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

Mobile Health Intervention Tools Promoting HIV Pre-Exposure Prophylaxis Among Adolescent Girls and Young Women in Sub-Saharan Africa: Scoping Review

BACKGROUND

In 2022, 3100 adolescent girls and young women in sub-Saharan Africa experienced new HIV infections each week. HIV pre-exposure prophylaxis (PrEP) is effective at preventing HIV but has limited uptake and persistence. Mobile health (mHealth) interventions can improve medication adherence; however, their utility to improve PrEP adherence among adolescent girls and young women is not well established.

OBJECTIVE

This scoping review synthesizes evidence supporting mHealth for PrEP among adolescent girls and young women in sub-Saharan Africa and identifies strategies for further evaluation.

METHODS

We searched PubMed and Google Scholar databases, expert referrals, and reference lists using the following eligibility criteria: (1) original research study or protocol; (2) English language; (3) publication between January 1, 2012, and August 31, 2023; (4) inclusion of adolescent girls and young women; (5) conducted in sub-Saharan Africa; and (6) use of mHealth tools to promote PrEP uptake, adherence, or persistence. Titles and abstracts were screened by 2 independent researchers. Full-text manuscripts were reviewed against all eligibility criteria to determine the final included studies. The characteristics and results of the included studies were abstracted and synthesized by mHealth tool type.

RESULTS

The search identified 482 unique citations. Title and abstract review removed 380 citations primarily for not including adolescent girls and young women or being conducted outside sub-Saharan Africa. The remaining 102 articles underwent full-text review, yielding 31 eligible publications reporting on 21 unique studies. The most common mHealth tool was SMS text message (n=11), followed by app (n=9), telehealth (n=3), website (n=4), and video (n=1). Few publications evaluated effectiveness, and the results were mixed. One study found that SMS text message reminders improved PrEP adherence, and another concluded that SMS text message reminders did not show a significant impact. Two studies found that differentiated service delivery, which included mHealth components, improved PrEP uptake or persistence; however, the findings could not be attributed solely to the mHealth components. Lastly, 1 website was shown to improve PrEP persistence. Several earlier-stage studies focused on values and preferences toward mHealth without reporting the impact on PrEP.

CONCLUSIONS

We found few rigorously evaluated mHealth interventions for supporting PrEP among adolescent girls and young women, preventing the ability to draw conclusions on its effectiveness. Studies documented high usability and acceptability but limited assessment of the impact on health outcomes. Secondary uses of mHealth were found for data collection and components of the standard of care. There is substantial room for growth in the innovative use of mHealth to support PrEP among adolescent girls and young women. Consideration of the strengths and limitations of mHealth tools in the local setting, review of past lessons learned, and intentional measurement of mHealth exposure and use could help advance this growing field.

How do gender transformative interventions reduce adolescent pregnancy in low- and middle-income countries: a realist synthesis

Background

Adolescent pregnancy poses a significant health challenge for girls aged 15-19 in low- and middle-income countries. While gender transformative interventions (GTIs) aim to address this issue, a substantial research gap exists concerning the underlying mechanisms contributing to their success. This study employs a realist synthesis approach to systematically investigate how, why, for whom, and in what contexts GTIs effectively reduce adolescent pregnancy.

Methods

A five-step realist review examined literature from four databases and five organisational repositories, including published and grey literature. The review focused on GTIs for adolescents aged 10-19 in low- or middle-income countries. Narrative synthesis and realist analysis were used to develop context-mechanism-outcome configurations.

Results

The review analysed 28 documents covering 14 interventions and proposing eight programme theories across three settings. In the school, creating a supportive environment to foster positive social norms and providing a safe space was emphasised. Comprehensive sexual health education to promote critical thinking, knowledge retention, and goal setting was one of the key strategies. Empowering boys to adopt positive gender norms for behaviour change was also identified. In the health facility, providing a safe, supportive, and confidential environment for accessing services, as well as using digital health apps to empower adolescents in sexual reproductive health, were key. In the community, empowering girls through life skills and economic support and involving community members to foster stronger interpersonal bonds and a gender-positive environment were highlighted. These interventions led to increased contraceptive use, delayed marriage, and reduced adolescent pregnancy.

