Vulnerabilities at First Sex and Their Association With Lifetime Gender-Based Violence and HIV Prevalence Among Adolescent Girls and Young Women Engaged in Sex Work, Transactional Sex, and Casual Sex in Kenya.

Marissa L Becker,Sevgi Aral,Parinita Bhattacharjee,Shajy Isac,Eve Cheuk,Helgar K Musyoki,Michael Pickles,James F Blanchard,Paul Sandstrom,Sharmistha Mishra,Peter Gichangi,Huiting Ma

doi:10.1097/qai.0000000000001826

Abstract

Background:Adolescent girls and young women (AGYW) experience high rates of HIV early in their sexual life course. We estimated the prevalence of HIV-associated vulnerabilities at first sex, and their association with lifetime gender-based violence (GBV) and HIV.Methods:We conducted a cross-sectional biobehavioral survey among AGYW (14–24 years) in Mombasa, Kenya in 2015. We compared the prevalence of first sex vulnerabilities across AGYW who self-identified as engaging in sex work (N = 408), transactional sex (N = 177), or casual sex (N = 714) and used logistic regression to identify age-adjusted associations between first sex vulnerabilities and outcomes (GBV after first sex; HIV).Results:The median age at first sex was 16 years (interquartile range 14–18). A total of 43.6% received gifts or money at first sex; 41.2% and 11.2% experienced a coerced and forced first sex, respectively. First sex vulnerabilities were generally more common among AGYW in sex work. GBV (prevalence 23.8%) and HIV (prevalence 5.6%) were associated with first sex before age 15 [GBV adjusted odds ratio (AOR) 1.4, 95% confidence interval (CI): 1.0 to 1.9; HIV AOR 1.9, 95% CI: 1.1 to 1.3]; before or within 1 year of menarche (GBV AOR 1.3, 95% CI: 1.0 to 1.7; HIV AOR 2.1, 95% CI: 1.3 to 3.6); and receipt of money (GBV AOR 1.9, 95% CI: 1.4 to 2.5; HIV AOR 2.0, 95% CI: 1.2 to 3.4).Conclusions:HIV-associated vulnerabilities begin at first sex and potentially mediate an AGYW's trajectory of risk. HIV prevention programs should include structural interventions that reach AGYW early, and screening for a history of first sex vulnerabilities could help identify AGYW at risk of ongoing GBV and HIV.

Highlights

Adolescent girls and young women (AGYW) experience high rates of HIV early in their sexual life course
gender-based violence (GBV) and HIV were associated with first sex before age 15 [GBV adjusted odds ratio (AOR) 1.4, 95% confidence interval (CI): 1.0 to 1.9; HIV AOR 1.9, 95% CI: 1.1 to 1.3]; before or within 1 year of menarche (GBV AOR 1.3, 95% CI: 1.0 to 1.7; HIV AOR 2.1, 95% CI: 1.3 to 3.6); and receipt of money (GBV AOR 1.9, 95% CI: 1.4 to 2.5; HIV AOR 2.0, 95% CI: 1.2 to 3.4)
HIV-associated vulnerabilities begin at first sex and potentially mediate an AGYW’s trajectory of risk

Summary

Introduction

Adolescent girls and young women (AGYW) experience high rates of HIV early in their sexual life course. Adolescent girls and young women (AGYW) experience a disproportionate burden of HIV-associated vulnerabilities leading to a disproportionate risk of HIV acquisition.[1] This is prominent in regions with high HIV prevalence such as Eastern and Southern Africa, where women aged 15–24 years comprise 10% of the adult population yet accounted for 26% of new HIV infections in 2016.2 In Kenya, overall HIV prevalence is 5.4% and AGWY. Vulnerabilities at First Sex Among Young Women accounted for 32% of the estimated 56,000 new adult HIV infections in 2016.3. A complex interplay of biological, behavioral, and structural factors contributes to the increased vulnerability to HIV acquisition among AGYW. Age at first sex (often defined as ,15 years of age5) is associated with increased risk of bacterial sexually transmitted infections partly due to cervical ectopy in adolescence,[6,7] higher levels of inflammatory cytokines in the female genital tract,[8,9] less condom use at first sex and subsequent sex acts,[10,11] and prevalent HIV infection.[4,12] AGYW who reach menarche and puberty early are more likely to engage in earlier (and often condomless) sexual activity than those who experience later menarche.[13,14,15] Sex with older men is common among AGYW, and is associated with increased HIV risk because older men are more likely to be living with HIV than younger men, and because the age-disparate and gender-based power dynamics undermine condom negotiation.[16,17,18,19] Structural factors including intimate partner violence and other forms of gender-based violence (GBV) are associated with HIV acquisition,[20,21,22] and GBV is common among AGYW.[23,24]

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Conclusion