in vulnerability to STIs/HIV among African-American women. Findings from this study support expanding structural-level interventions, emphasizing both high school and college graduation, as a means of reducing vulnerability to STIs/HIV among African-American women.

Decline in HIV prevalence among young women in Zambia: national-level estimates of trends mask geographical and socio-demographic differences

BACKGROUND

A decline in HIV incidence has been reported in Zambia and a number of other sub-Saharan countries. The trend of HIV prevalence among young people is a good marker of HIV incidence. In this study, different data sources are used to examine geographical and sub-population group differentials in HIV prevalence trends among men and women aged 15-24 years in Zambia.

DESIGN AND METHODS

We analysed ANC data for women aged 15-24 years from 22 sentinel sites consistently covered in the period 1994-2008, and HIV data for young men and women aged 15-24 years from the ZDHS 2001/2 and 2007. In addition, we systematically reviewed peer-reviewed articles that have reported findings on HIV prevalence and incidence among young people.

FINDINGS

Overall trends of the ANC surveillance data indicated a substantial HIV prevalence decline among young women in both urban and rural areas. However, provincial declines differed substantially, i.e. between 10% and 68% among urban women, and from stability to 86% among rural women. Prevalence declines were steeper among those with the highest educational attainments than among the least educated. The ZDHS data indicated a significant reduction in prevalence between the two survey rounds among young women only. Provincial-level ZDHS changes were difficult to assess because the sample sizes were small. ANC-based trend patterns were consistent with those observed in PMTCT-based data (2002-2006), whereas population-based surveys in a selected urban community (1995-2003) suggested that the ANC-based data underestimated the prevalence declines in the general populations of both young both men and women.

CONCLUSION

The overall HIV prevalence declined substantially among young women in Zambia and this is interpreted as indicating a decline in HIV incidence. It is noteworthy that overall national trends masked substantial differences by place and by educational attainment, demonstrating critical limitations in the current focus on overall country-level trends in epidemiological reports.

Knowledge base and caretaker-child communication about HIV in peri-urban schoolchildren of Lusaka, Zambia

Peri-urban communities, which face health risks of both urban and rural environments, have grown extensively with recent global urbanization. These communities' combination of multiple HIV risk factors with the lack of a formalized sexual education system sets the stage for high-risk behavior in peri-urban youth. We conducted a cross-sectional survey of children (ages 5-17, N=331) and accompanying caretakers in peri-urban Lusaka, Zambia, using both closed- and open-ended questions to investigate HIV knowledge and communication. We found that while 67% of children had heard of HIV, only 26% and 23% could accurately name a major mode of transmission and prevention, respectively. In a multivariate model, increasing age was the only significant demographic correlate of a child's ability to offer accurate responses to either question. Though HIV/AIDS knowledge levels were high in the eldest (14-17-year old) age group, in the 10-13-year-old age group accurate modes of transmission and prevention were provided by only 41% and 33% of study participants, respectively. Sharp instruments, particularly razor blades, were mentioned nearly as frequently as sexual intercourse with respect to both transmission and prevention, a response trend that predominated in the youngest age group but persisted into the oldest. Seventy percent of caretakers had not spoken with their child about HIV. A history of caretaker-child communication about HIV was associated with an increased likelihood of a child offering an accurate mode of transmission (OR 2.70, 95% confidence interval (CI) 1.41-5.18, p=0.0029) or prevention (OR 3.43, 95% CI 1.78-6.60, p=0.0002), in multivariate analyses. Our results demonstrate a lack of knowledge and dialog about HIV in the pre-adolescent subset of high-risk peri-urban youth, and uncover undue emphasis on razor blades as a major mode of disease transmission.