HIV among out-of-school youth in Eastern and Southern Africa: a review

School Dropout, Absenteeism and Coverage of Sexual and Reproductive Health Services in South Africa: Are Those Most at Risk Reached?

School attendance or completion is important for adolescents' development. Adolescents who drop out or are regularly absent from school are at higher risk of adverse sexual and reproductive health (SRH) outcomes. However, there is little evidence evaluating SRH service coverage among adolescents in and out of school. In the context of a large-scale combination HIV and pregnancy prevention intervention funded by the Global Fund, we compared the SRH intervention coverage and SRH risks among adolescent girls who dropped out of school with those who were still in school or who had completed grade 12 in South Africa. Among those still in school, we compared the SRH intervention coverage and SRH risk profiles of those with high versus low or no absenteeism. In 2017 to 2018, we conducted a household survey of adolescent girls aged 15 to 19 years in six of the ten combination intervention districts. Of 2515 participants, 7.6% had dropped out of school. Among the 1864 participants still in school, 10.8% had high absenteeism. Ever having had sex, and condomless sex were more prevalent among dropouts compared with non-dropouts. Dropouts were more likely to access SRH services such as condoms and contraceptives, except the combination prevention intervention services which were more likely to reach those who had not dropped out and were equally likely to reach those in school with high versus low/no absenteeism. Combination SRH prevention programmes can improve the accessibility of SRH services for adolescents in school/who complete school.

HIV, syphilis and sexual-risk behaviours' prevalence among in-and out-of-school adolescent girls and young women in Zambia: A cross-sectional survey study

BACKGROUND

In Zambia, 3.8% of young women and men aged 15-24 are HIV positive. However, like in most developing nations, HIV prevalence is higher among young women than young men (5.6% versus 1.8%). Despite the recognition of the rights of young people to sexual reproductive health (SRH) information and services, adolescent and young people (AYP) still face challenges in accessing healthcare in public health institutions including access to comprehensive knowledge on HIV/AIDs, HIV testing and contraceptives. The overall objective of the study was to collect baseline HIV, SRH and gender based violence (GBV) data at district level to inform the design of interventions targeting adolescent girls and young women (AGYW) aged 10-24 years in 20 districts of Zambia.

METHODS

A cross-sectional, mixed-methods study was conducted in 20 districts of Zambia with the highest incidence of HIV. Data was collected between August and October 2022 with a total response rate of 92% (12,813/13960), constituting 5979 (46.7%) in-school and 6834 (53.3%) out-of-school participants.

RESULTS

Overall, Mwinilunga, Chinsali, Chisamba and Chembe districts had the highest number of respondents, while Sinazongwe and Mungwi districts contributed the least. The overall age distribution was such that 12.6% (n = 1617) of those interviewed were aged 10 to 14 years, 35.4% (n = 4536) were aged 15-19 years, and 52.0% (n = 6660) were aged 20-24 years. The overall mean age at first sex among AGYW interviewed was 16.6 years which was broken down as follows: 16.2 years for in-school and 16.8 years for out of school. Overall, most of the respondents had first time sex with either their boyfriend (80.4%) or husband (15.6%), with 2.4% of the in-school participants reporting to have had their sexual debut in marriage compared to 21.0% among out-of-school AGYW. Prevalence of HIV was higher in the out-of-school compared to the in-school participants (5.5% vs 2.0%), Similarly, the prevalence of syphilis was higher in the out-of-school than the in-school participants (4.1% vs 1.5%).

CONCLUSION

The study focused on assessing the prevalence and vulnerability of HIV, syphilis, GBV, and SRH services uptake among adolescent girls and young women, and exploring factors affecting girls' stay-in-school and re-engagement. The study found that HIV and syphilis are still significant public health problems among adolescent girls and young women in Zambia, emphasizing the need for increased efforts to prevent and manage these infections.

Interventions connecting young people living in Africa to healthcare; a systematic review using the RE-AIM framework

Introduction

Africa's young people are among the least focused groups in healthcare linkage. The disproportionally high burden of youth-related health problems is a burden, especially in developing regions like Africa, which have a high population of young people. More information is needed about factors that impact linkages in healthcare and the sustainability of health interventions among young people in Africa.

Methods

A systematic literature search was performed from October 2020 to May 2022 in PubMed, CINAHL, Scopus, Global Health, and the Web of Science. Studies included in the review were conducted among young people aged 10-24 living in Africa, written in English, and published between 2011 and 2021. Results were reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Data was analyzed using narrative synthesis, synthesizing the details of the RE-AIM reporting component. Interventions were systematically compared using the Cochrane Collaboration risk-of-bias tool to evaluate the rigor of each intervention.

