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Center for Global Health

Prevalence of HIV, HSV-2, and Sexual Risk Behaviors among Secondary School Students in High Risk Districts in Amhara Region, Ethiopia.

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  1. Prevalence of HIV, HSV-2, and Sexual Risk Behaviors among Secondary School Students in High Risk Districts in Amhara Region, Ethiopia Mahesh Swaminathan1, B. Tegbaru2, B. Wolff3, N. Kleinman4, A. Alem5, W. Alemu6, R. Shiraishi1, P. Fonjungo3, T. Kenyon3 on behalf of the Amhara study group 1 U.S. Centers for Disease Control and Prevention, Atlanta GA USA; 2Ethiopian Health and Nutrition Research Institute, Addis Ababa, Ethiopia; 3 U.S. Centers for Disease Control and Prevention, Addis Ababa, Ethiopia, 4 Association of Schools of Public Health, Washington, DC, USA; 5Amhara HIV AIDS Prevention and Control Office, Bahir Dar, Amhara, Ethiopia; 6Amhara Health Bureau, Bahir Dar, Amhara, Ethiopia July 2, 2013 Abstract# TUPDC0103 Center for Global Health Division of Global HIV-AIDS

  2. Background and methods • In-school youth in Amhara region, Ethiopia are considered a vulnerable to HIV infection1,2 • Cross-sectional bio-behavioral survey • Objective: Estimate the prevalence of HIV, HSV2, and associated risk factors among secondary school students in districts with a high risk of HIV transmission in Amhara • Stratified multistage design. Population: 1338 secondary students15 years of age or older • Setting: Government supported secondary schools in high risk districts • Analyses weighted to account for study design 1Ethiopia HIV/AIDS Prevention & Control Office 2008 2Mekonnen Y et al2009.

  3. * No association with gender or living with parents/adult relatives • ¶ No association with age, gender, or exposure to school-based prevention programs

  4. Limitations • Study population is representative of students attending government schools in high risk districts in Amhara • Study is not nationally or regionally representative • Regions of Ethiopia are highly diverse • Students from private or vocational schools were not recruited • Findings apply to in-school youth only • Study did not include out of school youth

  5. Conclusions • Students are not a key population for HIV infection • The prevalence of HIV, HSV2, and sex was low among secondary school students in high risk districts in Amhara • School based interventions have increased HIV testing, but have no effect on condom use and may have a marginal impact on sexual debut • HIV testing is common, even amongst students at low risk or with no history of sex • Students living away from parental supervision are no more likely to engage in sex than those living at home

  6. Recommendations • Students in Amhara do not require the same kind and intensity of interventions as female sex workers, men who have sex with men, etc. • Testing and prevention services should focus on sexually active or high risk students • On-campus mass testing campaigns should be discouraged • Students should receive age-appropriate education regarding sex and HIV

  7. Investigators and institutional affiliations • CDC-Ethiopia^ • Solomon Fekadie • Peter Fonjungo, PhD • Thomas Kenyon, MD MPH • Nora Kleinman, MPH • Daniel Rosen, PhD • Brent Wolff, PhD*, § • Endale Workalemahu, MD MPH • CDC-Atlanta • Marta Ackers, MD MPH • Hongjiang Gao, PhD • PrabhuGounder, MD MPH • Mahesh Swaminathan, MD* • Irum Zaidi, MPH • Family Health International# • AddisuTessema, M.A • Girmachew Mamo, MD MPH¶ • Ethiopian Health and Nutrition Research Institute • BeleteTegbaru, PhD • EshetuLemaHaile, MSc • Amhara HIV and AIDS Prevention and Control Office • AtoEsheteGirmaZike , BSc • Amhara Health Bureau • Wondimu GebeyehuAlemu • Amhara Educational Bureau • MulugetaMesfin • Bahir Dar Health Research Laboratory Center • Genetu Alem, BScMSc • Federal HIV and AIDS Prevention and Control Office • Yibeltal Asefa, MD PhD* * Primary investigator ¶ Study coordinator ^ Funding source § Project officer # Implementing partner

