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1230 Loos Jasna Diversity Sexual Activity Protective Behaviours Hiv Positive Adolescents
- 1. The diversity in sexual activity and protective behaviours among HIV-positive adolescents aged 13 to 17 years in Uganda and Kenya Jasna Loos, Hilde Vandenhoudt & Christiana Nöstlinger Eric Wobudeya, Irene Murungi, Carolyn Nakanjaka & Sabrina Bakeera-Kitaka Daniel Fedha, Lilian Langat & Daniel Adipo
- 2. Background Growing numbers of adolescents living with HIV (ALH) Facing specific sexual and reproductive health (SRH) challenges (Bakeera-Kitaka et al. 2007, Birungi et al. 2009) “Positive Living for a Brighter Future” intervention Rigorous evaluation Baseline study • Sexual and reproductive health • HIV • Quality of life
- 3. Methods baseline study • Retrospective and cross-sectional study • 583 ALH aged 13-17 years – Convenience sample at paediatric HIV-care centres – Informed assent and parental consent • Standardised questionnaire – Guided by behavioural theories and based on validated questionnaires and formative research – Trained interviewers • First descriptive analysis – Stratified by country and gender – Using SPSS 19.0
- 4. Participants’ characteristics • Median age: 14 years • 55% girls – 45% boys 35% 31% 30% 25% 21% 20% Female 14% Male 15% 14% 10% 10% 10% 5% 0% Uganda- Kampala Kenya- Kisumu Kenya- Rural communities
- 5. Participants’ characteristics: HIV history • Median age informed about HIV status: 11 years ALH currently taking ARVs • 98% in care 100% 89% 90% 82% 80% • 70% on ARVs 70% 60% 51% 56% Female – 53% Kenya vs. 85% Uganda 50% 40% Male 30% 20% • 44% in peer support 10% 0% – 37% Kenya vs 51% Uganda Kenya Uganda
- 6. Participants’ characteristics • 23% still had both parents – 39% lost both parents, 38% lost one parent – 61% did not live with a biological parent • 88% of ALH were in school – Median age left school: 15 years – 58% couldn’t afford school fees
- 7. Sexual activity 123 ALH (21%) reported ever having had sex Sexually active adolescents living with HIV aged 13 to 17 years 40% Female 35% Male 30% 25% 18% 20% 15% 10% 16% 5% 6% 0% 3% Kenya Uganda
- 8. Sexual activity associated with… Sexually active Sexually in- Pearson Chi-square ALH experienced ALH / ANOVA Living in Kisumu 52% 21% .000 Luo 86% 65% .001 Out of school 27% 7% .000 Not taking ARVs 51% 24% .000 Age informed HIV-status 14 years 11 years .000 Friends had sex 98% 56% .000 Friends think having sex is a good 34% 11% .000 idea Parents think having sex is a good 10% 4% .006 idea Disclosed HIV status to friends 28% 18% .014 Disclosed to boy/girl friend 53% 23% .000 (sign. p < 0,05)
- 9. Sexually active ALH: Partners • 68% mentioned their sexual partners were friends • Median age: First sex Last sex ALH Their partner ALH Their partner Combined 13 years 13 years 15 years 16 years • Gender Male 12 years 11 years 15 years 14 years Female 14 years 15,5 years 16 years 18 years • Area Uganda 14 years 16 years 16 years 18,5 years Kenya 13 years 13 years 16 years 15 years
- 10. Sexually active ALH • 65% reported more than one sexual partner – Median of 2 sexual partners • 68% had their last sexual experience longer than three months ago • 17% reported first sex was forced – 14% reported last sex was forced • 2% said they were drunk at last sex
- 11. Sexually active ALH: Protective behaviour Used a condom at: 70% 66% 60% 50% 50% 45% 40% 38% Female 29% Male 30% 21% 20% 10% 0% First sex Last sex Ever used a condom • 12 girls (17%) became pregnant • 2 boys (4%) made a girl pregnant
- 12. Sexually inexperienced ALH 457 (79%) ALH reported they never had sex HIV-postive adolescents who have not been sexually active 100% 90% 80% 70% 52% 60% Female 50% 32% Male 40% 30% 20% 38% 34% 10% 0% Kenya Uganda
- 13. Sexually inexperienced ALH: Reasons • 41% feared the consequences of sex – Boys feared HIV-transmission (27%) – Girls feared pregnancy (15%) • In Uganda 32% didn’t feel ready to have sex • In Kenya 26% felt they were too young to have sex
- 14. Sexually inexperienced ALH: Intentions • 7% currently had a boy/girlfriend • 7% currently received gifts from someone special • 10% thought about having sex – 17% boys vs. 5% girls • 10% thought that they will have sex in the next 3 months – 13% boys vs. 8% girls
- 15. Conclusion Diversity in sexual activity and protective behaviours 79% ALH sexually inexperienced • Low intention of becoming sexually active • Different motivations for abstaining 21% ALH sexually active • First sex at 13 years & more partners • 43% never used a condom & 17% girls have been pregnant
- 16. Lessons for positive prevention • Take into account the diversity Comprehensive interventions for ALH Realistic prevention messages both groups & Safer sex practices Support to abstain until they are ready Developmental approach Rights based approach • Influence of contextual factors on sexual behaviour Enabling environment Encouraging school attendance Supportive peer norms
- 17. Acknowlegdments • Thank you for your attention • All the adolescents for answering our questions • Local study coordinators: Carolyn, Irene, Lilian and Daniel for the logistic miracle • Data managers, Daniel and Eric for their rigor • Funding agencies the Dutch AIDS fonds and the Belgian development cooperation
Editor's Notes
- Good day everyone,As you all know, every study is the result of a team effort. The is why I want to stress that I am presenting here today on behalf of my collegues at the Kenya Medical Research institute in Kisumu, Baylor Uganda base in Kampala and the Institute of tropical medicine. I will be talking about the diversity in sexual activity and protective behaviours among HIV-positive adolescents aged 13 to 17 years living in Uganda and Kenya. But before Igo into the findings, Ifirst would like to give you some background on the study and its methodology 25’’
