A community-based study to examine the effect of a youth HIV prevention intervention on young people aged 15-24 in South Africa: results of the baseline survey

Characterizing models of adolescent and youth-friendly health services in sub-Saharan Africa: a scoping review

This scoping review provides an up-to-date overview of the evidence on adolescent and youth-friendly health services (AYFHS) in sub-Saharan African countries. We conducted a search of four databases and grey literature sources to identify English language publications from January 1, 2005, to December 14th, 2022. The review synthesized evidence on the models and characteristics of AYFHS, the application of World Health Organization (WHO) standards, and whether AYFHS have improved young people's health outcomes. In total, 77 sources were included in the review, representing 47 AYFHS initiatives spanning 19 countries, and three multi-country reports. Most commonly, AYFHS were delivered in public health facilities and focused on sexual and reproductive health, with limited application of WHO standards. Some evidence suggested that AYFHS increased young people's health service utilization and contraceptives uptake. There is a clear need to strengthen and develop innovative and multi-pronged approaches to delivering and evaluating AYFHS in this region.

Extended cost-effectiveness analysis of interventions to improve uptake of diabetes services in South Africa

The rising prevalence of diabetes in South Africa (SA), coupled with significant levels of unmet need for diagnosis and treatment, results in high rates of diabetes-associated complications. Income status is a determinant of utilization of diagnosis and treatment services, with transport costs and loss of wages being key barriers to care. A conditional cash transfer (CCT) programme, targeted to compensate for such costs, may improve service utilization. We applied extended cost-effectiveness analysis (ECEA) methods and used a Markov model to compare the costs, health benefits and financial risk protection (FRP) attributes of a CCT programme. A population was simulated, drawing from SA-specific data, which transitioned yearly through various health states, based on specific probabilities obtained from local data, over a 45-year time horizon. Costs and disability-adjusted life years (DALYs) were applied to each health state. Three CCT programme strategies were simulated and compared to a 'no programme' scenario: (1) covering diagnosis services only; (2) covering treatment services only; (3) covering both diagnosis and treatment services. Cost-effectiveness was reported as incremental net monetary benefit (INMB) using a cost-effectiveness threshold of USD3015 per DALY for SA, while FRP outcomes were reported as catastrophic health expenditure (CHE) cases averted. Distributions of the outcomes were reported by income quintile and sex. Covering both diagnosis and treatment services for the bottom two quintiles resulted in the greatest INMB (USD22 per person) and the greatest CHE cases averted. There were greater FRP benefits for women compared to men. A CCT programme covering diabetes diagnosis and treatment services was found to be cost-effective, when provided to the poorest 40% of the SA population. ECEA provides a useful platform for including equity considerations to inform priority setting and implementation policies in SA.

HIV Related Behaviors Among Male Partners of Adolescent Girls and Young Women in Rural South Africa

Improving men's engagement in HIV prevention is not only essential for reducing their own HIV risk but also the risk of transmitting HIV to their female partners. We conducted a cross-sectional survey using a population-based sample of men (age 18-30) who reported being a partner of an adolescent girls and young women (AGYW) in South Africa (N = 2827). We used logit-binomial regression models to examine associations among men's partnership characteristics, HIV risk perceptions, and HIV-related behaviors and examine differences by male partner age (younger men (18-24) vs. older men (25-30)) and age difference between partners (age-concordant (< 5 years) vs. age-disparate (≥ 5 years)). Most men reported inconsistent condom use (85%) and nearly half reported engaging in transactional sex (48%). Older men were just as likely as younger men, and men with age-disparate and age-concordant partners, to inconsistently use condoms, engage in transactional sex, and perpetrate intimate partner violence. Most men also reported a very high interest in pre-exposure prophylaxis (PrEP) (77%) and half reported having an HIV test in the past year (50%). There were no differences by male partner age or age difference between partners in PrEP interest but older men and men in age-discordant relationships were more likely than younger men and men in age-concordant relationships to have an HIV test in the past year. Male partners of AGYW in South Africa are engaging in HIV-related behaviors and need HIV prevention interventions to reduce risk for themselves and their female partners.

Evidence and gap map report: Social and Behavior Change Communication (SBCC) interventions for strengthening HIV prevention and research among adolescent girls and young women (AGYW) in low- and middle-income countries (LMICs)

BACKGROUND

Adolescent girls and young women (AGYW), aged 15-24 years, are disproportionately affected by HIV and other sexual and reproductive health (SRH) risks due to varying social, cultural, and economic factors that affect their choices and shape their knowledge, understanding, and practices with regard to their health. Socio-Behavioral Change Communication (SBCC) interventions targeted at strengthening the capabilities of individuals and their networks have supported the demand and uptake of prevention services and participation in biomedical research. However, despite growing global recognition of the domain, high-quality evidence on the effectiveness of SBCC remains scattered. This evidence and gap map (EGM) report characterizes the evidence base on SBCC interventions for strengthening HIV Prevention and Research among AGYW in low- and middle-income countries (LMICs), identifying evidence gaps and outlining the scope of future research and program design.

OBJECTIVES

The objectives of the proposed EGM are to: (a) identify and map existing EGMs in the use of diverse SBCC strategies to strengthen the adoption of HIV prevention measures and participation in research among AGYW in LMICs and (b) identify areas where more interventions and evidence are needed to inform the design of future SBCC strategies and programs for AGYW engagement in HIV prevention and research.

METHODS

This EGM is based on a comprehensive search of systematic reviews and impact evaluations corresponding to a range of interventions and outcomes-aimed at engaging AGYW in HIV prevention and research - that were published in LMICs from January 2000 to April 2021. Based on guidance for producing a Campbell Collaboration EGM, the intervention and outcome framework was designed in consultation with a group of experts. These interventions were categorized across four broad intervention themes: mass-media, community-based, interpersonal, and Information Communication and Technology (ICT)/Digital Media-based interventions. They were further sub-categorized into 15 intervention categories. Included studies looked at 23 unique behavioral and health outcomes such as knowledge attitude and skills, relationship dynamics, household dynamics, health care services, and health outcomes and research engagement. The EGM is presented as a matrix in which the rows are intervention categories/sub-categories, and the columns are outcome domains/subdomains. Each cell is mapped to an intervention targeted at outcomes. Additional filters like region, country, study design, age group, funding agency, influencers, population group, publication status, study confidence, setting, and year of publication have been added.

SELECTION CRITERIA

To be eligible, studies must have tested the effectiveness of SBCC interventions at engaging AGYW in LMICs in HIV prevention and research. The study sample must have consisted of AGYW between the ages of 15-24, as defined by UNAIDS. Both experimental (random assignment) and quasi-experimental studies that included a comparison group were eligible. Relevant outcomes included those at the individual, influencer, and institutional levels, along with those targeting research engagement and prevention-related outcomes.

RESULTS

This EGM comprises 415 impact evaluations and 43 systematic reviews. Interventions like peer-led interactions, counseling, and community dialogues were the most dominant intervention sub-types. Despite increased digital penetration use of media and technology-driven interventions are relatively less studied. Most of the interventions were delivered by peers, health care providers, and educators, largely in school-based settings, and in many cases are part of sex-education curricula. Evidence across geographies was mostly concentrated in Sub-Saharan Africa (70%). Most measured outcomes focused on disease-related knowledge dissemination and enhancing awareness of available prevention options/strategies. These included messaging around consistent condom use, limiting sexual partners, routine testing, and awareness. Very few studies were able to include psychographic, social, and contextual factors influencing AGYW health behaviors and decisions, especially those measuring the impact of social and gender norms, relationship dynamics, and household dynamics-related outcomes. Outcomes related to engagement in the research were least studied.

CONCLUSION

This EGM highlights that evidence is heavily concentrated within the awareness-intent spectrum of behavior change and gets lean for outcomes situated within the intent-action and the action-habit formation spectrum of the behavior change continuum. Most of the evidence was concentrated on increasing awareness, knowledge, and building risk perception around SRH domains, however, fewer studies focused on strengthening the agency and self-efficacy of individuals. Similarly, evidence on extrinsic factors-such as strengthening social and community norms, relationships, and household dynamics-that determine individual thought and action such as negotiation and life skills were also found to be less populated. Few studies explore the effectiveness of these interventions across diverse AGYW identities, like pregnant women and new mothers, sex workers, and people living with HIV, leading to limited understanding of the use of these interventions across multiple user segments including key influencers such as young men, partners, families, religious leaders, and community elders was relatively low. There is a need for better quality evidence that accounts for the diversity of experiences within these populations to understand what interventions work, for whom, and toward what outcome. Further, the evidence for use of digital and mass-media tools remains poorly populated. Given the increasing penetration of these tools and growing media literacy on one end, with widening gender-based gaps on the other, it is imperative to gather more high-quality evidence on their effectiveness. Timely evidence generation can help leverage these platforms appropriately and enable intervention designs that are responsive to changing communication ecologies of AGYW. SBCC can play a critical role in helping researchers meaningfully engage and collaborate with communities as equal stakeholders, however, this remains poorly evidenced and calls for investigation and investment. A full list of abbreviations and acronyms are available in Supporting Information: Appendix F.

