AIDS and Behavior

, Volume 23, Issue 6, pp 1375–1386 | Cite as

Factors Influencing the Risk of Becoming Sexually Active Among HIV Infected Adolescents in Kampala and Kisumu, East Africa

  • Sabrina Bakeera-KitakaEmail author
  • Tom Smekens
  • Vicky Jespers
  • Eric Wobudeya
  • Jasna Loos
  • Robert Colebunders
  • Daniel Adipo
  • Adeodata Kekitiinwa
  • Philippa Musoke
  • Anne Buve
  • Christiana Nöstlinger
Original Paper


About 2.1 million adolescents aged 10–19 years are living with HIV, 80% of them in sub-Saharan Africa. Early sexual activity remains an important risk factor for HIV transmission and potentially result in negative health consequences including onward transmission of sexually transmitted infections. Cross-sectional data of 580 adolescents living with HIV (ALHIV) aged 13–17 years (317 girls and 263 boys) from Kenya and Uganda were analyzed to assess factors associated with risk to become sexually active. Factors associated with risk of sexual intercourse were identified using Kaplan–Meier survival curves and Cox regression with gender-stratified bi-and multivariable models. Slightly more females (22%) than males (20%) reported they have had sex. Multivariable models showed that being aware of one’s own HIV infection, and receiving antiretroviral treatment were negatively associated with risk of becoming sexually active, while subjective norms conducive to sexuality, and girls’ poor health experience increased the risk. In the final multi-variable models, schooling was protective for girls, but not for boys. Being more popular with the opposite sex was negatively associated with the outcome variable only for girls, but not for boys. This study expands the knowledge base on factors associated with onset of sexual activity among ALHIV, potentially informing positive prevention interventions.


Adolescents HIV Sexual activity Sexual risk behavior Eastern Africa 


Alrededor de 2.1 millones de adolescentes de entre 10 y 19 años viven con el VIH, el 80% de ellos residen en el África subsahariana. La actividad sexual precoz sigue siendo un factor de riesgo importante para la transmisión del VIH y puede tener consecuencias negativas para la salud, incluida la transmisión de infecciones de transmisión sexual. Los datos transversales de 580 adolescentes entre los 13–17 años (317 niñas y 263 niños) viviendo con el VIH y originarios de Kenia y Uganda fueron analizados para evaluar los factores asociados con el riesgo de volverse sexualmente activos. Los factores asociados con el riesgo de tener relaciones sexuales se identificaron usando las curvas de supervivencia de Kaplan–Meier y la regresión de Cox con modelos bi y multivariables estratificados por género. Un poco más de mujeres adolescentes (22%) que de hombres adolescentes (20%) informaron haber tenido relaciones sexuales. Los modelos multivariables mostraron que ser conscientes de la propia infección por VIH y recibir tratamiento antiretroviral se asociaron negativamente con el riesgo de volverse sexualmente activos, mientras que las normas subjetivas promoviendo la sexualidad y la mala salud experimentada por las mujeres adolescentes aumentaron el riesgo. En los modelos finales de variables múltiples, la escolarización resulto ser un factor de protección para las mujeres, pero no para los hombres adolescentes. Ser más popular con el sexo opuesto se asoció negativamente con la variable de resultado pero solo para las mujeres, no para los hombres adolescentes. Este estudio amplía la base de conocimientos sobre los factores asociados con el inicio de la actividad sexual en el VIH lo que podría contribuir a las intervenciones de prevención positivas.



All patients, care givers and the research team on the Brighter Future Study in Kenya and Uganda, and Melissa Stockwell for her constructive review of this manuscript.

Author Contribution

SBK, CN, JL and AB participated in the design of the study. SBK, DA implemented the study. VJ, EW analyzed the data. SBK, CN and VJ jointly wrote the first manuscript. All authors contributed to the subsequent drafts. The final version was read and approved by all authors. TS conducted the analysis for the revision of the manuscript. All authors contributed to the revised version of the manuscript.


AIDS Fonds, the Netherlands, Belgian Government through the framework agreement with the Belgian Developmental Cooperation.

Compliance with Ethical Standards

Conflict of interest

All authors have no conflict of interest to declare.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the authors. The study obtained ethical clearance from the Kenya Medical Research Institute (KEMRI) Ethical Review Committee, Makerere University College of Health Sciences Ethical Review Committee, Baylor College of Medicine Ethical Review Board, Uganda National Council of Science and Technology, the Institutional Review Board of the Institute of Tropical Medicine, Antwerp and the University of Antwerp, Belgium. All participants were recruited through an informed consent process.


