Sex in the shadow of HIV: factors associated with sexual risk among adolescents in a community-traced sample in South Africa

Toska, E

Abstract:: Background: Sub-Saharan Africa is home to 85% of the world’s HIV-positive adolescents: an estimated 1.3-2.2 million 10-19 year olds. Adolescents living with HIV face multiple sexual and reproductive health risks: unwanted pregnancies and the risk of mother-to-child-transmission, risk of infecting partners, co-infection with other STIs, and the rising but undocumented risk of re-infection by potentially resistant HI-virus strains. Using contraception, especially condoms, is...
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APA Style

Toska, E. (2017). Sex in the shadow of HIV: factors associated with sexual risk among adolescents in a community-traced sample in South Africa [PhD thesis]. University of Oxford.

MLA Style

Toska, E. Sex in the Shadow of HIV: Factors Associated with Sexual Risk among Adolescents in a Community-Traced Sample in South Africa. 2017. University of Oxford, PhD thesis.

Chicago Style

Toska, E. 2017. “Sex in the Shadow of HIV: Factors Associated with Sexual Risk among Adolescents in a Community-Traced Sample in South Africa.” PhD thesis, University of Oxford.
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Authors

+ Toska, E More by this author

Division:: SSD
Department:: Social Policy & Intervention
Role:: Author

Contributors

+ Cluver, L

Role:: Supervisor

+ Clarendon/ Green Templeton College Scholarship More from this funder

Funding agency for:: Toska, E
Grant:: NA

+ UNICEF More from this funder

Grant:: NA

+ CIPHER grant More from this funder

Grant:: 155-Hod

+ Evidence for HIV Prevention in Southern Africa More from this funder

Grant:: MM/EHPSA/UCT/ 05150014

+ Nuffield Foundation More from this funder

Grant:: CPF/41513

DOI:: 10.5287/ora-148abk0b8
Type of award:: DPhil
Level of award:: Doctoral
Awarding institution:: University of Oxford

Language:: English
Keywords:: adolesents

sexual risk taking

ALHIV

South Africa

HIV
Subjects:: AIDS (Disease)--Patients

Reproductive Health including Family Planning and Sexual Health (RH/FP-SH) Sub-Programme

Teenagers--Medical care
UUID:: uuid:e50ba696-e744-457b-a595-dfa55064b968
Deposit date:: 2017-07-19
ARK identifier:: ark:/29072/ora_e50ba696e744457ba595dfa55064b968