  8. Questions?

  9. References • 1Ethiopia HIV/AIDS Prevention & Control Office, Global HIV/AIDS Monitoring and Evaluation Team. HIV/AIDS in Ethiopia - an Epidemiological Synthesis. Global HIV/AIDS Program - Report Series. Washington, DC: World Bank; 2008. • 2Mekonnen Y, Daniel G, Solomon S, Degefu A, Tegbaru B. Magnitude of and risk factors for HIV infection among most-at-risk populations (MARPS) in Amhara Region. Addis Ababa, Ethiopia; 2009.

  10. Background1 • HIV in Ethiopia (pop. 73.8 million) in 2011 • HIV prevalence = 1.5% (1.9% in women, 1.0% in men) • HIV in Amhara region • HIV prevalence = 1.6% (2.2% in women, 1.0% in men,) • HIV prevalence of 4.2% compared to 0.6% in rural areas • HIV prevalence is higher in urban areas/transport corridors (4.2%) then in rural areas (0.6%) 1Central Statistical Agency [Ethiopia], ICF International. Ethiopia Demographic and Health Survey 2011. Addis Ababa, Ethiopia and Calverton, Maryland, USA: Central Statistical Agency and ICF International; 2012.

  11. Background • Ethiopia has rapidly expanded access to formal secondary education • Grades 9 to 12 enrolment grew 371,000 in 1994/5 1.7 million in 2009/10. The number of secondary schools grew 369  1,335 in the same time period.2 • New schools often built along transport corridors and roadside settlements3 where HIV infection is most concentrated4 1Dhoj JR, Verspoor A. Secondary Education in Ethiopia: Supporting Growth and Transformation. Washington, D.C: World Bank; 2013. 2 Ministry of Education. Education Statistics Annual Abstract (ESSA), 2003 EC (2010/11 GC). Addis Ababa, Ethiopia: Federal Democratic Republic of Ethiopia Ministry of Education; 2011. 3 Ministry of Education. Education Statistics Annual Abstract (ESSA), 2002 EC (2009/10 GC). Addis Ababa, Ethiopia: Federal Democratic Republic of Ethiopia Ministry of Education (MOE); 2010.

  12. Background • In-school youth are considered a group vulnerable to HIV infection1 • A 2008 survey in 5 purposively selected high risk districts in Amhara region found a 12% HIV sero-prevalence among secondary students (N=389)2 • Prevalence of 8% among girls, 16% among boys • Amhara officials requested a high quality follow-up study to verify these findings 1Ethiopia HIV/AIDS Prevention & Control Office, Global HIV/AIDS Monitoring and Evaluation Team. HIV/AIDS in Ethiopia - an Epidemiological Synthesis. Global HIV/AIDS Program - Report Series. Washington, DC: World Bank; 2008. 2Mekonnen Y, Daniel G, Solomon S, Degefu A, Tegbaru B. Magnitude of and risk factors for HIV infection among most-at-risk populations (MARPS) in Amhara Region. Addis Ababa, Ethiopia; 2009.

  13. Methods • Primary objective • Estimate the prevalence of HIV among secondary school students in high risk districts in the AmharaRegion • Secondary objectives • Estimate the prevalence of HSV-2 among secondary school students in high risk districts in the Amhara Region • Assess demographic, behavioral, structural and environmental factors associated with HIV and HSV-2 infection among secondary students high risk districts in the AmharaRegion

  14. Methods • Cross-sectional biological and behavioral survey • Behavioral questionnaire • Rapid HIV, HSV-2 testing • Study population • Age > 15 years • Currently enrolled and attending a government-run secondary school • Setting • Government-run secondary schools located in HIV high risk districts in Amhara region

