Many adolescent girls and young women with multiple risk factors for infection with HIV do not consider themselves to be at high risk for acquiring the infection or worry about HIV, according to research conducted in Malawi and published in the Journal of Acquired Immune Deficiency Syndromes.
The investigators identified 15 individual socio-economic, demographic, sexual and behavioural risk factors that were associated with an increased risk of infection with HIV. The presence of multiple risk factors was associated with increased HIV prevalence. Moreover, 52% of those with eight or more risk factors did not perceive themselves to have a high risk of acquiring HIV.
“Our findings suggest that the context of sexual behaviour may predict HIV prevalence more than individual behaviours,” comment the authors. “Social protection, behavioural, and biomedical interventions that aim to mitigate vulnerabilities in combination could produce greater impacts on HIV prevention than single-domain prevention.”
Adolescent girls and young women in sub-Saharan Africa have very high HIV prevalence and incidence. In Malawi, HIV prevalence among adolescent girls and young women aged between 15 and 24 years is between five and ten times higher than the prevalence among males in the same age group. Identifying which adolescent girls and young women are at highest risk of infection with HIV is important so that prevention initiatives can be properly targeted. It is also necessary to establish whether individuals at high risk of HIV accurately estimate their vulnerability to the infection.
Investigators from the multi-national Girl Power study, therefore, designed a cross-sectional study involving 1000 adolescent girls and young women recruited at four sites in Malawi between 2016 and 2017.
Participants completed a questionnaire enquiring about their HIV infection status, the presence of risk factors for infection with HIV, perceived risk of infection with HIV and worry about being infected with HIV.
Participants had a median age of 19 years and 3% reported that they were HIV positive. Two-thirds of those who reported being HIV negative said they had had a test for HIV within the previous three months.
Fifteen individual risk factors were associated with being infected with HIV, including older age, no household running water, few household assets, being an orphan, higher number of recent sexual partners, heavy alcohol use, past pregnancy, having a partner who travels frequently, transactional sex, concurrent partners, uncircumcised partner, an older partner and an HIV-positive partner.
The median number of risk factors was four per participant. HIV prevalence increased from 0.5% for those with fewer than four risk factors, to 6% for those with between five and seven risk factors and 21% for individuals with more than 8 or more risk factors.
The study also found that two factors which have featured prominently in prevention messages and programming for adolescent girls and young women – condom use and postponing sexual debut – were not associated with HIV status in this study population.
“Identifying a small subset of women at highest risk of HIV infection is possible,” write the investigators. “Such identification is important because it would allow for PrEP [pre-exposure prophylaxis] targeting to those at greatest risk. Replicating these findings in a larger cohort with an HIV incidence outcome is a critical next step.”
Approximately a quarter of those HIV-negative/unknown HIV status participants thought they had a high risk of infection with HIV. The presence of a higher number of risk factors was associated with higher perceived risk. However, 63% of individuals with five or more risk factors and 52% of those with eight or more risk factors did not perceive themselves to have a high risk of acquiring HIV.
Individual risk factors strongly associated with increased perception of HIV risk included no running water, few household assets, pregnancy history, partner travel, partner concurrency and transactional sex.
Worrying about HIV was reported by approximately 60% of HIV-negative/unknown participants. A higher burden of risk factors was associated with a higher probability of worry. However, a third of those with five or more risk factors and a fifth with eight or more risk factors reported that they were not worried about their HIV risk.
Partner travel, partner concurrency and older partner age were the factors most strongly associated with worry.
“The successful application of prevention services depends on at-risk individuals first perceiving risk, accessing services, and adopting behavioural changes and biomedical interventions designed to mitigate risk,” write the authors. “Long-term effectiveness of prevention strategies will depend on maintained risk perception among those who face ongoing risk.”
The investigators conclude that it is possible to identify younger women at risk of infection with HIV but that work is needed to help these individuals to accurately perceive their risk.