Sexual and reproductive health and rights knowledge, perceptions, and experiences of adolescent learners from three South African townships: qualitative findings from the Girls Achieve Power (GAP Year) Trial

Background: Adolescence is a time of psycho-social and physiological changes, with increased associated health risks including vulnerability to pregnancy, HIV, sexually transmitted infections, and gender-based violence. Adolescent learners, from three townships in South Africa, participated in a 44 session, after-school asset-building intervention (GAP Year), over 2 years providing sexual and reproductive health (SRH) education. This paper explores adolescent learners' SRH, sexual risk and rights knowledge; perceptions about transactional sex; and contraceptive method preferences and decision-making practices. Methods: The intervention was conducted in 13 secondary schools across Khayelitsha, Thembisa, and Soweto, South Africa. A baseline survey collected socio-demographic data prior to the intervention. Overall, 26 focus group discussions (FGDs): 13 male and 13 female learner groups, purposively selected from schools, after completing the intervention (2 years after baseline data collection). Descriptive analyses were conducted on baseline data. Qualitative data were thematically coded, and NVivo was used for data analysis. Results: In total, 194 learners participated in the FGDs. Mean age at baseline was 13.7 years (standard deviation 0.91). Participants acquired SRH and rights knowledge during the GAP Year intervention. Although transactional sex was viewed as risky, some relationships were deemed beneficial and necessary for material gain. Negative healthcare provider attitudes were the main barrier to healthcare service utilisation. There was awareness about the benefits of contraceptives, but some myths about method use. The injectable was the preferred contraceptive method, followed by the implant, with equal preference for condoms and oral pill. Conclusions : An afterschool intervention at school is a viable model for the provision of SRH and rights education to learners. Recommendations include the need for risk reduction strategies in the curriculum, dealing with misconceptions, and the promotion of informed decision making. Endeavours to ensure health services are youth friendly is a priority to limit barriers to accessing these services.

Determining HIV risk for Adolescent Girls and Young Women (AGYW) in relationships with "Blessers" and age-disparate partners: a cross-sectional survey in four districts in South Africa

BACKGROUND

HIV incidence among adolescent girls and young women (AGYW) remains high, with their male partners a prominent factor in sustaining these elevated rates. Partnership characteristics remain important metrics for determining HIV risk, with evidence indicating that AGYW engaged in transactional and age-disparate relationships face greater HIV exposure. This study examines the risk posed to AGYW in a relationship with a "Blesser", defined as male who provides his female partner with their material needs or desires in exchange for a sexual relationship, an age-disparate (5 or more years older) partner, and the potential compounded risk of being a relationship with a partner or partners who are considered both a "Blesser" and age-disparate.

METHODS

A cross -sectional household based representative sample of AGYW (aged between 12-24 years) were enrolled in the study (n = 18 926) from the districts of City of Johannesburg and Ekurhuleni in the Gauteng province and the Districts of eThekwini and uMgungundlovu in the province of KwaZulu-Natal (KZN) in South Africa between March 13, 2017 to June 22, 2018. Participants completed a structured questionnaire and provided finger-prick blood samples for laboratory measurements. Our analysis used descriptive statistics and multiple binary logistic regressions accounting for survey weights, clustering and stratification.

FINDINGS

The median age of the sample was 21 years old (Interquartile range: 19-23) and nearly three quarters (73.7%) were currently attending school. Whilst all relationships exposed AGYW to potential HIV risk, multiple binary logistic regression analysis revealed that AGYW in a relationship with both a Blesser and an age-disparate partner were more likely to be HIV positive (AOR: 3.12, 95% CI: 1.76-5.53, p < 0.001), diagnosed with an STI (AOR: 4.60, 95% CI: 2.99-7.08, p < 0.001), had 2 or more sexual partners in the previous 12 months (AOR: 6.37, 95% CI: 3.85-10.54, p < 0.001), engaged in sexual activity at age 15 or younger (AOR: 3.67, 95% CI: 2.36-5.69, p < 0.001) and more likely to have ever been pregnant (AOR: 2.60, 95% CI: 1.24-5.45, p < 0.05) than those not in a relationship with either a Blesser or age-disparate partner.

CONCLUSION

Different relationships present different HIV risk to AGYW. AGYW who had engaged in relationships with both a Blesser and an age-disparate partner were at greater HIV risk when examined against these relationships independent of one another. The data reveals the compounded HIV risk of being in both a transactional and age-disparate relationship.

Sexual and reproductive health and rights knowledge, perceptions, and experiences of adolescent learners from three South African townships: qualitative findings from the Girls Achieve Power (GAP Year) Trial

Background: Adolescence is a time of psycho-social and physiological changes, with increased associated health risks including vulnerability to pregnancy, HIV, sexually transmitted infections, and gender-based violence. Adolescent learners, from three townships in South Africa, participated in a 44 session, after-school asset-building intervention (GAP Year), over 2 years providing sexual and reproductive health (SRH) education. This paper explores adolescent learners’ SRH, sexual risk and rights knowledge; perceptions about transactional sex; and contraceptive method preferences and decision-making practices. Methods: The intervention was conducted in 13 secondary schools across Khayelitsha, Thembisa, and Soweto, South Africa. A baseline survey collected socio-demographic data prior to the intervention. Overall, 26 focus group discussions (FGDs): 13 male and 13 female learner groups, purposively selected from schools, after the intervention (2 years after baseline data collection). Descriptive analyses were conducted on baseline data. Qualitative data were thematically coded, and NVivo was used for data analysis. Results: In total, 194 learners participated in the FGDs. Mean age at baseline was 13.7 years (standard deviation 0.91). Participants acquired SRH and rights knowledge during the GAP Year intervention. Although transactional sex was viewed as risky, some relationships were deemed beneficial and necessary for material gain. Negative healthcare provider attitudes were the main barrier to healthcare service utilisation. There was awareness about the benefits of contraceptives, but some myths about method use. The injectable was the preferred contraceptive method, followed by the implant, with equal preference for condoms and oral pill. Conclusions: An afterschool intervention at school is a viable model for the provision of SRH and rights education to learners. Recommendations include the need for risk reduction strategies in the curriculum, dealing with misconceptions, and the promotion of informed decision making. Endeavours to ensure health services are youth friendly is a priority to limit barriers to accessing these services.

Transactional sex work and HIV among women in conflict-affected Northeastern Uganda: a population-based study

BACKGROUND

Armed conflict and the HIV pandemic are significant global health issues. Evidence of the association between armed conflict and HIV infection has been conflicting. Our objective was to examine the role of mediating risk factors, such as engagement in transactional sex work, to elucidate the relation between armed conflict and HIV infection.

METHODS

We used multistage sampling across three Northeastern Ugandan districts to randomly select 605 women aged 13 to 49 to answer cross-sectional surveys from January to May of 2016. We used multivariate logistic regression model with R 4.0.3 to examine if exposure to armed conflict has an indirect effect on reporting having an HIV-positive serostatus through engagement in transactional sex work. Age and district residence were included as covariates.

RESULTS

Exposure to armed conflict β = .16, SE = .04, p < .05, OR = 1.17, 95% [CI .08, .23] was significantly associated with reporting a HIV-positive serostatus. For each 1-unit increase in exposure to armed conflict (i.e., additional type of armed conflict exposure), there was a 17% increase in the odds of reporting a HIV-positive serostatus. Engagement in transactional sex work was not associated with reporting a HIV-positive serostatus β = .04, SE = .05, p = .37, 95% [CI - .051, .138]. We found district of residence, age, and interaction effects.

CONCLUSIONS

Although exposure to armed was associated with reporting an HIV-positive serostatus, this relationship was not mediated by engagement in transactional sex. Further research is needed on risk factors that mediate this relationship. The likelihood of reporting a HIV-positive serostatus increased with each additional type of exposure to armed conflict. Thus, screening for exposure to multiple traumatic stressors should occur in HIV prevention settings. Healthcare services that are trauma-informed and consider mental distress would likely improve HIV outcomes.

Development and Validation of a Sociodemographic and Behavioral Characteristics-Based Risk-Score Algorithm for Targeting HIV Testing Among Adults in Kenya

To inform targeted HIV testing, we developed and externally validated a risk-score algorithm that incorporated behavioral characteristics. Outpatient data from five health facilities in western Kenya, comprising 19,458 adults ≥ 15 years tested for HIV from September 2017 to May 2018, were included in univariable and multivariable analyses used for algorithm development. Data for 11,330 adults attending one high-volume facility were used for validation. Using the final algorithm, patients were grouped into four risk-score categories: ≤ 9, 10-15, 16-29 and ≥ 30, with increasing HIV prevalence of 0.6% [95% confidence interval (CI) 0.46-0.75], 1.35% (95% CI 0.85-1.84), 2.65% (95% CI 1.8-3.51), and 15.15% (95% CI 9.03-21.27), respectively. The algorithm's discrimination performance was modest, with an area under the receiver-operating-curve of 0.69 (95% CI 0.53-0.84). In settings where universal testing is not feasible, a risk-score algorithm can identify sub-populations with higher HIV-risk to be prioritized for HIV testing.

