Correlates of HIV risk among Ecuadorian adolescents

HIV/AIDS-related Knowledge and Behavior among School-attending Afro-Descendant Youths in Ecuador

BACKGROUND OR OBJECTIVES

HIV/AIDS transmission in Ecuador is considered a concentrated epidemic; therefore, there are some studies on high risk groups but there is limited published data regarding the HIV/AIDS risk factors among adolescents of African descent. In this study, we sought to explore the determinants of HIV/AIDS-related knowledge and behavior among afro-descendant youths attending schools in the city of Esmeraldas, Ecuador.

METHODS

A cross-sectional survey among school-attending youths was conducted in Esmeraldas, Ecuador in 2010. Our target population was afro-descendant youths attending the last two years of high school. Thirty public high schools enrolling students in junior and senior years were identified. Outcome data were analyzed in the form of three composite variables. A multivariate linear regression model was built for each outcome.

RESULTS

A total of 213 school-attending afro-descendant youths aged 14 to 21 years old were enrolled in this study. Gender distribution was almost equal with a 1:1.17 male to female ratio. Overall, students in this population scored well in comprehensive knowledge of HIV with 88% having medium or higher knowledge.

CONCLUSION AND GLOBAL HEALTH IMPLICATIONS

Knowledge of HIV and its determinants was medium to high, but knowledge of sexually transmitted diseases was low among afro-descendant Ecuadorian adolescents in our study. Results of this study might be instrumental in facilitating decision-making processes related to the planning, implementation, and evaluation of HIV/AIDS prevention and control strategies in this specific population.

A qualitative view of the HIV epidemic in coastal Ecuador

In 2013 approximately 37,000 people were living with HIV in Ecuador (prevalence 0.4%), representing a generalized epidemic where most new infections arise from sexual interactions in the general population. Studies that examine attitudes towards people living with HIV (PLWH), individual risk perception of acquiring HIV amongst Ecuadorians, and the ways in which levels of risk perception may affect risk behaviors are lacking. This qualitative study aimed to fill this gap in the literature by investigating these issues in the rural, coastal community of Manglaralto, Ecuador, which has among the highest incidence of HIV in Ecuador. We conducted interviews with 15 patients at Manglaralto Hospital. Analysis of interview transcripts revealed widespread negative attitudes towards PLWH, prevalent risk behaviors such as multiple sex partners and lack of condom use, and low individual risk-perception of contracting HIV. These findings underscore the need for increased efforts to prevent further growth of the HIV epidemic in Ecuador.

Risk Factors for HIV among Zambian Street Youth

The sub-Saharan African region has been disproportionately affected by Human Immunodeficiency Virus (HIV) and Zambia has one of the highest HIV prevalence rates within this region. Moreover, new incidences of HIV infection are increasing most rapidly among those 15 to 24 years of age. Though young people are at high risk for HIV infection, street youth are even more vulnerable given their exposure to high risk behaviors. The current study examines multiple levels of social influence on HIV infection among 250 street youth in Zambia. Results reveal that though the majority of youth understand what behaviors increase their risk for HIV, youth still hold many misconceptions about HIV/AIDS. Additionally, youth who do not have a home to return to and those who report parental drug misuse were significantly more likely to be HIV positive. This study underscores the need for further education among street youth regarding HIV knowledge.

Community embedded reproductive health interventions for adolescents in Latin America: development and evaluation of a complex multi-centre intervention

Background

Adolescents in Latin America are at high risk for unwanted and unplanned pregnancies, which often result in unsafe abortions or poor maternal health outcomes. Both young men and women in the region face an increased risk of sexually transmitted infections due to inadequate sexual and reproductive health information, services and counselling. To date, many adolescent health programmes have targeted a single determinant of sexual and reproductive health. However, recent evidence suggests that the complexity of sexual and reproductive health issues demands an equally multi-layered and comprehensive approach.

Methods

This article describes the development, implementation and evaluation design of the community-embedded reproductive health care for adolescents (CERCA) study in three Latin American cities: Cochabamba (Bolivia), Cuenca (Ecuador) and Managua (Nicaragua). Project CERCA’s research methodology builds on existing methodological frameworks, namely: action research, community based participatory research and intervention-mapping.

The interventions in each country address distinct target groups (adolescents, parents, local authorities and health providers) and seek improvement of the following sexual health behaviours: communication about sexuality, sexual and reproductive health information-seeking, access to sexual and reproductive health care and safe sexual relationships.