Results

A total of 2,383 potentially relevant citations were obtained after an initial database search. Retained in the final group were seventeen articles from electronic data searches; among these articles, 16 interventions were identified. Out of the seventeen studies, nine (53%) were randomized controlled trials, three (18%) were quasi-experimental designs, and five (29%) were observational studies. At the same time, the included interventions were reported on 20 (76.92%) of the 26 components of the RE-AIM dimensions. In eastern Africa, twelve (80%) interventions were conducted, and all the interventions addressed linkage to care for young people in preventing and treating HIV. The least reported RE-AIM dimensions were implementing and maintaining interventions connecting young people to care.

Discussion

Timely care remains critical to treating and preventing ailments. This review indicates that interventions created to link young people to care, especially HIV care, can help link them to health care and strengthen the programs. It is also clear that further research with more extended follow-up periods is needed to examine connections to care in all other aspects of health and to bridge the gap between research and practice in the care of young people in Africa.

Systematic Review Registration

PROSPERO [CRD42022288227].

Awareness, Utilization and Perception of Sexually Transmitted Infections Services Provided to Out-of-School-Youth in Primary Health Facilities in Tshwane, South Africa

BACKGROUND

Despite the availability of different health care initiatives and interventions, young people are still faced with barriers in accessing reproductive health care services; thus, they are exposed to health-related issues such as sexually transmitted infections.

AIM

To determine the awareness, utilization and perceptions about sexually transmitted infections services provided to out-of-school-youth in primary health facilities in the Tshwane district, Gauteng Province, South Africa.

METHODS

The study employed a quantitative, cross-sectional descriptive survey with a sample size of 219 to determine the level of awareness, utilization and perceptions about sexually transmitted infections services provided to out-of-school-youth in Tshwane district.

RESULTS

Out-of-school-youth between the ages of 18-24 years participated in the study. Most of the participants (90.8%, n = 199) were female. Service utilization was high in females compared to their male counterparts. There is availability of youth-friendly services in primary health care facilities, however, the level of service utilization among young people is still a challenge evidenced by 12.1% (n = 74) of participants who never sought treatment for STIs, although they had STI symptoms. Furthermore, 52.0% reported that they were not happy with the health services they received when they had STIs. These findings clearly indicate a gap in service delivery for young people regarding reproductive health issues; thus, the low health care seeking behavior among the youth. Condom use was 69.1% and/or inconsistently used among the youth; about 80% of the participants had low perceptions of the risk of contracting STIs. The self-reported risks of HIV and AIDS was 46.8%. Approximately 20% reported that they would not refuse to have sex if their partner did not want to use condoms. These findings showed risky behavior among the participants, and shows that the level of awareness about the risk of contracting STIs is still poor.

CONCLUSIONS

Irrespective of facilities with youth-friendly services, out-of-school-youth still display poor perceptions about sexually transmitted infections services due to health care providers' attitudes, limited resources, and working hours. Furthermore, the level of awareness regarding sexually transmitted infections is poor, hence the display of risky sexual behaviors.

Differences in Sexual Behavior and Partner Notification for Sexually Transmitted Infections Between the Out of School Youth and University Students in a Peri-Urban District in South Africa-A Cross-Sectional Survey

The increase in sexually transmitted infections (STIs) in young people is a public health concern. Among those in university and out of school, different contextual factors contribute to their risky sexual behavior and increased susceptibility to STIs and HIV. There are limited comparative studies examining risky sexual behavior and partner notification (PN) between these two groups, particularly in South Africa. We investigated sexual behaviors, self-reported STI diagnosis, health seeking behavior, and preferred PN methods of university students and out of school youth. A descriptive cross-sectional survey was used using convenient sampling to select 917 students across five health sciences universities and through periodic sampling 699 out of school youth were selected from two main local shopping centers in South Africa. Descriptive statistics, bivariate and multivariable logistic analysis were performed using Stata IC version 14. More university students (71.7%) than out of school youth were in casual relationships (28.3%), with half of out of school youth being in steady relations (50.2%). Moreover, university students (65.7%) used a condom in the past 6 months compared to their counterparts (34.3%). Of the 124 youth who were diagnosed with STI in the past 12 months, majority (n = 106, 85%) were out of school youth. The probability of notifying a partner about a STI infection was 82% among university students compared to their counterparts (p = >0.05). The odds of notifying a partner was 1.79 times more for those having multiple sexual partners than those who had only one partner. Both groups preferred a face-to-face STI disclosure with partner; however, more university students (67%) preferred SMS notification than PN referral slips as compared to out of school youth (42%). Both the university students and the out of school youth engaged in risky sexual behaviors. Both groups preferred face-to-face and clinic SMS partner notifications, even though university students were in the majority. There is a need for developing health promotion scripts on disclosing STIs to sexual partners to empower the majority of the youth who prefer face-to-face PN over the prescribed methods.

Teenage childbearing and school dropout in a sample of 18,791 single mothers in Cameroon

Background

Adolescent childbearing increases the risk of adverse health and social consequences including school dropout (SDO). However, it remains unclear why some teenage mothers drop out of school and others do not, especially in sub-Saharan Africa settings. We aimed to investigate the background and behavioral characteristics of single mothers, associated with school dropout in a sample of 18,791 Cameroonian girls, who had their first child during adolescence.

