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; 2 Ethiopian 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

Prevalence of HIV, HSV-2, and Sexual Risk Behaviors among Secondary

School Students in High Risk Districts in Amhara Region, Ethiopia

Center for Global Health

Division of Global HIV-AIDS

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 20082Mekonnen Y et al2009.

Student Characteristics (N=1317)n (%)

Median age, years [IQR] 17 [16-18]Male 688 (52)Single (Never married) 1252 (95.1)Living with parents/adult relatives 910 (69.1) HIV seropositive 1 (.08)HSV2 seropositive (N=1291) 18 (1.4)Ever had sex 195 (14.6)Median age at sexual debut, years [IQR] 16 (15-18) Sex in the last 18 months 105 (8.1)

Condom use at last sex among those sexually active in last 18 months by partner type (N=105)

Spouse 4 (4)Regular, non-spousal partner 35 (33)Casual partner 48 (46)

Ever tested for HIV 767 (58)Proportion of sexually naïve ever HIV tested (N=1212)

713 (56)

Multivariable AnalysisAdjusted Odds

Ratiop-

value

Younger age at sexual debut*

Marriage 4.0 <0.001

Exposure to school-based prevention programs

.59 0.08

Condom use at last sex¶

Partner type

Spouse referent

Regular non-spouse 14.1 0.01

Casual 33.0 0.01

History of HIV testing

Exposure to school-based prevention programs

1.45 0.03

Increasing age 1.14 <0.01

History of sexual activity 1.78 <0.01

Male sex 0.68 0.01* No association with gender or living with parents/adult relatives¶ No association with age, gender, or exposure to school-based prevention programs

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

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

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

Investigators and institutional affiliations

Ethiopian Health and Nutrition Research Institute Belete Tegbaru, PhD Eshetu Lema Haile, MSc

Amhara HIV and AIDS Prevention and Control Office Ato Eshete Girma Zike , BSc

Amhara Health Bureau Wondimu Gebeyehu Alemu

Amhara Educational Bureau Mulugeta Mesfin

Bahir Dar Health Research Laboratory Center Genetu Alem, BSc MSc

Federal HIV and AIDS Prevention and Control Office Yibeltal Asefa, MD PhD*

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 Prabhu Gounder, MD MPH Mahesh Swaminathan, MD* Irum Zaidi, MPH

Family Health International#

Addisu Tessema, M.A Girmachew Mamo, MD MPH¶

* Primary investigator ¶ Study coordinator^ Funding source § Project officer# Implementing partner

For more information please contact Centers for Disease Control and Prevention1600 Clifton Road NE, Atlanta, GA 30333Telephone, 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348E-mail: cdcinfo@cdc.gov Web: www.cdc.gov

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Questions?

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.

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.

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

1 Dhoj 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.

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.

Methods

Primary objective Estimate the prevalence of HIV among secondary school

students in high risk districts in the Amhara Region

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 Amhara Region

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

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

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%

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

Map of 13 high risk districts in Amhara where study was conducted

School Selection

Participant Enrollment

Student CharacteristicsTotal

(N=1317)Boys

(N=688)Girls

(N=629)n (%) n (%) n (%)

Grade9th 527 (40.0) 247 (35.9) 280 (44.5)10th 420 (31.9) 240 (34.9) 180 (28.6)11th 216 (16.4) 114 (16.5) 103 (16.3)12th 154 (11.7) 87 (12.7) 67 (10.7)

Marital StatusSingle 1252 (95.1) 670 (97.4) 582 (92.6)Married 45 (3.4) 12 (1.7) 33 (5.3)Divorced/

Separated20 (1.5) 6 (0.9) 13 (2.1)

Living Situation  With parents/adult relatives

910 (69.1) 436 (63.3) 475 (75.5)

Without parents/adult relative

407 (30.9) 252 (36.7) 154 (24.5)

Mean age, years [95% CI]

17.5 [17.3-17.7] 18.0 [17.7-18.2] 16.9 [16.7-17.1]

Results

HIV prevalence = 0.08% (1/1317) HSV2 prevalence = 1.4% (18/1291)

1.1% girls, 1.5% boys

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

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

0.279)

Ever had sex Sex in 18-month period prior to

study

Currently have a sexual partner

0

5

10

15

20

16.1

7.7

3.9

13

8.47.6

14.6

8.1

5.7

Reported sexual activity, all participants (N=1317)

Boys Girls Total

Perc

en

t of

all p

art

icip

an

ts

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

40%

38%

6%

16%

Girls (n=85)

12%

36%37%

2%

12%

Boys (n=110)

Spouse Regular Partner Casual PartnerSex Worker Other/Unknown

Use of Condom at Last Sex

History of HIV Testing0

10

20

30

40

50

60

70

80

90

100

3.5

93.8

33.3

85.1

46.4

76.4

Prevention behaviors among partici-pants sexually active in 18-month period

prior to study (N=105)

SpouseRegular PartnerCasual Partner

Perc

en

t of

part

icip

an

ts

56% of sexually naïve students (N=1212) had a

history of HIV testing

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

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

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

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