Associated Risk Factors of HIV Infection among Adolescent Girls and Young Women Seeking Services at a Tertiary Hospital in central Uganda

Iddi Matovu^1*, Miph Musoke¹

¹School of Post Graduate Studies and Research, Nkumba University, Uganda

^*Corresponding Author: Iddi Matovu, School of Post Graduate Studies and Research, Nkumba University, 237, Entebbe, Uganda

Received: 09 July 2024; Accepted:  18 July 2024; Published: 19 August 2024;

1. Introduction

Despite significant progress in the fight against HIV, adolescent girls and young women (AGYW) remain disproportionately affected by the epidemic [3,4]. In sub-Saharan Africa (SSA), the region most affected by HIV, AGYW aged 15-24 are three times as likely to acquire HIV as their male counterparts [5]. According to the UNAIDS report 2023, of the estimated 210,000 new HIV infections that occurred among AGYW globally in 2022, nearly two-thirds (160,000) were in SSA [4]. In Uganda, the prevalence of HIV among AGYW aged 15-24 is higher than among adolescent boys and young men (ABYM) of the same age group [3, 6]. In 2021, the HIV prevalence was estimated to be 4.2% and 2.4% among AGYW and ABYM aged 15-24 respectively [6,7].Additionally, according to the Uganda AIDS commission (UAC) report 2022-2023, AGYW accounted for over two-thirds of the new HIV infections in 2021 [3].

This disproportionate burden of HIV in this demographic is attributed to various factors, including socioeconomic, and structural factors [8, 9, 10, 11]. Furthermore, AGYW particularly in Africa face unique challenges, including early marriages, gender-based violence, stigma and limited access to education and healthcare, which exacerbate their vulnerability to HIV [12, 13, 14, 15].  

However, in different geographical contexts, each of these factors individually was not consistently associated with HIV infection among AGYW [16]. For instance, whereas high educational attainment was associated with reduced HIV infection rates in Malawi [17], for the opposite was observed in Zambia [18].  In Kenya [19] and Zimbabwe [20] early marriage was associated with increased new HIV infections.  However, this contrasts with findings from Cameroon, Guinea and Lesotho [21] where early marriages did not correlate with higher HIV infection rates. 

Understanding the prevalence and associated factors of HIV infection among AGYW in the central region, Uganda is crucial for informing targeted interventions and mitigating the spread of HIV among this vulnerable population. Therefore, in this study, we aimed to describe the prevalence and associated risk factors of HIV Infection among AGYW aged 15-24 years seeking care at an urban tertiary hospital in Uganda.

2. Materials and Methods

2.1 Study design and setting

This was a cross-sectional study which aimed to describe associated risk factors of HIV Infection among AGYW aged 15-24 years. The serosurvey was conducted between March to May 2023, among AGYW seeking services at Masaka regional referral hospital (MRRH), a public health facility serving a population of over two million people in central region, Uganda [22, 23].  The hospital offers tertiary and primary in-patient and out-patient health care services including youth friendly reproductive health services and gender-based violence support services [22]. On average, 150 AGYW seek out-patient care services from the facility daily.

2.2 Recruitment and Data Collection Procedures

All AGYW aged 15-24 years with unknown HIV status, currently residing in any of the central region study districts of Masaka, Lwengo, Sembabule, Lyantonde, Bukomansimbi, Kalungu, Rakai, and Kalangala, and attending Masaka hospital departments of MCH and OPD, were included in the study if they formally consented or assented and had parental/guardian approval (for those below 18 years of age) to participate in the study.

The minimum sample size was calculated using the general rule of thumb for logistic regression with a precision of 5% [24]. This initial sample size of 300 was increased by 20% to account for a potential dropout rate, as necessary for a non-experimental clinical survey [25] resulting in a final desired sample size of 375. Using proportion to size allocation, we enrolled 122 and 253 respondents from the Masaka Hospital OPD and MCH department respectively, as they waited to be evaluated by the health workers. Over 30 AGYW received care at each study site daily. Simple random sampling was used by assigning random numbers to potential respondents in the clinic waiting area on each recruitment day.

