Persistent Structural Correlates of HIV Risk: The Role of Educational Attainment and Early Sexual Debut Among Adolescent Girls and Young Women in Eswatini, 2016-2021 Restricted; Files Only

Abstract

Background: Adolescent girls and young women (AGYW) in Eswatini bear a disproportionate burden of HIV, with prevalence rates more than three times higher than their male peers. Early sexual debut (defined as first sex at or before age 15) and limited educational attainment are key structural determinants of HIV vulnerability. This study aimed to characterize the relationship between early debut, education, and HIV status among AGYW in Eswatini and assess whether these associations changed between 2016 and 2021 in the context of expanded HIV prevention programming.

Methods: Data were drawn from two cross-sectional, nationally representative surveys, the Swaziland HIV Incidence Measurement Surveys (SHIMS2 in 2016 and SHIMS3 in 2021). The analytic sample included sexually active AGYW aged 15–24 with confirmed HIV status. Early sexual debut and educational attainment were modeled as predictors of HIV status, while early debut was also examined as an outcome. Logistic regression models assessing early sexual debut as the outcome were stratified by survey year and adjusted for age, urban/rural residence, wealth quintile, employment, and education variables. Logistic regression models assessing HIV status as the outcome included early sexual debut, school attendance, highest level of education attained, employment, and survey year as predictors, with interaction terms testing whether associations changed over time.

Results: Among 2,185 AGYW, the prevalence of early sexual debut declined from 13.4% in 2016 to 9.9% in 2021, while HIV prevalence fell from 21.0% to 13.5%. Compared to those with only primary education, AGYW with tertiary education had significantly lower odds of early sexual debut (2021 aOR: 0.08; 95% CI: 0.02–0.28) and HIV positivity (aOR: 0.34; 95% CI: 0.22–0.52). Early sexual debut was associated with higher odds of HIV infection (aOR: 1.51; 95% CI: 0.78–2.91); however, this association was not statistically significant. Interaction terms, presented as aORs, indicated no significant temporal change in the relationship between early debut and HIV infection or between education and HIV over the five-year period.

Conclusions: Despite substantial progress in HIV prevention, including ART scale-up and expanded biomedical interventions, the associations between early sexual debut, educational attainment, and HIV status remained unchanged over time. Higher educational attainment consistently demonstrated a protective association with reduced odds of early sexual debut and HIV positivity. These findings underscore the enduring influence of structural factors, particularly educational access and attainment, in shaping HIV vulnerability among AGYW in Eswatini. Sustained investments in school retention and structural interventions are critical to reducing HIV vulnerability among AGYW in Eswatini.

Table of Contents

CHAPTER I: LITERATURE REVIEW........................................................................ 1

HIV Incidence and Prevalence in Eswatini.............................................................. 1

HIV Epidemic Control............................................................................................. 3

Youth, Adolescents, and HIV in Eswatini................................................................ 4

Early Sexual Debut and HIV Risk............................................................................ 6

Impact of the UNAIDS 95-95-95 Targets and Initiative in Eswatini....................... 9

Initiatives that Focus on AGYW............................................................................ 13

History of PHIA...................................................................................................... 18

SHIMS Methods..................................................................................................... 20

Gaps in Current Research and Knowledge............................................................. 23

CHAPTER II: MANUSCRIPT.................................................................................... 25

Introduction............................................................................................................ 25

Methods.................................................................................................................. 26

Study Population................................................................................................. 26

Study Variables and Data Sources...................................................................... 27

Data Analysis...................................................................................................... 28

Ethical Considerations........................................................................................ 29

Results.................................................................................................................... 31

Participants.......................................................................................................... 31

Trends in Sexual Debut....................................................................................... 31

Correlates of Early Sexual Debut....................................................................... 32

Correlates of HIV Status..................................................................................... 33

Discussion............................................................................................................... 34

CHAPTER III: PUBLIC HEALTH IMPLICATIONS.............................................. 39

TABLES AND FIGURES.......................................................................................... 42

REFERENCES........................................................................................................... 48

About this Master's Thesis

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School	Rollins School of Public Health
Department	Executive Masters of Public Health - MPH
Degree	M.P.H.
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Epidemiology Health Sciences, Public Health
Keyword	Eswatini Global Health HIV
Committee Chair / Thesis Advisor	Shah, Sarita, Emory University
Committee Members	Justman, Jessica, Columbia University

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