Why are Virgin Adolescents Worried about Contracting HIV/AIDS? Evidence from Four Sub-Saharan African Countries

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1 ORIGINAL RESEARCH ARTICLE Why ar Virgin Adolscnts Worrid about Contracting HIV/AIDS? Evidnc from Four Sub-Saharan African Countris Guilla Gorgs* 1, Bignami Simona and LGrand K. Thomas 1 Institut Supériur ds Scincs d la Population (ISSP)- Univrsité d Ouagadougou 03; Univrsité d Montréal, Montréal, Canada *For corrspondnc: gguilla@issp.bf; guilla@yahoo.com; Phon (6) Abstract Whthr wll foundd or not, prcptions of on s own HIV risk hav bn shown by halth bhavior modls to b an important factor in dtrmining individuals sxual bhavior. Although mpirical studis on th dtrminants of HIV risk prcption xist, only a fw hav focusd on adolscnts who ar not yt sxually activ. Using data from nationally-rprsntativ survys of adolscnts, w assss th factors associatd with HIV risk prcption among sxually inactiv adolscnts in four sub-saharan African countris at diffrnt stags of th HIV/AIDS pidmic (Burkina Faso, Ghana, Malawi and Uganda). Th rsults show that thr is no singl influnc on adolscnts HIV risk prcption, but rathr a rang of individual, nvironmntal and community factors such as schooling, knowldg about HIV, rgional HIV prvalnc and adolscnts social ntworks. Ths rsults can hlp bttr calibrat programs and policis addrssing sxual and rproductiv halth issus among adolscnts, a group that is disproportionatly affctd by nw HIV infctions. Afr J Rprod Halth 013 (Spcial Edition); 17[4]: 3-50). Kywords: HIV/AIDS, risk prcption, ordrd logistic analysis, Burkina Faso, Ghana, Malawi, Uganda Résumé Ls modèls comportmntaux n santé ont démontré qu, fondés ou non, ls prcptions individulls du risqu vis-à-vis du VIH constitunt un factur important qui détrmin l comportmnt sxul ds individus. Cpndant, bin qu'il xist ds étuds mpiriqus sur ls détrminants d la prcption du risqu du VIH, suls qulqus-uns ont mis l'accnt sur ls adolscnts qui n sont pas ncor sxullmnt actifs. En nous appuyant sur ds donnés d'nquêts rprésntativs au nivau national, nous évaluons ls facturs associés à la prcption du risqu vis-à-vis du VIH chz ls adolscnts sxullmnt inactifs dans quatr pays d'afriqu sub-saharinn à différnts stads d l'épidémi du VIH/Sida (Burkina Faso, Ghana, Malawi t Ouganda). Ls résultats montrnt qu'il n'xist pas un influnc uniqu d la prcption du risqu du VIH chz l adolscnt, mais plutôt un faiscau d facturs individuls, nvironnmntaux t communautairs au nombr dsquls la scolarisation, ls connaissancs sur l VIH, la prévalnc régional du VIH t ls résaux sociaux ds adolscnts. Cs résultats puvnt aidr à miux calibrr ls programms t ls politiqus portant sur ls qustions d santé sxull t rproductiv chz ls adolscnts, un group qui st touché d façon disproportionné par ls nouvlls infctions à VIH. Afr J Rprod Halth 013 (Spcial Edition); 17[4]: 3-50). Mots-clés: VIH/SIDA, prcption du risqu, analys logistiqu ordonné, Burkina Faso, Ghana, Malawi, Ouganda Introduction Halth bhavior modls suggst that th discrpancis oftn obsrvd btwn knowldg and bhavior can b xplaind by th fact that bhavior basd on knowldg is mdiatd by th prcption of individual risk 1,,3. For instanc, th AIDS risk rduction modl (ARRM) posits that bfor changing thir bhaviors, individuals nd to rcogniz that thy ar at risk 4. Similarly, a basic prmis of th Halth Blif Modl (HBM) is that an individual s prcption of bing vulnrabl to a thrat along with his blifs about th fficacy of actions h can tak to rduc th risk of contracting a disas, ar critical factors to xplain why individuals fail to follow halth rcommndations 5,6,7. For prvntion policis and programs, risk prcption is sn as an important African Journal of Rproductiv Halth Dcmbr 013 (Spcial Edition on HIV/AIDS); 17(4): 3

