Male Partner Age, Viral Load, and HIV Infection in Adolescent Girls and Young Women: Evidence From Eight Sub-Saharan African Countries

Abstract

Background: Conflicting evidence obscures the role of partnerships with older men in the HIV epidemic in adolescent girls and young women (AGYW, aged 15-24) in sub-Saharan Africa. We assessed the effect of partner age and potential mediators on AGYW HIV infection using data from Population-based HIV Impact Assessments in Eswatini, Lesotho, Malawi, Namibia, Tanzania, Uganda, Zambia, and Zimbabwe. Methods: PHIA surveys collect data on HIV-related outcomes. Recent infection was estimated using an HIV-1 LAg avidity assay algorithm. We examined the association between reported partner age and recent AGYW HIV infection, incorporating population-level HIV prevalence and viremia from the reported male age-band. Logistic regression analyses compared the odds of recent infection in AGYW with older male partners to those reporting same-age male partner, adjusting for AGYW age, country, and urban/rural residence. Dyadic analysis examined observed cohabitating partner age, HIV status, and viremia to assess associations with recent and prevalent infection in their AGYW spouses. Findings: Among 17,813 AGYW, increasing reported partner age was associated with higher odds of recent infection, with the highest odds for partners aged 35-44 years (adjusted odds ratio (aOR) 8·94, 95% CI 2·63-30·37) compared to partners aged 15-24. Population-level viremia was highest in this male age-band. Dyadic analyses of 5,432 partnerships confirmed the association between partner age-band of 35-44 and prevalent HIV infection (aOR 3·82, 95% CI 2·17-6·75). However, most new infections were in AGYW with partners aged 25-34, as the majority of AGYW had partners in this age-band. Interpretation: These results provide evidence that men aged 25-34 drive most AGYW infections, but partners over 9 years older than AGYW in the 35-44 age-band confer greater risk. Population-level infectiousness and male age should be incorporated into identifying high-risk typologies. Funding Information: This research publication has been supported by the President's Emergency Plan for AIDS Relief (PEPFAR) through the US Centers for Disease Control and Prevention (CDC) under the terms of cooperative agreements U2GGH001226 and U2GGH001271. Joanne Mantell and Susie Hoffman were supported by a NIMH Center Grant P30-MH43520 (Principal Investigator: Robert H. Remien, PhD). The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the funding agencies. Declaration of Interests: Authors declare that they have no competing interests. Ethics Approval Statement: A guardian or parent provided permission for interviewers to approach 10-17-year-olds who then assented. Informed consent/assent was documented via electronic signature, with witnesses verifying consent for illiterate individuals The PHIA protocols were approved by national ethics committees, and the institutional review boards at Columbia University Irving Medical Center, the University of California in San Francisco for Namibia, and the US Centers for Disease Control and Prevention.