In Managua, we implemented a randomised controlled study, and in Cochabamba and Cuenca we adopted a non-randomised controlled study to evaluate the effectiveness of Project CERCA interventions, in addition to a process evaluation.

Discussion

This research will result in a methodological framework that will contribute to the improved design and implementation of future adolescent sexual and reproductive health interventions.

Trial registration

ClinicalTrials.gov (NCT01722084)

Reducing harm from HIV/AIDS misconceptions among female sex workers in Tijuana and Ciudad Juarez, Mexico: A cross sectional analysis

Background

HIV prevalence is increasing among female sex workers (FSWs) in Mexico’s Northern border region, who experience multiple occupational risks. Improving vulnerable populations’ education, empowerment, and access to preventive services are important components of harm reduction strategies. Given the increasing interest in adapting harm reduction principles from drug use to sex work and other public health responses to the HIV epidemic, we used a sex work harm reduction framework to guide our investigation of FSWs’ HIV knowledge.

Methods

From 2004–2006, FSWs aged ≥18 years in Tijuana and Ciudad Juarez participated in a behavioral intervention study and completed structured interviews. Measures included HIV knowledge assessment and factors within each domain of our theoretical framework for sex work harms: (1) socio-demographic factors that may lead to sex work, (2) sex work characteristics and behaviors that may lead to harm, and (3) mutually reinforcing harms that lead to sex work and result from it (e.g., drug abuse). Negative binomial regression identified factors independently associated with suboptimal HIV knowledge (i.e., incorrect responses during the HIV knowledge assessment).

Results

Among 924 FSWs, the median proportion of incorrect responses was nearly one third (28% incorrect). Examination of item responses revealed misconceptions regarding specific transmission and prevention mechanisms, including prevention of mother to child transmission. Suboptimal HIV knowledge was independently associated with older age, lower education, living in Tijuana (vs. Ciudad Juarez), inconsistent condom use for vaginal sex with male clients, and lacking prior HIV testing.

Conclusions

Our application of a sex work harm reduction framework to the study of FSWs’ HIV knowledge is an important first step in enhancing HIV prevention efforts in Northern Mexican border cities. Our findings imply that interventions should identify and discredit local HIV misconceptions to improve knowledge of specific HIV transmission routes and self-protective strategies (e.g., condom negotiation). Interventions will require materials appropriate for women from diverse socio-economic backgrounds and may benefit from innovative harm reduction approaches such as peer education and outreach.

Predictors of condom use and refusal among the population of Free State province in South Africa

BACKGROUND

This study investigated the extent and predictors of condom use and condom refusal in the Free State province in South Africa.

METHODS

Through a household survey conducted in the Free Sate province of South Africa, 5,837 adults were interviewed. Univariate and multivariate survey logistic regressions and classification trees (CT) were used for analysing two response variables 'ever used condom' and 'ever refused condom'.

RESULTS

Eighty-three per cent of the respondents had ever used condoms, of which 38% always used them; 61% used them during the last sexual intercourse and 9% had ever refused to use them. The univariate logistic regression models and CT analysis indicated that a strong predictor of condom use was its perceived need. In the CT analysis, this variable was followed in importance by 'knowledge of correct use of condom', condom availability, young age, being single and higher education. 'Perceived need' for condoms did not remain significant in the multivariate analysis after controlling for other variables. The strongest predictor of condom refusal, as shown by the CT, was shame associated with condoms followed by the presence of sexual risk behaviour, knowing one's HIV status, older age and lacking knowledge of condoms (i.e., ability to prevent sexually transmitted diseases and pregnancy, availability, correct and consistent use and existence of female condoms). In the multivariate logistic regression, age was not significant for condom refusal while affordability and perceived need were additional significant variables.

CONCLUSIONS

The use of complementary modelling techniques such as CT in addition to logistic regressions adds to a better understanding of condom use and refusal. Further improvement in correct and consistent use of condoms will require targeted interventions. In addition to existing social marketing campaigns, tailored approaches should focus on establishing the perceived need for condom-use and improving skills for correct use. They should also incorporate interventions to reduce the shame associated with condoms and individual counselling of those likely to refuse condoms.

