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Nelson KA, Magut F, Mulwa S, Osindo J, Kamire V, Khagayi S, Pulerwitz J, Cook S, Gourlay A, Ziraba A, Kwaro D, Floyd S, Birdthistle I. Impact of DREAMS interventions on attitudes towards gender norms among adolescent girls and young women: Findings from a prospective cohort in Kenya. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0002929. [PMID: 38446820 PMCID: PMC10917282 DOI: 10.1371/journal.pgph.0002929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 01/26/2024] [Indexed: 03/08/2024]
Abstract
The DREAMS partnership aims to deliver a comprehensive package to reduce HIV incidence among adolescent girls and young women (AGYW), including through shifting gender norms. We evaluate DREAMS' effect on attitudes towards gender norms in two Kenyan settings. AGYW aged 15-22 in Nairobi (n = 852) and Gem (n = 761) were randomly selected for cohort enrolment in 2017-18 and followed-up to 2019. We described the proportion of AGYW and their male peers with equitable attitudes towards gender norms, using an adapted version of the GEM scale. We estimated the association between self-reported invitation to DREAMS (in 2017-18) and AGYW's attitudes towards two dimensions of gender norms, and then applied a causal inference framework to estimate the difference in the proportion of AGYW with equitable attitudes under the counterfactual scenarios that all versus none were DREAMS beneficiaries. We estimated that overall, 90.2% versus 87.1% of AGYW would have equitable norms around sexual and reproductive health decision-making in Nairobi if all versus none were DREAMS beneficiaries (+3.1; 95%CI:-2.5, +9.0). In Gem, we estimated a risk difference of +1.0 (89.6% vs 88.6%, 95%CI: -3.6,+5.6). There was no evidence for an effect of DREAMS on attitudes towards violence-related norms (Nairobi: 82.7% vs 82.2%, +0.5; 95%CI: -5.3,+6.5; Gem: 44.3% vs 48.2%, -3.9; 95%CI: -11.7,+3.0). We found no evidence of an impact of DREAMS invitation on individual attitudes towards gender norms. In some cases, equitable attitudes at enrolment left limited scope for improvement, and additional effort may be required to shift inequitable violence attitudes among both AGYW and their male peers.
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Affiliation(s)
- Kate Andrews Nelson
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Faith Magut
- Kenya Medical Research Institute, Kisumu, Kenya
| | - Sarah Mulwa
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
- African Population and Health Research Center, Nairobi, Kenya
| | - Jane Osindo
- African Population and Health Research Center, Nairobi, Kenya
| | | | | | - Julie Pulerwitz
- Population Council, Washington, D.C., United States of America
| | - Sarah Cook
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Annabelle Gourlay
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Abdhalah Ziraba
- African Population and Health Research Center, Nairobi, Kenya
| | | | - Sian Floyd
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Isolde Birdthistle
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
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Rosen JG, Musheke M, Mulenga D, Namukonda ES, Jani N, Mbizvo MT, Pulerwitz J, Mathur S. Multisectoral, Combination HIV Prevention for Adolescent Girls and Young Women: A Qualitative Study of the DREAMS Implementation Trajectory in Zambia. GLOBAL HEALTH, SCIENCE AND PRACTICE 2022; 10:GHSP-D-22-00089. [PMID: 36316147 PMCID: PMC9622277 DOI: 10.9745/ghsp-d-22-00089] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 09/13/2022] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To identify solutions to the implementation challenges with the DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe women) Partnership in Zambia, this study examines the rollout and evolution of the DREAMS Partnership's implementation. METHODS In September-October 2018, implementing partner (IP) staff (n=15) and adolescent girls and young women (AGYW) participating in DREAMS programming (n=32) completed in-depth interviews exploring early rollout and scale-up of DREAMS, experiences with program participation, and shifting service delivery approaches in response to emerging implementation challenges. Inductive and deductive thematic analysis of 47 interviews uncovered salient service delivery facilitators and barriers in the first 2 years of DREAMS implementation, which were subsequently mapped onto the following domains: reach, effectiveness, adoption, implementation, and