The roll-out of antiretroviral therapy (ART) has changed contexts of HIV risk, but the influence on HIV incidence among young women is not clear. We aimed to summarise direct estimates of HIV incidence among adolescent girls and young women since ART and before large investments in targeted prevention for those in sub-Saharan Africa. We did a systematic review and meta-analysis. We searched MEDLINE, Embase, Web of Science, Global Health, and CINAHL for studies reporting HIV incidence data from serological samples collected among females aged 15-24 years in ten countries (Kenya, Lesotho, Malawi, Mozambique, South Africa, Swaziland, Tanzania, Uganda, Zambia, and Zimbabwe) that were selected for DREAMS investment in 2015. We only included articles published in English. Our main outcome was to summarise recent levels and trends in HIV incidence estimates collected between 2005 and 2015, published or received from study authors, by age and sex, and pooled by region. 51 studies were identified from nine of the ten DREAMS countries; no eligible studies from Lesotho were identified. Directly observed HIV incidence rates were lowest among females aged 13-19 years in Kumi, Uganda (0·38 cases per 100 person-years); and directly observed HIV incidence rates were highest in KwaZulu-Natal, South Africa (7·79 per 100 person-years among females aged 15-19 years, and 8·63 in those aged 20-24 years), among fishing communities in Uganda (12·40 per 100 person-years in females aged 15-19 years and 4·70 in those aged 20-24 years), and among female sex workers aged 18-24 years in South Africa (13·20 per 100 person-years) and Zimbabwe (10·80). In pooled rates from the general population studies, the greatest sex differentials were in the youngest age groups-ie, females aged 15-19 years compared with male peers in both southern African (pooled relative risk 5·94, 95% CI 3·39-10·44) and eastern African countries (3·22, 1·51-6·87), and not significantly different among those aged 25-29 years in either region. Incidence often peaked earlier (during teenage years) among high-risk groups compared with general populations. Since 2005, HIV incidence among adolescent girls and young women declined in Rakai (Uganda) and Manicaland (Zimbabwe), and also declined among female sex workers in Kenya, but not in the highest-risk communities in South Africa and Uganda. Few sources of direct estimates of HIV incidence exist in high-burden countries and trend analyses with disaggregated data for age and sex are rare but indicate recent declines among adolescent girls and young women. In some of the highest-risk settings, however, little evidence exists to suggest ART availability and other efforts slowed transmission by 2016. Despite wide geographical diversity in absolute levels of incidence in adolescent girls and young women, risk relative to males persisted in all settings, with the greatest sex differentials in the youngest age groups. To end new infections among the growing population of adolescents in sub-Saharan Africa, prevention programmes must address gender inequalities driving excessive risk among adolescent girls. This work was conducted as part of a planning grant funded by the Bill & Melinda Gates Foundation.

HIV risk remains unacceptably high among adolescent girls and young women (AGYW) in southern and eastern Africa, reflecting structural and social inequities that drive new infections. In 2015, PEPFAR (the United States President’s Emergency Plan for AIDS Relief) with private-sector partners launched the DREAMS Partnership, an ambitious package of interventions in 10 sub-Saharan African countries. DREAMS aims to reduce HIV incidence by 40% among AGYW over two years by addressing multiple causes of AGYW vulnerability. This protocol outlines an impact evaluation of DREAMS in four settings. To achieve an impact evaluation that is credible and timely, we describe a mix of methods that build on longitudinal data available in existing surveillance sites prior to DREAMS roll-out. In three long-running surveillance sites (in rural and urban Kenya and rural South Africa), the evaluation will measure: (1) population-level changes over time in HIV incidence and socio-economic, behavioural and health outcomes among AGYW and young men (before, during, after DREAMS); and (2) causal pathways linking uptake of DREAMS interventions to ‘mediators’ of change such as empowerment, through to behavioural and health outcomes, using nested cohort studies with samples of ~ 1000–1500 AGYW selected randomly from the general population and followed for two years. In Zimbabwe, where DREAMS includes an offer of pre-exposure HIV prophylaxis (PrEP), cohorts of young women who sell sex will be followed for two years to measure the impact of ‘DREAMS+PrEP’ on HIV incidence among young women at highest risk of HIV. In all four settings, process evaluation and qualitative studies will monitor the delivery and context of DREAMS implementation. The primary evaluation outcome is HIV incidence, and secondary outcomes include indicators of sexual behavior change, and social and biological protection. DREAMS is, to date, the most ambitious effort to scale-up combinations or ‘packages’ of multi-sectoral interventions for HIV prevention. Evidence of its effectiveness in reducing HIV incidence among AGYW, and demonstrating which aspects of the lives of AGYW were changed, will offer valuable lessons for replication.