A structured questionnaire adapted from the 2011 Uganda AIDS Indicator Survey [26], the 2016 Uganda Demographic and Health Survey [27], and the HIV/AIDS Tool Kit [28] was used to collect data on factors associated with HIV infection outcomes among AGYW and HIV test results. The questionnaire was piloted among 20 AGYW aged 15-24 years at a non-participating facility before the real interview to evaluate the tool’s appropriateness, acceptance, and validity. It was revised until the content validity index was 0.877, exceeding the minimum recommended index of 0.7 for survey studies [29]. The questionnaire comprising 73 question items had Cronbach’s alpha of 0.790, was considered reliable [29, 30], and was used to assess the study variables.

The questionnaire was administered through face-to-face interviews by trained research assistants, in either English or Luganda language depending on the participant’s choice, at an appropriate venue within the health facility for privacy and confidentiality. Before participating in research activities, the research assistants received a three-day training conducted by the researcher on study scope and procedures including consent administration and data collection for the study. Both research assistants were fluent in English and Luganda.

All AGYW who were interviewed and were eligible for HIV testing were asked to voluntarily provide a blood sample. HIV testing was conducted using standard testing and quality-control procedures established by Uganda’s Ministry of Health [31] in compliance with the WHO standards [2]. All AGYW diagnosed with HIV infection were linked to the ART clinic on the same day of diagnosis for further clinical management.

The study protocol was cleared by the Uganda National Council for Science and Technology (NCST) (HS2554ES) and the Clarke International University Research Ethics Committee (CLARKE-2022-453). All participants provided written informed consent prior to participation in this study. The data collection procedures adhered to all acceptable ethical standards in healthcare research [32].

2.3 Study variables

The outcome (dependent) variable was HIV infection, measured by the occurrence of newly diagnosed HIV infection among AGYW who tested positive. Data on HIV serostatus was recorded as either HIV positive or Negative (0 = No, and 1 = Yes). The predictor (independent) variables included underlying socioeconomic and structural factors such as marital status, education level, wealth status, alcohol consumption, stigma, discrimination, laws, health policies, and access to risk reduction services.

2.4 Statistical analysis

Data was analyzed using Statistical Package for Social Sciences (SPSS) version 27.0 software. Both descriptive statistics (percentages and counts) and inferential statistics (chi-square and regression statistics) were employed.  Pearson chi-square tests were used for bivariate analysis to quantify the association between HIV infection and associated factors. Multivariate modelling using logistic regression was conducted to evaluate the effect of risk factors on HIV infection outcomes among the AGYW aged 15-24 years. Interaction terms with a p-value <0.05 were considered statistically significant. 

3. Results

The study achieved a sample size of 351 out of the required 375 AGYW participants aged 15-24 years, representing a 93.6% response rate among study subjects.

3.1 Demographic Attributes of AGYW in the Central Region, Uganda

Table 1: Demographic Charateristics of AGYW in the Central Region, Uganda

Source: Primary data, 2023

Table 1 presents the demographic characteristics among AGYW in the Central region, Uganda. The study included a total of 351 participants. The majority of the respondents were Catholics 52.7% (185), followed by Anglicans 22.2% (78) and Moslems 21.4% (75). Most of the participants were Ugandan nationals 97.4% (342), primarily of the Baganda tribe 62.7%, (220).  The age-group 20-24 years constituted 77.8% (273) of the paticipants. Additionally, 64.4% (226) were married or cohaniting, and 50.1% (176) had completed O'-Level secondary education.

3.2 HIV Prevalence among AGYW in the Central Region, Uganda

The study found an HIV positivity rate of 5.1% among the AGYW respondents aged 15-24 years in the central region, Uganda. AGYW with unsatisfactory HIV knowledge (12.5%), were more likely to acquire HIV infection, compared to those with satisfactory knowledge, 5.0%.