maintenance. RESULTS Key implementation successes identified by IP staff included using standardized recruitment and risk assessment tools across IP organizations, using a mentor model for delivering program content to AGYW, and offering centralized service delivery at venues accessible to AGYW. Implementation challenges identified early in the DREAMS Partnership's lifecycle were rectified through adaptive service delivery strategies. Monthly in-person coordination meetings were established to resolve IP staff jurisdictional disputes over recruitment and target setting. To address high participant attrition, IP staff adopted a cohort approach to sequentially recruit AGYW who enrolled together and provided social support to one another to sustain involvement in DREAMS programming. Prominent barriers to implementation fidelity included challenges recruiting the highest-risk AGYW (e.g., those out of school), limited resources to incentivize participation by young women, and inadequate planning to facilitate absorption of individual DREAMS interventions by the public sector upon project conclusion. CONCLUSIONS Delivering multisectoral HIV prevention programs like DREAMS with fidelity requires a robust implementation infrastructure (e.g., adaptable workplans and harmonized record management systems), early coordination between IP organizations, and sustained financial commitments from donors.
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Affiliation(s)
- Joseph G. Rosen
- Population Council, Lusaka, Zambia.,Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Correspondence to Joseph Rosen ()
| | | | | | | | - Nrupa Jani
- Social and Behavioral Research, Population Council, Washington, DC, USA
| | | | - Julie Pulerwitz
- Social and Behavioral Research, Population Council, Washington, DC, USA
| | - Sanyukta Mathur
- Social and Behavioral Research, Population Council, Washington, DC, USA
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Gumede D, Meyer-Weitz A, Zuma T, Shahmanesh M, Seeley J. A qualitative investigation of facilitators and barriers to DREAMS uptake among adolescents with grandparent caregivers in rural KwaZulu-Natal, South Africa. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000369. [PMID: 36962500 PMCID: PMC10022343 DOI: 10.1371/journal.pgph.0000369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 08/31/2022] [Indexed: 06/18/2023]
Abstract
Adolescents with grandparent caregivers have experienced challenges including the death of one or both parents due to HIV in sub-Saharan Africa. They may be left out of existing HIV prevention interventions targeting parents and children. We investigated the facilitators and barriers to DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored and Safe) programme uptake among adolescents with grandparent caregivers across different levels of the socio-ecological model in rural South Africa. Data were collected in three phases (October 2017 to September 2018). Adolescents (13-19 years old) and their grandparent caregivers (≥50 years old) (n = 12) contributed to repeat in-depth interviews to share their perceptions and experiences regarding adolescents' participation in DREAMS. Data were triangulated using key informant interviews with DREAMS intervention facilitators (n = 2) to give insights into their experiences of delivering DREAMS interventions. Written informed consent or child assent was obtained from all individuals before participation. All data were collected in isiZulu and audio-recorded, transcribed verbatim and translated into English. Thematic and dyadic analysis approaches were conducted guided by the socio-ecological model. Participation in DREAMS was most effective when DREAMS messaging reinforced existing norms around sex and sexuality and when the interventions improved care relationships between the adolescents and their older caregivers. DREAMS was less acceptable when it deviated from the norms, raised SRH information that conflicts with abstinence and virginity, and when youth empowerment was perceived as a potential threat to intergenerational power dynamics. While DREAMS was able to engage these complex families, there were failures, about factors uniquely critical to these families, such as in engaging children and carers with disabilities and failure to include adolescent boys in some interventions. There is a need to adapt HIV prevention interventions to tackle care relationships specific to adolescent-grandparent caregiver communication.
