Substance use problems undermine HIV treatment and secondary prevention efforts. Research is needed to better understand predictors of substance use among people living with HIV (PLWH). We examined whether internalized stigma and enacted HIV stigma are associated with three indicators of substance use among PLWH, including numbers of (1) substances used, (2) substances used at moderate to high risk, and (3) times substances were used before sex, through the mediator of depressive symptoms. Participants included 358 PLWH aged 18–35 years from Georgia, United States. At baseline, participants completed measures of internalized and enacted stigma, depressive symptoms, and substance use severity. Substance use was additionally tested with urinalysis. Following baseline, participants reported their use of substances before sex for 28 days through daily text messaging. Data were analyzed using path analysis in R. On average, participants tested positive for 1.24 (range: 0–6) substances used, reported moderate to high risk on 2.01 (range: 0–8) substances, and reported using substances 1.57 (range: 0–20) times before sex over 28 days. Internalized stigma and enacted stigma were associated with greater depressive symptoms, and depressive symptoms were associated with all three indicators of substance use. Moreover, the indirect effects between internalized and enacted stigma with indicators of substance use were significant, suggesting that depressive symptoms partially mediated associations between stigma and substance use. Interventions may be needed to address both stigma and depressive symptoms among PLWH to reduce substance use and support HIV treatment and prevention efforts.

Background. Prevention of both school dropout and teen pregnancy represent clear public health priorities for South Africa, yet their complex and potentially cyclical relationship has not been fully explored. Objective. To further understand how this relationship operates, we analyzed data from a randomized trial of young women aged 13 to 20 years enrolled in school in rural South Africa to estimate the association between pregnancy and subsequent dropout and between dropout and subsequent pregnancy. Method. We examined inverse probability (IP) of exposure-weighted survival curves for school dropout by pregnancy and for pregnancy by school dropout. We used weighted curves to calculate 1-, 2-, and 3-year risk differences and risk ratios. Additionally, we used an IP-weighted marginal structural cox model to estimate a hazard ratio (HR) for each relationship. Results. Dropout from school was associated with subsequent pregnancy (HR 3.58; 95% confidence interval [CI] [2.04, 6.28]) and pregnancy was associated with subsequent school dropout (HR 2.36; 95% CI [1.29, 4.31]). Young women who attended school but attended fewer days had a higher hazard of pregnancy than those who attended more school (HR 3.64; 95% CI [2.27, 5.84]). Conclusion. Pregnancy is both a cause and a consequence of school dropout. Consideration of school attendance and academic performance could ultimately enhance pregnancy prevention efforts in this population. Programs should be tailored differently for (1) girls who have dropped out of school, (2) those who are in school and at risk for pregnancy, and (3) those who are in school and become pregnant.

Adolescent girls and young women (AGYW) aged 15–24 years have among the highest risk for HIV and other sexually transmitted infections (STI) across sub-Saharan Africa. A latent class analysis (LCA) was conducted to identify intersecting social- and structural-level determinants of HIV/STI acquisition among AGYW in Ethiopia. AGYW were recruited from venues using time-location sampling, completing an interviewer-administered behavioral survey and biological testing for HIV, syphilis, and chlamydia. LCA was used to identify distinct groups, defined by social- and structural-level determinants of HIV/STI risk, among AGYW. Prevalence ratios (PR) and 95% confidence intervals (CI) compared differences in HIV/STI prevalence by group. A total of 1,501 AGYW were enrolled across Addis Ababa (March–May 2018) and Gambella (June–July 2019). We identified three patterns of vulnerability defined by schooling status, migration history, food insecurity, orphan status, social support, and employment. We labeled these groups as “highly vulnerable” (representing ~21% of the population), “stable, out-of-school, migrated” (~42%), and “stable, in-school, never migrated” (~37%). STI prevalence was nearly two-fold higher among AGYW in the “highly vulnerable” group compared to AGYW in the “stable, in-school, never migrated” group (PR 1.93; 95% CI 1.33, 2.80). Characterizing patterns of vulnerability among AGYW that reflect higher-level social and structural factors can help facilitate early identification of AGYW at the highest risk of HIV/STI acquisition, thus differentiating groups of AGYW who may most benefit from targeted HIV prevention interventions during adolescence and early adulthood.

Background: Epidemiological data are needed to characterize the age-specific HIV burden and engagement in HIV services among young, marginalized women in sub-Saharan Africa. Setting: Women aged ≥18 years who reported selling sex were recruited across 9 countries in Southern, Central, and West Africa through respondent driven sampling (N = 6592). Methods: Individual-level data were pooled and age-specific HIV prevalence and antiretroviral therapy (ART) coverage were estimated for each region using generalized linear mixed models. HIV-service engagement outcomes (prior HIV testing, HIV status awareness, and ART use) were compared among women living with HIV across age strata (18–19, 20–24, and ≥25 years) using generalized estimating equations. Results: By age 18%–19%, 45.4% [95% confidence interval (CI): 37.9 to 53.0], 5.8% (95% CI: 4.3 to 7.8), and 4.0% (95% CI: 2.9 to 5.4) of young women who sell sex were living with HIV in Southern, Central, and West Africa respectively. Prevalence sharply increased during early adulthood in all regions, but ART coverage was suboptimal across age groups. Compared with adult women ≥25, young women aged 18–19 were less likely to have previously tested for HIV [prevalence ratio (PR) 0.76; 95% CI: 0.72 to 0.80], less likely to already be aware of their HIV status (PR 0.48; 95% CI: 0.35 to 0.64), and less likely to be taking ART (PR 0.67; 95% CI: 0.59 to 0.75). Conclusions: HIV prevalence was already high by age 18–19 in this pooled analysis, demonstrating the need for prevention efforts that reach women who sell sex early in their adolescence. ART coverage remained low, with women in the youngest age group the least engaged in HIV-related services. Addressing barriers to HIV service delivery among young women who sell sex is central to a comprehensive HIV response.

Female sex workers (FSW) are affected by individual, network, and structural risks, making them vulnerable to poor health and well-being. HIV prevention strategies and local community-based programs can rely on estimates of the number of FSW to plan and implement differentiated HIV prevention and treatment services. However, there are limited systematic assessments of the number of FSW in countries across sub-Saharan Africa to facilitate the identification of prevention and treatment gaps. Here we provide estimated population sizes of FSW and the corresponding uncertainties for almost all sub-national areas in sub-Saharan Africa. We first performed a literature review of FSW size estimates and then developed a Bayesian hierarchical model to synthesize these size estimates, resolving competing size estimates in the same area and producing estimates in areas without any data. We estimated that there are 2.5 million (95% uncertainty interval 1.9 to 3.1) FSW aged 15 to 49 in sub-Saharan Africa. This represents a proportion as percent of all women of childbearing age of 1.1% (95% uncertainty interval 0.8 to 1.3%). The analyses further revealed substantial differences between the proportions of FSW among adult females at the sub-national level and studied the relationship between these heterogeneities and many predictors. Ultimately, achieving the vision of no new HIV infections by 2030 necessitates dramatic improvements in our delivery of evidence-based services for sex workers across sub-Saharan Africa.