Methods

We used data from a national registry of single mothers, collected during the years 2005–2008 and 2010–2011. Both bivariate analysis and logistic binary regression models were used to explore the relationship between adolescence motherhood and SDO controlling for a range of socio-economic, family, sexual and health seeking behavior characteristics.

Results

Among the 18,791 single mothers, 41.6% had dropped out of school because of pregnancy. The multivariable regression model showed that SDO was more common in those who were evicted from their parental home (aOR: 1.85; 95% CI: 1.69–2.04), those who declared having other single mothers in their family (aOR: 1.16; 95% CI 1.08–1.25) and in mothers who had their first child before 15. Using modern contraceptive methods, having declared no sexual partner during the last year and having less than 2 children were associated with a reduced likelihood of school dropout.

Conclusions

Strong social support is essential to ensure school continuity in this vulnerable population. Dropping out of school may put the teenage mother more at risk of unsafe health behaviour and new pregnancies.

There is compelling, worldwide evidence that pregnancy and birth during teenage years are significant contributors to high school dropout rates, especially in developing countries. Research has also shown that education continuity of teenage mothers can lessen the long term negative social consequences of teenage pregnancies and childbearing. In this study, we investigated the factors associated with school dropout in a sample of Cameroonian teenage mothers.

The information collected included socio-economic, family, sexual characteristics, and health-seeking behavior.

Among the 18,791 single mothers, 41.6% had dropped out of school because of pregnancy. School dropout was more common in those who were evicted from their parental home, those who declared having other single mothers in their family and in mothers who had their 1st child before 15. Using modern contraceptive methods, having declared no sexual partner during the last year and having less than 2 children were associated with a reduced likelihood of school dropout.

In conclusion, strong social support is essential to ensure school continuity in this vulnerable population. Dropping out of school may put the teenage mother more at risk of unsafe health behaviour and new pregnancies.

Sexual-risk behaviours and HIV and syphilis prevalence among in- and out-of-school adolescent girls and young women in Uganda: A cross-sectional study

Background

Adolescent girls and young women (AGYW) are at increased risk of sexually transmitted infections (STIs). We assessed sexual-risk behaviours and HIV and syphilis prevalence among AGYW in Uganda to inform the design of target-specific risk-reduction interventions.

Methods

This analysis utilizes data from 8,236 AGYW aged 10–24 years, collected in 20 districts, between July and August 2018. AGYW engaged in sexual-risk behaviour if they: a) reported a history of STIs; or b) had their sexual debut before age 15; or c) engaged in sex with 2+ partners in the past 12 months; or c) did not use or used condoms inconsistently with their most recent partners. We diagnosed HIV using Determine^TMHIV-1/2, Stat-Pak^TMHIV-1/2 and SD Bioline. We used SD Bioline Syphilis test kits to diagnose syphilis and Treponema Pallidum Hemagglutination Assay for confirmatory syphilis testing. Comparison of proportions was done using Chi-square (χ²) tests. Data were analysed using STATA (version 14.1).

Results

Of 4,488 AGYW (54.5%) that had ever had sex, 12.9% (n = 581) had their sexual debut before age 15; 19.1% (n = 858) reported a history of STIs. Of those that had ever had sex, 79.6% (n = 3,573) had sex in the 12 months preceding the survey; 75.6% (n = 2,707) with one (1) and 24.2% (n = 866) with 2+ partners. Condom use with the most recent sexual partner was low, with only 20.4% (n = 728) reporting consistent condom use while 79.6% (n = 2,842) reported inconsistent or no condom use. In-school AGYW were significantly less likely to have ever had sex (35.6% vs. 73.6%, P<0.001), to have had sexual debut before age 15 (7.7% vs. 15.5%, P<0.001) or to engage in sex with 2+ partners (5.3% vs. 15.8%, P<0.001). Consistent condom use was significantly higher among in-school than out-of-school AGYW (40.1% vs. 12.7%, P<0.001). Overall, 1.7% (n = 143) had HIV while 1.3% (n = 104) had syphilis. HIV and syphilis prevalence was higher among out-of-school than in-school AGYW (HIV: 2.6% vs. 0.9%; syphilis: 2.1% vs. 0.5%, respectively).

Conclusion

In-school AGYW engaged in more protective sexual behaviors and had less HIV and syphilis than their out-of-school counterparts. These findings suggest a need for target-specific risk-reduction interventions stratified by schooling status.

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

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

Factors influencing adolescent girls and young women's participation in a combination HIV prevention intervention in South Africa

Background

For interventions to reach those they are intended for, an understanding of the factors that influence their participation, as well as the facilitators and barriers of participation are needed. This study explores factors associated with participation in a combination HIV prevention intervention targeting adolescent girls and young women (AGYW) aged 15–24-years-old, as well as the perspectives of AGYW, intervention implementers, and facilitators who participated in this intervention.