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Affiliation(s)
- Dumile Gumede
- Centre for General Education, Durban University of Technology, Durban, South Africa
- Africa Health Research Institute, KwaZulu-Natal, Durban, South Africa
| | - Anna Meyer-Weitz
- School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Thembelihle Zuma
- Africa Health Research Institute, KwaZulu-Natal, Durban, South Africa
| | - Maryam Shahmanesh
- Africa Health Research Institute, KwaZulu-Natal, Durban, South Africa
- Institute for Global Health, University College London, London, United Kingdom
| | - Janet Seeley
- Africa Health Research Institute, KwaZulu-Natal, Durban, South Africa
- London School of Hygiene and Tropical Medicine, London, United Kingdom
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Bhushan NL, Stoner MCD, Groves AK, Kahn K, Pettifor AE. Partnership Dynamics and HIV-Related Sexual Behaviors Among Adolescent Mothers in South Africa: A Longitudinal Analysis of HIV Prevention Trials Network 068 Data. J Adolesc Health 2022; 71:63-69. [PMID: 35370076 PMCID: PMC9232891 DOI: 10.1016/j.jadohealth.2022.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 01/26/2022] [Accepted: 02/03/2022] [Indexed: 11/16/2022]
Abstract
PURPOSE In South Africa, adolescent mothers have a three times higher risk of HIV acquisition than nonadolescent mothers. Yet, limited evidence exists regarding how early childbearing may affect HIV risk. A better understanding of adolescent mothers' partnership dynamics and sexual behaviors is critical to tailoring interventions to prevent new infections. METHODS Data are from HIV Prevention Trials Network 068, a longitudinal study of adolescent girls and young women (AGYW) aged 13-20 in South Africa who were followed annually for up to 6 years. Log-binomial regression models were used to assess whether adolescent motherhood was associated with partnership dynamics (intimate partner violence, gender inequitable norms, low relationship power, no HIV prevention communication) and if the association between partnership dynamics and sexual behaviors (unprotected sex and transactional sex) varied by adolescent motherhood. Generalized estimating equations, with an exchangeable correlation structure, were used to account for nonindependence. RESULTS Adolescent mothers were more likely than nonadolescent mothers to be in partnerships characterized by intimate partner violence, low relationship power, gender inequitable norms, and no HIV prevention communication. A higher proportion were also more likely to experience these dynamics, as well as engage in transactional sex, after giving birth. Poor partnership dynamics put AGYW at a higher risk for unprotected sex and transactional sex, regardless of adolescent motherhood status. DISCUSSION Engaging adolescent mothers in interventions post birth and developing interventions that address power imbalances in AGYW's sexual partnerships have the potential to reduce engagement in HIV-related sexual behaviors and HIV risk in the long term.
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Affiliation(s)
- Nivedita L Bhushan
- Center for Communication Science, RTI International, Research Triangle Park, North Carolina.
| | - Marie C D Stoner
- Women's Global Health Imperative, RTI International, San Francisco, California
| | - Allison K Groves
- Department of Community Health and Prevention, Drexel University, Philadelphia, Pennsylvania
| | - Kathleen Kahn
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, South Africa
| | - Audrey E Pettifor
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, South Africa; Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Gottert A, Pulerwitz J, Heck CJ, Shabangu P, Lukhele B, Cawood C, Khanyile D, Apicella L, Okal J, Mathur S. Inroads for HIV prevention among men: findings from mixed methods research in the context of the DREAMS partnership in Southern Africa. AIDS 2022; 36:S85-S97. [PMID: 35766578 DOI: 10.1097/qad.0000000000003225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess trends in men's HIV risk factors and service use, and their experiences with prevention programming, during an intensive HIV response for adolescent girls and young women and their male partners. DESIGN Independent cross-sectional surveys in 2016-2017 and 2018 with men in Eswatini (20-34 years-old, n = 1391) and Durban, South Africa (20-40 years-old; n = 1665), complemented by 74 in-depth interviews (IDIs) with men exposed to HIV services/prevention programming. METHODS Survey recruitment was primarily at hot-spot venues. We assessed Round 1-2 trends in HIV risk factors and service use, overall and by HIV risk profiles. IDI respondents were identified via survey responses or program partners. RESULTS HIV risk factors were prevalent in both countries at each survey round, although there were reductions over time among the highest risk profiles in South Africa. Most men were engaged in HIV services (e.g. nearly two-thirds tested for HIV in the last year at round 2, with large increases in Eswatini). Qualitative data suggest HIV service uptake was facilitated by increased convenience and supportive information/messaging about HIV treatment efficacy. Men described eagerly receiving the information and support offered in HIV prevention programming, and effects on HIV risk reduction and newly engaging in HIV services. However, less than 15% of survey respondents reported being reached by such programming. CONCLUSION Important inroads have been made to engage men in HIV services and prevention programming in the two countries, including among the high-risk profiles. Still, improving coverage of comprehensive HIV prevention programming is critical, particularly for men most at risk.
