Date Published: September 28, 2018
Publisher: Public Library of Science
Author(s): Aoife M. Doyle, Sian Floyd, Kathy Baisley, Benedict Orindi, Daniel Kwaro, Thandiwe N. Mthiyane, Sheru Muuo, Maryam Shahmanesh, Abdhalah Ziraba, Isolde Birdthistle, Marie Laga.
The DREAMS (Determined Resilient Empowered AIDS-free, Mentored and Safe) Partnership aims to reduce HIV incidence among adolescent girls and young women (AGYW,15-24y) with a core package of evidence-based interventions. Some interventions, including voluntary HIV counselling and testing and circumcision, will be targeted at the male sexual partners of AGYW. A priority of DREAMS is to characterise the male partners for effective targeting.
Using population-based data (2010–2015) in three DREAMS impact evaluation settings in Kenya and South Africa, we describe the demographic characteristics and sexual behaviour of male partners reported by AGYW, and the characteristics of males who report sexual activity with AGYW.
In all settings, over 90% of recent male partners reported by AGYW were aged <35 years. Median ages of spousal and non-spousal partners were 29 and 23 years respectively in uMkhanyakude (rural South Africa) and 21 and 20 years respectively in Nairobi (urban Kenya). Most males reporting an AGYW partner had never been married (89%) and many were in school (39%). Most male partners reported only 1 AGYW partner in the past year; in Gem (rural Kenya) and Nairobi 25%-29% reported 2+(AGYW or older female) partners. Concurrent partners were reported by 16% of male partners in Gem and 3–4% in uMkhanyakude. Two thirds of male partners in Gem reported testing for HIV in the past 6 months and under half in uMkhanyakude reported testing for HIV in the past year. Almost all (96%) partners in Nairobi were circumcised, compared to 45% in Gem and 43% in uMkhanyakude. With almost all AGYW’s sexual partners aged 15–34 years, this is an appropriate target group for DREAMS interventions. Encouraging young men to reduce their number of partners and concurrency, and uptake prevention and treatment services such as HIV testing, circumcision and ART is crucial in the effort to reduce HIV among both AGYW and young men.
HIV incidence is high among adolescent girls and young women (AGYW, 15–24 y) in Eastern and Southern Africa due to social, behavioural and biological factors , and AGYW are increasingly targeted by HIV prevention interventions. AGYW who have unprotected sexual intercourse with multiple sexual partners are at higher risk of acquiring HIV [2, 3]. However, any increased risk of infection associated with a higher number of sexual partners will depend on the characteristics of the sexual partners (e.g., number of partners’ partners, duration of infection) and behaviour within the partnerships (e.g., frequency of sex, consistency of condom use)[4–6]. Key phenomena of sexual networks that are believed to be important determinants of HIV transmission within a population include concurrency (partnerships overlapping in time), and age-mixing and spatial bridging (connections between sexual networks usually constrained within age groups or geographical location) . Interest in the characterisation of sexual partners has led to the inclusion of detailed questions on sexual partners in many quantitative surveys in high HIV prevalence settings [8–10]. Qualitative methods have also been developed to identify partner types according to transactional and socio-economic needs .
Our analysis found that most partners of AGYW (including first partners) were young men under 35 years of age. Few male partners were married and many were still in school. HIV testing and circumcision uptake among partners of AGYW were relatively low and fell well short of national targets, except for Nairobi where reported circumcision was 96%. Many partners travelled overnight for work and/or were not living in the study area implying that, even when scaled-up, geographically-focused interventions like DREAMS are unlikely to reach all potential partners of AGYW (and may miss the higher risk partners). This highlights the importance for specific interventions for mobile populations. Partners of AGYW in Gem and Nairobi, rural and urban Kenya, reported relatively high levels of multiple and/or concurrent partners, and AGYW in Gem also reported that a relatively high proportion of their partners had concurrent partners. Taken together these findings emphasise the importance of understanding the risk within AGYW’s sexual networks as opposed to focusing only on the AGYW’s own reported behaviour.
The majority of the male partners of AGYW are aged 15–34 years confirming that this should be the target group for DREAMS interventions. Encouraging males in this age group to reduce their multiple and concurrent partners, and to take up prevention and treatment services such as HIV testing, circumcision and ART (Baisley et al, this Collection) is likely to reduce the risk of HIV infection among their AGYW partners . At least 60% of the male partners reported by 15–24 year old AGYW were 20–29 years old. Partners in this age group are more likely than younger men to be HIV positive, and less likely than older men to be aware of their HIV status or to link into care and treatment to achieve viral suppression (Baisley et al, this collection). If resources are limited then prioritising preventative and treatment interventions for 20–29 year old males may be an effective strategy to break the cycle of HIV transmission [6, 40]. However, differences observed in the characteristics of partners and partnerships between DREAMS settings reflect variations in the cultural, socio-economic and urban/rural contexts, and emphasise the importance of understanding the local context when designing prevention programmes (Saul et al, this Collection). Intervention approaches should be nuanced to take into account these varying contexts, and, ideally, should be developed around young men’s prevention needs for their own sake and not only as sexual partners of AGYW.