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Transactional sex increases HIV risk among adolescent girls and young women (AGYW). Understanding the individual and dyadic nature of transactional sex may provide evidence for risk reduction interventions. Multilevel logistic regression was used to cross-sectionally examine correlates of transactional sex among AGYW in Lilongwe, Malawi. Participants (N = 920) reported 1227 relationships. Individual-level associations were found between being divorced/widowed (AOR 5.07, 95% CI 1.93, 13.25), married (AOR 0.26, 95% CI 0.09, 0.72), or unstably housed (AOR 7.11, 95% CI 2.74, 18.47) and transactional sex. At the relationship-level, transactional sex occurred in relationships with: non-primary primary partners (AOR 4.06, 95% CI 2.37, 6.94), perceived partner concurrency (AOR 1.85, 95% CI 1.11, 3.08), and feared violence with couples HIV testing (AOR 2.81, 95% CI 1.26, 6.29), and less likely to occur in relationships with children (AOR 0.15, 95% CI 0.06, 0.38). Multiple co-occurring social and structural vulnerabilities increase transactional sex engagement warranting the need for social protection and gender transformative approaches.

In sub-Saharan Africa, adolescent girls and young women (AGYW) have high levels of unmet need for contraception, particularly those who are unmarried or nulliparous. Conversations with partners, peers, and family members influence AGYW contraceptive decision-making yet little is known about conversation content and impact or how they vary by relationship status and parity. This paper draws on qualitative data from 60 AGYW (aged 15-24) participating in a sexual and reproductive health study in Malawi to examine contraceptive conversation patterns among participants and their social ties. AGYW's relationship status and parity influenced whether they talked about contraceptives, who they talked to about contraceptives, and the type of contraceptives that were endorsed during conversations. Unmarried and nulliparous AGYW were less likely to discuss contraceptives with all social ties and when conversations occurred, norms and misinformation regarding nonbarrier methods were reinforced, and condoms were largely prescribed. Conversations with intimate partners often provided permission for contraceptive use while conversations with peers and older women in the family provided information on contraceptive methods. Our results highlight the unique roles that social ties play in AGYW contraceptive decision-making and suggest that existing contraceptive conversation patterns might exclude unmarried, nulliparous AGYW from accurate and comprehensive contraceptive information and options.

BackgroundAs adolescent girls and young women (AGYW) transition to adulthood, their interaction with their social context becomes a critical consideration for HIV prevention interventions. Few studies have examined what types of community groups and community spaces might be protective for AGYW HIV acquisition and related sexual behaviors.MethodsData were obtained from HIV Prevention Trials Network 068, a longitudinal study of AGYW (age 13-20 years) in rural South Africa. Survival analyses and generalized estimating equations were used to assess whether community group membership and time spent in community spaces were associated with HIV incidence and sexual behaviors (unprotected sex, transactional sex, and having an older partner).ResultsA total of 2245 AGYW were followed up for up to 4 years. Membership in church groups [adjusted hazard ratio (aHR): 0.75, 95% confidence interval (CI): 0.53 to 0.91] and dance groups (aHR: 0.89, 95% CI: 0.80 to 0.98) and spending time at church (aHR: 0.88, 95% CI: 0.79 to 0.98) were protective for HIV infection. Conversely, spending time at taverns was associated with higher HIV incidence (aHR: 1.27, 95% CI: 1.15 to 1.41). Membership in church groups and spending time at a family member's home and at church were protective for all 3 sexual behaviors. Spending time at a boyfriend's home and taverns was risky for all 3 sexual behaviors.ConclusionsThe results suggest that community spaces and community groups that include an element of adult supervision are potentially protective, whereas spaces and groups that provide an opportunity for AGYW to interact unsupervised with boyfriends or meet new partners are potentially risky.