Methods

This study used mixed-methods approach with quantitative household survey data from 4399 AGYW aged 15–24-years-old in six of the ten districts in which the intervention was implemented. In addition, qualitative methods included a total of 100 semi-structured in-depth interviews and 21 focus group discussions in five of the ten intervention districts with 185 AGYW who participated in one or more of the key components of the intervention, and 13 intervention implementers and 13 facilitators. Thematic analysis was used to explore the perspectives of participating and implementing the intervention.

Results

Findings reveal that almost half of AGYW (48.4%) living in the districts where the intervention took place, participated in at least one of the components of the intervention. For both 15–19-year-olds and 20–24-year-olds, factors associated with increased participation in the intervention included being HIV negative, in school, never been pregnant, and having had a boyfriend. Experiencing intimate partner violence (IPV) and/or sexual violence in the past 12 months was associated with increased levels of participation in the intervention for 20–24-year-olds only. In our analysis of the qualitative data, facilitators to participation included motivating participants to join the interventions through explaining the benefits of the programme. Barriers included misguided expectations about financial rewards or job opportunities; competing responsibilities, interests or activities; family responsibilities including childcare; inappropriate incentives; inability to disrupt the school curriculum and difficulties with conducting interventions after school hours due to safety concerns; miscommunication about meetings; as well as struggles to reach out-of-school AGYW.

Conclusion

Designers of combination HIV prevention interventions need to address the barriers to participation so that AGYW can attend without risking their safety and compromising their family, childcare and schooling responsibilities. Strategies to create demand need to include clear communication about the nature and potential benefits of such interventions, and the inclusion of valued incentives.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10462-z.

Is it time to RE-AIM? A systematic review of economic empowerment as HIV prevention intervention for adolescent girls and young women in sub-Saharan Africa using the RE-AIM framework

BACKGROUND

Economic empowerment (EE) HIV prevention programs for adolescent girls and young women (AGYW) in sub-Saharan Africa are gaining traction as effective strategies to reduce HIV risk and vulnerabilities among this population. While intervention effectiveness is critical, there are numerous factors beyond effectiveness that shape an intervention's impact. The objective of this systematic review was to assess the reporting of implementation outcomes of EE HIV prevention programs for AGYW in SSA, as conceptualized in the RE-AIM (reach, efficacy/effectiveness, adoption, implementation, and maintenance) framework.

METHODS

We searched PubMed, Ovid/MEDLINE, Science Direct, Ebscohost, PsycINFO, Scopus, and Web of Science for EE HIV interventions for AGYW in SSA. Study selection and data extraction were conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. Two researchers coded each article using a validated RE-AIM data extraction tool and independently extracted information from each article. The reporting of RE-AIM dimensions were summarized and synthesized across included interventions.

RESULTS

A total of 25 unique interventions (reported in 45 articles) met the predefined eligibility criteria. Efficacy/effectiveness 19(74.4%) was the highest reported RE-AIM dimension, followed by adoption 17(67.2%), reach 16(64.0%), implementation 9(38.0%), and maintenance 7(26.4%). Most interventions reported on RE-AIM components such as sample size 25(100.0%), intervention location 24(96.0%), and measures and results for at least one follow-up 24(96.0%). Few reported on RE-AIM components such as characteristics of non-participants 8(32.0%), implementation costs 3(12.0%), and intervention fidelity 0(0.0%).

CONCLUSIONS

Results of the review emphasize the need for future economic empowerment HIV prevention interventions for AGYW in SSA to report multiple implementation strategies and highlight considerations for translating such programs into real-world settings. Researchers should pay close attention to reporting setting-level adoption, implementation cost, and intervention maintenance. These measures are needed for policy decisions related to the full merit and worth of EE HIV interventions and their long-term sustainability for AGYW.

The Relationship Between School Dropout and Pregnancy Among Adolescent Girls and Young Women in South Africa: A HPTN 068 Analysis

Background. Prevention of both school dropout and teen pregnancy represent clear public health priorities for South Africa, yet their complex and potentially cyclical relationship has not been fully explored. Objective. To further understand how this relationship operates, we analyzed data from a randomized trial of young women aged 13 to 20 years enrolled in school in rural South Africa to estimate the association between pregnancy and subsequent dropout and between dropout and subsequent pregnancy. Method. We examined inverse probability (IP) of exposure-weighted survival curves for school dropout by pregnancy and for pregnancy by school dropout. We used weighted curves to calculate 1-, 2-, and 3-year risk differences and risk ratios. Additionally, we used an IP-weighted marginal structural cox model to estimate a hazard ratio (HR) for each relationship. Results. Dropout from school was associated with subsequent pregnancy (HR 3.58; 95% confidence interval [CI] [2.04, 6.28]) and pregnancy was associated with subsequent school dropout (HR 2.36; 95% CI [1.29, 4.31]). Young women who attended school but attended fewer days had a higher hazard of pregnancy than those who attended more school (HR 3.64; 95% CI [2.27, 5.84]). Conclusion. Pregnancy is both a cause and a consequence of school dropout. Consideration of school attendance and academic performance could ultimately enhance pregnancy prevention efforts in this population. Programs should be tailored differently for (1) girls who have dropped out of school, (2) those who are in school and at risk for pregnancy, and (3) those who are in school and become pregnant.