3.3 Associated Factors of HIV Infection

3.3.1 Association between HIV Infection and Socioeconomic Factors

Table 2: Multivariate logistic regression analysis model results for the association between socioeconomic factors and HIV Infection outcomes among AGYW in Central region, Uganda.

**Significant at 5% level. Source: Primary data, 2023

Table 2 presents the results of the multivariate logistic regression analysis for the association between socioeconomic factors and HIV Infection outcomes among AGYW in the Central region, Uganda. Alcohol use was significantly associated with an increased likelihood of HIV infection at the bivariate analysis level (COR= 0.281; 95%CI: 0.108- 0.733; p = 0.009< 0.05). After controlling for confounders, alcohol use (AOR =0.261; 95%CI: 0.09-0.74; p = 0.011< 0.05) remained significantly associated with HIV infection outcomes among AGYW in Central region.

3.4 Association between HIV Infection and Structural Factors

Table 3: Multivariate logistic regression analysis model results for the association between structural factors and HIV Infection outcomes among AGYW in Central region, Uganda.

**Significant at 5% level. Source: Primary data, 2023

Table 3 presents the results of the multivariate logistic regression analysis for the association between structural factors and HIV Infection outcomes among AGYW in Central region, Uganda.  Stigma (COR= 5.437; 95%CI: 0.777-16.637; p = 0.003< 0.05) was found to be significantly associated with HIV Infection outcomes at the bivariate analysis level. After adjustment for confounders, stigma (AOR =4.91; 95%CI: 1.523-15.812; p = 0.008< 0.05) remained significantly associated with HIV infection outcomes at the multivariate analysis level.

4. Discussion

AGYW aged 15-24 years in Sub-Saharan Africa, including Uganda and its Central Region, are disproportionately affected by HIV infection compared to their male peers [3, 4, 33]. This research aimed to identify factors associated with HIV infection among AGYW seeking services at a tertiary hospital in central Uganda.  

The results showed an HIV prevalence of 5.1% among AGYW aged 15-24 in the central region of Uganda. HIV infection was found to be significantly associated with alcohol use (AOR =0.261; 95%CI: 0.09-0.74; p = 0.011< 0.05) and stigma (AOR =4.91; 95%CI: 1.523-15.812; p = 0.008< 0.05).

Our findings show a remarkably higher HIV positivity rate of 5.1% compared to 2.9% reported among AGYW aged 15-24 in the central region of Uganda for the period 2020-2021 [6].   This increased prevalence underscores the need to scrutinize the current practices and policy decisions related to HIV prevention for AGYW in this region. It also highlights the inadequate progress being made towards the goal of ending the HIV/AIDS pandemic by 2030 [6,33].

The study results revealed that most HIV-positive respondents had low HIV knowledge implying that AGYW with better HIV knowledge were more likely to adopt appropriate behaviours to minimize their HIV risk. Improved HIV knowledge among AGYW has been reported to influence increased prevention behaviours such as condom use in other African nations [34].

In SSA, HIV/AIDS awareness is lower among women than men, with women constituting 58% of those with low awareness; where as they make up only 50% of those with high awareness [21]. In the same population, low HIV knowledge, specifically the knowledge of routes of HIV transmission, increased risky sexual behaviours and incident HIV infection outcomes [34]. These findings underscore the critical need to promote HIV awareness for infection prevention among AGYW. Satisfactory HIV knowledge emerges as a key factor in reducing HIV infections within this population. Therefore, it is essential to incorporate these insights when designing interventions aimed at reducing HIV infection rates among AGYW, with a strong emphasis on enhancing HIV knowledge. AGYW should be well-informed about how HIV is acquired, transmitted, prevented, and understand what factors increases their risk of HIV infection, to effectively minimize such risks.

The finding that alcohol use is significantly associated with HIV infection outcomes aligns with previous research in other countries. For example, a study conducted in South Africa [35] found that alcohol use was associated with an increased risk of HIV infection. Similarly, a study in Canada [36] reported that alcohol use was a significant predictor of HIV infection among young women.