Preventing mother-to-child transmission in Guayaquil, Ecuador: HIV knowledge and risk perception

An important step in preventing mother-to-child transmission is testing pregnant women for HIV. Health literacy measures, such as HIV knowledge and risk perception, may determine which women are tested in prenatal clinics where routine opt-out testing is not available. A survey was conducted in Guayaquil, Ecuador in 2006 (n=485), where approximately 0.7% of HIV tests in prenatal clinics were positive. Pregnant women over the age of 18 were invited to complete the survey in the waiting rooms at four city hospitals. There were 67.2% of women reported being tested previously for HIV. The most notable finding was that women who perceived a risk were 1.74 times more likely to request testing (p=0.021), but a woman's risk perception was not related to established risk factors. In addition, a physician's recommendation would result in the testing of nearly all women (94.3%). This data suggest that interventions in prenatal care clinics should incorporate educational strategies to increase accurate perception of personal risk. These efforts must occur in conjunction with increasing the access to HIV tests to achieve the goal of universal prenatal testing.

Adolescents can know best: using concept mapping to identify factors and pathways driving adolescent sexuality in Lima, Peru

The primary objective of this study was to identify and describe individual- and environmental-level factors that Peruvian adolescents perceive to be related to adolescent sexuality. A series of concept mapping sessions were carried out from January-March 2006 with 63 15-17 year olds from a low-income community near Lima in order for adolescents to: (1) brainstorm items that they thought were related to sexuality, (2) sort, group and rate items to score their importance for sexuality-related outcomes, and (3) create pathways from the groups of items to engaging in sex. Brainstorming resulted in 61 items, which participants grouped into 11 clusters. The highest rated clusters were personal values, respect and confidence in partner relationships, future achievements and parent-child communication. The pathway of decision-making about having sex primarily contained items rated as only moderately important. This study identified important understudied factors, new perspectives on previously-recognized factors, and possible pathways to sexual behavior. These interesting and provocative findings underscore the importance of directly integrating adolescent voices into future sexual and reproductive health research, policies and programs that target this population.

Confidence as a predictor of sexual and reproductive health outcomes for youth

PURPOSE

To assess the association between four positive youth development (PYD) constructs of confidence and adolescent sexual and reproductive health (ASRH) outcomes.

METHODS

We searched nine online databases to locate behavioral research that examined the association between four constructs of confidence (belief in the future, self-determination, clear and positive identity, and self-efficacy) and ASRH outcomes (e.g., ever had sex, condom use, contraception use, number of partners, pregnancy/birth, and sexually transmitted infection). Findings were coded as "protective," "risk," or "no association." The presence of at least two longitudinal studies reporting consistent significant associations for at least one ASRH outcome indicated evidence for a protective or risk association.

RESULTS

We found evidence to support two of the four PYD constructs of confidence (belief in the future and self-determination) as protective factors for ASRH outcomes. Evidence was insufficient to draw conclusions about clear and positive identity as a protective factor, and was mixed for self-efficacy. Measures of confidence varied considerably across the studies reviewed, reflecting varying definitions; often, the measures used had limited information on reliability. Few longitudinal investigations were identified, and available studies were inconsistent in how they examined the association between the PYD constructs and ASRH outcomes. Evidence for most constructs was insufficient to identify their influence on specific sub-groups of youth.

CONCLUSIONS

Despite the need for additional research, this review suggests that belief in the future and self-determination are promising protective factors. Further research is needed to better understand the potential for self-efficacy and clear and positive identity as protective factors.

Risk and protective factors that affect adolescent reproductive health in developing countries: a structured literature review

The primary focus of this article is to determine which risk and protective factors are most important to adolescent reproductive health in developing countries. A comprehensive and systematic literature search was conducted on studies that examined factors in relation to the following outcomes: ever had premarital sex, condom use, pregnancy, early childbearing, sexually transmitted infections, and HIV. While the search identified over 11,000 publications, only 61 were retained for the final analysis. The results show that factors which were significantly associated to the outcomes were primarily related to the adolescents themselves. In fact, very few factors outside the individual were found to be related to sexual risk behaviours. This contrasts to similar research conducted among youth samples in the US. While this review confirms the strong need for a broader research base on the risk and protective factors related to adolescent sexual and reproductive health in developing countries, it also does identify key factors that can be addressed through innovative programmes and policies to help improve adolescent reproductive health in the developing world.