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Affiliation(s)
| | | | - Craig J Heck
- Mailman School of Public Health, Columbia University, New York, NY, USA
| | | | | | - Cherie Cawood
- Epicentre Health Research, Pietermaretzburg, South Africa
| | - David Khanyile
- Epicentre Health Research, Pietermaretzburg, South Africa
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Birdthistle I, Kwaro D, Shahmanesh M, Baisley K, Khagayi S, Chimbindi N, Kamire V, Mthiyane N, Gourlay A, Dreyer J, Phillips-Howard P, Glynn J, Floyd S. Evaluating the impact of DREAMS on HIV incidence among adolescent girls and young women: A population-based cohort study in Kenya and South Africa. PLoS Med 2021; 18:e1003837. [PMID: 34695112 PMCID: PMC8880902 DOI: 10.1371/journal.pmed.1003837] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 02/25/2022] [Accepted: 10/05/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Through a multisectoral approach, the DREAMS Partnership aimed to reduce HIV incidence among adolescent girls and young women (AGYW) by 40% over 2 years in high-burden districts across sub-Saharan Africa. DREAMS promotes a combination package of evidence-based interventions to reduce individual, family, partner, and community-based drivers of young women's heightened HIV risk. We evaluated the impact of DREAMS on HIV incidence among AGYW and young men in 2 settings. METHODS AND FINDINGS We directly estimated HIV incidence rates among open population-based cohorts participating in demographic and HIV serological surveys from 2006 to 2018 annually in uMkhanyakude (KwaZulu-Natal, South Africa) and over 6 rounds from 2010 to 2019 in Gem (Siaya, Kenya). We compared HIV incidence among AGYW aged 15 to 24 years before DREAMS and up to 3 years after DREAMS implementation began in 2016. We investigated the timing of any change in HIV incidence and whether the rate of any change accelerated during DREAMS implementation. Comparable analyses were also conducted for young men (20 to 29/34 years). In uMkhanyakude, between 5,000 and 6,000 AGYW were eligible for the serological survey each year, an average of 85% were contacted, and consent rates varied from 37% to 67%. During 26,395 person-years (py), HIV incidence was lower during DREAMS implementation (2016 to 2018) than in the previous 5-year period among 15- to 19-year-old females (4.5 new infections per 100 py as compared with 2.8; age-adjusted rate ratio (aRR) = 0.62, 95% confidence interval [CI] 0.48 to 0.82), and lower among 20- to 24-year-olds (7.1/100 py as compared with 5.8; aRR = 0.82, 95% CI 0.65 to 1.04). Declines preceded DREAMS introduction, beginning from 2012 to 2013 among the younger and 2014 for the older women, with no evidence of more rapid decline during DREAMS implementation. In Gem, between 8,515 and 11,428 AGYW were eligible each survey round, an average of 34% were contacted and offered an HIV test, and consent rates ranged from 84% to 99%. During 10,382 py, declines in HIV incidence among 15- to 19-year-olds began before DREAMS and did not change after DREAMS introduction. Among 20- to 24-year-olds in Gem, HIV incidence estimates were lower during DREAMS implementation (0.64/100 py) compared with the pre-DREAMS period (0.94/100 py), with no statistical evidence of a decline (aRR = 0.69, 95% CI 0.53 to 2.18). Among young men, declines in HIV incidence were greater than those observed among AGYW and also began prior to DREAMS investments. Study limitations include low study power in Kenya and the introduction of other interventions such as universal treatment for HIV during the study period. CONCLUSIONS Substantial declines in HIV incidence among AGYW were observed, but most began before DREAMS introduction and did not accelerate in the first 3 years of DREAMS implementation. Like the declines observed among young men, they are likely driven by earlier and ongoing investments in HIV testing and treatment. Longer-term implementation and evaluation are needed to assess the impact of such a complex HIV prevention intervention and to help accelerate reductions in HIV incidence among young women.