However, a surprising finding in this study was that although alcohol intake was associated with HIV infection, the majority of AGYW respondents (11.0%) with HIV-positive outcomes had never used alcohol, compared to the 3.4% who had used alcohol.  Further research is needed to explore the underlying factors and mechanisms that may explain this unexpected result. Nonetheless, our findings highlight the importance of targeting AGYW aged 15-24 with interventions that incorporate multiple preventive approaches. These efforts should aim to increase their awareness and utilization of various HIV risk reduction services.

HIV Stigma has been found to be a crucial fator in shaping responses to HIV Infections in some communities [37] while it is not significant in others [38]. For example, in the United States, stigma was found not to have a statistically significant effect on HIV testing and PPeP use [39].

However, in this study, HIV stigma was found to be significantly associated with HIV infection among AGYW aged 15-24 years. This finding is consistent with past studies conducted in Egypt [40] and South Africa [41] that reported a statistically significant relationship between Stigma and HIV infection. Stigma impacts HIV infection by causing AGYW whether living with or without HIV, to fear seeking HIV information, prevention, and treatment services, as well as hesitating to disclose their HIV status [42]. The effects of stigma include individual reluctance to undergo HIV testing and a lack of empowerment to implement HIV prevention measures [43].  In addition, some cultural expectations such as condoning early marriages, glorifying non-marital sex, having multiple sexual partners, and seeking children especially male children, outside marriage, increase stigma among AGYW. This in-turn can negatively impact positive behavioural and biological practices for HIV infection prevention [37]. Structural interventions targeted at overcoming stigma aim to bring about collective community change [44], particularly those targeting specific high-risk subpopulations like AGYW [45]. Therefore, structural interventions to mitigate the negative effects of HIV stigma among AGYW in the central region should focus on transforming the broader context in which individual AGYW and their communities perceive stigma and HIV infection.

5. Conclusion

Alcohol use and HIV stigma were identified as factors that predicted HIV infection among AGYW in the Central Region of Uganda. Addressing these factors is crucial for improving HIV prevention and care outcomes in this population. Further research is needed to better understand the complex interplay of these factors and their impact on HIV risk among AGYW.

Recommendations

In light of the above findings, the study recommends that the MOH in collaboration with MoES and the MoGLSD, should strengthen the capacities of individuals, groups, and institutions to limit Alcohol use among AGYW in order to reduce new HIV infections in Central Uganda. Additionally, the MoH should develop training manuals for AGYW, families, communities, and institutions, to deliver necessary structural interventions to address HIV stigma among the AGYW aged 15–24 years in Central Uganda.

Acknowledgments

We appreciate AGYW aged 15-24 years who turned up at Masaka Hospital, cooperated with the study team, and contributed their significant time which made this study a success. Special thanks to Florence Namugenyi, Shadia Nantambi, Judith Nuwamanya, and David Muwonge for their research assistant role in supporting the study. Sincere appreciation to Associate Prof. Rose Clarke Nanyonga and Dr. Catherine Lwanira for their support in reviewing and editing the manuscript.

Conflicts of Interest

The authors declare that they have no conflicts of interest.

