Journal Article

Understanding HIV risks among adolescent girls and young women in informal settlements of Nairobi, Kenya: Lessons for DREAMS

Introduction
High incidence of HIV infection among adolescent girls and young women (AGYW) has been attributed to the numerous and often layered vulnerabilities that they encounter including violence against women, unfavourable power relations that are worsened by age-disparate sexual relations, and limited access to sexual and reproductive health information and services. For AGYW living in urban informal settlements (slums), these vulnerabilities are compounded by pervasive poverty, fragmented social networks, and limited access to social services including health and education. In this paper, we assess sexual risk behaviours and their correlates among AGYW in two slum settlements in Nairobi, Kenya, prior to the implementation of interventions under the Determined Resilient Empowered AIDS-free Mentored and Safe (DREAMS) Partnership.

Methods
We drew on secondary data from the Transition to Adulthood study, the most recent representative study on adolescent sexual behaviour in the two settlements. The study was nested within the Nairobi Urban Health and Demographic Surveillance System (NUHDSS). Data were collected in 2009 from 1,390 AGYW aged 12–23 years. We estimated the proportions of AGYW reporting ever tested for HIV, condom use, multiple sexual partners and age-disparate sex by socio-demographic characteristics. “High risk” sexual behaviour was defined as a composite of these four variables and age at first sex. Multivariable regression analyses were performed to identify factors associated with risk behaviours.

Results
Fifty-one percent of AGYW reported that they had ever tested for HIV and received results of their last test, with the proportion rising steeply by age (from 15% to 84% among those <15 years and 20–23 years, respectively). Of 578 AGYW who were sexually active in the 12 months preceding the survey, 26% reported using a condom at last sex, 4% had more than one sexual partner, and 26% had sex with men who were at least 5 years older or younger. All girls aged below 15 years who had sex (n = 9) had not used condoms at last sex. The likelihood of engaging in “high risk” sexual risk behaviour was higher among older AGYW (19–23 years), those in marital unions, of Luo ethnicity, out of school, living alone or with a friend (versus parents), living with spouse (versus parents), and those whose friends engaged in risky/anti-social behaviours. In contrast, Muslim faith, co-residence with both parents, and belonging to an organised social group were associated with lower odds of risky sexual behaviours.

Conclusion
Our study findings suggest that multifaceted approaches addressing the educational and social mediators of AGYW’s vulnerability and that also reach the people with whom AGYW live and interact, are needed to reduce the rapid onset of sexual risk during the adolescent years. There is a particular need to reach the youngest adolescent girls in poor urban settings, among whom condom use and awareness of HIV status is rare.