Cost and cost-effectiveness of voluntary medical male circumcision in street-connected youth: findings from an education-based pilot intervention in Eldoret, Kenya

Background

Voluntary medical male circumcision (VMMC) is a critical component of HIV prevention. VMMC policies have achieved initial targets in adult men yet continue to fall short in reaching younger men and adolescents.

Setting

We present the cost and scale-up implications of an education-based, VMMC intervention for adolescent street-connected males, for whom the street has become their home and/or source of livelihood. The intervention was piloted as part of the Engaging Street Youth in HIV Interventions Project in Eldoret, Kenya.

Methods

We used a micro-costing approach to estimate the average cost of a VMMC intervention in 116 street-connected youth. Average cost was estimated per individual and per cohort by dividing total cost per intervention by number of clients accessing the intervention over a 30-day period. Total average costs included direct and support procedure costs, educational costs, and direct research costs. Cost-effectiveness was measured in cost per DALYs averted over a 5 and 10-year period.

Results

The total cost of the intervention was $12,526 over the 30-day period, with an average cost per individual of $108. The direct VMMC procedure cost was approximately $9 per individual. Personnel costs contributed the greatest percentage to the total intervention cost (38.2%), with mentors and social workers representing the highest wage earners. Retreat-related and education costs contributed 51% and 13% respectively to the total average cost, with surgical equipment costs contributing less than 1%. At a cost of $108 per individual, the intervention averted 60166 DALYs in 5 years resulting in a cost per DALY averted of $267.

Conclusion

The VMMC intervention was highly cost-effective in Kenya, despite the additional costs incurred to reach SCY. Further scale-up may be warranted to effectively apply this intervention in comparable populations.

Electronic supplementary material

The online version of this article (10.1186/s12981-018-0207-x) contains supplementary material, which is available to authorized users.

Preliminary Impacts of an HIV-Prevention Program Targeting Out-of-School Youth in Postconflict Liberia

Adolescents in Sub-Saharan Africa account for greater HIV/STI (human immuno defiency virus/sexually transmitted infection) burdens and difficult-to-reach populations. This study implemented a community-based HIV/STI program to reach at-risk youth aged 15 to 17 years in postconflict Liberia. Using a randomized controlled trial, community youths were assigned to an adapted version of an effective HIV/STI program, Making Proud Choices, or attention-matched comparison curriculum, General Health Program. Both programs were of similar doses, reach and coverage, and administered in classroom settings by trained health educators. The findings suggest that the adapted HIV/STI program had positive effects on knowledge, sexual refusal and condom use self-efficacy, condom negotiation self-efficacy, positive condom attitudes, parental communication about sex, and negative condom attitudes over time. Culturally adapted community-based, behavioral-driven programs can positively affect mediators of sexual behaviors in at-risk adolescents in postconflict settings. This is the first published report of an evidence-based HIV/STI program on sexual risk-taking behaviors of community youths in Liberia.

Factors Driving the HIV Epidemic in Southern Africa

The HIV pandemic has disproportionately impacted sub-Saharan Africa and Southern Africa in particular. The concurrent presence of overlapping epidemic drivers likely underpins how and why the HIV epidemic is so explosive in this region, with implications for understanding approaches to reduce transmission. In this review, we discuss the relative contribution and interaction between epidemic drivers in the Southern African context, including factors both distally and proximally associated with the likelihood and degree of exposure to HIV and factors that increase the probability of transmission when exposure occurs. In particular, we focus on young women as a key population in need of HIV prevention and highlight factors that increase their risk on several levels.

Effect of Schooling on Age-Disparate Relationships and Number of Sexual Partners Among Young Women in Rural South Africa Enrolled in HPTN 068

BACKGROUND

Attending school may have a strong preventative association with sexually transmitted infections among young women, but the mechanism for this relationship is unknown. One hypothesis is that students who attend school practice safer sex with fewer partners, establishing safer sexual networks that make them less exposed to infection.

SETTING

We used longitudinal data from a randomized controlled trial of young women aged 13-20 years in the Bushbuckridge district, South Africa, to determine whether the percentage of school days attended, school dropout, and grade repetition are associated with having a partner 5 or more years older (age-disparate) and with the number of sexual partners in the previous 12 months.

METHODS

Risks of having an age-disparate relationship and number of sexual partners were compared using inverse probability of exposure weighted Poisson regression models. Generalized estimating equations were used to account for repeated measures.