Transactional sex and HIV infection among commercial farm workers in South Africa

Background

High prevalence of HIV infection has been reported among commercial farm workers in South Africa, but studies of the role of transactional sex in this epidemic is limited.

Objective

This study seeks to examine the association between transactional sex and HIV infection among commercial farm workers in South Africa.

Methods

This is a cross-sectional secondary data analysis of the Integrated Biological and Behavioural Surveillance Survey by the International Organization of Migration among farm workers in Mpumalanga and Limpopo Provinces, South Africa in 2010. The study included 2,758 sexually active farm workers. The outcome variable was HIV infection while the main explanatory variable was engagement in transactional sex. Other explanatory variables were sex, age, marital status, number of sex partners, food security, recent history of sexually transmitted infection, condom use at last sex with non-regular partner, history of sexual violence and migration status. Bivariate and multivariable logistic regression analyses were done to obtain unadjusted and adjusted odds ratios of the association between transactional sex and HIV infection.

Results

Engagement in transactional sex was common (19%) but not significantly associated with HIV infection (OR 1.1; CI 0.57-2.44). Female sex (1.93; 1.60-2.32), age 25 to 44 years, recent STI (OR 1.37; CI 1.18-1.58) and sexual violence (OR 1.39; CI 1.19-1.63) were significant risk factors for HIV infection.

Conclusion

Risky sexual behaviours were common among the farmworker population. HIV prevention interventions should include behavioural change communication and improved access to healthcare for STI and HIV treatment.

Caregiver self-efficacy to talk about sex predicts conversations about HIV transmission risk with perinatally infected young people in Zimbabwe

Given advances in care and treatment for HIV, perinatally infected young people are surviving into adolescence. These young people are making decisions about engaging in sexual relationships and it is critical to ensure they have the information they need to engage responsibly in sexual activity, particularly in an era where adherence to treatment could make their virus undetectable. The main objective of this analysis was to examine whether an HIV-positive young person's knowledge about forward transmission is associated with caregiver self-efficacy to talk about sex and general caregiver communication. Using data from a 12-month prospective cohort of caregivers of HIV-positive children aged 9-15 on ART and pre-ART in rural Zimbabwe, we found that caregiver self-efficacy to talk about sex predicted whether conversations about HIV transmission would occur between caregiver and the young person. However, by the end of 12-months, nearly two-thirds of caregivers of HIV-positive teenagers in our sample had still not explained how their adolescents could spread the virus to others despite these caregivers saying their adolescent should know this information at baseline. We discuss the implications for designing sexual and reproductive health (SRH) programs among populations of young people perinatally infected with HIV to ensure that this breakthrough generation receives the SRH support they need.

Modelling the impact of screening for chlamydia and gonorrhoea in youth and other high-prevalence groups in a resource-limited setting

OBJECTIVES

Modelling the potential impact of screening for chlamydia and gonorrhoea in youth and other populations in a resource-limited setting.

METHODS

We extended an agent-based model of heterosexual chlamydia and gonorrhoea transmission in South Africa to investigate the impact of screening strategies in key populations including youth, patients in HIV care, pregnant women and female sex workers (FSWs). Additionally, we compared the modelled impact of a standardised screening programme to results obtained from other published mathematical models of chlamydia screening.

RESULTS

All strategies resulted in reductions in general and targeted population chlamydia and gonorrhoea transmission. Opportunistic screening of patients in youth and HIV care was shown to be the most effective, and FSW screening was shown to be the most efficient strategy. Differences between models could be attributed to differences in the modelled heterogeneity in sexual behaviour as well as differences in assumptions about immunity following chlamydia recovery.

CONCLUSIONS

Taking modelling assumptions into account, opportunistic chlamydia and gonorrhoea screening of youth and those in HIV care represents a viable intervention for reducing sexually transmitted infections in the South African population.

Recently formed age-disparate partnerships are associated with elevated HIV-incidence among young women in South Africa

OBJECTIVE

Cross-sectional and cohort studies draw different conclusions on whether age-disparate partnerships increase HIV-acquisition risk for young women. We investigated whether age-disparities were associated with HIV-infection risk early in relationships. This could result in the exclusion of women who seroconverted during high-risk age-disparate partnerships from cohort studies of HIV incidence - which exclude HIV-positive women - and explain null findings in these studies.

DESIGN

Prospective cohort study.

METHODS

We used data on 15-24-year-old, HIV-negative women in heterosexual partnerships (N = 830) in KwaZulu-Natal, South Africa. The association between age-disparate partnering (i.e., male partner ≥5 years older) and subsequent HIV seroconversion was assessed using Cox hazard models. We examined heterogeneity in HIV-acquisition risk by duration of partnership (defined by quartiles) at cohort enrolment.

RESULTS

During 1139 person-years (mean: 1.4 years) of follow-up, 54 (6.5%) women seroconverted, a weighted HIV-incidence estimate of 4.41/100 person-years [95% confidence interval (CI): 3.30-6.06]. HIV-acquisition risk did not differ significantly between women in age-disparate vs. age-similar partnerships (adjusted hazard ratios: 1.10, 95% CI: 0.55-2.21). However, for women in the shortest partnership quartile (<1.09 years) at baseline, risk of HIV seroconversion was higher for women in age-disparate partnerships (adjusted hazard ratios: 3.13, 95% CI: 1.02-9.65, P = 0.047). HIV acquisition was not statistically different by partnership type among women in longer partnerships.

CONCLUSION

The association between age-disparate partnerships and HIV-acquisition risk is evident early in young women's relationships. Results provide a potential explanation for null findings in cohort studies, whose research designs may exclude women in such partnerships, and affirms the elevated risk of HIV acquisition for young women in age-disparate relationships.

Adolescent lives matter: preventing HIV in adolescents

Purpose of review

Many of the almost 2 million HIV infections that occurred globally in the last year occurred among adolescents and young people, particularly those from East and Southern Africa and within key populations. Global HIV epidemic control will require that new infections among these youth populations be curtailed. This review examines the most effective prevention approaches to reach these adolescent populations in the next 5 years.

Recent findings

Adolescents are in transition and are developmentally unique. They have specific needs and challenges, which if not addressed will result in less than successful interventions. Tailored, layered, combination prevention packages that take into account specific adolescent needs and involve biomedical, behavioural and structural components are recommended. These packages should be designed for and with the meaningful input of adolescents, and involve their peers in their implementation and execution. Where possible, age-appropriate health and social interventions that go beyond HIV should be bundled and offered in a variety of community-based venues that are already acceptable to and frequented by adolescents.

Summary

It is urgent that we reach adolescents globally with the most effective HIV prevention approaches. HIV prevention investment in this population has immediate and longer-term benefits.

Adult gonorrhea, chlamydia and syphilis prevalence, incidence, treatment and syndromic case reporting in South Africa: Estimates using the Spectrum-STI model, 1990-2017

OBJECTIVES

To estimate trends in prevalence and incidence of syphilis, gonorrhea and chlamydia in adult men and women in South Africa.

METHODS

The Spectrum-STI tool estimated trends in prevalence and incidence of active syphilis, gonorrhea and chlamydia, fitting South African prevalence data. Results were used, alongside programmatic surveillance data, to estimate trends in incident gonorrhea cases resistant to first-line treatment, and the reporting gap of symptomatic male gonorrhea and chlamydia cases treated but not reported as cases of urethritis syndrome.

RESULTS

In 2017 adult (15-49 years) the estimated female and male prevalences for syphilis were 0.50% (95% CI: 0.32-0.80%) and 0.97% (0.19-2.28%), for gonorrhea 6.6% (3.8-10.8%) and 3.5% (1.7-6.1%), and for chlamydia 14.7% (9.9-21%) and 6.0% (3.8-10.4%), respectively. Between 1990 and 2017 the estimated prevalence of syphilis declined steadily in women and men, probably in part reflecting improved treatment coverage. For gonorrhea and chlamydia, estimated prevalence and incidence showed no consistent time trend in either women or men. Despite growing annual numbers of gonorrhea cases - reflecting population growth - the estimated number of first line treatment-resistant gonorrhea cases did not increase between 2008 and 2017, owing to changes in first-line antimicrobial treatment regimens for gonorrhea in 2008 and 2014/5. Case reporting completeness among treated male urethritis syndrome episodes was estimated at 10-28% in 2017.

CONCLUSION

South Africa continues to suffer a high STI burden. Improvements in access and quality of maternal, STI and HIV health care services likely contributed to the decline in syphilis prevalence. The lack of any decline in gonorrhea and chlamydia prevalence highlights the need to enhance STI services beyond clinic-based syndromic case management, to reinvigorate primary STI and HIV prevention and, especially for women, to screen for asymptomatic infections.

'It's because I like things… it's a status and he buys me airtime': exploring the role of transactional sex in young women's consumption patterns in rural South Africa (secondary findings from HPTN 068)

BACKGROUND

'Transactional sex', defined as a non-marital, non-commercial sexual relationship in which money or material goods are exchanged for sex, is associated with young women's increased vulnerability to HIV infection. Existing research illustrates that the motivations for transactional sex are complex. The fulfilment of psycho-social needs such as the need to belong to a peer group are important factors underlying young women's desires to obtain certain consumption items and thus engage in transactional sex.