BackgroundIntimate partner violence (IPV) is a human rights violation and is associated with a variety of adverse physical and mental health outcomes. Collective efficacy, defined as mutual trust among community members and willingness to intervene on the behalf of the common good, has been associated with reduced neighbourhood violence. Limited research has explored whether community collective efficacy is associated with reduced incidence of IPV. This is of particular interest among adolescent girls and young women (AGYW) in sub-Saharan Africa, where the burden of HIV is greatest and IPV is common.MethodsWe collected longitudinal data among 2533 AGYW (ages 13-20) enrolled in the HPTN 068 cohort in Mpumalanga province, South Africa between 2011 and 2016. We included participants from 26 villages where community surveys were collected during the HPTN 068 study. Collective efficacy was measured at the village level via two population-based cross-sectional surveys in 2012 and 2014. Multivariable Poisson generalised estimating equation regression models estimated the relative risk ratio (RR) between village collective efficacy scores and subsequent physical IPV 12 month incidence, adjusting for village-level clustering and covariates.ResultsThirty-eight per cent of the cohort (n=950) reported at least one episode of recent physical IPV during follow-up. For every SD higher level of collective efficacy, there was a 6% lower level of physical IPV incidence (adjusted RR: 0.94; 95% CI 0.89 to 0.98) among AGYW after adjusting for covariates.ConclusionsCommunity-level interventions that foster the development of collective efficacy may reduce IPV among AGYW.

Alcohol use contributes to morbidity and mortality in developing countries by increasing the risk of trauma and disease, including alcohol dependence. Limited research addresses determinants of alcohol use beyond the individual level in sub-Saharan Africa. We test the association of community collective efficacy and alcohol outlet density with young men's drinking in a cross-sectional, locally representative survey conducted in rural northeast South Africa. Informal social control and cohesion show protective associations with men's heavy drinking, while alcohol outlet density is associated with more potential problem drinking. These findings provide initial support for intervening at the community level to promote alcohol reduction.

Background Given the success of cash programs in improving health outcomes and addressing upstream drivers of HIV risk such as poverty and education, there has been an increasing interest in their potential to improve HIV prevention and care outcomes. Recent reviews have documented the impacts of structural interventions on HIV prevention, but evidence about the effects of cash transfer programs on HIV prevention has not been systematically reviewed for several years. Methods and findings We did a systematic review of published and unpublished literature to update and summarize the evidence around cash programs for HIV prevention from January 2000 to December 17, 2020. We included studies with either a cash transfer intervention, savings program, or program to reduce school costs. Included studies measured the program's impact on HIV infection, other sexually transmitted infections (STIs), or sexual behaviors. We screened 1,565 studies and examined 78 in full-text review to identify a total of 45 peer-reviewed publications and reports from 27 different interventions or populations. We did not do a meta-analysis given the range of outcomes and types of cash transfer interventions assessed. Most studies were conducted in sub-Saharan Africa (N = 23; South Africa, Tanzania, Malawi, Lesotho, Kenya, Uganda, Zimbabwe, Zambia, and eSwatini) followed by Mexico (N = 2), the United States (N = 1), and Mongolia (N = 1)). Of the 27 studies, 20 (72%) were randomized trials, 5 (20%) were observational studies, 1 (4%) was a case-control study, and 1 (4%) was quasi-experimental. Most studies did not identify a strong association between the program and sexual behaviors, except sexual debut (10/18 finding an association; 56%). Eight of the 27 studies included HIV biomarkers, but only 3 found a large reduction in HIV incidence or prevalence, and the rest found no statistically significant association. Of the studies that identified a statistically significant association with other STIs (N = 4/8), 2 involved incentives for staying free of the STI, and the other 2 were cash transfer programs for adolescent girls that had conditionalities related to secondary schooling. Study limitations include the small number of studies in key populations and examining interventions to reduce school costs and matched saving programs. Conclusions The evidence base for large-scale impacts of cash transfers reducing HIV risk is limited; however, government social protection cash transfer programs and programs that incentivize school attendance among adolescent girls and young women show the greatest promise for HIV prevention., Author(s): Marie C. D. Stoner 1,2,*, Kelly Kilburn 3, Peter Godfrey-Faussett 4, Peter Ghys 4, Audrey E. Pettifor 1,5,6 Introduction Globally, cash transfers have become one of the most popular [...]