RESULTS

Young women who attended fewer school days (<80%) and who dropped out of school were more likely to have an age-disparate relationship (risk difference 9.9%, 95% confidence interval [CI]: 3.9% to 16.0%; risk difference (%) dropout 17.2%, 95% CI: 5.4% to 29.0%) and those who dropped out reported having fewer partners (count difference dropout 0.343, 95% CI: 0.192 to 0.495). Grade repetition was not associated with either behavior.

CONCLUSION

Young women who less frequently attend school or who drop out are more likely to have an age-disparate relationship. Young women who drop out have overall more partners. These behaviors may increase the risk of exposure to HIV infection in young women out of school.

The effect of school attendance and school dropout on incident HIV and HSV-2 among young women in rural South Africa enrolled in HPTN 068

OBJECTIVE

To estimate the association between school attendance, school dropout, and risk of incident HIV and herpes simplex virus type 2 (HSV-2) infection among young women.

DESIGN

We used longitudinal data from a randomized controlled trial in rural Mpumalanga province, South Africa, to assess the association between school days attended, school dropout, and incident HIV and HSV-2 in young women aged 13-23 years.

METHODS

We examined inverse probability of exposure weighted survival curves and used them to calculate 1.5, 2.5, and 3.5-year risk differences and risk ratios for the effect of school attendance on incident HIV and HSV-2. A marginal structural Cox model was used to estimate hazard ratios for the effect of school attendance and school dropout on incident infection.

RESULTS

Risk of infection increased over time as young women aged, and was higher in young women with low school attendance (<80% school days) compared with high (≥80% school days). Young women with low attendance were more likely to acquire HIV [hazard ratio (HR): 2.97; 95% confidence interval (CI): 1.62, 5.45] and HSV-2 (HR: 2.47; 95% CI: 1.46, 4.17) over the follow-up period than young women with high attendance. Similarly, young women who dropped out of school had a higher weighted hazard of both HIV (HR 3.25 95% CI: 1.67, 6.32) and HSV-2 (HR 2.70; 95% CI 1.59, 4.59).

CONCLUSION

Young women who attend more school days and stay in school have a lower risk of incident HIV and HSV-2 infection. Interventions to increase frequency of school attendance and prevent dropout should be promoted to reduce risk of infection.

Vijana Vijiweni II: a cluster-randomized trial to evaluate the efficacy of a microfinance and peer health leadership intervention for HIV and intimate partner violence prevention among social networks of young men in Dar es Salaam

Background

Intimate partner violence (IPV) and sexually transmitted infections (STIs), including HIV, remain important public health problems with devastating health effects for men and women in sub-Saharan Africa. There have been calls to engage men in prevention efforts, however, we lack effective approaches to reach and engage them. Social network approaches have demonstrated effective and sustained outcomes on changing risk behaviors in the U.S. Our team has identified and engaged naturally occurring social networks comprised mostly of young men in Dar es Salaam in an intervention designed to jointly reduce STI incidence and the perpetration of IPV. These stable networks are locally referred to as “camps.” In a pilot study we demonstrated the feasibility and acceptability of a combined microfinance and peer health leadership intervention within these camp-based peer networks.

Methods design

We are implementing a cluster-randomized trial to evaluate the efficacy of an intervention combining microfinance with health leadership training in 60 camps in Dar es Salaam, Tanzania. Half of the camps have been randomized to the intervention arm, and half to a control arm. The camps in the intervention arm will receive a combined microfinance and health leadership intervention for a period of two years. The camps in the control arm will receive a delayed intervention. We have enrolled 1,258 men across the 60 study camps. Behavioral surveys will be conducted at baseline, 12-months post intervention launch and 30-month post intervention launch and biological samples will be drawn to test for Neisseria gonorrhea (NG), Chlamydia trachomatis (CT), and Trichomonas vaginalis (TV) at baseline and 30-months. The primary endpoints for assessing intervention impact are IPV perpetration and STI incidence.

Discussion

This is the first cluster-randomized trial targeting social networks of men in sub-Saharan Africa that jointly addresses HIV and IPV perpetration and has both biological and behavioral endpoints. Effective approaches to engage men in HIV and IPV prevention are needed in low resource, high prevalence settings like Tanzania. If we determine that this approach is effective, we will examine how to adapt and scale up this approach to other urban, sub-Saharan African settings.

Trial registration

Clinical Trials.gov: NCT01865383. Registration date: May 24, 2013.

Leveraging strong social ties among young men in Dar es Salaam: A pilot intervention of microfinance and peer leadership for HIV and gender-based violence prevention

Gender inequality is at the core of the HIV patterns that are evident in sub-Saharan Africa. Gender-based violence (GBV) and lack of economic opportunity are important structural determinants of HIV risk. We piloted a microfinance and health promotion intervention among social networks of primarily young men in Dar es Salaam. Twenty-two individuals participated in the microfinance component and 30 peer leaders were recruited and trained in the peer health leadership component. We collected and analysed observational data from trainings, monitoring data on loan repayment, and reports of peer conversations to assess the feasibility and acceptability of the intervention. Eighteen of the loan recipients (82%) paid back their loans, and of these 15 (83%) received a second, larger loan. Among the loan defaulters, one died, one had chronic health problems, and two disappeared, one of whom was imprisoned for theft. The majority of conversations reported by peer health leaders focused on condoms, sexual partner selection, and HIV testing. Few peer leaders reported conversations about GBV. We demonstrated the feasibility and acceptability of this innovative HIV and GBV prevention intervention. The lessons learned from this pilot have informed the implementation of a cluster-randomised trial of the microfinance and peer health leadership intervention.