References

1. Amin ME. Social science research: conception, methodology and analysis. Makerere University (2005).
2. Aziz MM, Abdelrheem SS, Mohammed HM. Stigma and discrimination against people living with HIV by health care providers in Egypt. BMC Health Serv Res 23 (2023): 663.
3. Becker M, Mishra S, Bhattacharjee P, Musyoki H, Tennakoon A, et al. Differential Burden of HIV Among Adolescent Girls and Young Women by Places Associated With Sex Work: An Observational Study in Mombasa, Kenya. J Acquir Immune Defic Syndr 96 (2004): 121-129.
4. Bujang MA. A Step-by-Step Process on Sample Size Determination for Medical Research. Malays J Med Sci 28 (2021): 15-27.
5. Bujang MA, Sa'at N, Sidik T, Joo LC. Sample Size Guidelines for Logistic Regression from Observational Studies with Large Population: Emphasis on the Accuracy Between Statistics and Parameters Based on Real Life Clinical Data. Malays J Med Sci 25 (2018): 122-130.
6. Bujang MA, Sa'at N, Sidik TMITAB. Determination of Minimum Sample Size Requirement for Multiple Linear Regression and Analysis of Covariance Based on Experimental and Non-experimental Studies. Epidemiology Biostatistics and Public Health, 14 (2017): e12117-12111.
7. Comins CA, Rucinski KB, Baral S, Abebe SA, Mulu A, et al. Vulnerability profiles and prevalence of HIV and other sexually transmitted infections among adolescent girls and young women in Ethiopia: A latent class analysis. PLoS One 15 (2020): e0232598.
8. Cronbach LJ. Response Sets and Test Validity. Educational and Psychological Measurement 6 (1946): 475-494.
9. Damtie Y, Kefale B, Yalew M, Arefaynie M, Adane B, et al. HIV risk behavior and associated factors among people living with HIV/AIDS in Ethiopia: A systematic review and meta-analysis. PLoS One 17 (2022): e0269304.
10. Evans DW, Lucas N, Kerry R. The form of causation in health, disease and intervention: biopsychosocial dispositionalism, conserved quantity transfers and dualist mechanistic chains. Med Health Care Philos 20 (2017): 353-363.
11. Faust L, Yaya S. The effect of HIV educational interventions on HIV-related knowledge, condom use, and HIV incidence in sub-Saharan Africa: a systematic review and meta-analysis. BMC Public Health 18 (2018): 1254.
12. Fylkesnes K, Musonda RM, Kasumba K, Ndhlovu Z, Mluanda F, et al. The HIV epidemic in Zambia: socio-demographic prevalence patterns and indications of trends among childbearing women. Aids 11 (1997): 339-345.
13. Gichane MW, Moracco KE, Pettifor AE, Zimmer C, Maman S, et al. Socioeconomic Predictors of Transactional Sex in a Cohort of Adolescent Girls and Young Women in Malawi: A Longitudinal Analysis. AIDS Behav 24 (2020): 3376-3384.
14. Hargreaves JR, Pliakas T, Hoddinott G, Mainga T, Mubekapi-Musadaidzwa C, et al. The association between HIV stigma and HIV incidence in the context of universal testing and treatment: analysis of data from the HPTN 071 (PopART) trial in Zambia and South Africa. J Int AIDS Soc 25 (2022): e25931.
15. Horter S, Bernays S, Thabede Z, Dlamini V, Kerschberger B, et al. "I don't want them to know": how stigma creates dilemmas for engagement with Treat-all HIV care for people living with HIV in Eswatini. Afr J AIDS Res 18 (2018): 27-37.
16. HIV/AIDS Tool Kit. Implementation Guide for the HIV/AIDS KAP Questionnaire (2020).
17. Kembo J. Risk factors associated with HIV infection among young persons aged 15-24 years: evidence from an in-depth analysis of the 2005-06 Zimbabwe Demographic and Health Survey. Sahara J 9 (2020): 54-63.
18. Lunkuse JF, Kamacooko O, Muturi-Kioi V, Chinyenze K, Kuteesa MO, et al. Low awareness of oral and injectable PrEP among high-risk adolescent girls and young women in Kampala, Uganda. BMC Infect Dis 22 (2020): 467.
19. Lyle K, Weller S, Samuel G, Lucassen AM. Beyond regulatory approaches to ethics: making space for ethical preparedness in healthcare research. J Med Ethics 49 (2023): 352-356.
