Menu
Menu
Menu
Menu
Introduction: Adolescent girls and young women, including adolescent mothers, in Southern Africa have high HIV seroconversion and transmission. We need to know which risks drive HIV infections, and what can reduce these risks. Methods: We interviewed 1712 adolescent girls and young women (11–23 years), including 1024 adolescent mothers who had conceived before age 20 and had a living child, from two health municipalities of South Africa’s Eastern Cape Province between March 2018 and July 2019. Recruitment was through multiple community, school and health facility channels. Associations between adolescent motherhood and seven HIV risk behaviours (multiple sexual partners, transactional sex, age-disparate sex, condomless sex, sex on substances, alcohol use and not in education or employment) were investigated using the generalized estimating equations method for multiple outcomes specified with a logit link and adjusting for nine covariates. Using the same model, we investigated associations between having enough food at home every day in the past week (food security) and the same seven HIV risk behaviours. When we found evidence of moderation by HIV status, we report stratum-specific odds ratios. Results: Mean age was 17.51 years (SD: 2.54), 46% participants were living with HIV. Compared to non-mothers, adolescent mothers had lower odds of alcohol use (AOR = 0.47, 95% CI = 0.29–0.75), but higher odds of multiple sexual partners (AOR = 1.93, 95% CI = 1.35–2.74), age-disparate sex (HIV-uninfected AOR = 1.73, 95% CI = 1.03–2.91; living with HIV AOR = 5.10, 95% CI = 2.98–8.73), condomless sex (AOR = 8.20, 95% CI = 6.03–11.13), sex on substances (AOR = 1.88, 95% CI = 1.10–3.21) and not in education/employment (HIV-uninfected AOR = 1.83, 95% CI = 1.19–2.83; living with HIV AOR = 6.30, 95% CI = 4.09–9.69). Among non-mothers, food security was associated with lower odds of multiple sexual partners (AOR = 0.45, 95% CI = 0.26–0.78), transactional sex (AOR = 0.32, 95% CI = 0.13–0.82) and not in education/employment (AOR = 0.48, 95% CI = 0.29–0.77). Among adolescent mothers, food security was associated with lower odds of transactional sex (AOR = 0.17, 95% CI = 0.10–0.28), age-disparate sex (AOR = 0.66, 95% CI = 0.47–0.92), sex on substances (AOR = 0.51, 95% CI = 0.32–0.82), alcohol use (AOR = 0.45, 95% CI = 0.25–0.79) and not in education/employment (AOR = 0.56, 95% CI = 0.40–0.78). Conclusions: Adolescent motherhood is associated with multiple vulnerabilities to HIV infection and transmission. Social protection measures that increase food security are likely to reduce HIV risk pathways for adolescent girls and young women, especially adolescent mothers.
The study used a cross‐sectional design and was reported according to the Strengthening the Reporting of Observational Studies in Epidemiology checklist for cross‐sectional studies (Table S1) [31]. The study site was 180 communities spread across Amathole district and Buffalo City metropolitan municipalities of South Africa’s Eastern Cape Province. Interviews took place between March 2018 and July 2019. The Eastern Cape is one of the poorest provinces in South Africa with a Human Development Index around 0.67 [32]. The 2017 South African National HIV Prevalence, Incidence, Behaviour, and Communication Survey estimated that 10% of AGYWs in the province were living with HIV [33]. The study population was AGYW (11–25 years) without a live‐born child (non‐mothers), and AGYW who had conceived before age 20 and had a living child from that pregnancy (adolescent mothers). The study sample included AGYW participating in the Mzantsi Wakho (MW) cohort studying the lived experience of adolescents living with HIV [34], and the HEY BABY cohort studying resilience among adolescent parent families [35]. Recruitment for MW occured between March 2014 and September 2015. All adolescents (10–19 years) who had ever initiated HIV care in one of the 73 health facilities providing ART across the study site were contacted and invited to participate in the study. To prevent stigmatization of adolescents living with HIV, cohabiting or neighbouring adolescents were also invited to participate [34]. The study had 90% uptake at baseline and 94% retention at follow‐up interviews in 2018/2019. Recruitment for HEY BABY occured between March 2018 and July 2019 and used multiple channels that were developed with an advisory group of adolescent mothers [35]. First, all adolescent mothers in the MW cohort were invited to participate. Then, we contacted and invited participants using patient files at ART clinics and maternity obstetric units across the study site and teacher referrals at 43/149 randomly selected secondary schools. There was also community recruitment via door‐to‐door visits and referrals from community guides. Finally, to ensure recruitment of the most vulnerable adolescent mothers, we used referrals from local social workers, NGOs, and adolescent mothers themselves. Ethical approvals were obtained from the University of Oxford ({“type”:”entrez-nucleotide”,”attrs”:{“text”:”R48876″,”term_id”:”810902″}}R48876/RE001,SSD/CUREC2/12‐21), University of Cape Town (HREC 226/2017,CSSR 2013/4), Provincial Departments of Health and Basic Education, health facilities and schools. All adolescents and all primary caregivers (where adolescents were under 18 years old) gave voluntary informed consent, read aloud in cases of low literacy. There were no financial incentives for participation, but adolescents received a certificate and small gift pack, including toiletries for girls and babies. Interviews were conducted in a location of the adolescent’s choice and took 45–70 minutes. They used audio mobile‐assisted self‐interviewing on electronic tablets, assisted by local interviewers trained to adjust level of assistance by age, literacy and confidence of participants. Interviews took place in Xhosa or English, according to participant