2 indicator of prcivd suscptibility to infction and is thrfor considrd as an important prcondition for adopting protctiv bhaviors,8,3. Rcnt studis hav shown that adolscnt prcptions of thir own HIV risk can hlp thm rsolv to ngag in protctiv bhaviors, such as dlaying sxual activity, using condoms or sking voluntary counsling and tsting 9,10. Ths findings hav corroboratd arlir studis on adolscnts in a fw sub-saharan African contxts, whr high HIV risk prcption was associatd with adoption of protctiv bhaviors 11,1,13,14,15,8,16. Th main limitation of this litratur is that although such attituds ar undrstandabl, givn individuals past or prsnt risky sxual bhaviours 17,18,19,10, vry fw studis hav focusd on prcption of HIV risk and its implications among adolscnts who ar not yt sxually activ. In contrast to ths studis, w aim to highlight th dtrminants of HIV risk prcption among sxually inactiv adolscnts. Using data collctd in 004 from nationally-rprsntativ survys of adolscnts, this study aims to dtrmin th influnc of individual background charactristics, contxtual factors and social ntworks on th prcption of HIV risk among sxually inactiv adolscnts in four sub-saharan countris at diffrnt stags of th AIDS pidmic: Burkina Faso, Ghana, Malawi and Uganda. This qustion is of grat intrst bcaus of its potntial significanc for prvntion programs and policis. Sxually inactiv adolscnts ar indd sn as a window of hop bcaus thy hav grat potntial for avoiding risky sxual bhaviors in which sxually activ adolscnts ar alrady ngagd. Thrfor, focusing on adolscnts who hav not yt bcom sxually activ is likly to b an ffctiv approach to addrssing th pidmic, particularly in high HIV prvalnc countris 0. Factors associatd with HIV risk prcption among adolscnts Abundant vidnc xists as to th influnc of ducation on HIV risk prcption. Through thir schooling, adolscnts acquir skills that nabl thm to b wll-informd and attntiv to HIV mssags 1. Adolscnts immdiat nvironmnt, thir rlationships with prs and othr community mmbrs, and schools and rligious affiliation ar othr important factors influncing thir acquisition of knowldg, xprincs and prcptions on a wid rang of issus including sxual and rproductiv halth,3,4,5. Ths nvironmntal contxts of complx rlationships (family, frinds, prs, school, and community) ar likly to influnc prsonal blifs and prcptions 5. Communication is indd on of th prim factors influncing adolscnts HIV prcptions. According to social thoris, opinions and actions toward HIV/AIDS ar shapd through discussions within prsonal communication circls,3,4. Social ntwork thoris such as social influnc similarly posit that attituds with rspct to sxual bhaviors and HIV-rlatd issus can b strongly influncd by th prvailing opinions and attituds in an individual s social nvironmnt 6. Ths includ intractions and discussions with parnts and othr family mmbrs as wll as prs about issus that ar rlvant or of intrst 5. Typically, adolscnts shar thir undrstanding of HIV and sxual bhavior within thir frinds ntworks 7,8,9. Studis hav shown that, whn shard with thir ntwork, ducatd adolscnts xprincs may lad thir prs toward a nw way of thinking about thir own HIV risks. This diffusion is likly to sprad nw viws of HIV risk prcptions as wll as mrging sxual bhavior options in th futur 30. Howvr, by sharing information and xprinc with thir ntwork mmbrs, adolscnts may also ovrmphasiz atypical vnts. In such cass, if individuals in th ntwork do not hav any nw information that can forc a r-valuation of long- Th xisting litratur suggsts that HIV risk hld blifs, prcptions ar likly to mov away prcption is influncd by svral factors. from ralitis 30,1. As Lloyd 1 notd, whil Although this litratur has mainly focusd on adolscnts may b unawar of crtain dangrs, prcptions among sxually activ individuals, w thy also s dangrs whr thy do not xist. rviw many of th factors that ar likly to also Morovr, prcptual biass ar likly to b influnc HIV risk prcptions among sxually xacrbatd by th tndncy for ngativ vnts to inactiv individuals. xrt a disproportionat influnc on blifs 30. African Journal of Rproductiv Halth Dcmbr 013 (Spcial Edition on HIV/AIDS); 17(4): 33

3 Among othr possibl contxtual influncs, prvious studis hav shown that HIV risk prcption is basd not only on an individual s own bhavior or that of his partnr, but also on th lvl of HIV/AIDS-rlatd morbidity and mortality within his widr community 31,9. Knowldg of and prsonal tis to popl who did of AIDS or who liv with HIV mak th pidmic a ral part of adolscnts livs, which is likly to shap thir prcption of thir own risk 30,3. Prcptions of HIV risk formd on th basis of HIV prvalnc in th immdiat nvironmnt may prsist vn with dclining HIV incidnc bcaus thy may lad to a lasting prcptual fram that is rsistant to rvision 30. Study stting This prvalnc rat is also highr among adolscnt womn ag (4%) than among adolscnt mn (1%). As for Burkina Faso, th BFDHS shows that 1% of adults ag ar infctd with prvalnc bing highr among womn (1.%) than among mn (0.8%). This prvalnc rat is 0.1% among adolscnt womn ag whil it is 0.4% among adolscnt mn. Finally, in Ghana, according to th 011 HIV Sntinl survy 38, th HIV prvalnc was.0% and.1% in 010 and 011 rspctivly, rvaling a marginal incras of pandmic with a highr prvalnc in urban sits. Data and mthods Data sourcs Th pidmiological profils of th four study Data com from th National Survys of countris diffr with rgard to HIV/AIDS Adolscnts (NAS) carrid out in 004 in Burkina prvalnc and adolscnts sxual activity. This Faso, Ghana, Malawi, and Uganda. Th NAS ar comparativ approach (across and within modld on th Dmographic and Halth Survys countris) nabls th idntification of common (DHS), but hav two faturs that mak thm pattrns and associations, as wll as significant particularly appropriat for th purposs of this diffrncs in adolscnts sxual bhaviors and analysis: first, thy intrviwd adolscnts countris prvntion fforts. In addition, th starting at 1 yars of ag (whras th DHS only inclusion of data from diffrnt sub-rgions of intrviws rspondnts agd 15 yars and abov); sub-saharan Africa (East, Wst, and South) in and scond, thy includd dtaild qustions on diffrnt stags of th HIV/AIDS is likly to adolscnts charactristics and sxual bhaviors. incras our undrstanding both of adolscnts Th survys wr nationally rprsntativ and risk for HIV/AIDS, STDs, and unintndd houshold-basd. Th sampling dsign ntaild a prgnancy and of how thy manag th multipl first-stag systmatic slction of cnsus risks thy fac in various contxts. numration aras (EAs) and a scond stag Dspit som signs of stabilization compard to slction of housholds within th slctd EAs th past dcads 33, th HIV pandmic in Uganda is basd on th sampling fram and th clustrs usd still at a worrying lvl. Estimats from th 011 by th National Statistical Offics for th latst Uganda AIDS Indicator Survy 34, indicat that, Dmographic and Halth Survys. All ligibl d among Ugandan adults, 7.3% ar HIV-positiv, facto rsidnts agd 1 to 19 yars in ach with prvalnc bing highr among womn at sampld houshold wr includd in th survy. vry ag group xcpt in th ag group Consnt from a parnt or cartakr was rquird (8.%) than among mn (6.1%). Rsults also show for adolscnt minors (1-17 yars) bfor th a slight incras in HIV prvalnc sinc th 004- ligibl adolscnt was authorizd to participat in 05 UHSBS 35, from 6.4 to 7.3% of adults ag 15- th survy. 49. In th ag group, HIV prvalnc is W includ in th prsnt analysis only 3.0% among womn and 1.7% among mn 34. adolscnts who rportd to hav vr hard of In Malawi, th MDHS shows that 11 HIV/AIDS at th tim of th survy, bcaus HIV prcnt of adults ag ar infctd with HIV. risk prcption was masurd only for this group. Th HIV prvalnc rat is 13% among womn As rportd in Tabl 1, this group rprsnts th ag 15-49, whil among mn ag it is 8%. majority of adolscnts in all countris, so that our African Journal of Rproductiv Halth Dcmbr 013 (Spcial Edition on HIV/AIDS); 17(4): 34