METHODS

We use a mixed-methods approach to explore the relationship between transactional sex and consumption patterns among young women in rural Mpumalanga province, South Africa. In the secondary analysis of 693 sexually active young women, we use factor analysis to group the different consumption items and we use multivariable logistic regression to demonstrate the relationship between transactional sex and consumption patterns. The qualitative study uses five focus group discussions and 19 in-depth interviews to explore further young women's motivations for acquiring different consumption items.

RESULTS

The quantitative results show that young women that engage in transactional sex have higher odds of consuming items for entertainment (e.g., movie tickets) than on practical items (e.g., food and groceries). The qualitative findings also revealed that young women's perceptions of items that were considered a 'need' were strongly influenced by peer pressure and a desire for improved status. Further, there was a perception that emerged from the qualitative data that relationships with sugar daddies offered a way to acquire consumer goods associated with a 'modern lifestyle', such as items for personal enhancement and entertainment. However, young women seem aware of the risks associated with such relationships. More importantly, they also develop relationship with partners of similar age, albeit with the continued expectation of material exchange, despite engaging in the relationship for love.

CONCLUSION

This study shows that young women are willing to take certain risks in order to have a degree of financial independence. Interventions that provide alternative methods of attaining this independence, such as the provision of cash transfers may have potential in preventing them from engaging in transactional relationships. Further, the psycho-social reasons that drive young women's motivations for consumption items resulting in risky sexual behaviours need to be better understood.

Genital Chlamydia trachomatis and Neisseria gonorrhoeae infections among women in sub-Saharan Africa: A structured review

Chlamydia trachomatis and Neisseria gonorrhoeae constitute major public health problems among women, but the burden of infection in sub-Saharan Africa is poorly documented. We conducted a structured review of the prevalence and incidence of genital, oral and anal C. trachomatis and N. gonorrhoeae infection in women in sub-Saharan Africa. We searched Medline, EMBASE and Web of Science over a 10-year period for studies on epidemiology of genital, oral and anal chlamydial infection and gonorrhoea in women in all countries of sub-Saharan Africa. We assessed geographic and demographic differences in prevalence and incidence of infection; weighted mean prevalence estimates were calculated with a random-effect model. A total of 102 study results were included, with data available for 24/49 of sub-Saharan countries. The weighted prevalence of chlamydial infection was lower among women in community-based studies (3.9%; 95% CI: 2.9-5.1%) than for women recruited at primary healthcare facilities (6.0%; 95% CI: 4.2-8.4%, p < 0.001); the same was observed for gonorrhoea (2.2%; 95% CI: 1.2-4.0% vs. 4.2%; 95% CI: 3.2-5.6%, p < 0.001). Prevalence of Chlamydia among sex workers was 5.5% (95% CI: 4.2-7.3%) and gonorrhoea 7.6% (95% CI: 5.4-11%). Seven studies reported on incidence which varied between 0.75-28 and 2.8-17 per 100 person-years-at-risk for chlamydial infection and gonorrhoea, respectively. Only two studies reported on anal infections and one on oral infection. This overview underscores the considerable incidence and prevalence of genital C. trachomatis and N. gonorrhoeae in women in different settings in sub-Saharan Africa. Better control strategies are warranted to reduce the burden of infection and to prevent long-term complications of these infections.

Study protocol for a longitudinal study evaluating the impact of rape on women's health and their use of health services in South Africa

INTRODUCTION

South Africa is a country known for its high levels of HIV infection and sexual violence. Although the interface between gender-based violence, HIV and mental health has been described, there are substantial gaps in knowledge of the medium-term and long-term health impact. The 2010 Global Burden of Disease study excluded many health outcomes associated with rape and other forms of gender-based violence because systematic reviews revealed huge gaps in data and poor evidence of health effects. This study aims to describe the incidence and attributable burden of physical and mental health problems (including HIV acquisition) in adult women over a 2-year postrape period, through comparison with a cohort of women who have not been raped. The study will substantially advance our understanding of the impact of rape and will generate robust data to assist in the development of postrape health services and the delivery of evidence-based care.

METHODS AND ANALYSIS

This longitudinal study seeks to recruit 1008 rape-exposed and 1008 rape non-exposed women. Women were recruited from health services, and assessments were carried out at baseline, 3, 6, 9, 12, 18 and 24 months. Outcome measures include exposure to risk factors; mental health status; cardio-metabolic risks; and biomarkers for HIV, sexually transmitted infections, pregnancy and stress. The primary analysis will be to compare HIV incidence in the two groups using log-rank tests. Appropriate models to predict health outcomes over time will also be applied.

ETHICS AND DISSEMINATION

The South African Medical Research Council's Ethics Committee approved the study. As rape is a key element of the study, the safety and protection of participants guides the research process. We will adopt a research uptake strategy to ensure dissemination to policy makers, service providers and advocacy groups. Peer-reviewed journal articles will be published.

Planning community-based assessments of HIV educational intervention programs in sub-Saharan Africa

A key consideration in planning studies of community-based HIV education programs is identifying a sample size large enough to ensure a reasonable probability of detecting program effects if they exist. Sufficient sample sizes for community- or group-based designs are proportional to the correlation or similarity of individuals within communities. As a result, efficient and effective design requires reasonable a priori estimates of the correlational structure among individuals within communities. In this study, we investigate the degree of correlation among individuals within communities and regions using samples of sixth-grade adolescents from 609 local area district communities and 122 regions in 15 sub-Saharan African nations. We develop nation-specific and international summaries of these correlations using variance partitioning coefficients from multilevel models and subsequently assess the extent to which different types of background variables delineate key sources of these correlations. The results suggest persistent differences among communities and regions and that the degree of correlation among individuals within communities varied considerably by nation. The findings underscore the importance of empirically derived values of design parameters that are anchored in evidence specific to the outcome, nation and context of the planned study.

Boys are not exempt: Sexual exploitation of adolescents in sub-Saharan Africa

Research on youth sexual exploitation in Africa has largely neglected the experiences of exploited boys. To date, much of the research in sub-Saharan Africa continues to consider boys mainly as exploiters but not as exploited. Using the only publicly available population-based surveys from the National Survey of Adolescents, conducted in four sub-Saharan African countries - Burkina Faso, Ghana, Malawi, and Uganda-we assessed factors associated with transactional sexual behaviour among never-married adolescent boys and girls. We also examined whether boys' reported sexual exploitation was linked to similar risky sexual behaviours as has been noted among girls in sub-Saharan Africa. Results from our analyses indicated that even though adolescent girls have a somewhat higher likelihood of reporting sexual abuse and exploitation, the odds of trading sex were significantly elevated for previously traumatized boys (that is those with a history of sexual and physical abuse) but not for their female counterparts. Just like adolescent girls, transactional sexual behaviour was associated with the risk of having concurrent multiple sexual partners for boys. These findings support the reality of boys' sexual exploitation within the African context, and further highlight the importance of including males in general and boys in particular in population-based studies on sexual health, risk, and protective factors in the sub-Saharan African region. Understanding the factors linked to sexual exploitation for both boys and girls will help in developing policies and programs that could improve the overall sexual and reproductive health outcomes among adolescents and youth in sub-Saharan Africa.

Transactional sex and risk for HIV infection in sub-Saharan Africa: a systematic review and meta-analysis

INTRODUCTION

Young women aged 15 to 24 years in sub-Saharan Africa continue to be disproportionately affected by HIV. A growing number of studies have suggested that the practice of transactional sex may in part explain women's heightened risk, but evidence on the association between transactional sex and HIV has not yet been synthesized. We set out to systematically review studies that assess the relationship between transactional sex and HIV among men and women in sub-Saharan Africa and to summarize the findings through a meta-analysis.

METHODS

The search strategy included 8 databases, hand searches in 10 journals, and searches across 17 websites and portals for organizations as informed by expert colleagues. A systematic review of cross-sectional and longitudinal studies was carried out for studies on women and men who engage in transactional sex published up through 2014. Random effects meta-analysis was used to further examine the relationship between transactional sex and prevalent HIV infection across a subset of studies with the same exposure period. Analyses were conducted separately for men and women.

RESULTS

Nineteen papers from 16 studies met our inclusion criteria. Of these 16 studies, 14 provided data on women and 10 on men. We find a significant, positive, unadjusted or adjusted association between transactional sex and HIV in 10 of 14 studies for women, one of which used a longitudinal design (relative risk (RR)=2.06, 95% confidence interval (CI): 1.22 -3.48). Out of 10 studies involving men, only 2 indicate a positive association between HIV and transactional sex in unadjusted or adjusted models. The meta-analysis confirmed general findings from the systematic review (unadjusted meta-analysis findings are significant for women (n=4; pooled odds ratio (OR)=1.54, 95% CI: 1.04-2.28; I2=42.5%, p=0.156), but not for men (n=4; pooled OR=1.47, 95% CI: 0.85-2.56; I2=50.8%, p=0.107).