choice. Confidentiality was maintained except when participants disclosed serious risk of harm to themselves or others. In these cases, safeguarding processes were followed. For reports of current abuse, recent rape or suicidality, participants were immediately supported to access post‐exposure prophylaxis, pregnancy prevention and child protection measures with government or NGO services. Findings of the study are shared with communities, health facilities and government in research areas as part of embedded local knowledge sharing. Measures and scales were pre‐piloted with 34 local adolescents, including adolescent mothers. Input to questionnaire design was given by the South African National Departments of Health, Basic Education, and Social Development, the South African National AIDS Council, UNICEF, PEPFAR, USAID and local NGOs. All questionnaires are available at www.youngcarers.org.za. We assessed seven high‐risk behaviours for HIV infection and transmission, using questions adapted from the National Survey of HIV and Risk Behaviour among young South Africans, the PREPARE trial and the Child Behaviour Checklist Youth Self‐Report [36] (all self‐report): (1) Multiple sexual partners, measured as 2+ sexual partners in the past year [37], (2) Transactional sex, measured as past‐year receipt of money, drinks, clothes, airtime, a place to stay, lifts in a car/taxi, better marks at school, school fees, food or other material exchange for having sex; (3) Age disparate sex, measured as a sexual partner more than 5 years older in the past year; (4) Condomless sex, measured as ever not using a condom for the duration of sex in the past year; (5) Sex on substances, measured as having sex when drunk or using drugs in the past year; (6) Alcohol use, measured as responding “somewhat true” or “definitely yes” to the question “I drink alcohol to have a good time, without my caregivers knowing or approving in the past six months” [38], (7) Not in education or employment, measured as non‐enrolment in primary school, secondary school, university, college, further education and training, and not currently being paid a salary/wage full‐time or part‐time at the time of interview. Measured as conception of first child before age 20 according to the World Health Organization’s definition [39]. Mothers’ age at conception was calculated by subtracting a conservative estimate of 294 days from first child’s date of birth, and comparing this to mother’s date of birth. Measured as having enough food at home every day in the previous seven days, using the South African National Food Consumption Survey food frequency questionnaire, adapted in pre‐piloting with local adolescents [40]. We considered nine covariates: participant HIV status, age, relationship status, parental monitoring, rural/urban household location, number of household residents, informal/shack housing, maternal orphanhood and paternal orphanhood. HIV status was assessed using clinical files for all participants recruited from health facilities. For girls and women not recruited via a health facility, HIV status was measured by participant self‐report during a series of semi‐structured questions by trained research assistants at the beginning of each interview, and confirmed in medical records where possible. For adolescent mothers, we cross‐checked self‐reported HIV statuses with data extracted from participants’ Road To Health card (a routine patient‐held medical record summarizing a child’s health in the first 5 years of life). Parental monitoring was assessed using relevant items from the youth self‐report form of the Alabama Parenting Questionnaire [41]. Being in a relationship was measured as reporting a current boyfriend/girlfriend or being married. Number of household residents considered individuals living in a home for four or more nights per week. The analysis was carried out in seven stages [42]. We first investigated the relationship between HIV risk behaviours and adolescent motherhood. For this, we described the characteristics of participants and prevalence of seven HIV risk behaviours overall and by adolescent motherhood status. Second, we investigated the prevalence of HIV risk behaviours among non‐mothers and adolescent mothers by HIV status. Third, we used the generalized estimating equations (GEE) method for multiple outcomes specified with a logit link, to simultaneously model associations between adolescent motherhood and our seven HIV risk behaviours [43]. We used the GEE approach as (1) multiple outcomes were clustered within individuals, (2) interest lay in the fixed parameters of the model and (3) the GEE approach is more robust than a random intercept model to misspecification of the covariance structure between multiple outcomes [44]. The model controlled for food security and all nine additional covariates to reduce the risk of confounding bias and increase precision, and it was specified with an unstructured covariance structure as we had no theoretical justification that outcomes would be correlated equally [43]. Fourth, using the same model, we tested if relationships between motherhood and HIV risk behaviours were moderated by HIV status. Fifth, we investigated the relationship between food security and HIV risk behaviours, stratified by adolescent motherhood. Sixth, we tested if relationships between food security and HIV risk behaviours were moderated by HIV status. Seventh, still stratified by adolescent motherhood, we calculated adjusted probabilities and adjusted probability differences comparing the two scenarios: “not experiencing food security” and “experiencing food security.” All analyses were conducted in Stata 15 and missing values were handled by listwise deletion. We investigated the impact of controlling for sexual debut in our analyses. This served to identify which associations may be related to higher rates of first sexual experience in adolescent mothers as compared to non‐mothers.