Conclusion

This realist synthesis proposes eight nuanced programme theories of successful GTIs, providing essential insights for developing, implementing, and improving future programmes. These findings offer a foundation for effective strategies to mitigate adolescent pregnancy in diverse socio-cultural contexts.

Registration

PROSPERO: CRD42023398293.

Community and familial dynamics influencing risk behavior for HIV acquisition among adolescent girls and young women in Uganda: Qualitative analysis using Protective Motivation Theory

BACKGROUND

In Uganda, adolescent girls', and young women's (AGYW-15-24 years) current HIV prevalence is fourfold compared with their male counterparts due to compounded social, economic, and environmental factors. Using the Protective Motivation Theory (PMT), we explored HIV-acquisition risk sources and perceived protective factors from AGYW and caregivers' perspective.

MATERIALS AND METHODS

During 2018, we conducted a qualitative study guided by PMT to explore factors influencing HIV acquisition among AGYW. We purposively sampled two groups of key informants, AGYW at high-risk for HIV acquisition (uninfected) and AGYW living with HIV, varied by age and place of residence (urban/rural). We conducted 34 focus group discussions with AGYW, nine with AGYW parents, and 25 key informant interviews. Data were analyzed using the framework method based on the PMT and developed from participants' narratives.

RESULTS

AGYW were knowledgeable about HIV, HIV acquisition risk factors, and HIV prevention interventions. Nonetheless, few AGYW knew about pre-exposure prophylaxis (PrEP). Imbalance in power relations between the genders explained inability of AGYW making safe healthy decisions, with social norms giving men power over women. Parents modelling positively influenced HIV risk behavior. Many AGYW viewed staying in school a protective factor both while at school and further for life. AGYW identified alcohol use, desire for material possessions, discounting HIV disease severity, social norms, and poverty as barriers to engaging in self-protective behaviors. Several AGYW believed that access to AGYW-focused programs would facilitate healthy sex-positive, protective behaviors.

DISCUSSION

While PMT focuses on individual factors confirmed by our findings, we found HIV risk behavior to be influenced by complex contextual factors including poverty, gender inequality and cultural norms. Distinct HIV risk factors among AGYW require policy and comprehensive targeted interventions addressing violence, alcohol consumption, increased economic opportunities, educational opportunities, safe-sex practices, and PrEP scale-up which may prevent HIV in AGYW and facilitate HIV epidemic control.

Giving adolescent girls and young women a foothold: Economic strengthening as a key protection strategy against HIV infection in South Africa

This paper focused on the prevention of HIV transmission for adolescent girls and young women (AGYW), through a layered approach which included economic strengthening as a core strategy, especially for the most vulnerable. Based on multi-year data in KwaZulu-Natal, South Africa, we assessed the outcomes of an economic strengthening model developed by TB HIV Care (THC) in the Determined, Resilient, Empowered, AIDS-free, Mentored and Safe (DREAMS) HIV prevention programme. The methods used are primarily qualitative. In 2021, 2022, and 2024 DREAMS implementation staff (n = 72) and economic strengthening beneficiaries (n = 73) from four districts were interviewed on the dynamics of the model and its emerging outcomes. The qualitative data were supplemented by monitoring data. The study results showed that, while longer-term outcomes for the beneficiaries were unclear, the short and medium-term benefits of economic strengthening activities for vulnerable AGYW were highly promising. Not only did beneficiaries gain valuable technical and life skills through training, but they showed increased confidence and hope for the future, and a new sense of empowerment. They also experienced social asset building and an increase in their social, economic, and emotional efficacy. Importantly, beneficiaries also showed signs of behaviour change, away from risky behaviours towards protective ones. The paper concludes that layered economic strengthening initiatives targeted towards those most at risk AGYW, is an important pillar of efforts to reduce HIV infection; however, challenges around taking such initiatives to scale and tracking long-term outcomes remain.