Ethnic differences in sexual behaviour among unmarried adolescents and young adults in Zimbabwe

Understanding the social and cultural contextual determinants of sexual behaviour of adolescents and young adults is an essential step towards curtailing the spread of HIV. This study examined the effects of one cultural factor, ethnicity, on sexual abstinence, faithfulness, condom use at last sex, and risky sex among young people in Zimbabwe. Data from the cross-sectional, population-based 2005-06 Zimbabwe Demographic and Health Survey were used. Net of the effect of sociodemographic and social-cognitive factors, and using multinomial logistic regression, ethnicity was found to have a strong and consistent effect on sexual behaviour among youth. In addition, the study found that there were ethnic-specific and within-gender differences in sexual behaviour, for both men and women. Shona youth were more likely to be abstinent than Ndebele youth. Compared with Shona youth, Ndebele youth were more likely to have engaged in risky sex. However, Ndebele men were more likely have used condoms at last sex, compared with Shona men. For both men and women, sexual behaviour was more socially controlled. School attendance and religion exerted protective effects on sexual abstinence. For men only, those living in rural areas were less likely to be faithful and more likely to have engaged in risky sexual behaviour than those living in urban areas. The study attests to the fact that ethnic norms and ideologies of sexuality need to be identified and more thoroughly understood. In addition, the study provides evidence that in order to promote safe and healthy sexuality among young people in Zimbabwe, cultural, social and gender-specific approaches to the development of HIV prevention strategies should be seriously considered. Current success in the Abstinence, Being faithful and Condom use (ABC) approach could be strengthened by recognizing and responding to cultural forces that reproduce and perpetuate risky sexual behaviours.

Knowledge of and attitudes towards HIV/AIDS among school teachers in Belize

OBJECTIVES

Although Belize currently has the highest rate of HIV infection in Central America, HIV/AIDS education is not formally included in the school curriculum. We assessed HIV/AIDS-related knowledge and attitudes of Belizean teachers.

METHODS

Ninety-one teachers completed a survey of 55 questions developed by the Centers for Disease Control and Prevention (CDC, Atlanta, Georgia, USA). Four outcomes included 'Knowledge of HIV/AIDS', 'Attitude towards people with HIV/AIDS', 'Instructional confidence', and 'Comfort with sensitive topics'. Multivariable linear regression was used to identify factors associated with the outcomes.

RESULTS

The majority of teachers scored in the average range for all four outcomes, as defined in this study. Statistically significant higher comfort and confidence levels were found for teachers with prior experience teaching responsible sexuality, those with formal training in HIV/AIDS, and for secondary school teachers. Knowledge scores did not differ significantly between any groups.

CONCLUSIONS

While in general teachers in Belize have good HIV/AIDS-related knowledge, attitude, comfort, and instructional confidence, there are several subgroups of teachers who have lower comfort and instructional confidence scores. These subgroups can be targeted for HIV/AIDS training in order to increase their effectiveness as HIV/AIDS educators.

Sex, condoms, gender roles, and HIV transmission knowledge among adolescents in León, Nicaragua: implications for HIV prevention

There are few peer-reviewed studies of HIV/AIDS-related knowledge, attitudes, beliefs and practices among adolescents in Central America. A population-based cross-sectional survey was conducted among 246 adolescents in León, Nicaragua, where there is reason for concern about a rise in HIV infections. In many respects, León adolescents were typical of those in other Latin American countries, with a mixture of correct and incorrect knowledge about transmission of HIV and sexually transmitted infections, a higher proportion of males than females reporting having had sex or using condoms, and inconsistent condom use. While some sexual attitudes conformed to the ideology of machismo, others did not, providing an opening for prevention interventions. Some dimensions of HIV/AIDS stigma were high, and most adolescents disapproved of same-sex sexual behaviour. Intervention against homosexuality-related stigma is particularly urgent because a concentrated HIV epidemic may be emerging in Nicaragua among men who have sex with men. Personal religious beliefs did not appear to pose a barrier to condom use. In a multivariate model, being out of school was a significant correlate of having had sex and of insufficient HIV/AIDS-related knowledge. Accordingly, HIV prevention interventions must reach adolescents both in and out of school. A multi-component approach to prevention is needed, including programmes based in schools, communities, the mass media and health facilities.

Longitudinal test of a multiple domain model of adolescent condom use

A comprehensive multiple domain model (MDM) to understand condom use in adolescents was proposed and tested using structural equation modeling of data at three time points. The proposed model integrates social psychological theory, demographic and personality factors, social environment, and situational/contextual variables. Adolescents who were sexually active at time 2 (6 months after baseline) and time 3 (1 year after time 2) and completed surveys at all three time points were included in the analyses (N = 511). An iterative process of model testing resulted in a structural equation model that provided a good fit to the data (CFI = .92, RMSEA = .04). Models comparing gender and race as moderators also were calculated and supported the generalizability of the model. Results provide support for an MDM that goes beyond traditional social psychological models for a broader understanding of condom use in adolescents. Implications for further theory testing and safer sexual interventions are discussed.

