Food security reduces multiple HIV infection risks for high-vulnerability adolescent mothers and non-mothers in South Africa: a cross-sectional study

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Study Justification:
This study aimed to understand the factors that contribute to high HIV infection rates among adolescent girls and young women in South Africa, particularly those who are adolescent mothers. By identifying the specific risks associated with HIV transmission and exploring potential interventions, the study aimed to inform strategies to reduce HIV vulnerability in this population.
Highlights:
– The study included 1712 adolescent girls and young women, including 1024 adolescent mothers, from two health municipalities in South Africa’s Eastern Cape Province.
– The study found that adolescent mothers had higher odds of engaging in multiple sexual partners, age-disparate sex, condomless sex, sex on substances, and being not in education or employment compared to non-mothers.
– Food security was associated with lower odds of engaging in multiple sexual partners, transactional sex, and being not in education or employment among both non-mothers and adolescent mothers.
– The study suggests that social protection measures that increase food security can reduce HIV risk pathways for adolescent girls and young women, especially adolescent mothers.
Recommendations:
Based on the study findings, the following recommendations can be made:
1. Implement social protection measures that address food insecurity among adolescent girls and young women, particularly adolescent mothers.
2. Develop targeted interventions to address the specific risks identified in the study, such as multiple sexual partners and age-disparate sex.
3. Strengthen educational and employment opportunities for adolescent girls and young women to reduce their vulnerability to HIV infection.
4. Enhance access to comprehensive sexual and reproductive health services, including HIV prevention and treatment, for adolescent girls and young women.
Key Role Players:
To address the recommendations, the following key role players may be needed:
1. Government agencies responsible for health, education, and social development.
2. Non-governmental organizations (NGOs) working in the field of HIV prevention and youth empowerment.
3. Healthcare providers and clinics offering sexual and reproductive health services.
4. Schools and educational institutions.
5. Community leaders and advocates for adolescent girls and young women.
Cost Items for Planning Recommendations:
While the actual costs will vary depending on the specific interventions and strategies implemented, the following cost items should be considered in planning:
1. Funding for social protection programs targeting food security, including provision of nutritious meals and support for income generation activities.
2. Resources for developing and implementing targeted interventions, such as educational materials, training programs, and counseling services.
3. Investment in educational and vocational programs to improve access to education and employment opportunities for adolescent girls and young women.
4. Budget for strengthening healthcare services, including HIV prevention and treatment, and ensuring availability of contraceptives and other reproductive health supplies.
5. Costs associated with community engagement and awareness campaigns to promote behavior change and reduce stigma around HIV and adolescent motherhood.
Please note that the above cost items are estimates and should be further refined based on the specific context and resources available.

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is strong, but there are some areas for improvement. The study used a cross-sectional design and reported according to the Strengthening the Reporting of Observational Studies in Epidemiology checklist. The sample size was large, with 1712 participants, and the study included both adolescent mothers and non-mothers. The associations between adolescent motherhood and seven HIV risk behaviors were investigated using appropriate statistical methods. The study also examined the association between food security and HIV risk behaviors, stratified by adolescent motherhood. However, there are a few areas for improvement. Firstly, the abstract does not provide information on the response rate or representativeness of the sample, which could affect the generalizability of the findings. Secondly, the abstract does not mention any limitations of the study, such as potential confounding factors or biases. Finally, the abstract does not provide any recommendations for future research or implications for policy and practice. To improve the evidence, it would be helpful to include this additional information in the abstract.

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.

Based on the information provided, here are some potential innovations that could improve access to maternal health:

1. Mobile health (mHealth) interventions: Develop mobile applications or text messaging services that provide information and support to adolescent mothers regarding maternal health, HIV prevention, and contraception. These interventions can help increase knowledge and awareness, promote healthy behaviors, and provide access to resources and services.

2. Community-based interventions: Implement community-based programs that focus on improving food security for adolescent mothers. This can include initiatives such as community gardens, nutrition education, and income-generating activities to ensure access to nutritious food and reduce the risk of HIV infection.