Blesser relationships among orphaned adolescent girls in contexts of poverty and gender inequality in South African townships

The term blesser has become part of South Africa's contemporary lexicon, replacing the older terminology of 'sugar daddy.' While much recent literature has focused on the blesser phenomenon, the voices of orphaned adolescent girls on their entanglement in blesser relationships have had insufficient attention. Using the theory of gender and power as an analytical lens, this qualitative study analyses the visual and textual data generated by orphaned adolescent girls on their relationships with blessers. To generate data, the participants used photovoice to represent their relationships with older male sexual partners in their resource-poor South African township neighbourhoods. Our analysis reveals a set of factors that render orphaned adolescent girls vulnerable to age-disparate relationships, such as the structural dimensions of their lives, including their status as orphaned girls, heteropatriarchy, age-based hierarchies, and poverty in their households and communities. On the other hand, our analysis explores the less understood area of the relative agency, intentionality, and proactive approach that orphaned girls take to initiating and negotiating blesser relationships. The findings have implications for further research that will expand our understanding of girls' agency-and the structural limits to that agency-in adverse socio-cultural circumstances. Such research holds potential for interventions that might enable orphaned girls to better advocate for themselves in the context of unequal power relations.

Correlates of Adherence to Oral and Vaginal Pre-exposure Prophylaxis (PrEP) Among Adolescent Girls and Young Women (AGYW) Participating in the MTN-034/REACH Trial

We evaluated correlates of adherence to PrEP, including daily oral tenofovir disoproxil fumarate in combination emtricitabine (oral FTC/TDF) and the monthly dapivirine ring (ring)among adolescent girls and young women (AGYW) in the MTN-034/REACH study. We enrolled 247 AGYW aged 16-21 years in South Africa, Uganda and Zimbabwe (ClinicalTrials.gov: NCT03074786). Participants were randomized to the order of oral FTC/TDF or ring use for 6 months each in a crossover period, followed by a 6-month choice period. We assessed potential adherence correlates-individual, interpersonal, community, study, and product-related factors-quarterly via self-report. We measured biomarkers of adherence monthly; high adherence was defined as > 4 mg dapivirine released from returned rings or intracellular tenofovir diphosphate levels ≥ 700 fmol/punch from dried blood spots (DBS). We tested associations between correlates and objective measures of high adherence using generalized estimating equations. High adherence to oral FTC/TDF was significantly associated with having an older primary partner (p = 0.04), not having exchanged sex in the past 3 months (p = 0.02), and rating oral FTC/TDF as highly acceptable (p = 0.003). High ring adherence was significantly associated with unstable housing (p = 0.01), disclosing ring use to a male family member (p = 0.01), and noting a social benefit from study participation (p = 0.03). All associations were moderate, corresponding to about 6%-10% difference in the proportion with high adherence. In our multinational study, correlates of adherence among African AGYW differed for oral FTC/TDF and the ring, highlighting the benefit of offering multiple PrEP options.

Adolescents' risky sexual behaviours and practices: Implications for sexuality education implementation in Zambia

BACKGROUND

 Adolescents' risky sexual behaviours (RSB) are detrimental to their sexual and reproductive health (SRH) well-being and present a serious public health threat, particularly in low- and middle-income countries (LMICs).

AIM

 This study aims to assess RSB among Grade 12 school-going adolescents after exposure to comprehensive sexuality education (CSE).

SETTING

 This study was conducted in Kitwe district, Zambia.

METHODS

 This cross-sectional study included 807 Grade 12 pupils at 13 selected secondary schools. Data were collected using a structured questionnaire. Proportionate probability sampling involving 13 schools was employed. Risky sexual behaviours binary outcome variables were based on transactional sex, sex while drunk, multiple sexual partners, age-disparate sexual relationships, and condomless sex. We conducted univariate and bivariate analyses to summarise sociodemographic factors and fitted binary and multivariable logistic regression models.

