IPV is associated with lower ART use, half the odds of self-reported ART adherence and significantly worsened viral suppression among women. To ensure the health of HIV-positive women, it is essential for clinical programmes to address conditions that impact engagement in care and treatment. IPV is one such condition, and its association with declines in ART use and adherence requires urgent attention.

Reducing rates of teenage pregnancy is an important part of the agenda of action for meeting most of the Millenium Development Goals. South Africa has important lessons for other countries in this regard as the rate of teenage pregnancy is high but has declined very substantially over the last twenty years. The country experiences waves of moral panic about teenage pregnancy, with assertions that current problems are rooted in accepting or even encouraging the sexual appetites of young people rather than sternly disciplining them. In this paper, we argue that the key to success in teenage pregnancy reduction has been an empowering social policy agenda that has sought to work with young people, making them aware of their rights and the risks of sexual intercourse. Furthermore, family responses and education policy have greatly reduced the potential negative impact of teenage pregnancy on the lives of teenage girls. There is tremendous scope for further progress in reducing teenage pregnancy and we argue that this lies in paying more attention to issues of gender and sexuality, including the terms and conditions under which teenagers have sex. There needs to be critical reflection and engagement with men and boys on issues of masculinity, including their role in child rearing, as well as examination within families of their engagement with supporting pregnancy prevention and responses to pregnancies.

IntroductionAdolescents having unprotected heterosexual intercourse are at risk of HIV infection and unwanted pregnancy. However, there is little evidence to indicate whether pregnancy in early adolescence increases the risk of subsequent HIV infection. In this paper, we tested the hypothesis that adolescent pregnancy (aged 15 or younger) increases the risk of incident HIV infection in young South African women.MethodsWe assessed 1099 HIV-negative women, aged 15–26 years, who were volunteer participants in a cluster-randomized, controlled HIV prevention trial in the predominantly rural Eastern Cape province of South Africa. All of these young women had at least one additional HIV test over two years of follow-up. Outcomes were HIV incidence rates per 100 person years and HIV incidence rate ratios (IRRs) estimated by Poisson multivariate models. Three pregnancy categories were created for the Poisson model: early adolescent pregnancy (a first pregnancy at age 15 years or younger); later adolescent pregnancy (a first pregnancy at age 16 to 19 years); and women who did not report an adolescent pregnancy. Models were adjusted for study design, age, education, time since first sexual experience, socio-economic status, childhood trauma and herpes simplex virus type 2 infection.ResultsHIV incidence rates were 6.0 per 100 person years over two years of follow-up. The adjusted IRR was 3.02 (95% CI 1.50–6.09) for a pregnancy occurring at age 15 or younger. Women with pregnancies occurring between 16 and 19 years of age did not have a higher incidence of HIV (IRR 1.08; 95% CI 0.64–1.84). Early adolescent pregnancies were associated with higher partner numbers and a greater age difference with partners.ConclusionsEarly adolescent pregnancies increase the incidence of HIV among South African women. The higher risk is associated with sexual risk behaviours such as higher partner numbers and a greater age difference with partners rather than a biological explanation of hormonal changes during pregnancy.

BackgroundAlthough teenage pregnancies in South Africa have declined, the short and longer term health and social consequences are a potential public health concern. This longitudinal study aimed to describe the range of risk and protective factors for incident unwanted and unplanned pregnancies occurring over 2 years of follow-up among a cohort of adolescent women in the Eastern Cape, South Africa. It also investigated the relationship between gender inequality and gender-based violence and subsequent unplanned and unwanted pregnancies among the cohort.ObjectiveTeenage girls, aged 15–18 years (n=19), who were volunteer participants in a cluster randomized controlled trial and who had data from at least one follow-up were included in this analysis. To assess risk and protective factors for incident unwanted or unplanned pregnancies, we constructed multivariate polytomous regression models adjusting for sampling clusters as latent variables. Covariates included age, having a pregnancy prior to baseline, education, time between interviews, study intervention arm, contraceptive use, experience of intimate partner violence, belief that the teenage girl and her boyfriend are mutual main partners, and socioeconomic status.ResultsOverall, 174 pregnancies occurred over the 2-year follow-up period. Beliefs about relationship control were not associated with unwanted and unplanned pregnancies, nor were experiences of forced first sex or coerced sex under the age of 15. Hormonal contraception was protective against unplanned pregnancies (OR 0.40; 95% CI 0.21–0.79); however, using condoms was not protective. Physical abuse (OR 1.69; 95% CI 1.05–2.72) was a risk factor for, and having a pregnancy prior to baseline was protective against an unwanted pregnancy (OR 0.25; 95% CI 0.07–0.80). Higher socioeconomic status was protective for both unplanned and unwanted pregnancies (OR 0.69; 95% CI 0.58–0.83 and OR 0.78; 95% CI 0.64–0.96). Believing that the teenage girl and her boyfriend were mutual main partners doubled the odds of reporting both an unplanned and unwanted pregnancy (OR 2.58 95% CI 1.07–6.25, and OR 2.21 95% CI 1.13–4.29).ConclusionAlthough some of the measures of gender inequity were not associated with unplanned and unwanted pregnancies, there is evidence of the role of both gender power and socioeconomic status. This was evident in teenage girls who experienced physical violence being more likely to have an unwanted pregnancy. Interventions to prevent teenage pregnancies need to be tailored by socioeconomic status because some teenagers may see having a pregnancy as a way to have a more secure future. Interventions that engage with relationship dynamics of teenagers are essential if unwanted and unplanned pregnancies are to be prevented.

Women who experience intimate partner violence (IPV) are more likely to be HIV positive. Many of these women never receive any relevant services, and those who do often access them only after events have escalated to a crisis requiring the police or emergency medical care. Evidence from other settings suggests that routinely asking women about experiences of partner violence is received positively. Voluntary counseling and testing (VCT) services would seem an ideal opportunity to screen for IPV in South Africa. However, in low resource settings, VCT is carried out by lay counselors with few skills. We therefore conducted a qualitative study that explored women's experience of IPV screening in VCT services, and explored implications for VCT counseling. The study was conducted in a clinic in Johannesburg where we trained the lay counselors to do IPV screening. In-depth interviews were conducted with 35 women attending VCT services. Participants were recruited before they attended VCT, and 12 women participated in a follow-up interview. A focus group was held with lay counselors a year after the intervention was implemented. Findings suggest that women were supportive of being asked about their experiences of IPV during VCT sessions. Reasons for supporting IPV screening at VCT services include the limited access of many women to health services. Many women who were aware of their HIV risk felt powerless to discuss condom use, HIV testing, and infidelity with their male partners. Women directly related such experience of gender power inequality to HIV risk. One year after training, there was no evidence of screening continuing. Our findings suggest that the focus should shift from asking about violence to equipping counselors to discuss gender inequality in relationships more broadly. This needs to be part of basic counselor training as it is integral to approaching HIV risk reduction.