A global campaign to end “child marriage” has emerged over the last decade as part of growing international commitments to address gender inequities and improve female wellbeing. Campaigns typically assert that young brides have negligible autonomy in the marriage process and that marrying under 18 years has resolutely negative impacts on wellbeing. Yet, surprisingly few studies explore local attitudes towards marriage and its timing within contexts where early marriage is most common. As such our understanding of motivations and potential conflicts of interest leading female adolescents into marriage remain poorly informed by viewpoints of people purportedly at risk. We present an exploratory study of attitudes to early marriage in northwestern Tanzania where marriage before or shortly after 18 years is normative. We use focus group discussions, complimented by a survey of 993 women, to investigate local views on marriage. We explore (i) why people marry, (ii) when marriage is deemed appropriate, and (iii) who guides the marriage process. Contrary to dominant narratives in the end child marriage movement, we find that women are frequently active rather than passive in the selection of when and who to marry. Furthermore, marriage is widely viewed as instrumental in acquiring social status within one’s local community. Our conclusions illuminate why rates of early marriage remain high despite potential negative wellbeing consequences and increasingly restrictive laws. We discuss our results in relation to related qualitative studies in other cultural contexts and consider the policy implications for current efforts to limit early marriage in Tanzania and beyond.

Low fertility across Europe highlights the need to understand reproductive decisions in high-income countries better. Availability of support may be one factor influencing reproductive decisions, though within high-income countries availability varies between environments, including socio-economic environments. We test whether receiving higher levels of support, from different sources (informal and formal) and of different types (practical and emotional), is positively correlated with second births in the United Kingdom (UK) Millennium Cohort Study, and whether these relationships differ by socio-economic position (SEP). Our hypothesis is only partially supported: receiving emotional support correlates with higher likelihood of second birth, but the opposite is true for practical support. Availability of different types of support varies across SEP, but relationships between support and fertility are similar, with one exception: kin-provided childcare increases the likelihood of birth only among lower-SEP women. Our results highlight that not all support is equal in the decision to have a second child.

Studies of the association between wealth and fertility in industrial populations have a rich history in the evolutionary literature, and they have been used to argue both for and against a behavioral ecological approach to explaining human variability. We consider that there are strong arguments in favor of measuring fertility (and proxies thereof) in industrial populations, not least because of the wide availability of large-scale secondary databases. Such data sources bring challenges as well as advantages, however. The purpose of this article is to illustrate these by examining the association between wealth and reproductive success in the United States, using the National Longitudinal Study of Youth 1979. We conduct a broad-based exploratory analysis of the relationship between wealth and fertility, employing both cross-sectional and longitudinal approaches, and multiple measures of both wealth (income and net worth) and fertility (lifetime reproductive success and transitions to first, second and third births). We highlight the kinds of decisions that have to be made regarding sample selection, along with the selection and construction of explanatory variables and control measures. Based on our analyses, we find a positive effect of both income and net worth on fertility for men, which is more pronounced for white men and for transitions to first and second births. Income tends to have a negative effect on fertility for women, while net worth is more likely to positively predict fertility. Different reproductive strategies among different groups within the same population highlight the complexity of the reproductive ecology of industrial societies. These results differ in a number of respects from other analyses using the same database. We suggest this reflects the impossibility of producing a definitive analysis, rather than a failure to identify the “correct” analytical strategy. Finally, we discuss how these findings inform us about (mal)adaptive decision-making.

Global health studies typically characterise adolescent marriage as a fundamental risk to female wellbeing. In contrast, ethnographic research among communities ‘at risk’ identifies that early marriage is often viewed as an opportunity weighed against locally feasible alternatives. Addressing this contradiction, we document perceived risks and opportunities of marriage, positioning them among wider concerns facing female adolescents in north-western Tanzania. On the basis of these data, we then provide recommendations for global efforts to end the marriage of minors. Thirteen focus groups and 26 in-depth interviews were conducted in 2019 with female adolescents, young women and men, and parents of female adolescents from a semi-urban community where adolescent marriage is normative. Data were compiled to synthesise narratives of adolescent risk and opportunity. Marriage was viewed as an opportunity for adolescent girls, bringing benefits such as increased social status. Risks sometimes outweighed benefits of marriage, but marriage remained desirable when structural constraints, like poverty, limited feasible alternatives and when adolescents faced similar risks, like pregnancy, outside of marriage. We conclude that remaining unmarried does not shield adolescents from adversity, and campaigns targeting adolescent marriage via criminalisation, without diminishing other risks of adolescence, may further limit rather than expand options for adolescent girls.