CONCLUSIONS

Transactional sex is associated with HIV among women, whereas findings for men were inconclusive. Given that only two studies used a longitudinal approach, there remains a need for better measurement of the practice of transactional sex and additional longitudinal studies to establish the causal pathways between transactional sex and HIV.

Multiple sexual partnerships among female adolescents in rural Uganda: the effects of family structure and school attendance

BACKGROUND

A better understanding is needed of the contextual factors that influence HIV risk behaviors among female adolescents in sub-Saharan Africa. The objectives of this study were to assess the influence of family structure on lifetime sexual partners and on the number of sexual partners in the last year among female adolescents in rural Rakai, Uganda. In addition, the study assessed whether the influence of family structure on these outcomes differed by the school attendance status of the adolescents.

METHODS

The sample consisted of 2337 unmarried adolescent girls, aged 15-19, enrolled in the Rakai Community Cohort Study. The last survey interview within the time period of 2001-2008 available for each girl was used. Analyses were stratified by age (15-17 year olds and 18-19 year olds) and school status. Multinomial logistic and poisson regressions were used.

RESULTS

Living in a household with a biological father was protective against both outcomes. Family structure was not associated with the outcomes among in-school adolescents but it was significantly associated with the outcomes among out-of-school adolescents.

CONCLUSION

The findings suggest that understanding the familial context in which female adolescents develop, as well as its interaction with school attendance, is important for HIV prevention efforts. Both research and programmatic initiatives must consider the interplay between the family and school domains when considering ways to reduce HIV acquisition among adolescent women.

Sexual Behaviour of Men and Women within Age-Disparate Partnerships in South Africa: Implications for Young Women's HIV Risk

Background

Age-disparate partnerships are hypothesized to increase HIV-risk for young women. However, the evidence base remains mixed. Most studies have focused only on unprotected sex among women in the partnership. Consequently, little is known about other risky behaviours, such as transactional sex, alcohol use, and concurrency, as well as the behaviours of the men who partner with young women. We therefore examined differences in various sexual behaviours of both young women and their male partners by partnership age difference.

Methods

We used nationally representative data from South Africa (2012) on partnerships reported by 16–24 year old black African women (n = 818) and by black African men in partnerships with 16–24 year old women (n = 985). We compared sexual behaviours in age-disparate partnerships and age-similar partnerships, using multiple logistic regression to control for potential confounders and to assess rural/urban differences.

Results

Young women in age-disparate partnerships were more likely to report unprotected sex than young women in similar-aged partnerships (aOR:1.51; p = 0.014; 95%CI:1.09–2.11). Men in partnerships with young women were more likely to report unprotected sex (aOR:1.92; p<0.01; 95%CI:1.31–2.81), transactional sex (aOR:2.73; p<0.01; 95%CI:1.64–4.56), drinking alcohol before sex (aOR:1.60; p = 0.062; 95%CI:0.98–2.61), and concurrency (aOR:1.39; p = 0.097; 95%CI:0.94–2.07) when their partners were five or more years younger. The association between age-disparate partnerships and transactional sex (aOR:4.14; p<0.01; 95%CI: 2.03–8.46) and alcohol use (aOR:2.24; p<0.013; 95%CI:1.20–4.19) was only found in urban areas.

Conclusions

Results provide evidence that young women’s age-disparate partnerships involve greater sexual risk, particularly through the risky behaviours of their male partners, with the risk amplified for young women in urban areas.

Transactional sex among young women in rural South Africa: prevalence, mediators and association with HIV infection

INTRODUCTION

Young adolescent women in sub-Saharan Africa are three to four times more likely to be HIV-positive than boys or men. One of the relationship dynamics that is likely to be associated with young women's increased vulnerability to HIV is transactional sex. There are a range of HIV-related risk behaviours that may drive this vulnerability. However, to date, limited epidemiological data exist on the role of transactional sex in increasing HIV acquisition, especially among young women in sub-Saharan Africa. Our paper presents data on the prevalence of self-reported engagement in transactional sex and explores whether transactional sex is associated with increased risk of HIV infection among a cohort of young, rural, sexually active South African women. We also explore whether this relationship is mediated through certain HIV-related risk behaviours.

METHODS

We analyzed baseline data from a phase III trial of conditional cash transfers for HIV prevention of 693 sexually active, school-going young women aged 13-20 years in rural South Africa. We examined the association between young women's engagement in transactional sex and HIV infection. Transactional sex is defined as a non-commercial, non-marital sexual relationship whereby sex is exchanged for money and/or gifts. We explored whether this relationship is mediated by certain HIV-related risk behaviours. We used logistic and multinomial regression and report unadjusted and adjusted odds ratios with 95% CI.

RESULTS

Overall, 14% (n=97) of sexually active young women reported engaging in transactional sex. Engagement in transactional sex was associated with an increased risk of being HIV-positive (aOR: 2.5, CI: 95% 1.19-5.25, p=0.01). The effect size of this association remained nearly unchanged when adjusted for certain other dimensions of HIV risk that might help explain the underlying pathways for this relationship.

CONCLUSIONS

This study provides quantitative support demonstrating that transactional sex is associated with HIV infection in young women. Even though the specific variables tested do not mediate the relationship, a potential explanation for this association may be that the men with whom young women are having sex belong to networks of sexually connected individuals who are at a "high risk" for HIV infection. The results highlight the importance of structural intervention approaches that can alter the context of young women's HIV risk.

Rethinking HIV prevention to prepare for oral PrEP implementation for young African women

INTRODUCTION

HIV incidence remains high among young women in sub-Saharan Africa in spite of scale-up of HIV testing, behavioural interventions, antiretroviral treatment and medical male circumcision. There is a critical need to critique past approaches and learn about the most effective implementation of evidence-based HIV prevention strategies, particularly emerging interventions such as pre-exposure prophylaxis (PrEP).

DISCUSSION

Women in sub-Saharan Africa are at increased risk of HIV during adolescence and into their 20s, in part due to contextual factors including gender norms and relationship dynamics, and limited access to reproductive and sexual health services. We reviewed behavioural, behavioural economic and biomedical approaches to HIV prevention for young African women, with a particular focus on the barriers, opportunities and implications for implementing PrEP in this group. Behavioural interventions have had limited impact in part due to not effectively addressing the context, broader sexual norms and expectations, and structural factors that increase risk and vulnerability. Of biomedical HIV prevention strategies that have been tested, daily oral PrEP has the greatest evidence for protection, although adherence was low in two placebo-controlled trials in young African women. Given high efficacy and effectiveness in other populations, demonstration projects of open-label PrEP in young African women are needed to determine the most effective delivery models and whether women at substantial risk are motivated and able to use oral PrEP with sufficient adherence to achieve HIV prevention benefits.

CONCLUSIONS

Social marketing, adherence support and behavioural economic interventions should be evaluated as part of PrEP demonstration projects among young African women in terms of their effectiveness in increasing demand and optimizing uptake and effective use of PrEP. Lessons learned through evaluations of implementation strategies for delivering oral PrEP, a first-generation biomedical HIV prevention product, will inform development of new and less user-dependent PrEP formulations and delivery of an expanding choice of prevention options in HIV prevention programmes for young African women.

A network-level explanation for the differences in HIV prevalence in South Africa's racial groups

Analyses of individual-level risk factors have not been able to adequately explain why HIV has spread so extensively in southern Africa and why this has occurred especially within certain racial or ethnic groups. Using data from a longitudinal study of a representative sample of adolescents aged 14-22 living in Cape Town, South Africa, this article presents evidence of how differences in individual-level risk factors as well as sexual network structures between different racial or ethnic groups may help explain the differential spread of HIV in South Africa. Particular emphasis is placed on how levels of partner concurrency, respondent concurrency, mutual concurrency, serial concurrency and numbers of sexual partners and an average early age of sexual debut combine in different ways in the different racial or ethnic groups to create networks of sexual partnerships that differ in the density of their interconnections and hence potential for HIV spread. These network-level differences offer a potential explanation for the observed generalised HIV epidemic seen among the population of black South Africans.

Cervical ectopy: associations with sexually transmitted infections and HIV. A cross-sectional study of high school students in rural South Africa

OBJECTIVES

It has been hypothesised that ectopy may be associated with increased susceptibility to sexually transmitted infections (STIs). In this cross-sectional study, we wanted to explore the association between STIs (including HIV) and cervical ectopy.

METHODS

We included 700 sexually active young women attending randomly selected high schools in a rural district in KwaZulu-Natal, South Africa. The district is endemic of HIV and has a high prevalence of STIs. We did computer-assisted measurements of the ectocervical area covered by columnar epithelium (ectopy) in colposcopic images and STI analyses on cervicovaginal lavage and serum samples. All participating women answered a questionnaire about sexual behaviour and use of contraceptives.

