Gains in Education May Explain Decline in HIV Among Ugandan Girls

Abstract

Trends in HIV incidence among youth in Rakai, Uganda, during a recent 12-year period varied substantially by sex and age, according to a prospective population-based cohort study. (1) Among women aged 15-19, the rate of new infections declined by more than four-fifths during the study period; however, no change was found among women aged 20-24 or among men in either age-group. In addition, school enrollment increased, particularly among 15-19-year-olds, and rates of sexual initiation and marriage generally decreased; medical circumcision increased among males. The majority of the decline in HIV incidence among teenage women, according to the researchers, can be explained by the reduction in sexual initiation, which in turn was related to higher school enrollment. In the study, Santelli and colleagues analyzed data from 15-24-year-olds who took part in one or more of the nine rounds of the Rakai Community Cohort Study that were conducted between 1999 and 2011. This period--the third decade of the HIV epidemic in the district-saw implementation of multiple HIV prevention and treatment programs, and came soon after introduction of a new national policy of universal primary education that abolished tuition fees. During community surveys conducted roughly annually, participants completed questionnaires about their demographic, behavioral, reproductive and health characteristics, and provided specimens for HIV and STI testing. The investigators evaluated trends in HIV acquisition and in risk factors; used univariate and multivariate analyses to assess correlations between these trends; and performed decomposition analysis to determine the extent to which various risk factors may have contributed to changes in HIV incidence. Analyses were based on 22,164 participants aged 15-24 residing in 43 communities. The researchers found that the rate of new HIV infections acquired between survey rounds was consistently higher among female youth (10-16 per 1,000 person-years) than among their male counterparts (6-10 per 1,000 person-years). Over the study period, women aged 15-19 had an 86% reduction in HIV incidence (from 17 to 2 new infections per 1,000 person-years); in contrast, women aged 20-24 and men of either age-group had no change in HIV incidence. Overall, the prevalence of HIV infection fell among females (from 9% in 1999 to 6% in 2011), whereas it remained unchanged among males (2-3%). Trends in risk factors showed that the proportion of youth enrolled in school increased among all subgroups, but especially among teenage women (from 26% to 59%) and men (from 43% to 66%); similarly, the proportion who had ever had sex decreased among all youth, but the decline was greatest among 15-19-year-old women (from 76% to 50%) and men (from 63% to 41%). The proportion who had ever been married fell among teenage women (from 46% to 24%), teenage men (from 5% to 1%) and men aged 20-24 (from 52% to 37%). …