RESULTS

 The prevalence of RSB was 40.4%. Drinking alcohol (adjusted odds ratio [AOR] = 20.825; 95% CI [6.7-64.489]); ever had sex (AOR = 9.024; 95% CI [1.953-41.704]); school location (AOR = 6.50; 95% CI [1.61-26.24]); living with mother only (AOR = 4.820; 95% CI [1.328-17.493]); sex (male) (AOR = 2.632; 95% CI [1.469-4.713]), watching pornography (AOR = 1.745; 95% CI [1008-3.021]); religion (AOR = 0.472; 95% CI [0.250-0.891]) and attending religious functions (AOR = 0.317; 95% CI [0.118-0.848]) were significantly associated with RSB. Of the sexually active pupils, 221 (67.7%), 64 (19.6%) and 41 (12.5%) were in the low, medium and high-risk categories, respectively.

CONCLUSION

 Close to half of the respondents engaged in RSB. This is a significant number that needs intervention. The CSE programme needs to be linked with structural programmes that address the social drivers of RSB among adolescents.Contribution: The study provides a backdrop for evaluating current CSE strategies in LMICs.

Measuring HIV outcomes for adolescent girls and young women programs in Africa: Using the polling booth survey technique

INTRODUCTION

Adolescent girls and young women (AGYW) remain highly vulnerable to the risk of acquiring HIV (Human immunodeficiency virus). This study was conducted to measure behavioral, biomedical and structural outcomes for the Global Fund funded AGYW programmes in five African countries with high burden of HIV including Botswana, Cameroon. Lesotho, Malawi and Namibia.

METHODS

The study used a mixed methods approach to collect behavioral, structural and biomedical outcome data. Quantitative data were collected through 418 Polling Booth Survey (PBS) sessions from 4,581 AGYWs. Participants were recruited through a community-based multistage sampling technique using sampling weights for urban and rural communities. 23 Focus Group Discussions (FGD) were conducted to understand barriers to use of HIV prevention programme and community recommendations for improved coverage. Ethical approvals were obtained from the ethics review board in all five countries.

RESULTS

More than 50% of the respondents from all five countries reported to be sexually active, and at least 30% or more of those who were sexually active had multiple sex partners. There were wide variations between the countries in condom use with a non-marital sexual partner which ranged between 66% in Namibia to 42% in Cameroon. Cameroon (44%) had high percentage of AGYWs with independent income source while school drop-outs were higher in Malawi (55.5%) and Lesotho (46.6%). Nearly 1/4th of AGYWs in all countries, except Namibia, reported experiencing intimate partner violence. Nineteen percent of the respondents were pregnant in the last 12 months, and 50% of those pregnancies were unplanned. Lesotho had the highest proportion of AGYW (90.5%) ever tested for HIV, followed by Malawi (87.5%), Botswana (75%), Cameroon (69%) and Namibia (62.6%).

DISCUSSION

There is diversity across the countries, with country-wise and age-wise variations in results. In all countries, the AGYW programme will benefit from a more targeted approach to reach out to the most vulnerable AGYW, strengthening structural interventions, strengthening linkage to PrEP (Pre-Exposure Prophylaxis) and ART (Antiretroviral Therapy) for those who are living with HIV and a strong linkage with reproductive health services. The assessment helped countries to understand the gaps and opportunities to improve the HIV prevention programme with AGYW.

Associations between lifetime pregnancy and sexual risk behaviors among 15-24-year-old adolescent girls and young women in South Africa: Secondary analyses of the 2016 Demographic Health Survey