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Affiliation(s)
- Isolde Birdthistle
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Daniel Kwaro
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Maryam Shahmanesh
- Africa Health Research Institute, Mtubatuba, KwaZulu-Natal, South Africa
- Institute for Global Health, University College London Institute of Child Health, London, United Kingdom
| | - Kathy Baisley
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Africa Health Research Institute, Mtubatuba, KwaZulu-Natal, South Africa
| | - Sammy Khagayi
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Natsayi Chimbindi
- Africa Health Research Institute, Mtubatuba, KwaZulu-Natal, South Africa
| | - Vivienne Kamire
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Nondumiso Mthiyane
- Africa Health Research Institute, Mtubatuba, KwaZulu-Natal, South Africa
| | - Annabelle Gourlay
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Jaco Dreyer
- Africa Health Research Institute, Mtubatuba, KwaZulu-Natal, South Africa
| | - Penelope Phillips-Howard
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Judith Glynn
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Sian Floyd
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
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Mulwa S, Chimoyi L, Agbla S, Osindo J, Wambiya EO, Gourlay A, Birdthistle I, Ziraba A, Floyd S. Impact of the DREAMS interventions on educational attainment among adolescent girls and young women: Causal analysis of a prospective cohort in urban Kenya. PLoS One 2021; 16:e0255165. [PMID: 34383805 PMCID: PMC8360512 DOI: 10.1371/journal.pone.0255165] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 07/09/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND DREAMS promotes a comprehensive HIV prevention approach to reduce HIV incidence among adolescent girls and young women (AGYW). One pathway that DREAMS seeks to impact is to support AGYW to stay in school and achieve secondary education. We assessed the impact of DREAMS on educational outcomes among AGYW in Nairobi, Kenya. METHODS AND FINDINGS In two informal settlements in Nairobi, 1081 AGYW aged 15-22 years were randomly selected in 2017 and followed-up to 2019. AGYW reporting invitation to participate in DREAMS during 2017-18 were classified as "DREAMS beneficiaries". Our main outcome was being in school and/or completed lower secondary school in 2019. We used multivariable logistic regression to quantify the association between being a DREAMS beneficiary and the outcome; and a causal inference framework to estimate proportions achieving the outcome if all, versus no, AGYW were DREAMS beneficiaries, adjusting for the propensity to be a DREAMS beneficiary. Of AGYW enrolled in 2017, 79% (852/1081) were followed-up to 2019. In unadjusted analysis, DREAMS beneficiaries had higher attainment than non-beneficiaries (85% vs 75% in school or completed lower secondary school, Odds Ratio (OR) = 1.9; 95%CI: 1.3,2.8). The effect weakened with adjustment for age and other confounders, (adjusted OR = 1.4; 95%CI: 0.9,2.4). From the causal analysis, evidence was weak for an impact of DREAMS (estimated 83% vs 79% in school or completed lower secondary school, if all vs no AGYW were beneficiaries, difference = 4%; 95%CI: -2,11%). Among AGYW out of school at baseline, the estimated differences were 21% (95%CI: -3,43%) among 15-17 year olds; and 4% (95%CI: -8,17%) among 18-22 year olds. CONCLUSIONS DREAMS had a modest impact on educational attainment among AGYW in informal settlements in Kenya, by supporting both retention and re-enrolment in school. Larger impact might be achieved if more AGYW were reached with educational subsidies, alongside other DREAMS interventions.