- A growing number of adolescents are living with HIV. According to UNAIDS 7 million children and young people below 24 years are living with HIV worldwide. Majority of them in Africa. As been confirmed in these past 4 days, a growing number of studies are showing that adolescents living with HIV face specific sexual and reproductive health challenges. Yet, evidence based interventions helping them address these challenges, are scarce. To fill this gap our team developed an intervention called Positive living for a Brighter Future. This group-level intervention is comprehensive, culturally sensitive and age-appropriate. Brighter Future has been implemented with 176 adolescent in 15 groups and had given promising results in process evaluation. Including self-reported improved condom, avoidance of risky situations and peer pressure, self-esteem, adherence. Since this results are promising, we are preparing for a outcome evaluation and that is we conducted a baseline study. Since the intervention addresses SRH as part of the broader context of positive living, we didn’t only assess sexual and reproductive health, and its determinants in the baseline stuyd but also coping with HIV, such as adherence and disclosure and their overall quality of life. For thispresentationwhich is a late braker, I present the findings of a first descriptive analysis focusing on the sexualactivityandprotectivebehaviours of these adolescents. Further analysis of other topics is stillongoing. 1’ 25’’BaselinestudySexual activity and protective behaviourKnowledgePersonal attitudesPerceived social normsSelf-efficacy (Rotherham-Borus et al. 1997)Safer sex intentions (Lux & Petosa, 1994)Quality of lifeStigma (Wright et al., 2007)Self-esteem (Rosenberg, 1965)(Kidscreen, Ravens-Sieber et al., 2007)AdherenceDisclosure
- For this retrospectieve and cross-sectional study, we interviewed a convenience sample of 583 adolescents living with HIV aged 13 to 17 years, recruited at various pediatric HIV-care centres in Kampala Uganda and Nyansa region, Kenya. After obtaining informed assent from the adolescents, and informed consent from their caregivers, the adolescents were guided through a standardized questionnaire by trained interviewers. The questionnaire guided by behavioural theories consisted of validated questionnaires and new questions based on formative research. In total between 188 and 222 questions were answerd in 50 minutes to one hourThe data was analysed using SPSS 19 and stratified by country and gender.30’
- So, what were the characteristics of our participants?They were between 13 and 17 years old, with a median age of 14. Slightly more girls participated.As you can see in the graph, girls were over-represented in the Ugandan sub-sample. In Uganda all participants were from urban Kampala. In Kenya, 28% were recruited form Kisumu, the capital of Nyanza province and 21% were from rural communities at the shores of lake Victoria, namely the villages Asembo and Gem.When speaking about Kenya and Uganda, I refer to these regions, without implying that our samples are representative for the countries. 30’’15% Baganda, 8% Banyakitara;for the rest Luhya, BanyankoleandBasoga(all of Kenyanparticipants)
- All participants were HIV positive and aware of it. Most were informed about their HIV status when they were 11 years old. Since we recruited from HIV care facilities, 98% were in care and 70% were taking ARVs. As you can see from the graph, in the Ugandan sub-sample more adolescents were on ARVs than in Kenya. Slightly more boys than girls were taking ARVs. 44% of participants were members of support groups, this was less in Kenya than in Uganda. 30’
- Looking at the family situation, we found that 23% still had both biological parents, 39% were complete orphans, 38% had lost one parent. This means that 61% were not living with their biological parents but with the extended family. In terms of schooling, 88% of the participants were in school, slightly more boys than girls. Those who had left school, did this at a median age of 15 years, and mostly because they couldn't afford school fees. In the Kenyan sub-sample 6 girls said they had to leave school because they became pregnant.45’
- When it comes to the sexual activity In the overall sample, 21% of the adolescents reported ever having had sex. However, we found a big difference between the Kenyan sub-sample where 34% said they had sex, and Uganda where 9% said they had sex. In both countries slightly more girls were sexually experienced than boys, but this was not significant20’
- Because of this difference, we did a first bivariate analysis revealed associations between being sexually active and the following variables. One of the most remarkable one are is the association with being out of school. One in four of those who reported being sexually active was not in school, compared to 7% of those who were sexually inexperienced. Having sex was also related to peer norms. 98% of those who had sex, said also their friends had sex, compared to 56% of the friends of those who were sexually inexperienced. In the same line, if they thought that their friends would find it a good idea to have sex, they were more likely to report having had sex. The correlation with what the parents thought about having sex was also significant. Another remarkable association is the link between sexual activity and disclosure. The participants who reported sexual behavior had disclosed their HIV-status more often to friends and also to their boyfriend or girlfriend. 45’’