Adolescent girls and young women (AGYW) in South Africa are highly vulnerable to HIV and poor sexual and reproductive health (SRH) outcomes. Interventions must respond to the unique needs of different AGYW groups, such as AGYW who have ever been pregnant. The objective of the study is to examine associations between pregnancy and sexual risk behaviors among AGYW in South Africa. This study used the 2016 nationally representative Demographic and Health Survey (DHS) of South Africa (n = 1935, 15-24 years old). Sexual risk behavior outcomes included: early sexual debut (defined as having sexual intercourse before the age of 15 years), age-disparate relationship (defined as having sexual partners who are five years and older in the past one month), multiple sexual partnerships, no condom use at last sex, and lastly, cumulative sexual risk (defined as reporting at least two of the outcomes: early sexual debut, age-disparate relationship, multiple sexual partners, and no condom use at last sex). Data analyses were conducted using logistic regression in STATA version 16. Statistical significance was determined at a P-value less than 0.05, with 95% confidence interval reported. AGYW who experienced lifetime pregnancy were more likely to report early sexual debut (OR = 1.71, 95%CI = 1.30-2.32), age-disparate relationships (OR = 1.58, 95%CI = 1.20-2.08), no condom use at last sex (OR = 2.77, 95%CI = 2.09-3.69), and cumulative sexual risk (OR = 1.82, 95%CI = 1.38-2.41). Multiple sexual partnerships showed no significant associations with lifetime pregnancy. Married or cohabiting AGYW were more likely to report cumulative sexual risk behaviors. (OR = 2.67, 95%CI = 1.91-3.71). Cumulative sexual risk behaviors were lower among AGYW with secondary education (OR = 0.57, 95%CI = 0.33-0.99) and those from rich households (OR = 0.62, 95%CI = 0.43-0.88). The findings underscore the need for interventions promoting safe sex and relationships, especially among AGYW who have experienced pregnancy. Programming should address the structural, socio-economic drivers of early pregnancy.

Age-disparate and intergenerational sex partnerships and HIV: the role of gender norms among adolescent girls and young women in Malawi

BACKGROUND

Age-mixing (age-disparate [5-9 years difference] and intergenerational [≥ 10 years difference]) partnerships are hypothesized drivers of HIV in adolescent girls and young women (AGYW; 15-24 years). These partnerships are often associated with increased gender inequities which undermine women's agency and assertiveness. We assessed whether age-mixing partnerships were associated with HIV in Malawi and if endorsement of inequitable gender norms modifies this relationship.

METHODS

We analyzed data from the Malawi Population-based HIV Impact Assessment, a nationally representative household survey conducted in 2015-2016. Participants underwent HIV testing and completed questionnaires related to actively endorsed gender norms and sexual risk behavior. We used multivariate logistic regression and multiplicative interaction to assess associations among AGYW who reported the age of their primary sex partner from the last year.

RESULTS

The analysis included 1,958 AGYW (mean age = 19.9 years, SD = 0.1), 459 (23.4%) and 131 (6.7%) of whom reported age-disparate and intergenerational partnerships, respectively. AGYW in age-mixing partnerships accounted for 13% of all AGYW and were older, more likely to reside in urban areas, to be married or cohabitating with a partner, and to have engaged in riskier sexual behavior compared with AGYW in age-concordant partnerships (p < 0.05). HIV prevalence among AGYW in age-disparate and intergenerational partnerships was 6.1% and 11.9%, respectively, compared with 3.2% in age-concordant partnerships (p < 0.001). After adjusting for residence, age, education, employment, wealth quintile, and ever been married or cohabitated as married, AGYW in age-disparate and intergenerational partnerships had 1.9 (95% CI: 1.1-3.5) and 3.4 (95% CI: 1.6-7.2) greater odds of HIV, respectively, compared with AGYW in age-concordant partnerships. Among the 614 (31% of the study group) who endorsed inequitable gender norms, AGYW in age-disparate and intergenerational partnerships had 3.5 (95% CI: 1.1-11.8) and 6.4 (95% CI: 1.5-27.8) greater odds of HIV, respectively, compared with AGYW in age-concordant partnerships.

CONCLUSIONS

In this Malawi general population survey, age-mixing partnerships were associated with increased odds of HIV among AGYW. These findings highlight inequitable gender norms as a potential focus for HIV prevention and could inform interventions targeting structural, cultural, and social constraints of this key group.