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Affiliation(s)
- Sarah Mulwa
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
- African Population and Health Research Center, Nairobi, Kenya
| | - Lucy Chimoyi
- Research Management Department, The Aurum Institute, Johannesburg, South Africa
| | - Schadrac Agbla
- Department of Health Data Science, University of Liverpool, Liverpool, United Kingdom
| | - Jane Osindo
- African Population and Health Research Center, Nairobi, Kenya
| | | | - Annabelle Gourlay
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Isolde Birdthistle
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Abdhalah Ziraba
- African Population and Health Research Center, Nairobi, Kenya
| | - Sian Floyd
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
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Atkins K, Rucinski K, Mudavanhu M, Holmes L, Mutunga L, Kaufman MR, Bassett J, Van Rie A, Schwartz SR. Sexual Relationship Types, Partner HIV Self-Testing, and Pre-Exposure Prophylaxis Among South African Adolescent Girls and Young Women: A Latent Class Analysis. J Acquir Immune Defic Syndr 2021; 86:413-421. [PMID: 33196552 PMCID: PMC10358829 DOI: 10.1097/qai.0000000000002569] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 09/28/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Sexual relationships among adolescent girls and young women (AGYW) are influenced by social, economic, and gender dynamics. Understanding AGYW's different relationship types and their implications for HIV risk is important for development of tailored interventions. We sought to identify relationship typologies among AGYW and their impact on uptake of HIV prevention interventions. METHODS From May 2018 to February 2019, 2200 HIV-negative AGYW (ages 16-24) in Johannesburg, South Africa, participated in an HIV prevention intervention involving distribution of HIV self-test kits to their male partners. AGYW were also offered pre-exposure prophylaxis. At baseline, AGYW completed a questionnaire, and outcomes were assessed for 3 months. We used latent class analysis to identify relationship types and mixture modeling to estimate the impact of relationship type on engagement in prevention interventions. RESULTS We identified 3 relationship types: "stable, empowered relationships with older partners" (class 1, n = 973); "shorter, empowered relationships with peer partners" (class 2, n = 1067); and "shorter relationships with risky partners" (class 3, n = 160). Compared with AGYW in class 1 relationships, AGYW in class 2 and 3 relationships were less likely to complete partner testing alongside HIV results sharing (class 2 adjusted risk ratio: 0.89, 95% confidence interval: 0.85 to 0.95; class 3 adjusted risk ratio: 0.84, 95% confidence interval: 0.73 to 0.94). Pre-exposure prophylaxis uptake was highest in class 3 (11.2%) compared with class 2 (3.8%) and class 1 (1.0%; P < 0.001). CONCLUSIONS Relationship type impacts uptake of HIV prevention interventions among South African youth. Intervention effectiveness could be optimized by using tailored approaches to HIV risk mitigation among AGYW.