4 slction critria ar not likly to xrt a significant bias in th analysis. In all four countris, among rspondnts who had vr hard of HIV/AIDS, considrably mor than half rportd that thy wr not sxually activ at th tim of th survy. Tabl 1: Intrviwd rspondnts includd in th analysis, by gndr and country Burkina Faso Ghana Malawi Uganda Boys Girls Total Boys Girls Total Boys Girls Total Boys Girls Total Total numbr intrviwd Has vr hard of HIV/AIDS Numbr Prcnt , , Has vr hard of HIV/AIDS and not sxually activ Numbr Prcnt Prcnt of th total numbr intrviwd Prcnt of thos who hav vr hard of HIV/AIDS Masurmnt of HIV risk prcption HIV risk prcption was masurd through th following survy qustion: Do you think your chancs of gtting HIV/AIDS ar grat, modrat, small, or you hav no chanc at all? This qustion was askd of all adolscnts intrviwd who rportd that thy had vr hard of HIV/AIDS, rgardlss of whthr thy rportd bing sxually activ. Rspondnts could giv an stimat of thir prcivd risk of HIV infction using th rspons options for this qustion, or could choos to say that thy did not know what thir chancs wr. Rspondnts could also indicat whthr thy wr HIV positiv. Th survy qustion usd to masur HIV risk prcption in ths survys was idntical to th on askd in th third phas of th Dmographic and Halth Survys, and in othr similar survys that hav bn carrid out in sub-saharan Africa. In all countris thr wr a surprisingly high proportion of sxually inactiv adolscnts who thought thy had a high liklihood of contracting HIV/AIDS, vn though thy had not bgun sxual activity (Tabl ). Ovrall, 4.% of boys and 9.1% of girls thought thy had a high liklihood of contracting HIV/AIDS. Whn looking at individual countris, th proportion of virgin adolscnts who rportd that thy had no chanc or a small chanc of gtting HIV/AIDS was highr (mor than 50% ) in th two lowprvalnc countris, Burkina Faso and Ghana, than in th two high-prvalnc countris, Malawi and Uganda. Yt, vn in Uganda, approximatly two-thirds of adolscnts of ithr sx prcivd som risk (small, modrat or grat) of contracting HIV/AIDS in th futur, and mor than 40% prcivd a high risk. It is important to not that 5 to 15% of adolscnts rportd not knowing thir chancs of gtting AIDS. Tabl : Prcntag distribution of sxually inxprincd adolscnts who hav vr hard of HIV/AIDS by socio-dmographic charactristics, sx, and country Slf-prcivd risk of gtting HIV Burkina Faso Ghana Malawi Uganda All countris Boys Girls Boys Girls Boys Girls Boys Girls Boys Girls African Journal of Rproductiv Halth Dcmbr 013 (Spcial Edition on HIV/AIDS); 17(4): 35

5 Grat Modrat Small No chanc at all Don t know Has HIV Ag Education Non Primary Scondary Has discussd AIDS with family mmbrs Ys No Has discussd AIDS with frinds Ys No Thinks that a halthy looking prson can hav HIV Ys No Don t know HIV prvalnc in th rgion of rsidnc Lss than % % % Mor than 8% Plac of rsidnc Rural Urban Houshold walth quintil Poorst Scond Middl Fourth Walthist Sampl siz Analytic mthods W bgan th analysis by comparing th charactristics of virgin adolscnts by lvl of HIV risk prcption using th appropriat chisquar statistics to assss significanc. Thn w constructd two sts of ordrd logistic rgrssion modls by gndr: on modl without intractions and on modl that introducd intractions btwn som indpndnt variabls in ordr to captur diffrncs in ffcts within and btwn sub-groups of adolscnts. Modld intractions includd having discussd AIDS with frinds and country of rsidnc, having discussd AIDS with family mmbrs and country of rsidnc, having discussd AIDS with frinds and ag, having African Journal of Rproductiv Halth Dcmbr 013 (Spcial Edition on HIV/AIDS); 17(4): 36