Preferences, educational messaging, and demand creation channels for multipurpose-prevention technologies (MPTs) among women in South Africa

BACKGROUND

South African women, including female sex workers (FSWs), are disproportionately affected by HIV, experience a high unmet need for contraception and high rates of sexually transmitted infections (STIs). Products that address the interlinked risk between HIV, unplanned pregnancy, and other STIs are needed. There are several multipurpose-prevention technologies (MPTs) in development, aimed at preventing both HIV and pregnancy. This study aimed to explore educational messaging and demand creation channels to improve the potential uptake of a hypothetical MPT implant, using participatory action research. It also aimed to look at product and service provision attributes preferred by potential end users.

METHODS

Between July and August 2022, 303 PrEP-eligible adolescent girls and young women (AGYW) (18-24 years), women > 24 years, and FSW's (≥ 18 years) participated in 4-hour workshops, where they were asked about their ideal messaging and demand creation channels and their preferences for different attributes of an MPT implant. Quantitative descriptive analysis was conducted to determine the frequency and ranking for each demand creation message, channel, and each product and service provision attribute, by population group. A chi-square test was used to assess MPT implant characteristics associated with age. Qualitative data were analysed using deductive and thematic analysis.

RESULTS

A total of 104 AGYW, 157 women > 24 years, and 42 FSWs participated in the PAR workshops. Participants preferred demand creation messages that were empowering, motivational and encouraged body autonomy. The use of slang was popular. Community radio stations and newspapers, social media, and information at hospitals and clinics were participants' preferred MPT demand creation channels because they were easily accessible. Providing long-term and dual HIV and pregnancy protection, receiving implant services at the local clinic, manageable side effects, discreet and private implant, and numbing the area before insertion and removal, were the most preferred product and service provision attributes.

CONCLUSION

Early considerations for women's product preferences are key to product development. Educational messaging around the MPT implant should be empowering and in local languages, this may motivate women to learn more about it and use it. Multiple demand creation channels should be used to engage both young and older populations, which may ensure better reach.

Evidence of HIV incidence reduction in young women, but not in adolescent girls, in KwaZulu-Natal, South Africa

Objectives

We estimated changes in the HIV incidence from 2013-2018 in Eshowe/Mbongolwane, KwaZulu-Natal, South Africa where Médecins Sans Frontières is engaged in providing HIV testing and care since 2011.

Methods

Using data from two cross-sectional household-based surveys conducted in 2013 and 2018, with consenting participants aged 15-59 years, we applied the incidence estimation frameworks of Mahiane et al and Kassanjee et al.

Results

In total, 5599 (62.4% women) and 3276 (65.9% women) individuals were included in 2013 and 2018, respectively. We found a mean incidence in women aged 20-29 years of 2.71 cases per 100 person-years (95% confidence interval [CI]: 1.23;4.19) in 2013 and 0.4 cases per 100 person-years (95% CI: 0.0;1.5) in 2018. The incidence in men aged 20-29 years was 1.91 cases per 100 person-years (95% CI: 0.87; 2.93) in 2013 and 0.53 cases per 100 person-years (95% CI: 0.0; 1.4) in 2018. The incidence decline among women aged 15-19 was -0.34 cases per 100 person-years (95% CI: -1.31;0.64).

Conclusions

The lack of evidence of incidence decline among adolescent girls is noteworthy and disconcerting. Our findings suggest that large-scale surveys should seriously consider focusing their resources on the core group of women aged 15-19 years.

"I fear those things": non-uptake of contraceptives, and barriers to use among adolescent girls and young women at high risk of HIV infection in Kampala, Uganda

Background

Adolescent girls and young women involved in risky behaviors are vulnerable to multiple health problems, yet sexual and reproductive health services remain underutilized. We evaluated factors associated with non-uptake of contraceptives and barriers to use among adolescent girls and young women (14-24 years old) at high risk of HIV infection in an environment where contraceptives were provided at no cost.