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Affiliation(s)
- Kaitlyn Atkins
- Social and Behavioral Interventions Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Katherine Rucinski
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | | | - Leah Holmes
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | | | - Michelle R. Kaufman
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | | | - Annelies Van Rie
- Department of Epidemiology and Social Medicine, University of Antwerp, Antwerp, Belgium
| | - Sheree R. Schwartz
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
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The Nairobi Urban Health and Demographic Surveillance of slum dwellers, 2002–2019: Value, processes, and challenges. GLOBAL EPIDEMIOLOGY 2020. [DOI: 10.1016/j.gloepi.2020.100024] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Variations in HIV Risk by Young Women's Age and Partner Age Disparity in Rural South Africa (HPTN 068). J Acquir Immune Defic Syndr 2020; 83:350-356. [PMID: 31904708 DOI: 10.1097/qai.0000000000002270] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Nearly all population-level research showing positive associations between age-disparate partnerships and HIV acquisition among adolescent girls and young women (AGYW) has classified age disparity as ≥5 or ≥10 years. We describe variations in 1-year risk of HIV infection after exposure to sexual partner(s) of continuous age disparities. METHODS Longitudinal data from the HPTN 068 randomized trial in South Africa were used to estimate 1-year risk of HIV infection at various age pairings. The parametric g-formula was used to estimate risk at up to 5 annual time points, stratified by maximum partner age difference, maximum partner age, and AGYW age. RESULTS AGYW reported an older partner in 86% of 5351 age pairings. The 1-year risk of HIV infection rapidly increased with maximum partner age difference among girls ages 13-14 years, from 0·01 with a same-age partner, to 0·21 with a partner 10 years older, and 0·24 with a partner 15 years older. A gradual increase occurred among AGYW ages 15-16 years, up to 0·13 with a partner 15 years older, and 0·09 among AGYW 17-18 years with partners 8-11 years older. Risk of HIV infection among AGYW ages 19-21 years remained relatively constant across maximum partner age differences. CONCLUSIONS Age differences between AGYW and their sexual partners have a greater effect on HIV-risk infection in younger compared with older AGYW. Considering both the age of an AGYW and her sexual partners provides granular insight into identifying key groups for HIV transmission prevention efforts.
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Thior I, Rowley E, Mavhu W, Kruse-Levy N, Messner L, Falconer-Stout ZJ, Mugurungi O, Ncube G, Leclerc-Madlala S. Urban-rural disparity in sociodemographic characteristics and sexual behaviors of HIV-positive adolescent girls and young women and their perspectives on their male sexual partners: A cross-sectional study in Zimbabwe. PLoS One 2020; 15:e0230823. [PMID: 32324764 PMCID: PMC7179911 DOI: 10.1371/journal.pone.0230823] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Accepted: 03/09/2020] [Indexed: 11/19/2022] Open
Abstract
We conducted a cross sectional survey in Zimbabwe to describe urban-rural disparity in socio-demographic characteristics and sexual behaviors of HIV-positive adolescent girls and young women (AGYW) and their male sexual partners. Between September and November 2016, we interviewed 360 sexually active HIV positive AGYW, aged 15––24 years attending ART and PMTCT clinics in urban and rural health facilities in Harare and Mazowe district respectively. HIV positive AGYW in rural areas as compared to those in urban areas were older, less educated, more frequently married or cohabiting, had lower number of male sexual partners in their lifetime and in the last 12 months preceding the survey. They were mostly heterosexually infected, more likely to disclose their status to a family member and to be more adherent to ART (OR = 2.5–95% CI = 1.1–5.5). Most recent male sexual partners of HIV positive AGYW in urban areas as compared to those from rural areas were mainly current or former boyfriends, single, more educated, less likely to have a child with them and to engage in couple voluntary counseling and testing (CVCT). They were more likely to patronize dancing and drinking venues and involved in transactional sex (OR = 2.2–95% CI: 1.2–4). They were also more likely to be circumcised (OR = 2.3–95% CI: 1.3–4.1) and to use condom more consistently in the last 12 months preceding the survey. Our study findings called for the strengthening of HIV prevention interventions in urban areas among HIV positive AGYW who had more than one partner in their lifetime or are patronizing dancing and drinking venues. In Zimbabwe, promotion of CVCT, index testing, male circumcision and condom use should be sustained to engage male sexual partners of both urban and rural HIV positive AGYW in HIV prevention.