Sexual and Reproductive Health Among Ugandan Youth: 2003-04 to 2012

PURPOSE

Suboptimal sexual and reproductive health (SRH) increases morbidity, mortality, and gender inequity and slows development. In Uganda, youths represent 20% of the population, and the burden of sexually transmitted infections (STIs), including human immunodeficiency virus (HIV), is substantial.

METHODS

We analyzed survey data collected using the lot quality assurance sampling (LQAS) technique from two time periods, 2003-2004 and 2012. We assessed knowledge, behaviors, and access to SRH services of youths aged 15-24 years. Using logistic regression, we examined factors associated with these indicators.

RESULTS

All indicators have improved between the early and later time period. Youths knowing where to get HIV tests increased from <40% to 80% (both sexes); the number of youths reporting ever having an HIV test increased from 8% to 48% (males) and 10% to 64% (females). Knowledge of other STIs improved but remains low; only half of respondents know signs and symptoms of STIs, and less than half know what action to take when infected. In the late period, 85% of female youths, compared with 93% of males reported knowing where to obtain condoms. The proportion of youths reporting sexual debut before age 15 years decreased, less so for males than that for females. Increased age and level of education are associated with positive change for most indicators.

CONCLUSIONS

Over the last decade, progress has been made toward improving the SRH of young people in Uganda. Further efforts are required to ensure universal access and sufficient health education to facilitate the continued improvement of safe sexual behaviors among youth aged 15-24 years.

Relationship between school dropout and teen pregnancy among rural South African young women

BACKGROUND

Sexual activity may be less likely to occur during periods of school enrolment because of the structured and supervised environment provided, the education obtained and the safer peer networks encountered while enrolled. We examined whether school enrolment was associated with teen pregnancy in South Africa.

METHODS

Using longitudinal demographic surveillance data from the rural Agincourt sub-district, we reconstructed the school enrolment status from 2000 through 2011 for 15 457 young women aged 12-18 years and linked them to the estimated conception date for each pregnancy during this time. We examined the effect of time-varying school enrolment on teen pregnancy using a Cox proportional hazard model, adjusting for: age; calendar year; household socioeconomic status; household size; and gender, educational attainment and employment of household head. A secondary analysis compared the incidence of pregnancy among school enrolees by calendar time: school term vs school holiday.

RESULTS

School enrolment was associated with lower teen pregnancy rates [adjusted hazard ratio (95% confidence interval): 0.57 (0.50, 0.65)].This association was robust to potential misclassification of school enrolment. For those enrolled in school, pregnancy occurred less commonly during school term than during school holidays [incidence rate ratio (95% confidence interval): 0.90 (0.78, 1.04)].

CONCLUSIONS

Young women who drop out of school may be at higher risk for teen pregnancy and could likely benefit from receipt of accessible and high quality sexual health services. Preventive interventions designed to keep young women in school or addressing the underlying causes of dropout may also help reduce the incidence of teen pregnancy.

Prevalence of sexually transmitted infections including HIV in street-connected adolescents in western Kenya

PURPOSE

The objectives of this study were to characterise the sexual health of street-connected adolescents in Eldoret, Kenya, analyse gender disparity of risks, estimate the prevalence of sexually transmitted infections (STIs), and identify factors associated with STIs.

METHODS

A cross-sectional study of street-connected adolescents ages 12-21 years was conducted in Eldoret, Kenya. Participants were interviewed and screened for Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, herpes simplex virus-2, syphilis and HIV. Descriptive statistics and logistic regression were used to identify factors associated with having any STI.

RESULTS

Of the 200 participants, 81 (41%) were female. 70.4% of females and 60.5% of males reported sexual activity. Of those that participated in at least one STI test, 28% (55/194) had ≥1 positive test, including 56% of females; 14% (28/194) had >1 positive test. Twelve females and zero males (6% overall, 14.8% of females) were HIV positive. Among females, those with HIV infection more frequently reported transactional sex (66.7% vs. 26.1%, p=0.01), drug use (91.7% vs. 56.5%, p=0.02), and reported a prior STI (50.0% vs. 14.7%, p<0.01). Having an adult caregiver was less likely among those with HIV infection (33.3% vs. 71.0%, p=0.04). Transactional sex (AOR 3.02, 95% CI (1.05 to 8.73)), a previous STI (AOR 3.46 95% CI (1.05 to 11.46)) and ≥2 sexual partners (AOR 5.62 95% (1.67 to 18.87)) were associated with having any STI.