Methods

We conducted a mixed methods study, utilizing data from a baseline cross sectional survey and qualitative in-depth interviews. Survey participants tested negative for pregnancy and reported willingness to use contraception. Non-uptake of contraceptives was defined as not taking contraception at any study visit (baseline and throughout the study). Logistic regression model was used to assess factors associated with non-uptake of contraceptives. We purposively selected participants for interviews to discuss their knowledge and experiences with contraceptives and make suggestions to improve uptake. Qualitative data were analyzed thematically.

Results

All 285 participants were included in the analysis. Out of the 285 participants 127 were not using contraceptives and of the 127, 44 (34.6%) did not take up any method throughout the study while 43 of the 83 remaining participants (who took up a method) chose male condoms only. Non-uptake of contraceptives was less likely among older women (20-24 years) (aOR = 0.32, 95% CI 0.16-0.89) compared to younger women (less than 20 years). Qualitative data showed that concerns about future fertility, fear of associated side effects and influence from close relations contributed to non-uptake of contraception.

Conclusion

Non-uptake of contraceptives was common despite the promotion and provision of contraceptives in the context of a research study mainly because adolescents lack autonomy while making contraceptive decisions. Identifying and addressing their concerns and continued counselling on contraceptive use alongside condom promotion may improve uptake and utilization of contraceptives.

The dynamics of sexual risk amongst South African youth in age-disparate relationships

Introduction

South Africa has the highest burden of HIV in the world with over 8 million people living with HIV. Young women and girls account for a quarter of new HIV infections while making up only 10% of the population. A key driver of HIV incidence is transactional and survival sex between adolescent girls or young women and older men (the latter referred to as 'sugar-daddies' or 'blessers'). This paper expands on the existing literature on age-disparate and intergenerational relationships to provide social and behavioural interpretations of how young men, commonly omitted from studies on this topic, and women in concurrent relationships with both their peers and older partners perceive and navigate sexual risk.

Method

We conducted a qualitative study in a rural setting of uMgungundlovu District, KwaZulu-Natal Province, with purposively selected male and female participants aged 18-24 years old in age-disparate relationships. Semi-structured in-depth interviews (IDI) were conducted and analysed using interpretative phenomenological analysis (IPA) to explore existing information, motivations, and behavioural practices around relationships and sexual risk.

Results

The themes and related sub-themes found through IPA included the following: (1) navigating dating: narratives that show a strong preference for being in an age-disparate relationship; the challenges that young people face when choosing an older person as a side partner; and social media applications seen as creating opportunities to meet side partners; and (2) the distribution of love and trust in a multi-party sexual network: condom (mis)use differentiates between straights-those in a serious relationship-and sides; and the power of eye-test seroguessing, the praxis of testing people visually for HIV in nullifying existing knowledge about sexual and reproductive health risk.

Discussion

This research offers an understanding of how schemas of non-condom use are organised. We observed that while condom-less sex is often viewed as essential to building social capital in a serious relationship, it is not the only factor that determines sexual relationship power. Eye-test seroguessing not only develops consortium (trust, reciprocity, and solidarity), but it fulfils the psycho-social need to belong to a network of serious relationships. Moreover, it is critical to the enactment of masculinities because it consolidates femininity to keep men happy, i.e., by being passive in the sexual encounter, women constrain their self-efficacy to act contrary to the conventions of reputable women. Therefore, it is plausible that in the serosorting that occurs prior to unprotected sexual acts, the power of eye-test seroguessing limits the ability to engage in safe sexual practices.

HIV acquisition prior to entry into formal sex work: inference from next-generation viral sequencing

OBJECTIVE

To infer the timing of HIV acquisition in relation to self-reported events in the sexual life course of adolescent girls and young women (AGYW) who self-identify as female sex workers (FSW) in Mombasa, Kenya.

DESIGN

Next-generation viral sequencing of samples of AGYW living with HIV in the Transitions study, a cross-sectional bio-behavioural survey of AGYW aged 14-24 years in Mombasa, Kenya.

METHOD

Dried blood spot specimens were collected from study participants ( n  = 37, all FSW). A portion of the HIV pol gene was sequenced using an in-house next-generation sequencing assay for HIV drug resistance mutation genotyping. Estimated time since infection (ETI) was inferred using the HIV EVO web-based tool ( https://hiv.biozentrum.unibas.ch/ETI/ ), and data on self-reported events were obtained from the survey.