Introduction: Cross-sectional methods can be used to estimate HIV incidence for surveillance and prevention studies. We evaluated assays and multi-assay algorithms (MAAs) for incidence estimation in subtype C settings. Methods: We analysed samples from individuals with subtype C infection with known duration of infection (2442 samples from 278 adults; 0.1 to 9.9 years after seroconversion). MAAs included 1-4 of the following assays: Limiting Antigen Avidity assay (LAg-Avidity), BioRad-Avidity assay, CD4 cell count and viral load (VL). We evaluated 23,400 MAAs with different assays and assay cutoffs. We identified the MAA with the largest mean window period, where the upper 95% confidence interval (CI) of the shadow was 1000 copies/mL), and two MAAs previously optimized for subtype B settings. We compared these cross-sectional incidence estimates to observed incidence in an independent longitudinal cohort. Results: The optimal MAA was LAg-Avidity 400 copies/mL. This MAA had a mean window period of 248 days (95% CI: 218, 284), a shadow of 306 days (95% CI: 255, 359), and provided the most accurate and precise incidence estimate for the independent cohort. The widely used LAg algorithm had a shorter mean window period (142 days, 95% CI: 118, 167), a longer shadow (410 days, 95% CI; 318, 491), and a less accurate and precise incidence estimate for the independent cohort. Conclusions: An optimal MAA was identified for cross-sectional HIV incidence in subtype C settings. The performance of this MAA is superior to a testing algorithm currently used for global HIV surveillance. Keywords: Cross-sectional incidence testing; Southern Africa; Subtype C; Women; Epidemiology, 1 | INTRODUCTION Accurate methods for estimating HIV incidence are critical for HIV surveillance and for evaluating the effectiveness of HIV prevention efforts [1]. Traditional longitudinal cohort studies are costly [...]

Introduction: Prevalence of HIV among young women in South Africa remains extremely high. Adolescent peer groups have been found to be an important influence on a range of health behaviours. The characteristics of young women's friendships might influence their sexual health and HIV risk via connections to sexual partners, norms around sexual initiation and condom use, or provision of social support. We investigated associations between young women's friendships and their Herpes Simplex Virus Type 2 (HSV-2) and HIV infection status in rural South Africa.Methods: Our study is a cross-sectional, egocentric network analysis. In 2011 to 2012, we tested 13- to 20-year-old young women for HIV and HSV-2, and collected descriptions of five friendships for each. We generated summary measures describing friend socio-demographic characteristics and the number of friends perceived to have had sex. We used logistic regression to analyse associations between friend characteristics and participant HIV and HSV-2 infection, excluding likely perinatal HIV infections.Results: There were 2326 participants included in the study sample, among whom HIV and HSV-2 prevalence were 3.3% and 4.6% respectively. Adjusted for participant and friend socio-demographic characteristics, each additional friend at least one year older than the participant was associated with raised odds of HIV (odds ratio (OR) = 1.37, 95% CI 1.03 to 1.82) and HSV-2 (adjusted OR=1.41, 95% CI 1.18 to 1.69). Each additional friend perceived to have ever had sex also raised the odds of HIV (OR = 1.29, 95% CI 1.03 to 1.63) and HSV-2 (OR=1.18, 95% CI 1.03 to 1.35).Discussion: We found good evidence that a greater number of older friends and friends perceived to have had sex were associated with increased risk for HSV-2 and HIV infection among young women.Conclusions: The characteristics of young women's friendships could contribute to their risk of HIV infection. The extent to which policies or programmes influence age-mixing and young women's normative environments should be considered.Keywords: HIV; young women; adolescents; social networks; friendships; peer influence; social norms; HSV-2; South Africa, 1 | INTRODUCTIONSouth Africa has a severe HIV epidemic with young women at high risk for infection [1,2]. While young women's sexual behaviours can influence their HIV risk [3], the [...]

In this special issue of the Journal of the International AIDS Society, we focus on research and perspectives that put adolescents and young people at the centre of their HIV [...]