Research Article: School, Supervision and Adolescent-Sensitive Clinic Care: Combination Social Protection and Reduced Unprotected Sex Among HIV-Positive Adolescents in South Africa

Date Published: September 8, 2016

Publisher: Springer US

Author(s): Elona Toska, Lucie D. Cluver, Mark E. Boyes, Maya Isaacsohn, Rebecca Hodes, Lorraine Sherr.


Social protection can reduce HIV-risk behavior in general adolescent populations, but evidence among HIV-positive adolescents is limited. This study quantitatively tests whether social protection is associated with reduced unprotected sex among 1060 ART-eligible adolescents from 53 government facilities in South Africa. Potential social protection included nine ‘cash/cash-in-kind’ and ‘care’ provisions. Analyses tested interactive/additive effects using logistic regressions and marginal effects models, controlling for covariates. 18 % of all HIV-positive adolescents and 28 % of girls reported unprotected sex. Lower rates of unprotected sex were associated with access to school (OR 0.52 95 % CI 0.33–0.82 p = 0.005), parental supervision (OR 0.54 95 % CI 0.33–0.90 p = 0.019), and adolescent-sensitive clinic care (OR 0.43 95 % CI 0.25–0.73 p = 0.002). Gender moderated the effect of adolescent-sensitive clinic care. Combination social protection had additive effects amongst girls: without any provisions 49 % reported unprotected sex; with 1–2 provisions 13–38 %; and with all provisions 9 %. Combination social protection has the potential to promote safer sex among HIV-positive adolescents, particularly girls.

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There are an estimated 1.3–2.2 million HIV-positive adolescents in Sub-Saharan Africa, both vertically and horizontally infected [1]. Studies have documented high rates of unprotected sex reported by HIV-positive adolescents even after HIV infection (27–90 %) [2–5]. While rates of unprotected sex among HIV-positive adolescents are comparable to those among the general adolescent population [2], HIV-positive adolescents are a key population for reducing onwards HIV transmission to sexual partners and children. In addition, HIV-positive adolescents experience a range of vulnerabilities that are likely to reduce the efficacy of HIV prevention programmes aimed at general populations, including cognitive and mental health issues [6, 7], family-related challenges [8, 9] and material deprivation [10, 11].

Findings from this study have several important implications. First, we found high rates of unprotected sex reported by HIV-positive adolescents, and significantly higher rates of virological failure amongst HIV-positive adolescents engaging in unprotected sex, suggesting greater transmission risk to uninfected peers. It is clear that effective programming to reduce sexual risk behavior for this vulnerable group is essential.




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