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Affiliation(s)
- Ibou Thior
- PATH, Washington, D.C, United States of America
- * E-mail:
| | | | - Webster Mavhu
- Centre for Sexual Health & HIV/AIDS Research, Harare, Zimbabwe
| | | | - Lyn Messner
- EnCompass LLC, Rockville, Maryland, United States of America
| | | | - Owen Mugurungi
- AIDS and TB, Ministry of Health and Child Care, Harare, Zimbabwe
| | - Getrude Ncube
- AIDS and TB, Ministry of Health and Child Care, Harare, Zimbabwe
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Gourlay A, Birdthistle I, Mthiyane NT, Orindi BO, Muuo S, Kwaro D, Shahmanesh M, Baisley K, Ziraba A, Floyd S. Awareness and uptake of layered HIV prevention programming for young women: analysis of population-based surveys in three DREAMS settings in Kenya and South Africa. BMC Public Health 2019; 19:1417. [PMID: 31666043 PMCID: PMC6824290 DOI: 10.1186/s12889-019-7766-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 10/11/2019] [Indexed: 12/25/2022] Open
Abstract
Background The DREAMS Partnership is an ambitious effort to deliver combinations of biomedical, behavioural and structural interventions to reduce HIV incidence among adolescent girls and young women (AGYW). To inform multi-sectoral programming at scale, across diverse settings in Kenya and South Africa, we identified who the programme is reaching, with which interventions and in what combinations. Methods Randomly-selected cohorts of 606 AGYW aged 10–14 years and 1081 aged 15–22 years in Nairobi and 2184 AGYW aged 13–22 years in uMkhanyakude, KwaZulu-Natal, were enrolled in 2017, after ~ 1 year of DREAMS implementation. In Gem, western Kenya, population-wide cross-sectional survey data were collected during roll-out in 2016 (n = 1365 AGYW 15–22 years). We summarised awareness and invitation to participate in DREAMS, uptake of interventions categorised by the DREAMS core package, and uptake of a subset of ‘primary’ interventions. We stratified by age-group and setting, and compared across AGYW characteristics. Results Awareness of DREAMS was higher among younger women (Nairobi: 89%v78%, aged 15-17v18–22 years; uMkhanyakude: 56%v31%, aged 13-17v18–22; and Gem: 28%v25%, aged 15-17v18–22, respectively). HIV testing was the most accessed intervention in Nairobi and Gem (77% and 85%, respectively), and school-based HIV prevention in uMkhanyakude (60%). Among those invited, participation in social asset building was > 50%; > 60% accessed ≥2 core package categories, but few accessed all primary interventions intended for their age-group. Parenting programmes and community mobilisation, including those intended for male partners, were accessed infrequently. In Nairobi and uMkhanyakude, AGYW were more likely to be invited to participate and accessed more categories if they were: aged < 18 years, in school and experienced socio-economic vulnerabilities. Those who had had sex, or a pregnancy, were less likely to be invited to participate but accessed more categories. Conclusions In representative population-based samples, awareness and uptake of DREAMS were high after 1 year of implementation. Evidence of ‘layering’ (receiving multiple interventions from the DREAMS core package), particularly among more socio-economically vulnerable AGYW, indicate that intervention packages can be implemented at scale, for intended recipients, in real-world contexts. Challenges remain for higher coverage and greater ‘layering’, including among older, out-of-school AGYW, and community-based programmes for families and men.
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Affiliation(s)
- Annabelle Gourlay
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | - Isolde Birdthistle
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | | | | | - Sheru Muuo
- Africa Population and Health Research Center, Nairobi, Kenya
| | - Daniel Kwaro
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Maryam Shahmanesh
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa.,Institute for Global Health, University College London, London, UK
| | - Kathy Baisley
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.,Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
| | - Abdhalah Ziraba
- Africa Population and Health Research Center, Nairobi, Kenya
| | - Sian Floyd
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
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