- So, Who were the sexual partners of these adolescents?In about two thirds the sexual partners the sexual partner was a friend, at first sex, as well as last sex. This was more often reported by girls, boys also reported neighbors and schoolmates. Overall median age of first sex (sexual intercourse) was 13 years. First sexual partners had the same age. Yet we found some differences in gender and country. Boys had their first sex at the age of 12 and mostly had younger partners, girls were 14 years old when they had sex for the first time and had slightly older partners. This trend is maintained for the last sexual encounter. There were also some country specific differences: In Uganda participants were older both at their first encounter. 40’
- 65% reported having had more than one partner, the median number of partners was 2 both for boys and girls. They had sex sporadically, 68% reported that their last sexual experience was longer than three months ago.Most sex was voluntary, however, 17% said that their first sex was forced. 14% said their last sexual intercourse was forced.Alcohol or drug use was not prevalent, in the total sample 3% mentioned ever using alcohol, 1% ever used drugs. Only 2% reported that they were when having sex (also first sex?). 35’
- If we look at the protective behaviors of the adolescents who were sexually experienced, we see that 25% used a condom the first time they had sex. This increased to 45% at last sex. As you can see from the graph, in both cases girls reported more condom use than boys. Overall, 57% reported they had ever used a condom. Again more girls reported life-time condom use.In this sample of 123 sexually active adolescents, 12 girls reported a pregnancy, 2 boys said they had made a girl pregnant. In total, 9 life births were reported. 45’’
- 79% of our participants reported they never had sex. Again we see this country difference, with 66% said they never had sex in Kenya versus 90% in Uganda.15’’
- Main reasons for not having sex were unwanted consequences of sexual activity:41% were afraid of the consequences of sex, like transmitting HIV to somebody else. This was more often mentioned by boys than by girls.Girls were more concerned about pregnancies as a consequence of sex.Other consequences mentioned as reason for not having sex were infections with other STIs, re-infection and dropping out of school. Apart from these consequences, in Uganda 32% said they didn’t feel ready to have sex. In Kenya 26% said they felt to young to have seks.25’’
- We also asked the participants about their intentions to have sex, which is a good proxy for future sexual activity.We found that most were unlikely to have sex soon. 7% reported having a boyfriend currently, and 7% received gifts from a special someone, this was 8% among girls and 6% among boys. 10% thought about having sex. This was more often reported by boys, 17% vs. 5% among girls. It was also more often reported in the Uganda sample than in Kenya.10% said is was likely they would have sex in the next 3 months, again boys believed this more often than girls. It was also more often mentioned in Kenya than in Uganda. 25’
- Based on this first descriptive analysis it is fair to say their is large diversity in sexual activity and protective behaviors among ALH aged 13 to 17 yearsMajority of them reported not being sexually active yet and have little intention of becoming sexually active soon. Fear of HIV-transmission is an important protective attitude in this for boys, girls worried more about pregnancies. In Kenya they talk about the sexual norm of being too young to have sex, while in Uganda they focus on their personal feelings of not being ready of sexOn the other hand, One in five of the HIV-positive adolescents reported having had sex and initiated this at a young age of 13 years and had more than one partner. Their protective behaviors are worrisome, 43% reported never using a condom and 17% of girls had been pregnant. 45”
- So which are the lessons for positive prevention?Sexual activity and protective behaviors among ALH are diverse. Positive prevention targeting these adolescents living with HIV, should take into account that diversity.This means that just as proven to be most effective for young people in general, interventions for adolescents living with HIV interventions should be comprehensive. This means that an intervention should contain preventive messages should be realistic for both groups. In one intervention, adolescents who are already sexually active should be encouraged to obtain safer sex habits. While the same intervention, those who did not have sex yet, should be supported to abstain until they are ready to have sex. This is an important rationale for a developmental approach, given that becoming sexually active is part of growing up. This is also important in the rational of a rights based approach, given that also people with HIV have the right to a fulfilling sex life.The first bivariate analysis showed already showed the influence of contextual factors on sexual behavior. Therefor I want to stress once more, what has been pointed out numberous time during this conference. Intervention should not stand on their own, but an enabling environment should be created. In the case of adolescents living with HIV, efforts, such as keeping ALH in school and reinforcing supportive peer norms and behaviors should work along with comphrensive sexual and reproductive health interventions.50”