6 discussd AIDS with family mmbrs and ag, and AIDS knowldg and ag. W prsnt th marginal ffct of changs in th intracting indpndnt variabls on adolscnts HIV risk prcption. Th stimation of intraction trms allowd us to infr how th ffct of on indpndnt variabl on HIV risk prcption varid by th magnitud of anothr indpndnt variabl. To tst th magnitud of th intraction ffcts, and givn that w usd nonlinar modls, w computd th cross drivativ of th xpctd valu of th dpndnt variabl 39. Thrfor, statistical significanc cannot b obtaind dirctly from th cofficint of th intraction trm in Tabl 4, but must b basd rathr on th stimatd cross-partial drivativ To do so, w usd STATA s lincom command that allows th calculation of th corrct intraction ffcts as wll as thir standards rrors (Tabls 5 and 6). Bcaus of small sampl sizs for crtain catgoris, analyss wr also prformd by combining th data from all four countris. To adjust for diffrncs in sampl sizs across countris, poold wights for ach country wr gnratd and usd in all poold multivariat analyss. Th dpndnt variabl in all analyss was th lvl of HIV risk prcption catgorizd as follows: no, small, modrat and grat chanc. In th dscriptiv analysis, w also includd rspondnts who rportd not knowing thir chancs of gtting HIV/AIDS; howvr, this group was xcludd from th multivariat logistic rgrssion analysis. Th indpndnt variabls includd in th analyss ar dscribd blow. Ag With rgard to ag, w usd th classical division of adolscnc into arly adolscnc (1 14 yars), middl adolscnc (15 17 yars), and lat adolscnc (18 19 yars). This grouping is usd in most studis 1-4, bcaus it is wll-rcognizd that ach ag group has gndr-spcific physiological charactristics, socio-cultural manings and policy implications. Education Adolscnts who had vr attndd school wr askd th following qustion: What is th highst lvl of school you hav attndd? It is worth noting that contrary to th othr thr countris, in Ghana thr was a middl lvl (junior scondary school) aftr th primary lvl. In ordr to allow comparisons btwn countris, primary and junior scondary schools wr groupd in a sam catgory (primary) in this country. HIV/AIDS convrsational ntworks Adolscnts wr askd with whom thy had discussd HIV/AIDS. W constructd two indicators to masur HIV/AIDS convrsational ntworks: th first on basd on answrs mntioning family mmbrs and th othr on basd on thir frinds. In th first instanc, w groupd answrs including fathr, mothr, brothrs, sistrs, and othr family mmbrs as family ntworks. HIV Knowldg To masur corrct HIV knowldg w usd a standard indicator, that is, accurat (ys) answrs to th following qustion: Is it possibl for a halthy-looking prson to hav th AIDS virus? HIV prvalnc in th rgion of rsidnc Givn that th National Adolscnts Survys did not collct biomarkr data on HIV prvalnc, w masurd rgional HIV prvalnc using data collctd in othr national survys that wr carrid out approximatly at th sam tim as th National Adolscnts Survys. Ths ar: th 003 DHS for Burkina Faso and Ghana, th 004 DHS for Malawi and th 004 HIV/AIDS Sro- Bhavioural Survy for Uganda. From this information, w can assss th gographical distribution of adolscnts by HIV prvalnc (s Tabl abov). Ovrall, adolscnts wr concntratd in rgions whr HIV prvalnc was btwn and 4%. Howvr, mor than on out of four adolscnts livd in rgions whr prvalnc was btwn 4 and 8% whil on in fiv adolscnts livd in rgions whr HIV prvalnc African Journal of Rproductiv Halth Dcmbr 013 (Spcial Edition on HIV/AIDS); 17(4): 37

7 was mor than 8%. Focusing on ach country, w found that th majority of adolscnts rsidd in rgions whr HIV prvalnc was lss than % (Burkina Faso), btwn and 4% (Ghana), btwn 4 and 8% (Uganda), and mor than 8% (Malawi). Othr xplanatory variabls Houshold walth quintils wr constructd from qustions about houshold assts, srvics and othr facilitis using th DHS walth indx approach 43. Th othr indpndnt variabls usd in th modls includd plac of rsidnc (rural vs. urban) and country of rsidnc. Rsults Dscriptiv rsults mal adolscnts agd 1-14 yars blivd that thy had a high liklihood of contracting HIV, 44% of thos agd yars old hld this blif. Th diffrncs wr mor pronouncd among fmal adolscnts: 33% of thos agd 1-14 yars thought thy had a high liklihood of catching HIV whil 57% of thos agd yars thought this (p<0.001). Th sam pattrn was obsrvd among Ugandan fmal adolscnts, whr 45% of th youngst ons prcivd a grat risk of contracting HIV compard to 56.5% of thir countrparts agd yars (p<0.001). It is worth noting that across all ag groups and among both sxs, Ghana and Malawi had th highst proportion of adolscnts who thought that thy had no risk of contracting HIV. HIV risk prcption also varid by lvl of ducation across th four countris, although ach country xhibitd diffrnt pattrns. In Ghana, among adolscnts of both sxs, thos without any ducation blivd that thy had a highr liklihood of contracting HIV compard to thos with a high-school ducation. Th sam tndncy was obsrvd in Malawi, but only among mal adolscnts, for whom 69% of thos without any ducation blivd that thy had a high liklihood of contracting HIV compard to 40.8% among thos with a scondary school ducation or highr. Findings in Tabl indicat that dspit high lvls of HIV risk prcption across all countris, fw adolscnts had talkd with a family mmbr about HIV. Thr wr also important gndr diffrncs, with girls bing mor likly than boys to talk to family mmbrs, spcially in Uganda. Ovrall, th poold country rsults show that whil 15.6% of mal adolscnts had talkd with family mmbrs on th issu, a highr proportion of fmals (8%) rportd that thy did so. On th Rsults showd th rvrs in Uganda among othr hand, across all countris, a highr adolscnts of both sxs: th highr th proportion of mal adolscnts rportd talking to ducational lvl, th gratr th prcivd risk of frinds about HIV-rlatd mattrs compard to catching HIV. In Burkina Faso and Ghana, fmals. adolscnts of both sxs without any ducation Th misconcption that halthy-looking popl wr lss abl to stimat thir liklihood of cannot hav HIV infction was still widsprad in contracting HIV. th four countris (Tabl ). Almost on Adolscnts of both sxs in Burkina Faso and adolscnt in thr in Burkina and Uganda and on Ghana, and fmal adolscnts in Uganda, who in fiv in Malawi and Ghana indicatd that discussd HIV-rlatd issus with family mmbrs halthy-looking prson could not b HIV positiv. wr significantly mor likly to bliv thy had This misconcption was mor prvalnt among a grat risk of catching HIV. On th othr hand, adolscnt girls than among adolscnt boys in all having discussd HIV-rlatd issus with frinds th four countris xcpt Burkina Faso. dcrasd th prcption of bing at grat HIV risk Tabls 4a and 4b compar th charactristics of among adolscnts of both sxs in Malawi and sxually inxprincd adolscnts includd in th Uganda, whil it incrasd this prcption in analysis by thir lvl of HIV risk prcption. Ghana among adolscnts of both sxs. Across th four countris, th lvl of adolscnts In Burkina Faso, adolscnts of both sxs who prcivd HIV risk was highr among oldr corrctly rportd that a halthy-looking prson adolscnts of both sxs, spcially in Malawi could hav HIV/AIDS wr significantly mor and Uganda. Thus, in Malawi, although 35% of likly to prciv thmslvs at grat risk of African Journal of Rproductiv Halth Dcmbr 013 (Spcial Edition on HIV/AIDS); 17(4): 38