  15. Methods • High risk districts (N=13) identified in Amhara during mapping exercise • Defined as areas of elevated risk of HIV transmission based on: • HIV testing data from voluntary and counseling (VCT) and antenatal care (ANC) sites • Presence of known structural risk factors (e.g., sex trade, truck stops, nearby military bases, etc.) • Key informant interviews

  16. Methods • Stratified multistage design • Strata is grade range served by school • 4 strata: Grade 9 only schools, high schools (grades 9-10), preparatory schools (grades 11-12) and combined schools (9 – 12) • 30/42 eligible schools selected • Students selected proportional to the gender ratio within each school • Planned sample size = 1338 • Powered to estimate an HIV prevalence = 5% +/- 1.5%

  17. Methods • Behavioral questionnaire administered face to face by trained staff using netbooks • Serum and DBS card collected from each participant • On-site rapid HIV test • HSV2 test performed on serum at regional reference lab • Analyses were weighted and controlled for survey design • Performed with Stata version 10.1

  18. Map of 13 high risk districts in Amharawhere study was conducted

  19. School Selection

  20. Participant Enrollment

  21. Results • HIV prevalence = 0.08% (1/1317) • HSV2 prevalence = 1.4% (18/1291) • 1.1% girls, 1.5% boys

  22. Results • 1317 students agreed to HIV test/interview • 1291 agreed to additional HSV2 test • Mean age(years) = 17.5 [95% CI: 17.3-17.7] • 52% boys, 95% were never married, 69% lived with parents/adult relative • HIV prevalence = 0.08% (1/1317) • HSV2 prevalence = 1.4% (18/1291) • 14.6% reported ever having sex • Median age sexual debut = 16 (IQR: 15-18) • 8.1% reported sex in the 18-month period prior to the study • Condoms used at last sex by 4% with spouses, 33% with regular partners, and 46% with casual partners • 58% ever tested for HIV • 56% of sexually naïve students (N=1212) had a history of HIV testing

  23. Median age sexual debut = 16 (IQR: 15-18) 16 (IQR: 15-17) for boys, 17 (IQR: 14-18) for girls (p-value = 0.279)

  24. Most recent sexual partner amongst students who ever had sex (N=195)

  25. 56% of sexually naïve students (N=1212) had a history of HIV testing

  26. Results – Multivariable Analysis • Younger age at sexual debut • Marriage: aOR = 4.0, p-value <0.001 • Exposure to school based prevention programs: aOR = 0.59, p-value =0.08 • No association with gender or living with parents/adult relatives • Condom use at last sex • Partner type (referent = spouse): regular partners aOR = 14.1, p-value =0.01); casual partners aOR = 33.0, p-value =0.01 • No association with age, gender, or exposure to school based prevention programs • History of HIV testing • Exposure to school based prevention programs: aOR=1.45, p-value =0.03 • age: aOR = 1.14, p-value<0.01 • a history sexual activity: aOR = 1.78, p-value<0.01 • male gender: aOR = 0.68, p-value=0.01

  27. Limitations • Study population is representative of students attending government schools in high risk districts in Amhara • Study is not nationally or regionally representative • Regions of Ethiopia are highly diverse • Students from private or vocational schools were not recruited • Findings apply to in-school youth only • Study did not include out of school youth

  28. Conclusions • Students are not a key population for HIV infection • The prevalence of HIV, HSV-2, and sex was low among secondary school students in high risk districts in Amhara • School based interventions have increased HIV testing, but have no effect on condom use and may have a marginal impact on sexual debut • Students living away from parental supervision are no more likely to engage in sex than those living at home • HIV testing is common, even amongst students at low risk or with no history of sex

  29. Recommendations • Students should not receive the same kind and intensity of interventions as female sex workers, men who have sex with men, etc. • Testing and prevention services should focus on sexually active or high risk students • On-campus mass testing campaigns should be discouraged • Students should receive age-appropriate education regarding sex and HIV

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