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

Delivery platforms for reaching adolescents with nutrition interventions in low- and middle-income countries

Adolescents in low- and middle-income countries (LMICs) are a vulnerable population given increased nutritional needs as puberty approaches. School-based nutrition programs exist in some settings, but the comprehensive provision of nutrition services requires knowledge of the mechanisms to reach out-of-school adolescents. A comprehensive scoping review was performed using formal and informal search strategies to landscape all potential delivery platforms with nutrition services to reach adolescents. Peer-reviewed studies, institutional strategies, program evaluations, and programmatic reports in LMICs were reviewed, including gray literature. A total of 87 out of 270 identified publications and reports describing nutrition programs for adolescents were identified. Although nutrition programs targeted at adolescents were sparse, various innovative and inclusive delivery platforms were included, such as school feeding programs, school-based anemia control, and nutrition-friendly school initiatives; health facility-based, youth-friendly health and nutrition services; social safety nets targeted at adolescents; community-based approaches targeting youth development and peer education within youth centers and faith-based settings; and technology-based platforms, including digital health services and mass media communication sensitization and mobilization efforts. Existing delivery mechanisms and platforms in health and other sectors that target adolescents offer great potential to extend nutrition interventions to this vulnerable yet hard-to-reach population.

The Feasibility and Acceptability of Using Mobile Applications for HIV Testing, Prevention, and Treatment Among Adolescent Girls and Young Women in Cameroon: A Cross-Sectional Study

ABSTRACT

Adolescent girls and young women (AGYW) are vulnerable populations to HIV/AIDS. We conducted a cross-sectional survey among 637 AGYW in Cameroon to study the feasibility and willingness to use mobile applications (apps) for HIV testing, prevention, and treatment. We found that phone ownership is high among AGYW, where 93.9% ( n = 598) of them (median age: 22 years, interquartile range: 21-24 years) had access to a smartphone, 49.5% ( n = 315) frequently searched for health information, and 48.9% ( n = 312) frequently used health-related apps. AGYW's willingness to use mobile apps for HIV testing, prevention, and treatment were 87.9% ( n = 560), 84.4% ( n = 538), and 84.9% ( n = 541), respectively. The high willingness to use apps was associated with older age, HIV testing, and searching for health information on a phone. Barriers to willingness included having no internet access, concerns about internet cost and privacy, and lack of consistent access to a smartphone.

Comprehensive sexuality education for out-of-school young people living with HIV and young people with disabilities: findings from a formative research study in Malawi

This formative study was undertaken between June 2020 and April 2021 to provide evidence to inform the design and delivery of comprehensive sexuality education (CSE) in Malawi for young people living with HIV (YPLHIV) and young people with disabilities (YPWD). The study included a desk review of the situation of these two groups and a mapping of CSE programmes and delivery approaches in Malawi. The study findings show that YPWD and YPLHIV in Malawi are marginalised groups, face stigma and discrimination, and are more vulnerable to abuse, warranting CSE that addresses their needs. Yet, they are often left out of sexuality education such as school-based programmes (due to early school drop-outs) and out-of-school programmes, as well as traditional modes. Furthermore, in instances where they have access to sexuality education, there is little evidence to suggest that the sexuality education that they receive is designed to address their needs, thus raising questions about its relevance. There is need for tailored CSE that addresses the needs of these groups and that is delivered using an approach that is easily accessible to them.

"We just do it … we are dead already": Exploring the sexual behaviors of youth living with HIV

INTRODUCTION

This study aims to describe the sexual behaviors of youth living with human immunodeficiency virus (HIV) in Malawi. As a high-risk population, understanding the contextual factors that shape their sexual behaviors is of particular interest when designing strategies to reduce HIV transmission.

METHODS

Semi-structured qualitative interviews were used to collect information about sexual behaviors from 22 youth (12 females and 10 males) living with HIV aged from 15 to 24 years. All participants were recruited from a specialized HIV clinic in Malawi. Thematic analysis was applied to identify current themes.

RESULTS

The majority of participants were sexually active. Engaging in sexual behaviors was largely related to social processes identified in three main themes: (1) Risk-taking in pursuit of confidence and maturity; (2) A lack of voice in decision making concerning practising safe sex; (3) Perceived barriers to safe sex practice such as poverty, dropping out of school, and personal perspectives about transmitting HIV to others.

CONCLUSION

Our results suggest that prevention strategies targeting youth social and economic vulnerabilities to social influences are needed to enhance their personal and social skills. We suggest nurturing cultural and religious ceremonies and involving elders to equip youth with skills and knowledge for the prevention of HIV transmission.

