Page 153 - SAHCS HIVMed Journal Vol 20 No 1 2019

Page 6 of 8 Original Research

known to be HIV-infected prior to the initial YaTsie household inconsistent condom use). For example, in our cohort,
survey, adolescent and young adult females were significantly food insecurity and lack of cell phone were associated
more likely to have documentation of undergoing HIV with higher prevalence of transactional sex among females.
testing in the 12 months prior to the survey compared with Cash transfer programmes have been shown to decrease
males (50% vs. 29%, respectively; p < 0.0001). transactional sex and intergenerational sex in adolescent
females. 13,14 There is also some evidence pointing to an
Among adolescent females, 44% (148) reported having at association between educational level and HIV acquisition. 15,16
least one child or currently being pregnant. This rate was De Neve et al. found that increasing education through
higher among young adult females at 73% (842). Among to secondary level resulted in a reduction of absolute
adolescent females, 89% of those with a child or who were cumulative risk of HIV infection of 8.1 percentage points
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currently pregnant reported having previously tested for (p = 0.008). PEPFAR has adopted educational subsidies as a
HIV, compared with only 47% of nulliparous female component of its DREAMS programme to address structural
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adolescents (p < 0.0001). Among young adult females, 95% of drivers of HIV risk among young females. While cash
those with a child or who were currently pregnant reported transfers, educational subsidies or block grants may not
having previously participated in HIV testing, compared address all risky sexual practices, integration of these
with 71% of nulliparous female young adults (p < 0.0001). types of incentives into existing combination prevention
programming may contribute to reductions in HIV
There was a trend towards increased HIV prevalence among acquisition in adolescent females.
the 769 adolescents and young adults reporting ≥ two risky
sexual practices when compared with the 1542 adolescents In our survey, males were more likely to report sexual debut
and young adults who reported only one or no risky sexual before 15 years of age, a finding consistent with the Botswana
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practices (10% vs. 7%, respectively; p = 0.07). Among the 769 AIDS Impact Survey (BAIS IV) 2013. Mhalu et al. observed
adolescents and young adults who reported engaging in ≥ similar differences in self-reported early sexual debut prior to
age 15 among Tanzanian adolescents and young adult males
two risky sexual practices, 45% had documentation of HIV and females aged 15–24 years living with HIV, but with a
testing in the past 12 months and this testing prevalence was strikingly higher prevalence of early sexual debut at 85% for
significantly higher than the prevalence of 40% among males compared to 68% for females (p = 0.05). Preventive
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adolescents and young adults reporting one or no risky programming may lead to a decline in age at sexual debut.
sexual practices (p < 0.0001).
For example, from 1999 to 2016 in Uganda, the number of
Discussion participants in the 15–19 year age group who reported never
having initiated sex increased from 35% to 56% (p < 0.0001)
Female adolescents and young adults aged 16–24 years in among males and from 28% to 55% among females
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Botswana were significantly more likely than their male (p < 0.0001), and decline in early sexual debut among
counterparts to report being sexually active, and to report females with concurrent school enrolment achieved
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inconsistent condom use, engagement in transactional sex significant reduction in HIV infections. This highlights the
and participation in intergenerational sex with a partner ≥ 10 value of contextualising prevention programming to gender-
years older. These practices have been shown to be associated and age-specific HIV acquisition risk factors.
with higher risk of HIV acquisition. 9,10 With female
adolescents and young adults experiencing the highest HIV The high proportions of both adolescents and young adults
incidence globally, programmes targeting structural and reporting secondary education presents an engagement
behavioural drivers of these practices could significantly avenue for reinforcing safer sexual practices in young
reduce overall HIV incidence in high burden HIV settings. persons. A randomised study in Kenya found that school-
based programming resulted in a reduction in unsafe sexual
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Adolescent and young adult females participating in the practices among teenagers. In a pilot programme in
YaTsie study were more likely to be HIV-infected than their Botswana, peer messengers were effective in educating
male counterparts. This is consistent with current HIV adolescents on the HIV risk associated with intergenerational
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epidemiological patterns with adolescent and young adult sex and had an overall impact on sexual behaviours. In
females having the fastest growing incidence of HIV. In Western Cape, South Africa, a peer-education curriculum
11
addition, the higher frequency of intergenerational sex designed for adolescents was found to qualitatively improve
reported by young women in the YaTsie study compared to adolescent self-efficacy in sexual relations and HIV
young men has also been described in other high HIV knowledge. 24,25
11
12
prevalence settings such as Zimbabwe and Uganda.
Similarly, the association between intergenerational sex and Adolescent and young adult females in our cohort were more
higher HIV prevalence in young women that we found has likely to have participated in HIV testing previously
been observed elsewhere. Prevention programmes should compared with their male counterparts, and pregnant
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be specifically tailored to address the unique behaviours or females or those with at least one child were significantly
social challenges that place young women at a higher risk for more likely to have participated in HIV testing previously
HIV acquisition (transactional sex, intergenerational sex, than nulliparous females. This most likely relates to

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