Adolescents’ girls and young (AGYW) people represent a growing share of people living with HIV worldwide. In 2019, it was estimated that over 1.7 million adolescents were living with HIV worldwide, with approximately 88% of all HIV infected adolescents residing in sub-Saharan Africa (1). The World Health Organization (WHO) estimated that 30% of all new HIV infections globally occur among young people aged 10–24. Adolescents aged 10–19 account for approximately 5% of all people living with HIV worldwide, but 10% of all new HIV infections are occurring amongst adolescents (2). The 2015/16 Malawi Demographic and Health Survey (MDHS) estimated that the HIV prevalence among young people was 3%. The HIV prevalence among AGYW was approximately 5 times higher compared to their male counterparts (4.9% versus 1%) respectively (3). The Malawi Population based HIV Impact Assessment (MPHIA) estimated that the HIV prevalence among young people aged 15 to 24 was 2.5% with high prevalence reported among AGYW compared to adolescent boys and young men (3.4% versus 1.5%) respectively (4).
HIV infection among AGYW is predicted by many factors broadly categorized into structural determinants and sexual behavior factors. Structural drivers of HIV are factors that relate to socio-economic, educational attainment, service provision and organizational factors (5). Sexual behavior factors are those that relate to early sexual debut, multiple and concurrent partnerships, transactional sex practices, low condom use and drug and substance abuse (6–10). History of anal sex, having a partner suspected of having or known to be HIV positive and multiple and concurrent sexual partners have shown to be strongly correlated with HIV infections among AGYW (11). Evidence has been documented on the protective effect of sexuality education and parental education on HIV acquisition (8). Gender inequalities, violence against women (VAW), stigma & discrimination and limited access to sexual & reproductive health information and services are some of the structural factors that hinder adolescent girls and young women’s ability to protect themselves from HIV (12). HIV infection poses a serious threat to the AGYW’s educational attainment and future carrier prospects. HIV infected AGYW are associated with low school attendance and high school dropouts due to HIV related morbidity (13). While HIV infection has not been shown to affect enrolment in schools, a study on HIV and educational attainments in South Africa found that adolescent HIV infection significantly reduced their school progress index (14). Among women aged 15–44, HIV is one of the leading causes of death globally with higher death rates among AGYW (15).
Combination HIV prevention has shown to be a key strategy in achieving the United Nations AIDS 95, 95, 95 target set in 2014. The target states that by 2020, 95% of people living with HIV will know their status, 95% of those diagnosed with HIV will receive sustained antiretroviral therapy and 95% of those receiving antiretroviral therapy will have their viral load suppressed (16). Most HIV prevention strategies mainly that focus on correct and consistent condom use and are largely male dominated which leaves women with less control (17). Evidence from studies on use of PreP for HIV prevention have shown that PreP is an effective additional preventive measure for AGYW (17, 18).
Early sexual debut defined sexual intercourse occurring typically before the age of 15 and below has been shown to be associated with higher chances of contacting STIs including HIV (19–22). Knowing the effect of early sexual debut will help design interventions that target AGYW with elevated risk. The purpose of this study was to assess the effect of early sexual debut on HIV acquisition among AGYW in Malawi using MPHIA dataset.