3. Integrated healthcare services: Establish integrated healthcare services that provide comprehensive care for adolescent mothers, including maternal health services, HIV testing and treatment, family planning, and psychosocial support. This approach can improve access to multiple services in one location, reducing barriers to care.

4. Peer support programs: Develop peer support programs for adolescent mothers, where they can connect with and receive support from other young mothers who have similar experiences. Peer support can help reduce feelings of isolation, provide emotional support, and share knowledge and strategies for managing maternal health and HIV prevention.

5. School-based interventions: Implement interventions in schools to promote sexual and reproductive health education, including information on maternal health, HIV prevention, and contraception. This can help ensure that adolescent girls have access to accurate and comprehensive information to make informed decisions about their health.

6. Strengthening healthcare systems: Invest in strengthening healthcare systems to ensure that maternal health services are accessible, affordable, and of high quality. This can include training healthcare providers, improving infrastructure and equipment, and ensuring the availability of essential medicines and supplies.

These innovations can help address the multiple vulnerabilities faced by adolescent mothers in relation to HIV infection and transmission, and improve their access to maternal health services and support.
AI Innovations Description
Based on the description provided, the recommendation to improve access to maternal health is to implement social protection measures that increase food security for adolescent girls and young women, especially adolescent mothers. The study found that food security was associated with lower odds of engaging in high-risk behaviors for HIV infection and transmission, such as multiple sexual partners, transactional sex, and not being in education or employment. By addressing food insecurity, which is a key determinant of health, it is likely to reduce the pathways for HIV risk among adolescent girls and young women, ultimately improving their overall maternal health outcomes.
AI Innovations Methodology
Based on the provided information, here are some potential recommendations to improve access to maternal health:

1. Implement comprehensive sexual education programs: Providing accurate and age-appropriate information about sexual and reproductive health can help adolescent girls and young women make informed decisions and reduce risky behaviors.

2. Increase access to contraception: Ensuring that adolescent girls and young women have access to a wide range of contraceptive methods can help them prevent unintended pregnancies and reduce the risk of HIV transmission.

3. Strengthen antenatal care services: Improving the quality and availability of antenatal care services can help identify and address health issues early on, reducing the risk of complications during pregnancy and childbirth.

4. Enhance postnatal care and support: Providing postnatal care services and support to adolescent mothers can help them recover from childbirth, promote breastfeeding, and address any physical or mental health concerns.

5. Promote gender equality and empowerment: Addressing underlying social and gender norms that contribute to vulnerability and HIV risk among adolescent girls and young women can help improve their overall health and well-being.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could be developed using a combination of quantitative and qualitative research methods. Here is a brief outline of a possible methodology:

1. Conduct a baseline survey: Gather data on the current status of maternal health access, including factors such as healthcare utilization, knowledge, attitudes, and behaviors related to maternal health, and barriers to access.

2. Develop intervention strategies: Based on the identified recommendations, design specific intervention strategies that target the identified barriers and address the needs of the population.

3. Implement the interventions: Roll out the intervention strategies in selected communities or healthcare facilities, ensuring proper implementation and monitoring of the interventions.

4. Collect data on the impact: Measure the impact of the interventions by collecting data on key indicators, such as changes in healthcare utilization, knowledge, attitudes, and behaviors related to maternal health.

5. Analyze the data: Use statistical analysis techniques to analyze the collected data and assess the impact of the interventions on improving access to maternal health.

6. Evaluate the interventions: Conduct an evaluation of the interventions to assess their effectiveness, feasibility, and sustainability. This can include feedback from the target population, healthcare providers, and other stakeholders.

7. Refine and scale-up: Based on the evaluation findings, refine the intervention strategies and develop a plan for scaling up successful interventions to reach a larger population.

By following this methodology, it would be possible to simulate the impact of the recommended interventions on improving access to maternal health and identify the most effective strategies for implementation.

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