London School of Hygiene and Tropical Medicine (Stöckl and Watts), Independent Consultant (Kalra), UNAIDS (Jacobi)
"In many sub-Saharan African countries, there are disturbingly high levels of HIV infection among young women - with the discrepancies in ratios of HIV infection between 16- and 24-year-old girls compared with boys being eightfold higher in some settings."
This article reports on the findings from a systematic review that was conducted to summarise published evidence on the association between early sexual debut and women's risk of HIV infection in sub-Saharan Africa. [Footnotes are removed throughout by the editor.] Authors are members of the Department for International Development (DFID)-funded STRIVE Research Consortium; research had funding from Joint United Nations Programme on HIV/AIDS (UNAIDS).
From an open start date until January 2012, the research aggregated PubMed research articles using a combination of taxonomy terms. "Of the 26 results in the 23 articles, which reported unadjusted associations between early sexual début and women's increased HIV infection risk, 13 found a significant association....." Further analyses suggest that women who start sex at a young age are not solely at increased HIV risk because they are simply exposed to HIV risk for longer by being sexually active. Four of eight studies that controlled for factors related to women's sexual risk behaviour, such as number of lifetime partners, lack of condom use, or other risky sexual practices, maintained a significant association between early sexual début and women's increased HIV risk. However, only two studies that controlled for women's age difference with their first sexual partner, whether the partner was drunk or on drugs during their first sexual intercourse or the partner's estimated HIV infection risk continued to show a significant association between women's onset of sexual début and their HIV infection risk. "No influence was established on the association between early onset of sexual début and women's HIV infection risk by differing socio-economic and demographic factors in all three studies that solely controlled for these factors (see Table 6). In addition, no study included information on the biological risk pathways, such as physiological immaturity or genital trauma, nor on determinants of early first sex relating to gender inequality, such as whether the first sex was forced, child sexual abuse or social norms supporting transactional sex apart from low levels of education and socio-economic status of women."
"Overall, this systematic review established that higher-quality studies consistently found significant associations between early sexual début and HIV, which remained after socio-demographic factors were controlled for. Where significance remained after controlling for later sexual behaviours, it may be that HIV risk is increased at first sex - due potentially to genital trauma and/or the partner being more likely to be HIV infected. Similarly, studies that found that the association disappears may reflect that early sexual début is associated with later higher HIV risk behaviours. Especially given evidence of the later impacts of coerced sex on women's mental health, it could be that forced first sex is an important explanatory factor explaining the subsequent later patterns of high-risk behaviours.
These factors are complex and highly gendered. Poverty, limited education and livelihood options for girls; social norms regarding early sex and/or marriage, sex between older men and younger girls; and levels of child sexual abuse and violence are all potentially important. The review illustrates the need for further evidence, including for additional research to better understand the determinants and implications of early sexual début for women, the links with HIV risk, and to identify areas amenable to intervention. This is a challenging research and intervention agenda, but one that needs to be developed if girls' vulnerability to HIV is to be effectively addressed."
American Journal of Reproductive Immunology Special Issue: Sexual Violence and HIV Transmission, Volume 69, Issue Supplement s1, pages 27-40, February 2013, accessed June 18 2013. Image credit: Imperial College London