8 catching HIV. Th sam pattrn was obsrvd among Ghanaian mal and Malawian fmal adolscnts. Across all countris, adolscnts of both sxs who dclard that thy did not know if a halthy-looking prson could b HIV positiv wr also lss capabl of stimating thir liklihood of contracting HIV. Th rsults also showd that, ovrall, rgions with high HIV prvalnc had th highst proportion of adolscnts of both sxs who blivd that thy had a high liklihood of contracting HIV. This pattrn is particularly obsrvabl in Malawi and Uganda. On th othr hand, thr is no clar pattrn in th lvl of prcivd risk btwn urban and rural aras in most of th four countris. Nvrthlss, rural Ugandan mal adolscnts ar significantly mor likly to prciv grat risk of contracting HIV compard to thir urban countrparts. Tabl 3a: HIV risk prcption by slctd sociodmographic charactristics: Sxually inxprincd boys Burkina Faso Ghana Malawi Gra t Modrat Smal l Non DK Numb r Gra t Modrat Smal l Non DK Numb r Gra t Modrat Ag *** Education *** *** Non Primary Scondary Has discussd AIDS with ** family mmbrs Ys No Has discussd AIDS with frinds 13. African Journal of Rproductiv Halth Dcmbr 013 (Spcial Edition on HIV/AIDS); 17(4): 39 Smal l Non D K Numb r *** Ys No Thinks that a halthylooking *** *** could b HIV + Ys No Don t know HIV prvalnc in th rgion of rsidnc ** *** Lss than %

9 -4% % Mor than 8% Plac of rsidnc * Rural Urban Houshol d walth * quintil Poorst Scond Middl Fourth Walthist Ovrall Tabl 3a continud Uganda All countris Grat Modrat Small Non DK Numbr Grat Modrat Small Non DK Numbr Ag *** Education Non Primary Scondary Has discussd AIDS with family mmbrs * Ys No Has discussd AIDS with frinds *** Ys No Thinks that a halthy-looking prson could b HIV + Ys No Don t know HIV prvalnc in th rgion of rsidnc Lss than % % % Mor than 8% Plac of rsidnc *** Rural Urban Houshold walth quintil *** African Journal of Rproductiv Halth Dcmbr 013 (Spcial Edition on HIV/AIDS); 17(4): 40

10 Poorst Scond Middl Fourth Walthist Ovrall Not: Rspondnts who hav nvr hard of HIV or who dclard to alrady hav HIV ar xcludd. All figurs wr calculatd using th appropriat country survy wights, or poold wights for all countris. Chi-squar tsts assss diffrncs btwn lvl of HIV risk prcption; *p<.05. **p<.01. ***p<.001. Tabl 3b: HIV risk prcption by slctd sociodmographic charactristics: Sxually inxprincd girls Burkina Faso Ghana Malawi Gra t Modrat Smal l Non DK Numb r Gra t Modrat Smal l Non DK Numb r Gra t Modrat Ag ** ** *** Educatio n *** *** Non Primary Scond ary Has discussd AIDS with *** * family mmbrs Ys No Has discussd AIDS *** ** with frinds Ys No Thinks that a halthylooking prson *** *** *** could b HIV + Ys No Don t know HIV prvalnc in th rgion of rsidnc * *** *** Lss than % % African Journal of Rproductiv Halth Dcmbr 013 (Spcial Edition on HIV/AIDS); 17(4): 41 Smal l Non DK Numb r