Comprehensive HIV/AIDS knowledge and safer sex negotiation among adolescent girls and young women in sub-Saharan Africa

Globally, HIV/AIDS remains a public health issue, especially in sub-Saharan Africa (SSA). Despite the increased advocacy and dissemination of comprehensive HIV/AIDS information in SSA, it appears that little progress has been made to reduce the incidence of HIV/AIDS in the sub-region. This study, therefore, examined the association between comprehensive HIV/AIDS knowledge and safer sex negotiation among adolescent girls and young women in SSA. Data were taken from the Demographic and Health Surveys conducted between 2010 and 2019 in 30 countries in SSA. The study sample comprised 37,364 adolescent girls and young women aged 15-24. A multivariable binary logistic regression analysis was done to test the hypothesis that there is a positive association between comprehensive HIV/AIDS knowledge and safer sex negotiation. Adolescent girls and young women who had comprehensive knowledge on HIV/AIDS were more likely to negotiate for safer sex compared with those who had no comprehensive knowledge on HIV/AIDS (AOR=1.31, 95% CI: 1.22-1.41). At the country level, the positive association between comprehensive knowledge on HIV/AIDS and safer sex negotiation was significant in Chad, Congo DR, Gambia, Guinea, Liberia, Ethiopia and Malawi. On the other hand, in Togo, adolescent girls and young women who had comprehensive HIV/AIDS knowledge were less likely to negotiate for safer sex. These findings can inform policies and programmes on the crucial role of comprehensive HIV/AIDS education and knowledge in increasing safer sex negotiation among adolescent girls and young women in SSA. The study recommends that Togo needs to address certain practices such as intimate partner violence against adolescent girls and young women, which prevent them from negotiating for safer sex, despite their higher knowledge on comprehensive HIV/AIDS. Lessons can be learnt from Chad, Congo DR, Gambia, Guinea, Liberia, Ethiopia and Malawi about the scale-up of programmes and interventions targeted at young women.

Prevalence and correlates of comprehensive HIV/AIDS knowledge among adolescent girls and young women aged 15-24 years in Malawi: evidence from the 2015-16 Malawi demographic and health survey

Background

HIV epidemic remains a major public health issue in Malawi especially among adolescent girls and young women (AGYW). Comprehensive HIV/AIDS knowledge (defined as correct knowledge of two major ways of preventing the sexual transmission of HIV and rejection of three misconceptions about HIV) is a key component of preventing new HIV infections among AGYW. Therefore, the aim of this study was to identify the correlates of comprehensive HIV/AIDS knowledge among AGYW in Malawi.

Methods

The study was based on cross-sectional data from the 2015–2016 Malawi Demographic and Health Survey. It involved 10,422 AGYW aged 15–24 years. The outcome variable was comprehensive HIV/AIDS knowledge. Data were analysed using descriptive statistics, bivariate and multivariable logistic regression model. All the analyses were performed using complex sample analysis procedure of the Statistical Package for Social Sciences to account for complex survey design.

Results

Approximately 42.2% of the study participants had comprehensive HIV/AIDS knowledge. Around 28% of the participants did not know that using condoms consistently can reduce the risk of HIV and 25% of the participants believed that mosquitoes could transmit HIV. Multivariable logistic regression model demonstrated that having higher education (AOR = 2.97, 95% CI: 2.35–3.75), belonging to richest households (AOR = 1.24, 95% CI: 1.05–1.45), being from central region (AOR = 1.65, 95% CI:1.43–1.89), southern region (AOR = 1.65, 95% CI: 1.43–1.90),listening to radio at least once a week (AOR = 1.27, 95% CI: 1.15–1.40) and ever tested for HIV (AOR = 1.88, 95% CI: 1.68–2.09) were significantly correlated with comprehensive HIV/AIDS knowledge.

Conclusions

The findings indicate that comprehensive HIV/AIDS knowledge among AGYW in Malawi is low. Various social-demographic characteristics were significantly correlated with comprehensive HIV/AIDS knowledge in this study. These findings suggest that public health programmes designed to improve comprehensive HIV/AIDS knowledge in Malawi should focus on uneducated young women, those residing in northern region and from poor households. There is also a need to target AGYW who have never tested for HIV with voluntary counselling and testing services. This measure might both improve their comprehensive HIV/AIDS knowledge and awareness of their health status.

Social, Behavioral, and Cultural factors of HIV in Malawi: Semi-Automated Systematic Review

BACKGROUND

Demographic and sociobehavioral factors are strong drivers of HIV infection rates in sub-Saharan Africa. These factors are often studied in qualitative research but ignored in quantitative analyses. However, they provide in-depth insight into the local behavior and may help to improve HIV prevention.

OBJECTIVE

To obtain a comprehensive overview of the sociobehavioral factors influencing HIV prevalence and incidence in Malawi, we systematically reviewed the literature using a newly programmed tool for automatizing part of the systematic review process.

METHODS

Due to the choice of broad search terms ("HIV AND Malawi"), our preliminary search revealed many thousands of articles. We, therefore, developed a Python tool to automatically extract, process, and categorize open-access articles published from January 1, 1987 to October 1, 2019 in the PubMed, PubMed Central, JSTOR, Paperity, and arXiV databases. We then used a topic modelling algorithm to classify and identify publications of interest.

RESULTS

Our tool extracted 22,709 unique articles; 16,942 could be further processed. After topic modelling, 519 of these were clustered into relevant topics, of which 20 were kept after manual screening. We retrieved 7 more publications after examining the references so that 27 publications were finally included in the review. Reducing the 16,942 articles to 519 potentially relevant articles using the software took 5 days. Several factors contributing to the risk of HIV infection were identified, including religion, gender and relationship dynamics, beliefs, and sociobehavioral attitudes.

CONCLUSIONS

Our software does not replace traditional systematic reviews, but it returns useful results to broad queries of open-access literature in under a week, without a priori knowledge. This produces a "seed dataset" of relevance that could be further developed. It identified known factors and factors that may be specific to Malawi. In the future, we aim to expand the tool by adding more social science databases and applying it to other sub-Saharan African countries.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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