20. Mabaso M, Sokhela Z, Mohlabane N, Chibi B, Zuma K, et al. Determinants of HIV infection among adolescent girls and young women aged 15-24 years in South Africa: a 2012 population-based national household survey. BMC Public Health 18 (2018): 183.
21. Magadi MA. Understanding the gender disparity in HIV infection across countries in sub-Saharan Africa: evidence from the Demographic and Health Surveys. Sociol Health Illn 33 (2011): 522-539.
22. Mathur S, Heck CJ, Kishor Patel S, Okal J, Chipeta E, et al. Temporal shifts in HIV-related risk factors among cohorts of adolescent girls and young women enrolled in DREAMS programming: evidence from Kenya, Malawi and Zambia. BMJ Open 12 (2020): e047843.
23. Mathur S, Pilgrim N, Patel SK, Okal J, Mwapasa V, et al. HIV vulnerability among adolescent girls and young women: a multi-country latent class analysis approach. Int J Public Health 65 (2020): 399-411.
24. Adolescent Health Policy Guidelines and Service Standards. MOH (2012).
25. Consolidated Guidelines for Prevention and Treatment of HIV in Uganda. MOH (2016).
26. Masaka Regional Referral Hospital. MOH (2019).
27. Mokgatle M, Madiba S. Community Perceptions of HIV Stigma, Discriminatory Attitudes, and Disclosure Concerns: A Health Facility-Based Study in Selected Health Districts of South Africa. Int J Environ Res Public Health 20 (2023).
28. Murewanhema G, Musuka G, Moyo P, Moyo E, Dzinamarira T. HIV and adolescent girls and young women in sub-Saharan Africa: A call for expedited action to reduce new infections. IJID Reg 5 (2020): 30-32.
29. Musekiwa A, Silinda P, Bamogo A, Twabi HS, Mohammed M, et al. Prevalence and factors associated with self-reported HIV testing among adolescent girls and young women in Rwanda: evidence from 2019/20 Rwanda Demographic and Health Survey. BMC Public Health, 22(2022): 1281.
30. Napierala Mavedzenge S, Olson R, Doyle AM, Changalucha J, Ross DA. The epidemiology of HIV among young people in sub-Saharan Africa: know your local epidemic and its implications for prevention. J Adolesc Health 49 (2011): 559-567.
31. Nyblade L, Ndirangu JW, Speizer IS, Browne FA, Bonner CP, et al. Stigma in the health clinic and implications for PrEP access and use by adolescent girls and young women: conflicting perspectives in South Africa. BMC Public Health 22 (2022): 1916.
32. Pantelic M, Steinert JI, Park J, Mellors S, Murau F. 'Management of a spoiled identity': systematic review of interventions to address self-stigma among people living with and affected by HIV. BMJ Glob Health 4 (2018): e001285.
33. Sang JM, Matthews DD, Meanley SP, Eaton LA, Stall RD. Assessing HIV Stigma on Prevention Strategies for Black Men Who Have Sex with Men in the United States. AIDS Behav 22 (2018): 3879-3886.
34. Schausberger B, Mmema N, Dlamini V, Dube L, Aung A, et al. We have to learn to cooperate with each other: a qualitative study to explore integration of traditional healers into the provision of HIV self-testing and tuberculosis screening in Eswatini. BMC Health Services Res 21 (2021): 1314.
35. Shuper PA, Neuman M, Kanteres F, Baliunas D, Joharchi N, et al. Causal considerations on alcohol and HIV/AIDS--a systematic review. Alcohol 45 (2010): 159-166.
36. Facts on HIV and AIDS in Uganda 2021 (2021).
37. The Annual Joint AIDS Review, FY 2022/2023, Final Report (2023).
38. National population and housing census 2014-Main Report. Uganda Bureau of Statistics (2016).
39. Uganda Bureau of Statistics - UBOS, & ICF. Uganda Demographic and Health Survey 2016 (2018).
40. In danger: UNAIDS Global AIDS Update -Full report (2022).
41. Global HIV & AIDS statistics — Fact sheet (2023).
42. Uganda Population-Based HIV Impact Assessment (UPHIA) 2020-2021 Summary Sheet (2022).
43. HIV and AIDS: Key facts. World Health Organization (2022).
44. The Global Health Observatory: Data on the size of the HIV epidemic (2023).
45. Ziraba A, Orindi B, Muuo S, Floyd S, Birdthistle IJ, et al. Understanding HIV risks among adolescent girls and young women in informal settlements of Nairobi, Kenya: Lessons for DREAMS. PLoS One 13 (2018): e0197479.