11 4-8% Mor than 8% Plac of rsidnc *** *** Rural Urban Houshol d walth ** *** quintil Poorst Scond Middl Fourth Walthist Ovrall Tabl 3b continud Uganda All countris Grat Modrat Small Non DK Numbr Grat Modrat Small Non DK Numbr Ag Education Non Primary Scondary Has discussd AIDS with family mmbrs Ys No Has discussd AIDS with frinds *** Ys No Thinks that a halthy-looking prson could b HIV + Ys No Don t know HIV prvalnc in th rgion of rsidnc Lss than % % % Mor than 8% Plac of rsidnc *** Rural Urban Houshold walth quintil Poorst Scond Middl Fourth Walthist Ovrall Not: Rspondnts who hav nvr hard of HIV or who dclard to alrady hav HIV ar xcludd. All figurs wr calculatd using th appropriat country survy wights, or poold wights for all countris. Chi-squar tsts assss diffrncs btwn lvl of HIV risk prcption; *p<.05, **p<.01, ***p<.001. African Journal of Rproductiv Halth Dcmbr 013 (Spcial Edition on HIV/AIDS); 17(4): 4

12 Multivariat rgrssion rsults Th multivariat rgrssion analysis aimd to idntify th prsonal, nvironmntal and community factors that shapd adolscnts HIV risk prcption bfor thy bcam sxually activ. As indicatd prviously, two sts of ordrd logistic rgrssion modls wr constructd for ach sx (Tabl 4): a modl without intractions and a modl with a sris of intractions btwn som of th indpndnt variabls. Influnc of individual charactristics (ag, ducation, HIV knowldg) on th lvl of HIV risk prcption Th rsults in Tabl 4 show that among both boys and girls, oldr ag was significantly associatd with highr HIV risk prcption compard to young ag (1-14 yars) (odds ratio of 1.7 for boys of both and yars; 1.1 and 1.77 for girls of and yars, rspctivly). Rsults for ducation wr, on th contrary, significant only for boys. Mal adolscnts with primary or scondary ducation wr significantly lss likly to bliv thy had a high risk of contracting HIV compard to thos without any ducation (odds ratio of 0.56 and 0.53 rspctivly for primary and scondary lvl); for girls th pattrn was irrgular and non-significant. As for knowldg about HIV, both mal and fmal adolscnts with inaccurat HIV knowldg (that is, thos who thought that a halthy-looking prson could not b HIV positiv) wr mor likly to hav a lowr HIV risk prcption as compard to thos with accurat knowldg. Th sam pattrn was obsrvd among both mals and fmals who did not know if a halthy-looking prson could b HIV positiv or not. Convrsational ntworks influnc on HIV risk prcption Th ffct of adolscnts ntworks on thir HIV risk prcption was capturd through th influnc of thir discussions about HIV within thir prsonal communication circls. Frinds ntworks appar to b significantly associatd with th lvl of prcivd HIV risk, spcially among girls: girls who discussd HIVrlatd issus with frinds had a highr prcivd risk compard to thos who did not discuss th issu with frinds (odds ratio of 1.3); for boys th corrsponding odds ratio was 1.1 and p<0.1. Thr was also a significant and incrasing influnc of family ntworks on risk prcption for both boys and girls (odds ratio of 1.4 and 1.30, rspctivly). Association btwn charactristics of adolscnts nvironmnt (typ of rsidnc, rgional HIV prvalnc, houshold socioconomic status, country of rsidnc) and thir HIV risk prcption Th typ of rsidnc (urban vs. rural) appard to hav no significant association with th lvl of HIV risk prcption for both boys and girls (Tabl 4). HIV prvalnc in th rgion of rsidnc, howvr, was significantly associatd with HIV risk prcption. Compard to thos from rgions with lss than % HIV prvalnc, adolscnt boys rsiding in rgions with an HIV prvalnc of 4% or highr prcivd thmslvs to b at highr risk. On th othr hand, th odds of prcivd high HIV risk wr significantly lowr whn th HIV prvalnc in th rgion of rsidnc was btwn % and 4%, compard to rgions with lss than % of HIV prvalnc. Th sam pattrn was obsrvd among girls, but to a lssr xtnt. Thr was also a significant association btwn houshold socioconomic status and HIV risk prcption among both mal and fmal adolscnts. Compard to adolscnts from th poorst walth quintil, thos from th othr quintils wr mor likly to prciv that thy had a highr risk of gtting HIV. With rgard to th association btwn country of rsidnc and HIV risk prcption, living in Uganda was significantly associatd with highr prcivd risk for both boys and girls (odds ratio of.13 and 3.74 rspctivly), as compard to Burkina Faso. Th sam pattrn was obsrvd for boys in Ghana compard to boys in Burkina Faso (odds ratio of 1.45). African Journal of Rproductiv Halth Dcmbr 013 (Spcial Edition on HIV/AIDS); 17(4): 43

13 Tabl 4: Odds ratios for HIV risk prcption among sxually inxprincd adolscnts from multivariat ordrd logistic rgrssion (poold data), by sx Without intractions With intractions Boys P-valu Girls P-valu Boys P-valu Girls P-valu Ag Education Non Primary Scondary Adolscnt s ntworks Had AIDS discussion with Family mmbrs Had AIDS discussion with Frinds Knowldg: A halthy-looking prson can b HIV positiv Ys No Don t know HIV prvalnc in th living rgion Lss than % % % Mor than 8% Typ of Rsidnc Rural Urban Houshold walth indx Poorst Scond Middl Fourth Walthist Country of rsidnc Burkina Faso Ghana Malawi Uganda Intractions AIDS discussion with frinds in Burkina (Rf) 1 1 AIDS discussion with frinds in Ghana AIDS discussion with frinds in Malawi AIDS discussion with frinds in Uganda AIDS discussion with family mmbrs in Burkina (Rf) 1 1 AIDS discussion with family mmbrs in Ghana AIDS discussion with family mmbrs in Malawi AIDS discussion with family mmbrs in Uganda AIDS discussion with frinds among 1-14 yars old (Rf) 1 1 AIDS discussion with frinds among AIDS discussion with frinds among AIDS discussion with family among 1-14 yars old (Rf) 1 1 AIDS discussion with family among AIDS discussion with family among Knowldg among 1-14 yars old (Rf) 1 1 A halthy-looking prson cannot b HIV positiv_ A halthy-looking prson cannot b HIV positiv_ Don t know if a halthy-looking prson can b HIV African Journal of Rproductiv Halth Dcmbr 013 (Spcial Edition on HIV/AIDS); 17(4): 44