RESULTS

The median ETI among FSW was 3.4 (interquartile range = 1.7, 6.3) years, with a median ETI of 1.5 years prior to entry into formal sex work. We estimated that 74.1% (95% confidence interval = 53.7-88.9%) of participants living with HIV and who self-identified as FSW likely acquired HIV prior to self-identification as a sex worker.

CONCLUSIONS

Findings suggest a large fraction of prevalent HIV infection among AGYW engaged in sex work stems from acquisition prior to entry into formal sex work. Current HIV prevention programs tailored for sex workers may miss key opportunities for HIV prevention as they are designed to reach women after entry into formal sex work, signaling a need for tailored programs to reach high-risk AGYW earlier on in their sexual life course.

"Girls Are the Ones Who Save the Family": Factors and Consequences of Engaging in Age-Disparate Transactional Sex Relationships

The 2019 Kenya Violence Against Children Survey highlighted the increased prevalence of sexual violence experienced by girls; 62.6% of girls who have experienced childhood sexual violence reported multiple incidents before age 18. Studies have shown that transactional sex (TS) relationships are a source of sexual violence, particularly age-disparate TS. TS is defined as sex that is a nonmarital, noncommercial relationship driven by the assumption that sex is exchanged for material support or other benefits. TS is common among adolescents and young women in sub-Saharan Africa, with the prevalence varying from as low as 5% to as high as 80%. This qualitative study explored the factors influencing age-disparate TS relationships in two rural districts, Mutomo and Ikutha Wards of Kitui South Sub County, Kenya. Four focus group discussions were conducted with primary (12-14 years of age) and secondary schoolgirls (15-18 years of age). The study results identified several main themes, which were grouped into two major themes: influencing factors and consequences. Influencing factors include material/basic needs, school-related influences, parental influence, peer pressure, and perpetrator access, while consequences include health and social consequences. Our study found that girls' sense of agency, social pressure, and economic vulnerability impacted their decision to engage in age-disparate TS. These relationships' power dynamics and exploitative nature increase girls' risk of experiencing gender-based sexual violence and adverse health and social outcomes. Our study suggests that explicitly addressing individual risk behaviors will not effectively reduce the incidence of TS relationships. Interventions should be focused on understanding the social-cultural beliefs of TS and shifting the narrative that has continued to fuel a patriarchal society in which women and girls have limited decision-making power in relationships.

Introduction and integration of PrEP and sexual and reproductive health services for young people: Health provider perspectives from South Africa

South Africa has one of the largest HIV epidemics in the world, with particularly high prevalence among adolescent girls and young women (AGYW). Oral PrEP was introduced in the public sector in 2016 in a phased manner. Given the important role played by health providers, research was undertaken to understand their experiences of and attitudes towards introduction of PrEP as a new HIV prevention method, and its integration within broader sexual and reproductive health (SRH) services for youth. A survey was undertaken with 48 purposively sampled health providers working in primary health care facilities and mobile clinics in three provinces in South Africa. Qualitative analysis was performed on free-text responses to open-ended questions in the survey, using an inductive approach to code the data in NVivo v.12 software. Health providers expressed concerns about adding a new service to an already overburdened health system, and worried that young people seeking PrEP would divert staff from other critical services. While most recognised the benefits and opportunities afforded by HIV and SRH service integration, providers highlighted the extra time and resources such integration would require. Many were anxious that PrEP would encourage disinhibition and increase unprotected sex among AGYW, and held judgemental attitudes about young people, seen as largely incapable of taking responsibility for their health. Findings underscore the importance of consulting health providers about implementation design and providing channels for them to express their misgivings and concerns, and training needs to be designed to address provider attitudes and values. Opportunities need to be sought to strengthen the provision of adolescent and youth friendly services-including adolescent-health provider dialogues. Insights from this study can assist in guiding the introduction of new HIV prevention methods into the future.