Related item:: Sex in the Shadown of HIV: Factors associated with sexual risk among adolescents in a community-traced sample in South Africa
Description:: Background: Evidence on sexual risk-taking among HIV-positive adolescents and youth in sub-Saharan Africa is urgently needed. This systematic review synthesizes the extant research on prevalence, factors associated with, and interventions to reduce sexual risk-taking among HIV-positive adolescents and youth in sub-Saharan Africa. Methods: Studies were located through electronic databases, grey literature, reference harvesting, and contact with researchers. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Quantitative studies that reported on HIV-positive participants (10–24 year olds), included data on at least one of eight outcomes (early sexual debut, inconsistent condom use, older partner, transactional sex, multiple sexual partners, sex while intoxicated, sexually transmitted infections, and pregnancy), and were conducted in sub-Saharan Africa were included. Two authors piloted all processes, screened studies, extracted data independently, and resolved any discrepancies. Due to variance in reported rates and factors associated with sexual risk-taking, meta-analyses were not conducted. Results: 610 potentially relevant titles/abstracts resulted in the full text review of 251 records. Forty-two records (n = 35 studies) reported one or multiple sexual practices for 13,536 HIV-positive adolescents/youth from 13 sub-Saharan African countries. Seventeen cross-sectional studies reported on individual, relationship, family, structural, and HIV-related factors associated with sexual risk-taking. However, the majority of the findings were inconsistent across studies, and most studies scored <50% in the quality checklist. Living with a partner, living alone, gender-based violence, food insecurity, and employment were correlated with increased sexual risk-taking, while knowledge of own HIV-positive status and accessing HIV support groups were associated with reduced sexual risk-taking. Of the four intervention studies (three RCTs), three evaluated group-based interventions, and one evaluated an individual-focused combination intervention. Three of the interventions were effective at reducing sexual risk-taking, with one reporting no difference between the intervention and control groups. Conclusion: Sexual risk-taking among HIV-positive adolescents and youth is high, with inconclusive evidence on potential determinants. Few known studies test secondary HIV-prevention interventions for HIV-positive youth. Effective and feasible low-cost interventions to reduce risk are urgently needed for this group.
Related item:: School, Supervision and Adolescent-Sensitive Clinic Care: Combination Social Protection and Reduced Unprotected Sex Among HIV-Positive Adolescents in South Africa
Description:: Social protection can reduce HIV-risk behavior in general adolescent populations, but evidence among HIVpositive adolescents is limited. This study quantitatively tests whether social protection is associated with reduced unprotected sex among 1060 ART-eligible adolescents from 53 government facilities in South Africa. Potential social protection included nine ‘cash/cash-in-kind’ and ‘care’ provisions. Analyses tested interactive/additive effects using logistic regressions and marginal effects models, controlling for covariates. 18 % of all HIV-positive adolescents and 28 % of girls reported unprotected sex. Lower rates of unprotected sex were associated with access to school (OR 0.52 95 % CI 0.33–0.82 p = 0.005), parental supervision (OR 0.54 95 % CI 0.33–0.90 p = 0.019), and adolescentsensitive clinic care (OR 0.43 95 % CI 0.25–0.73 p = 0.002). Gender moderated the effect of adolescentsensitive clinic care. Combination social protection had additive effects amongst girls: without any provisions 49 % reported unprotected sex; with 1–2 provisions 13–38 %; and with all provisions 9 %. Combination social protection has the potential to promote safer sex among HIV-positive adolescents, particularly girls.
Related item:: Sex and secrecy: How HIV-status disclosure affects safe sex among HIV-positive adolescents
Description:: HIV-positive adolescents who engage in unsafe sex are at heightened risk for transmitting or re-acquiring HIV. Disclosure of HIV-status to sexual partners may impact on condom use, but no study has explored the effects of (i) adolescent knowledge of one’s HIV-status, (ii) knowledge of partner status and (iii) disclosure to partners, on safer sex behaviour. This study aimed to identify whether knowledge of HIV-status by HIV-positive adolescents and partners was associated with safer sex. Eight fifty eight HIV-positive adolescents (10–19 years old, 52% female, 68.1% vertically infected) who had ever initiated antiretroviral treatment in 41 health facilities in the Eastern Cape, South Africa, were interviewed using standardised questionnaires. Quantitative analyses used multivariate logistic regressions, controlling for confounders. Qualitative research included interviews, focus group discussions and observations with 43 HIV-positive teenagers and their healthcare workers. N = 128 (14.9%) of the total sample had ever had sex, while N = 109 (85.1%) of sexually active adolescents had boy/ girlfriend. In total, 68.1% of the sample knew their status, 41.5% of those who were sexually active and in relationships knew their partner’s status, and 35.5% had disclosed to their partners. For adolescents, knowing one’s status was associated with safer sex (OR = 4.355, CI 1.085–17.474, p = .038). Neither knowing their partner’s status, nor disclosing one’s HIV-status to a partner, were associated with safer sex. HIV-positive adolescents feared rejection, stigma and public exposure if disclosing to sexual and romantic partners. Counselling by healthcare workers for HIV-positive adolescents focused on benefits of disclosure, but did not address the fears and risks associated with disclosure. These findings challenge assumptions that disclosure is automatically protective in sexual and romantic relationships for HIV-positive adolescents, who may be illequipped to negotiate safer sex. There is a pressing need for effective interventions that mitigate the risks of disclosure and provide HIV-positive adolescents with skills to engage in safe sex.

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Sex in the shadow of HIV: factors associated with sexual risk among adolescents in a community-traced sample in South Africa

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Sex in the shadow of HIV: factors associated with sexual risk among adolescents in a community-traced sample in South Africa

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