14 positiv_15-17 Don t know if a halthy-looking prson can b HIV positiv_ Total numbr of obsrvations Cut Cut Intraction ffcts of som variabls on adolscnts' HIV risk prcption W stimatd intraction trms to assss to what xtnt th ffct of on indpndnt variabl on HIV risk prcption dpndd on th chang in anothr indpndnt variabl. W addrssd th following qustions, du to thir programmatic implications: Is th ffct of family ntworks on HIV risk prcption th sam for 1-14, 15-17, and yars old? Is th significant ffct of knowldg on HIV risk prcption th sam for all ag sub-groups? Is thr any variation in th obsrvd ffcts within sub-groups? Th intraction ffcts of som variabls on adolscnts' HIV risk prcption ar shown in Tabls 6 and 7. In tabl 5, for all countris, th cofficints of th intraction btwn discussion with family mmbrs and countris (.15, 1.46, 1.15, and 1.11, rspctivly for Burkina, Ghana, Malawi, and Uganda) should b intrprtd using adolscnt boys and girls who did not discuss HIV in Burkina Faso as th rfrnc catgory (notd as 1). Givn that thr is no intraction trm whn thr is no discussion, th cofficints in this tabl for thos who did not discuss (1.41 and 0.89; 1.04 and 1.84;.53 and 4.30, rspctivly for boys and girls in Ghana, Malawi, and Uganda) ar xactly th sam as th cofficints obtaind in Tabl 4 (column with intractions) for ach country. In th sam way, for all ag groups in Tabl 5, th cofficints for th intraction btwn discussion with family mmbrs and ag groups ar intrprtd using adolscnt boys and girls who did not discuss HIV among 1-14 yars old as th rfrnc catgory (notd as 1). Th cofficints for thos who did not discuss (1.47 and 1.39; 1.48 and 1.98, rspctivly for boys and girls agd and yars) ar xactly th sam as th cofficints obtaind in Tabl 4 (column with intractions) for ach ag group. Thus, Tabl 5 shows that, in Burkina Faso, among both boys and girls, having had a discussion of AIDS with family ntworks was significantly associatd with highr HIV risk prcption (odds ratio of.15 and 1.96 rspctivly) compard to thos who did not hav any discussion. In th othr countris, only Ghanaian adolscnt mals who had discussd AIDS with family mmbrs wr significantly mor likly to prciv that thy had a highr risk compard to thir countrparts from Burkina Faso (odds ratio of 1.46). Tabl 5: Intraction ffcts of discussion with family mmbrs on sxually inactiv adolscnt's HIV risk prcption Country Burkina Had discussd AIDS with family mmbrs OR Had not discussd AIDS OR (95% CI) (95% CI) Mal Fmal Mal Fmal.15*** [ ] 1.96*** [ ] 1 1 Ghana Malawi Uganda 1.46* [ ] 1.15 [ ] 1.11 [ ] 1.8 [ ] 0.96 [ ] 1.6 [ ] 1.41 [ ] 1.04 [ ].53*** [ ] 0.89 [ ] 1.84* [ ] 4.30*** [ ] Ag groups 1-14yars old.15*** [ ] 1.96*** [ ] 1 1 African Journal of Rproductiv Halth Dcmbr 013 (Spcial Edition on HIV/AIDS); 17(4): 45

15 [ ].5* [ ] 1.77** [ ].6* [ ] 1.47*** [ ] 1.48** [ ] 1.39** [ ] 1.98*** [ ] Significant at: *p<0.05, **p<0.01, ***p<0.001 With rgard to intraction ffct btwn ag and AIDS discussion with family ntworks, having had a discussion about AIDS with family mmbrs was significantly associatd with highr HIV risk prcption among both mal and fmal adolscnts within ag groups as compard to thir countrparts of 1-14 yars old who did not hav ths discussions, xcpt for boys agd yars. In particular, among thos agd 1-14 yars, both mal and fmal adolscnts who discussd HIV with family mmbrs wr mor likly to prciv that thy had a highr HIV risk than thos of th sam group who did not hav ths discussions (odds ratio of.15 and 1.96 rspctivly for mals and fmals adolscnts 1-14 yars). Th sam tndncy was obsrvd for th yar sub-group, whr having discussd HIV with family ntworks was significantly associatd with highr HIV risk prcption for both mal and fmal adolscnts (odds ratio of.5 and.6 rspctivly), as compard to thos agd 1-14 yars who did not discuss HIV. Tabl 6: Intraction ffcts of knowldg (a halthy-looking prson could b HIV positiv) and ag on sxually inactiv adolscnts HIV risk prcption No, a halthy-looking prson could not b HIV positiv Don t know if a halthy-looking prson could b HIV positiv Ys, a halthy-looking prson could b HIV positiv Ag Mal Fmal Mal Fmal Mal Fmal [ ] 0.90 [ ] 0.48*** [ ] 0.6* [ ] * [ ] 0.7** [ ] 0.40*** [ ] 0.54* [ ] 1.47*** [ ] 1.39** [ ] *** [ ] 0.68 [ ] 0.40 [ ] 1.03 [ ] 1.48** [ ] 1.98*** [ ] Significant at: *p<0.05, **p<0.01, ***p<0.001 Th intraction ffcts of knowldg and ag on sxually inactiv adolscnts' HIV risk prcption ar prsntd in Tabl 6. Adolscnts agd yars who had inaccurat HIV knowldg (that is, thos who said that a halthylooking prson could not b HIV positiv, or that thy did not know) wr significantly lss likly to prciv that thy had a highr risk of HIV (odds ratio of 0.74 and 0.7, rspctivly, for boys and girls) compard to thir countrparts of agd 1-14 yars who knw that a halthy-looking prson could b HIV positiv. Th sam pattrn was obsrvd for mal adolscnts agd yars: adolscnt boys in this ag group who rportd that a halthy-looking prson could not b HIV positiv wr significantly lss likly to prciv that thy had a highr risk of HIV (odds ratio of 0.44), as compard to thir countrparts agd 1-14 yars who knw that a halthy-looking prson could b HIV positiv. Similar rsults wr obsrvd among adolscnts who rportd that thy did not know whthr a halthy-looking prson could b HIV positiv but only for thos agd 1-14 and yars: adolscnts agd 1-14 yars who did not know if a halthy-looking prson could b HIV positiv wr significantly lss likly to prciv a highr risk of HIV (odds ratio of 0.48 and 0.6,rspctivly, for boys and African Journal of Rproductiv Halth Dcmbr 013 (Spcial Edition on HIV/AIDS); 17(4): 46