RESULTS

The mean age was 19.1 years. Ectopy was found in 27.2%, HIV in 27.8%, chlamydia in 25.3% and gonorrhoea in 15.6%. We found that age, parity, chlamydia and gonorrhoea, years since menarche, years since sexual debut and number of sexual partners were associated with ectopy. In multivariate analysis with chlamydia infection as the dependent variable, women with ectopy had increased odds of having chlamydia infection (adjusted OR 1.78, p=0.033). In women under 19 years of age, we found twofold higher odds of being HIV-positive for those with ectopy (OR 2.19, p=0.014).

CONCLUSIONS

In conclusion, cervical ectopy is associated with Chlamydia trachomatis infection and HIV in the youngest women.

From 'sugar daddies' to 'sugar babies': exploring a pathway among age-disparate sexual relationships, condom use and adolescent pregnancy in South Africa

Background Adolescent pregnancy has been linked to adverse outcomes. Most studies proposing risk pathways for adolescent pregnancy in South Africa are qualitative, hypothesising links among age-disparate relationships, reduced condom use and higher pregnancy rates. No known South African studies have quantitatively explored pathways to adolescent pregnancy.

OBJECTIVES

This study aimed to: (i) identify the factors associated with adolescent pregnancy and (ii) explore a pathway of risk by assessing whether condom use mediated the relationship between age-disparate sexual relationships and adolescent pregnancy.

METHODS

A cross-sectional survey of 447 sexually active girls aged 10-19 years was undertaken in six health districts of South Africa. Multivariate logistic regressions controlled for confounders. Mediation tests used bootstrapping.

RESULTS

Consistent condom use (β=-2.148, odds ratio (OR)=8.566, P≤0.001) and school enrolment (β=-1.600, OR=0.202, P≤0.001) were associated with lower pregnancy rates. Age-disparate sex (β=1.093, OR=2.982, P≤0.001) and long-term school absences (β=1.402, OR=4.061, P≤0.001) were associated with higher pregnancy rates. The indirect effect of age-disparate sex on adolescent pregnancy through condom use was significant, irrespective of age, age at sexual initiation, poverty and residential environment (B=0.4466, s.d.=0.1303, confidence interval: 0.2323-0.7428).

CONCLUSION

This survey supports hypotheses that inability to negotiate condom use in age-disparate sexual relationships may drive adolescent pregnancy. Interventions addressing these relationships, facilitating condom use and increasing access to sexual health services among adolescents might avert unwanted pregnancies.

It takes 2: partner attributes associated with sexually transmitted infections among adolescents

OBJECTIVES

The aims of this study were to identify partner attributes associated with sexually transmitted infections (STIs) among adolescents and to summarize implications for research and prevention.

DESIGN

The design of this study was systematic review.

METHODS

We identified peer-reviewed studies published in 1990 through 2010 that assessed 1 or more partner attributes in relation to a biologically confirmed STI among adolescents (15-24 years) by searching MEDLINE and included articles. Studies that included adolescents but more than 50% of the sample or with mean or median age of 25 years or greater were excluded.

RESULTS

Sixty-four studies met the eligibility criteria; 61% were conducted in high-income countries; 80% were cross sectional; and 91% enrolled females and 42% enrolled males. There was no standard "partner" definition. Partner attributes assessed most frequently included the following: age, race/ethnicity, multiple sex partners, and STI symptoms. Older partners were associated with prevalent STIs but largely unrelated to incidence. Black race was associated with STIs but not uniformly. Partners with multiple partners and STI symptoms seem to be associated with STIs predominantly among females. Although significant associations were reported, weaker evidence exists for the following: other partner sociodemographics, sexual and other behaviors (sexual concurrency, intimate partner violence, substance use, travel), and STI history. There were no apparent differences by STI.

CONCLUSIONS

Partner attributes are independently associated with STIs among male and female adolescents worldwide. These findings reinforce the importance of assessing partner attributes when determining STI risk. Prevention efforts should continue to promote and address barriers to condom use. Increased efforts are needed to screen and treat STIs and reduce risky behavior among men. A standard partner definition would facilitate the interpretation of findings in future studies.

Routine HIV testing in adolescents and young adults presenting to an outpatient clinic in Durban, South Africa

Objectives

Although youth (12–24 years) in Sub-Saharan Africa have a high HIV risk, many have poor access to HIV testing services and are unaware of their status. Our objective was to evaluate the proportion of adolescents (12–17 years) and young adults (18–24 years) who underwent HIV testing and the prevalence among those tested in an urban adult outpatient clinic with a routine HIV testing program in Durban, South Africa.

Design

We conducted a retrospective cross-sectional analysis of adolescent and young adult outpatient records between February 2008 and December 2009.

Methods

We determined the number of unique outpatient visitors, HIV tests, and positive rapid tests among those tested.

Results

During the study period, 956 adolescents registered in the outpatient clinic, of which 527 (55%) were female. Among adolescents, 260/527 (49%, 95% CI 45–54%) females underwent HIV testing compared to 129/429 (30%, 95% CI 26–35%) males (p<0.01). The HIV prevalence among the 389 (41%, 95% CI 38–44%) adolescents who underwent testing was 16% (95% CI 13–20%) and did not vary by gender (p = 0.99). During this period, there were 2,351 young adult registrations, and of these 1,492 (63%) were female. The proportion consenting for HIV testing was similar among females 980/1,492 (66%, 95% CI 63–68%) and males 543/859 (63%, 95% CI 60–66%, p = 0.25). Among the 1,523 (65%, 95% CI 63–67%) young adults who underwent testing, the HIV prevalence was 22% (95% CI 19–24%) in females versus 14% in males (95% CI 11–17%, p<0.01).

Conclusions

Although the HIV prevalence is high among youth participating in an adult outpatient clinic routine HIV program, the uptake of testing is low, especially among 12–17 year old males. There is an urgent need to offer targeted, age-appropriate routine HIV testing to youth presenting to outpatient clinics in epidemic settings.

Vaginal microbicides to prevent human immunodeficiency virus infection in women: perspectives on the female genital tract, sexual maturity and mucosal inflammation

Topically applied vaginal microbicides to protect against human immunodeficiency (HIV) virus infection offer an important female-controlled prevention strategy. Microbicides have been in development for more than 2 decades, and have included various agents that disrupt cellular and microbial membranes (surfactants), restore the natural acidic protective pH of the vagina (acid buffers), and those that interfere with interactions between HIV envelope proteins and cellular receptors (anionic polymers). Although none of these candidate microbicides have shown significant protection against HIV in clinical trials, a topical gel, including the antiretroviral drug tenofovir (TFV) 1% was the first microbicide to be tested to show some protection against HIV infection. This review explores the effect of female genital tract biology and anatomy, mucosal inflammation, and age on the effectiveness of microbicides to prevent HIV infection.

Gender inequity norms are associated with increased male-perpetrated rape and sexual risks for HIV infection in Botswana and Swaziland

Background

There is limited empirical research on the underlying gender inequity norms shaping gender-based violence, power, and HIV risks in sub-Saharan Africa, or how risk pathways may differ for men and women. This study is among the first to directly evaluate the adherence to gender inequity norms and epidemiological relationships with violence and sexual risks for HIV infection.

Methods

Data were derived from population-based cross-sectional samples recruited through two-stage probability sampling from the 5 highest HIV prevalence districts in Botswana and all districts in Swaziland (2004–5). Based on evidence of established risk factors for HIV infection, we aimed 1) to estimate the mean adherence to gender inequity norms for both men and women; and 2) to model the independent effects of higher adherence to gender inequity norms on a) male sexual dominance (male-controlled sexual decision making and rape (forced sex)); b) sexual risk practices (multiple/concurrent sex partners, transactional sex, unprotected sex with non-primary partner, intergenerational sex).

Findings

A total of 2049 individuals were included, n = 1255 from Botswana and n = 796 from Swaziland. In separate multivariate logistic regression analyses, higher gender inequity norms scores remained independently associated with increased male-controlled sexual decision making power (AORmen = 1.90, 95%CI:1.09–2.35; AORwomen = 2.05, 95%CI:1.32–2.49), perpetration of rape (AORmen = 2.19 95%CI:1.22–3.51), unprotected sex with a non-primary partner (AORmen = 1.90, 95%CI:1.14–2.31), intergenerational sex (AORwomen = 1.36, 95%CI:1.08–1.79), and multiple/concurrent sex partners (AORmen = 1.42, 95%CI:1.10–1.93).

Interpretation

These findings support the critical evidence-based need for gender-transformative HIV prevention efforts including legislation of women's rights in two of the most HIV affected countries in the world.

Sexual risk behaviors among HIV-infected South African men and women with their partners in a primary care program: implications for couples-based prevention

We studied 1163 sexually-active HIV-infected South African men and women in an urban primary care program to understand patterns of sexual behaviors and whether these behaviors differed by partner HIV status. Overall, 40% reported a HIV-positive partner and 60% a HIV-negative or status unknown partner; and 17.5% reported >2 sex acts in the last 2 weeks, 16.4% unprotected sex in the last 6 months, and 3.7% >1 sex partner in the last 6 months. Antiretroviral therapy (ART) was consistently associated with decreased sexual risk behaviors, as well as with reporting a HIV-negative or status unknown partner. The odds of sexual risk behaviors differed by sex; and were generally higher among participants reporting a HIV-positive partner, but continued among those with a HIV-negative or status unknown partner. These data support ART as a means of HIV prevention. Engaging in sexual risk behaviors primarily with HIV-positive partners was not widely practiced in this setting, emphasizing the need for couples-based prevention.