CONCLUSIONS

Street-connected adolescents in Eldoret, Kenya are engaged in high-risk sexual behaviours and females in particular have a substantial burden of STIs and HIV. There is a need for STI interventions targeted to street-connected youth.

Material deprivation affects high sexual risk behavior among young people in urban slums, South Africa

Young people in urban slums adopt HIV risk behaviors influenced by their neighborhood factors. Three critical factors in urban slums of Southern and Eastern Africa--the region most affected by the HIV epidemic in the world--are unmet needs of housing, food, and health care, which are associated with HIV sexual risks. Yet, there has been limited attention on how the combination of unmet needs of housing, food, and health care--i.e., material deprivation-relates to sexual risk behavior among young people in urban slums. Cross-sectional data were extracted from the LoveLife survey in South African four provinces--KwaZulu Natal, Mpumalanga, Eastern Cape, and Gauteng, to examine the association between material deprivation and sexual risk behavior among young people aged 18-23 years (263 males, 267 females) in urban slums. Adjusted logistic regression models showed that material deprivation was significantly associated with increased odds of high sexual risk taking for young men (adjusted OR = 1.20; 95 % CI = 1.10, 5.58) and young women (adjusted OR = 1.43; 95 % CI = 1.35, 3.28). Financial difficulty--a proxy for other deprivations--was the most salient influence on young women's high sexual risk taking (adjusted OR = 2.11; 95 % CI = 1.66, 2.70). Localized behavioral HIV prevention interventions should target young people in deprived households.

From coitus to concurrency: sexual partnership characteristics and risk behaviors of 15-19 year old men recruited from urban venues in Tanzania

Understanding the uptake and patterns of sexual partnerships of adolescent males reveals their risky behaviors that could persist into adulthood. Using venue-based sampling, we surveyed 671 male youth ages 15-19 from an urban Tanzanian neighborhood about their sexual partnerships during the past 6 months. The proportion of males who had ever had sex increased with age (21 % at age 15; 70 % at age 17; 94 % at age 19), as did the proportion who engaged in concurrency (5 % at age 15; 28 % at age 17; 44 % at age 19). Attendance at ≥2 social venues per day and meeting a sexual partner at a venue was associated with concurrency. Concurrency was associated with alcohol consumption before sex among 18-19 year olds and with not being in school among 15-17 year olds. We find that concurrency becomes normative over male adolescence. Venue-based sampling may reach youth vulnerable to developing risky sexual partnership patterns.

The impact of education and globalization on sexual and reproductive health: retrospective evidence from eastern and southern Africa

The objective of this study is to qualify the relationship between sexual and reproductive health (SRH) and educational attainment in eastern and southern Africa (ESA). We hypothesize that the regional level of globalization is a moderating factor in the relationship between SRH and educational attainment. Using retrospective data from Kenya, Malawi, Tanzania, and Zambia, the associations between SRH (eight indicators), educational attainment, and globalization were examined using multilevel logistic regression analysis. It was found that the model fit for every SRH outcome indicator increased significantly after including the interaction between globalization and educational attainment, supporting the hypothesis. Depending on the level of globalization, three types of relationships between education and SRH were found: (1) for the indicators "more than four children," "intercourse before 17 years," "first child before 20 years," and "one or more child died" education is risk-decreasing, and the reduction is stronger in more globalized regions; (2) for the indicators "condom use at last intercourse" and "current contraceptive use" education is risk-decreasing, and the reduction is stronger in less globalized regions; (3) for the indicators "HIV positive" and "more than four lifetime sexual partners" education is risk increasing, but only in less globalized regions. In conclusion, these effects are related to three types of access: (1) access to services, (2) access to information, and (3) access to sexual networks. The findings highlight the relevance of globalization when analyzing the association between SRH and education, and the importance of structural factors in the development of effective SRH promotion interventions.

Transactional sex risk across a typology of rural and urban female sex workers in Indonesia: a mixed methods study

Context-specific typologies of female sex workers (FSWs) are essential for the design of HIV intervention programming. This study develops a novel FSW typology for the analysis of transactional sex risk in rural and urban settings in Indonesia. Mixed methods include a survey of rural and urban FSWs (n=310), in-depth interviews (n=11), key informant interviews (n=5) and ethnographic assessments. Thematic analysis categorises FSWs into 5 distinct groups based on geographical location of their sex work settings, place of solicitation, and whether sex work is their primary occupation. Multiple regression analysis shows that the likelihood of consistent condom use was higher among urban venue-based FSWs for whom sex work is not the only source of income than for any of the other rural and urban FSW groups. This effect was explained by the significantly lower likelihood of consistent condom use by rural venue-based FSWs (adjusted OR: 0.34 95% CI 0.13-0.90, p=0.029). The FSW typology and differences in organisational features and social dynamics are more closely related to the risk of unprotected transactional sex, than levels of condom awareness and availability. Interventions need context-specific strategies to reach the different FSWs identified by this study's typology.