16 girls), compard to thir countrparts agd 1-14 both sxs in th four countris lads us to furthr yars who knw that a halthy-looking prson qustion th consistncy and rliability of could b HIV positiv. Th sam tndncy was obsrvd for adolscnts agd yars (odds ratio of 0.40 and 0.54, rspctivly, for boys and girls). adolscnts rsponss in contxts whr having sx is viwd as shamful and whr virginity is on of th most important valus, spcially for unmarrid womn. Unfortunatly, absnt othr data sourcs to Discussion validat th answrs givn in th survys, w cannot assss th xtnt to which adolscnts gav Data from four nationally rprsntativ survys of adolscnts carrid out in Burkina Faso, Ghana, truthful answrs whn intrviwd. Whn w tak thir rsponss at fac valu, w find that Malawi and Uganda showd that a surprisingly adolscnts immdiat nvironmnt, thir high proportion of sxually inactiv adolscnts blivd that thy hav a high liklihood of contracting HIV in th futur. This finding bgs intractions with prs and othr community mmbrs, schools and rligious mmbrship as wll as th broad socio-cultural viw, smd to th qustion as to why this should b th cas, constitut th main factors shaping thir sinc it is wll known that in this rgion HIV/AIDS is mainly sxually transmittd. On obvious answr would b that adolscnts did not truthfully answr th survy qustion about having bn sxually activ. In othr words, it could b th cas that adolscnts who wr actually sxually activ, and wr thus worrid about bing at risk of contracting HIV/AIDS, did not want to shar this information with an unknown intrviwr. Givn th administration of th survy in th houshold, th prsnc of othr popl within haring distanc, or th far othrs might har may also hav influncd adolscnts rsponss, although all prcautions wr takn to avoid this circumstanc. At last a fw studis in sub-saharan Africa hav shown that som rports about individual prcptions of HIV risk. HIV prvalnc in th rgion of rsidnc was strongly associatd with a high lvl of concrn about HIV, spcially whr prvalnc was rlativly high. This finding dmonstrats th influnc of th social nvironmnt surrounding adolscnts on thir prcptions 30,6. It is also consistnt with what Bühlr and Kohlr 3 found in Knya, whr prcivd risks wr dpndnt on prcptions prvailing within prsonal clos circls. W also found that adolscnts with a primary or scondary ducation had lowr HIV risk prcption than thos without any ducation. It is also plausibl that ducatd adolscnts may hav rportd lowr risk prcptions bcaus thy wr mor informd and bttr prpard to accuratly sxual bhaviour could b unrliabl. For assss thir own risk profil 13. xampl, in a study that compard rports on first sxual ncountrs btwn a standard survy and an in-dpth intrviw in Malawi, Poulin 44 found that a significant proportion of adolscnt girls who claimd in th survy to hav nvr bn sxually activ rportd sxual xprinc during th in-dpth intrviw fildd shortly thraftr. Plummr t al 45 and Mnsch t al 46, found that a significant numbr of womn who dclard that thy had nvr had intrcours tstd positiv for HIV in Tanzania and Malawi, two sttings whr HIV infction in th ovrwhlming majority of cass is a rsult of unprotctd sx. Th fact that our rsults show highr lvl of prcivd HIV risk among oldr and lss ducatd adolscnts of Th rsults showd a statistically significant intraction btwn HIV-rlatd knowldg and ag subgroups. This is important vidnc that inaccurat knowldg combind with ag lads to a gratr undrstimation of HIV risk prcption: th oldr and mor ignorant th adolscnt is, th gratr th undrstimation of risk prcption. Ths rsults ar consistnt with what Millstin and Halprn-Flshr 47 found in thir study in th Unitd Stats, whr adolscnts wr lss likly than wr young adults to s thmslvs as invulnrabl. Th rsults also highlight th urgncy of dvloping ffctiv intrvntion programs to protct th nxt gnrations in sub- Saharan Africa from HIV by quipping young African Journal of Rproductiv Halth Dcmbr 013 (Spcial Edition on HIV/AIDS); 17(4): 47