HIV prevention in young people in sub-Saharan Africa: a systematic review

PURPOSE

To systematically review and update evidence on the effectiveness of youth HIV/AIDS prevention interventions in sub-Saharan Africa (SSA) and to make evidence-based policy recommendations to guide efforts toward meeting the United Nations General Assembly Special Session HIV/AIDS goals.

METHODS

Recent evidence (January 2005-December 2008) on the effectiveness of interventions to improve reported sexual behavior and biological outcomes among youth in SSA was assessed using the Steady, Ready, Go! (SRG) approach and synthesized with an earlier SRG review (January 1990-June 2005).

RESULTS

A total of 23 studies were included following screening of approximately 1,200 citations. School-based, adult-led, curriculum-based interventions showed clear evidence of reducing reported risky sexual behavior. Interventions in health facilities increased the use of services when made accessible and more youth-friendly. In geographically defined communities, both interventions specifically targeting youth and community-wide interventions reduced reports of risky sexual behavior.

CONCLUSIONS

HIV prevention among youth is a top priority in SSA. The most promising interventions should be scaled-up now, with careful evaluation, while exploring supplementary interventions to impact HIV incidence.

Changes in sexual risk behavior before and after HIV seroconversion in Southern African women enrolled in a HIV prevention trial

BACKGROUND

We examine changes in sexual risk behaviors before and after HIV seroconversion in southern African women enrolled in the Methods for Improving Reproductive Health in Africa trial.

METHODS

HIV testing and counseling, and assessment of sexual behaviors by audio computer-assisted self-interviewing were performed approximately every 3 months. We compared the following sexual behaviors: being sexually active, coital frequency, consistent male condom use, use of any female condoms, anal sex, and >1 sex partner, at study visits before and after HIV seroconversion.

RESULTS

During the trial, 327 women seroconverted to HIV, contributing 718 pre-HIV and 1110 post-HIV study visits. Women were significantly more likely to report consistent condom use at visits after HIV seroconversion compared with visits before HIV infection [adjusted odds ratio, (AOR): 1.36 (95% confidence interval (CI): 1.11 to 1.67)] and were less likely to have >1 male sex partner after serconversion [AOR: 0.66 (95% CI: 0.48 to 0.91)]. Women reported less frequently being sexually active [AOR: 0.63 (95% CI: 0.39 to 1.02)], fewer episodes of sex [>4 sex acts over the past week AOR: 0.74 (95% CI: 0.60 to 0.91)], and a reduction in anal sex [AOR: 0.58 (95% CI: 0.36 to 0.95)] at visits after HIV seroconversion. The observed reductions in sexual risk behaviors persisted over time.

CONCLUSIONS

Women significantly decreased their sexual risk behaviors after HIV seroconversion, but these changes were relatively modest, suggesting the need for further secondary prevention. Timely notification of HIV status coupled with prevention messages can contribute to reductions in sexual risk behaviors.

A tale of two countries: rethinking sexual risk for HIV among young people in South Africa and the United States

PURPOSE

To compare the sexual behaviors of young people in South Africa (SA) and the United States (US) with the aim to better understand the potential role of sexual behavior in HIV transmission in these two countries that have strikingly different HIV epidemics.

METHODS

Nationally representative, population-based surveys of young people aged 18-24 years from SA (n = 7,548) and the US (n = 13,451) were used for the present study.

RESULTS

The prevalence of HIV was 10.2% in SA and <1% in the US. Young women and men in the US reported an earlier age of first sex than those in SA (mean age of coital debut for women: US [16.5], SA [17.4]; for men: US [16.4], SA [16.7]). The median number of lifetime partners is higher in the US than in SA: women: US (4), SA (2); men: US (4), SA (3). The use of condom at last sex is reported to be lower in the US than in SA: women: US (36.1%), SA (45.4%); men: US (48%), SA (58%). On average, young women in SA report greater age differences with their sex partners than young women in the US.

CONCLUSION

Young people in the US report riskier sexual behaviors than young people in SA, despite the much higher prevalence of HIV infection in SA. Factors above and beyond sexual behavior likely play a key role in the ongoing transmission of HIV in South African youth, and thus should be urgently uncovered to develop maximally effective prevention strategies.

Who gets tested for HIV in a South African urban township? Implications for test and treat and gender-based prevention interventions

BACKGROUND

With increasing calls for linking HIV-infected individuals to treatment and care via expanded testing, we examined sociodemographic and behavioral characteristics associated with HIV testing among men and women in Soweto, South Africa.

METHODS

We conducted a cross-sectional household survey involving 1539 men and 1877 women as part of the community-randomized prevention trial Project ACCEPT/HPTN043 between July 2007 to October 2007. Multivariable logistic regression models, stratified by sex, assessed factors associated with HIV testing and then repeated testing.

RESULTS

Most women (64.8%) and 28.9% of men reported ever having been tested for HIV, among whom 57.9% reported repeated HIV testing. In multivariable analyses, youth and students had a lower odds of HIV testing. Men and women who had conversations about HIV/AIDS with increasing frequency and who had heard about antiretroviral therapy were more likely to report HIV testing, and repeated testing. Men who had ≥ 12 years of education and who were of high socioeconomic status, and women who were married, who were of low socioeconomic status, and who had children under their care had a higher odds of HIV testing. Women, older individuals, those with higher levels of education, married individuals, and those with children under their care had a higher odds of reporting repeated HIV testing. Uptake of HIV testing was not associated with condom use, having multiple sex partners, and HIV-related stigma.

CONCLUSIONS

Given the low uptake of HIV testing among men and youth, further targeted interventions could facilitate a test and treat strategy among urban South Africans.

Decreased sexual risk behavior in the era of HAART among HIV-infected urban and rural South Africans attending primary care clinics

OBJECTIVE

In light of increasing access to HAART in sub-Saharan Africa, we conducted a longitudinal study to assess the impact of HAART on sexual risk behaviors among HIV-infected South Africans in urban and rural primary care clinics.

DESIGN

Prospective observational cohort.

METHODS

We conducted a cohort study at rural and urban primary care HIV clinics in South Africa consisting of 1544 men and 4719 women enrolled from 2003 to 2010, representing 19703 clinic visits. The primary outcomes were being sexually active, unprotected sex, and more than one sex partner and were evaluated at 6 monthly intervals. Generalized estimated equations assessed the impact of HAART on sexual risk behaviors.

RESULTS

Among 6263 HIV-infected men and women, over a third (37.2%) initiated HAART during study follow-up. In comparison to pre-HAART follow-up, visits while receiving HAART were associated with a decrease in those reporting being sexually active [adjusted odds ratio: 0.86 (95% confidence interval: 0.78-0.95)]. Unprotected sex and having more than one sex partner were reduced at visits following HAART initiation compared to pre-HAART visits [adjusted odds ratio: 0.40 (95% confidence interval: 0.34-0.46) and adjusted odds ratio: 0.20 (95% confidence interval: 0.14-0.29), respectively].

CONCLUSION

Sexual risk behavior significantly decreased following HAART initiation among HIV-infected South African men and women in primary care programs. The further expansion of antiretroviral treatment programs could enhance HIV prevention efforts in Africa.

Economically motivated relationships and transactional sex among unmarried African American and white women: results from a U.S. national telephone survey

OBJECTIVE

We explored links among economically motivated relationships, transactional sex, and risk behavior for human immunodeficiency virus (HIV) and sexually transmitted infections (STIs) among unmarried African American and white women.

METHODS

We drew on data from 1,371 unmarried African American and white women aged 20 to 45 years that we collected via a random-digit-dial telephone survey in the U.S.

RESULTS

Of all respondents, 33.3% (95% confidence interval 28.8, 38.0) reported staying in a relationship longer than they wanted to because of economic considerations. African American women were more likely than white women to report starting a relationship due to economic considerations (21.6% vs. 10.5%) and having transactional sex with someone who was not a regular partner (13.1% vs. 2.9%). These behaviors were all associated with lack of education, experience of economic hardship, need to care for dependents, and increased levels of HIV/STI risk. All three behaviors were associated with having more sexual partners. Staying in a sexual relationship because of economic considerations was also associated with anal sex, reduced condom use, and concurrent sexual partnerships. Transactional sex with non-regular partners was associated with concurrent sexual partnerships, binge drinking, drug use, perceived concurrency by main partner, and having high-risk sexual partners.

CONCLUSION

HIV/STI risk-reduction policies and programs in the U.S. need to explicitly address overall economic disempowerment among women, as well as racial disparities in poverty. These economic disparities likely contribute both to increasing rates of HIV among women in the U.S. and to the extraordinary racial disparities in HIV/STI risk among American women.