Do perceptions of friends' behaviors affect age at first sex? Evidence from Cebu, Philippines

PURPOSE

To explore the effect of perceptions of friends' romantic and physical behaviors on adolescent sexual behavior and the relative influence of friends' sexual behaviors and maternal attitudes on age at first sex.

METHODS

Using longitudinal data collected from 1943 adolescents who have never had sex at baseline in Cebu, Philippines, logistic regression assessed whether adolescents' perceptions of friends' sexual behaviors, measured at ages 14 to 16 years, were associated with age at first intercourse. Survival analysis assessed the hazard of having first intercourse by ages 17 to 19 years. Final models adjusted for sociodemographics, mothers'/caretakers' disapproval of premarital sex, living with a caretaker, and the adolescents' own behaviors at baseline.

RESULTS

Boys and girls, who at ages 14 to 16 years, perceived that their friends had ever had boyfriends/girlfriends, dated, held hands, kissed, petted or had sex were significantly more likely to have experienced that behavior by ages 17 to 19 years. For each additional behavior an adolescent perceived his or her friends to have experienced, the hazard of having sex at a younger age increased by 1.15 (p = .02) among boys and 1.19 (p < .002) among girls, after adjusting for mothers'/caretakers' disapproval of premarital sex and other factors.

CONCLUSIONS

These results demonstrate the important role of peers in light of competing influences in adolescents' lives. They provide support for asking at early ages what romantic and physical behaviors adolescents think their friends have experienced. Interventions can use such information to better prepare adolescents to make responsible and informed decisions about sexuality.

The influence of power on HIV risk among pregnant women in rural Haiti

Given that condom use is not directly under a woman's control, the sexual division of power may play an important role in sexual behavior among pregnant women. We assessed the influence of factors related to the theory of gender and power (e.g., relationship power, abuse history, and sexual communication) on sexual behavior (e.g., two or more partners in the year prior to pregnancy, condom use, condom-use intentions, and STI diagnosis) among 196 pregnant women recruited from five community dispensaries in rural Haiti. Results showed that gender and power factors significantly related to sexual behavior. Gender and power factors were most significant for condom use and intention to use condoms, accounting for 18 and 25% of the variance above and beyond HIV knowledge and demographic covariates, respectively. These results suggest the need to create prevention interventions that restore power imbalances, provide support for women suffering abuse, and strengthen communication skills.

Associations among condom use, sexual behavior, and knowledge about HIV/AIDS. A study of 13,293 public school students

BACKGROUND

This school-based study explored associations between Mexican young people's condom use, other sexual behaviors, and HIV/AIDS knowledge.

METHODS

Students (n=13,293, 11-24 years of age) from a random sample of public schools in the central Mexican state of Morelos completed a self-administered questionnaire. We performed logistic regression analysis of condom use and sexual behavior variables and a knowledge-based index on HIV/AIDS prevention and transmission.

RESULTS

Average age at sexual debut was 13.6 +/- 1.9 years among young men and 14.2 +/- 2.2 years among young women; 34.5% of sample participants reported using condoms during their first sexual intercourse. More students had intermediate HIV/AIDS knowledge levels (46%, 95% confidence interval [95% CI], 45.2-46.9) than high levels (37%, 95% CI 36.2-37.8, p <0.01). Students knew more concerning HIV transmission than about prevention of HIV infection. Among young men, high levels of HIV/AIDS knowledge increased likelihood of condom use (odds ratio [OR] 1.4, 95% CI, 1.1-1.7), while among young women high levels of knowledge decreased likelihood of using condoms (OR 0.7, 95% CI, 0.5-1.0). Young men with high levels of HIV/AIDS knowledge were more likely to have had three or more sexual partners (OR 1.7, 95% CI, 1.3-2.2), but young women with high knowledge levels were more likely to have only one lifetime sexual partner (OR 0.6, 95% CI, 0.4-0.9).

CONCLUSIONS

As in previous studies in smaller samples, levels of knowledge with regard to HIV/AIDS were low in Mexican youth. HIV/AIDS education programs for Mexican students should focus on conveying knowledge on HIV prevention. Because apparently knowledge is not directly correlated with condom use among young women, prevention strategies that deal with social acceptability of condoms and social skills related with condom negotiation are also needed.