Behavior change interventions to prevent HIV infection among women living in low and middle income countries: a systematic review

We conducted a systematic review of behavioral change interventions to prevent the sexual transmission of HIV among women and girls living in low- and middle-income countries. PubMed/MEDLINE, Web of Science, the Cochrane Library, and other databases and bibliographies were systematically searched for trials using randomized or quasi-experimental designs to evaluate behavioral interventions with HIV infection as an outcome. We identified 11 analyses for inclusion reporting on eight unique interventions. Interventions varied widely in intensity, duration, and delivery as well as by target population. Only two analyses showed a significant protective effect on HIV incidence among women and only three of ten analyses that measured behavioral outcomes reduced any measure of HIV-related risk behavior. Ongoing research is needed to determine whether behavior change interventions can be incorporated as independent efficacious components in HIV prevention packages for women or simply as complements to biomedical prevention strategies.

Do behavioural differences help to explain variations in HIV prevalence in adolescents in sub-Saharan Africa?

OBJECTIVE

To compare adolescent risk factors for HIV infection in two countries with high adolescent HIV prevalence and two lower prevalence countries with the aim of identifying risk factors that may help explain differences in adolescent HIV prevalence.

METHODS

Data were available from two nationally representative surveys (South Africa, Zimbabwe), two behavioural intervention trials (Tanzania, Zimbabwe) and one population-based cohort (Uganda). Data on variables known or postulated to be risk factors for HIV infection were compared.

RESULTS

Few risk behaviours were markedly more common in the high HIV prevalence populations. Risk factors more common in high HIV prevalence settings were genital ulcers and discharge, and women were more likely to report older male partners.

DISCUSSION

Age mixing may be an important determinate of HIV prevalence in adolescents. Potential reasons for the general lack of association between other adolescent risk factors and adolescent HIV prevalence include adult HIV prevalence, misreported behaviour, different survey methods and other unmeasured adolescent behaviours. If adult factors dominate adolescent HIV risk, it would help explain the failure of behavioural interventions targeted at adolescents and suggests future interventions should include adults.

HIV prevention for South African youth: which interventions work? A systematic review of current evidence

BACKGROUND

In South Africa, HIV prevalence among youth aged 15-24 is among the world's highest. Given the urgent need to identify effective HIV prevention approaches, this review assesses the evidence base for youth HIV prevention in South Africa.

METHODS

Systematic, analytical review of HIV prevention interventions targeting youth in South Africa since 2000. Critical assessment of interventions in 4 domains: 1) study design and outcomes, 2) intervention design (content, curriculum, theory, adaptation process), 3) thematic focus and HIV causal pathways, 4) intervention delivery (duration, intensity, who, how, where).

RESULTS

Eight youth HIV prevention interventions were included; all were similar in HIV prevention content and objectives, but varied in thematic focus, hypothesised causal pathways, theoretical basis, delivery method, intensity and duration. Interventions were school- (5) or group-based (3), involving in- and out-of-school youth. Primary outcomes included HIV incidence (2), reported sexual risk behavior alone (4), or with alcohol use (2). Interventions led to reductions in STI incidence (1), and reported sexual or alcohol risk behaviours (5), although effect size varied. All but one targeted at least one structural factor associated with HIV infection: gender and sexual coercion (3), alcohol/substance use (2), or economic factors (2). Delivery methods and formats varied, and included teachers (5), peer educators (5), and older mentors (1). School-based interventions experienced frequent implementation challenges.

CONCLUSIONS

Key recommendations include: address HIV social risk factors, such as gender, poverty and alcohol; target the structural and institutional context; work to change social norms; and engage schools in new ways, including participatory learning.

Risk factors for HIV infection among Haitian adolescents and young adults seeking counseling and testing in Port-au-Prince

OBJECTIVES

Many Haitian adolescents and youth are highly vulnerable to HIV infection. It was important to define the risk factors of the young people who are already seeking care.

METHODS

Among 3391 sexually active 13- to 25-year-olds in our Voluntary Counseling and Testing (VCT) Center in Port-au-Prince from October 2005 to September 2006, we assessed associations between demographic and behavioral factors and HIV status using multivariable logistic regression analyses.

RESULTS

We diagnosed HIV infection in 6.3% of 2533 females and 5.5% of 858 males. Age-specific prevalence was 3.4% for 13- to 15-year-olds, 4.7% for 16-19, and 6.8% for 20-25 (P = 0.02). Poor education, not residing with parents, currently or formerly married, having a child, and being self-referred or referred by others VCT services were significant predictors of HIV in females. HIV infection was associated with considering oneself at higher risk, although most youth did not recognize this risk. HIV in females was also associated with suspected/confirmed sexually transmitted infection, especially genital ulcers (ORadj = 2.28, 95% confidence interval: 1.26 to 4.13), years of sexual activity (Ptrend = 0.07), and suspicion that partners had other partners or an sexually transmitted infection. Among males, HIV was associated with drug use (though uncommon) and sexual debut with a casual/unknown person (ORadj = 3.18, 95% confidence interval: 1.58 to 6.42). HIV-infected young people were more likely to be rapid plasma reagin positive and less likely to use condoms.

CONCLUSION

Young Haitians are a key target for HIV prevention and care and avail themselves readily of youth-focused VCT services.

Use of injectable progestin contraception and risk of STI among South African women

OBJECTIVE

This study was conducted to determine the association between the use of injectable progestin contraception (IPC) and the risk of infection with Neisseria gonorrhoeae (GC), Chlamydia trachomatis (CT), bacterial vaginosis (BV) and Trichomonas vaginalis (TV) among women in South Africa.

METHODS

From August 1999 through May 2001, 643 HIV-1-negative women were recruited from family planning clinics in Orange Farm, South Africa. IPC [norethisterone enanthate (NET-EN) and depot medroxyprogesterone acetate (DMPA)] users and nonhormonal contraception users were recruited in approximately equal numbers. Eligible participants were seen at enrolment and on four follow-up visits over a 12-month period; 567 returned for at least one follow-up visit. Multivariable Poisson regression models with generalized estimating equations were used to compute the incidence rate ratios (IRRs) for infections with GC, CT, BV and TV by use of NET-EN or DMPA relative to nonuse during follow-up.

RESULTS

In multivariable models, the use of DMPA slightly increased the risk of infection with CT [IRR=1.24; 95% confidence interval (95% CI)=0.80-1.94] and GC (IRR=1.30; 95% CI=0.58-2.98), although these associations were not statistically significant. In contrast, DMPA appeared to be protective for TV (IRR=0.35; 95% CI=0.12-1.01), although this estimate was very imprecise. The use of both DMPA and NET-EN was associated with a decreased risk of BV.

CONCLUSIONS

The use of DMPA among women in this study population was associated with an increased - but not statistically significant - risk of cervical infection with chlamydia and gonorrhea, and a decreased risk of TV and BV. Given the inconsistencies and limitations of the data describing an increased risk of CT and GC with IPC use, the potential risk of sexually transmitted infections (STIs) must be balanced against the risk of unintended pregnancy and its health consequences, especially in developing countries. Women opting to use IPC should be counseled to use condoms to protect against STIs and HIV.

Perceptions of HIV and fertility among adolescents in Soweto, South Africa: stigma and social barriers continue to hinder progress

The scale up of highly active antiretroviral therapy (HAART) for the treatment of HIV has raised new concerns relating to fertility desires and outcomes. Among these concerns is social stigma surrounding HIV and childbearing. High rates of infection and patterns of high fertility make adolescents a crucial demographic to qualify perceptions of HIV and fertility. We conducted two focus groups (n = 11 males, n = 8 females) with participants ascertained from an HIV adolescent community advisory board in Soweto, South Africa. Adolescents raised concern over re-infection by HIV positive couples attempting to conceive. They also used this concern to justify their attitudes that HIV positive couples should adopt when faced with the desire to have children. Lastly, participants spoke of a need to revise adolescent sexual and reproductive health services to make them more youth-friendly where users could avoid stigma generated by community healthcare workers. This study adds to the growing literature that calls for an evaluation of adolescent HIV educational programs and a healthcare worker intervention that specifically targets stigma surrounding HIV and childbearing.

Sexual violence and reproductive health outcomes among South African female youths: a contextual analysis

OBJECTIVES

We studied whether female youths from communities with higher sexual violence were at greater risk of negative reproductive health outcomes.

METHODS

We used data from a 2003 nationally representative household survey of youths aged 15-24 years in South Africa. The key independent variable was whether a woman had ever been threatened or forced to have sex. We aggregated this variable to the community level to determine, with control for individual-level experience with violence, whether the community-level prevalence of violence was associated with HIV status and adolescent pregnancy among female, sexually experienced, never-married youths.

RESULTS

Youths from communities with greater sexual violence were significantly more likely to have experienced an adolescent pregnancy or to be HIV-positive than were youths from communities experiencing lower sexual violence. Youths from communities with greater community-level violence were also less likely to have used a condom at their last sexual encounter. Individual-level violence was only associated with condom nonuse.

CONCLUSIONS

Programs to reduce adolescent pregnancies and HIV risk in South Africa and elsewhere in sub-Saharan Africa must address sexual violence as part of effective prevention strategies.