  1. 1.
  2. 2.
    UNICEF Analysis of UNAIDS 2012 HIV and AIDS Estimates. UNICEF; 2013.
  3. 3.
    Siberry GK, Abzug MJ, Nachman S. Executive Summary: 2013 update of the guidelines for the prevention and treatment of opportunistic infections in HIV-exposed and HIV-infected children. Pediatr Infect Dis J. 2013;32(12):1303–7.Google Scholar
  4. 4.
    Kim AA, Mukui I, Katana A, et al. Progress in reversing the HIV epidemic through intensified access to antiretroviral therapy: results from a nationally representative population-based survey in Kenya, 2012. PLoS ONE. 2016;11(3):e0148068.Google Scholar
  5. 5.
    Bakanda C, Birungi J, Mwesigwa R, et al. Survival of HIV-infected adolescents on antiretroviral therapy in Uganda: findings from a nationally representative cohort in Uganda. PLoS ONE. 2011;6(4):e19261.Google Scholar
  6. 6.
    Kotchick BA, Shaffer A, Miller KS, Forehand R. Adolescent sexual risk behavior: a multi-system perspective. Clin Psychol Rev. 2001;21(4):493–519.Google Scholar
  7. 7.
    Gevers A, Jewkes R, Mathews C, Flisher A. ‘I think it’s about experiencing, like, life’: a qualitative exploration of contemporary adolescent intimate relationships in South Africa. Culture Health Sex. 2012;14(10):1125–37.Google Scholar
  8. 8.
    UNICEF Analysis of UNAIDS 2012 HIV and AIDS Estimates. UNICEF; 2013.
  9. 9.
    Lowenthal ED, Bakeera-Kitaka S, Marukutira T, Chapman J, Goldrath K, Ferrand RA. Perinatally acquired HIV infection in adolescents from sub-Saharan Africa: a review of emerging challenges. Lancet Infect Dis. 2014;14(7):627–39.Google Scholar
  10. 10.
    Mergui A, Giami A. The sexuality of HIV-infected-adolescents: literature review and thinking on the unthinkables of sexuality. Archives de pediatrie: organe officiel de la Societe francaise de pediatrie. 2011;18(7):797–805.Google Scholar
  11. 11.
    Toska E, Pantelic M, Meinck F, Keck K, Haghighat R, Cluver L. Sex in the shadow of HIV: a systematic review of prevalence, risk factors, and interventions to reduce sexual risk-taking among HIV-positive adolescents and youth in sub-Saharan Africa. PLoS ONE. 2017;12(6):e0178106.Google Scholar
  12. 12.
    Birungi H, Obare F, Mugisha JF, Evelia H, Nyombi J. Preventive service needs of young people perinatally infected with HIV in Uganda. AIDS Care. 2009;21(6):725–31.Google Scholar
  13. 13.
    Bakeera-Kitaka S, Nabukeera-Barungi N, Nostlinger C, Addy K, Colebunders R. Sexual risk reduction needs of adolescents living with HIV in a clinical care setting. AIDS Care. 2008;20(4):426–33.Google Scholar
  14. 14.
    Birungi H, Obare F, van der Kwaak A, Namwebya JH. Maternal health care utilization among HIV-positive female adolescents in Kenya. Int Perspect Sex Reprod Health. 2011;37(3):143–9.Google Scholar
  15. 15.
    Wanyenze RK, Hahn JA, Liechty CA, et al. Linkage to HIV care and survival following inpatient HIV counseling and testing. AIDS Behav. 2011;15(4):751–60.Google Scholar
  16. 16.
    Shapiro K, Ray S. Sexual health for people living with HIV. Reprod Health Matters. 2007;15(29):67–92.Google Scholar
  17. 17.
    Roosa MW, Tein J-Y, Reinholtz C, Angelini PJ. The relationship of childhood sexual abuse to teenage pregnancy. J Marriage Fam. 1997;59(1):119–30.Google Scholar
  18. 18.
    Grant MJ, Hallman KK. Pregnancy-related school dropout and prior school performance in KwaZulu-Natal. South Africa. Stud Fam Plan. 2008;39(4):369–82.Google Scholar
  19. 19.
    Lightfoot MA, Kasirye R, Comulada WS, Rotheram-Borus MJ. Efficacy of a culturally adapted intervention for youth living with HIV in Uganda. Prevent Sci. 2007;8(4):271–3.Google Scholar
  20. 20.
    DiClemente RJ. Psychosocial determinants of condom use among adolescents. Thousand Oaks: Sage; 1992.Google Scholar
  21. 21.
    Fisher JD, Fisher WA. Theoretical approaches to invidivual-level change in HIV risk behavior. CHIP Documents. 2000:4.Google Scholar
  22. 22.
    Kasen S, Vaughan RD, Walter HJ. Self-efficacy for AIDS preventive behaviors among tenth grade students. Health Edu Behav. 1992;19(2):187–202.Google Scholar
  23. 23.
    Catania JA, Coates TJ, Greenblatt RM, et al. Predictors of condom use and multiple partnered sex among sexually-active adolescent women: implications for aids-related health interventions. J Sex Res. 1989;26(4):514–24.Google Scholar
  24. 24.
    Bearinger LH, Sieving RE, Ferguson J, Sharma V. Global perspectives on the sexual and reproductive health of adolescents: patterns, prevention, and potential. Lancet. 2007;369(9568):1220–31.Google Scholar
  25. 25.
    Leclerc-Madlala S. Age-disparate and intergenerational sex in southern Africa: the dynamics of hypervulnerability. AIDS. 2008;22:S17–25.Google Scholar
  26. 26.
    Moore SM, Rosenthal DA. Sexuality in adolescence: current trends. Abingdon: Routledge; 2007.Google Scholar
  27. 27.
    Loos J, Nöstlinger C, Murungi I, et al. Having sex, becoming somebody: a qualitative study assessing (sexual) identity development of adolescents living with HIV/AIDS. Vulnerable Child Youth Stud. 2013;8(2):149–60.Google Scholar
  28. 28.
    Kabiru CW, Beguy D, Undie C-C, Zulu EM, Ezeh AC. Transition into first sex among adolescents in slum and non-slum communities in Nairobi, Kenya. J Youth Stud. 2010;13(4):453–71.Google Scholar
  29. 29.
    Bankole A, Biddlecom A, Singh S, Guiella G, Zulu E. Sexual behavior, knowledge and information sources of very young adolescents in four sub-Saharan African countries. Afr J Reprod Health. 2007;11(3):28–43.Google Scholar
  30. 30.
    Eggers SM, Mathews C, Aaro LE, McClinton-Appollis T, Bos AE, de Vries H. Predicting Primary and Secondary Abstinence Among Adolescent Boys and Girls in the Western Cape, South Africa. AIDS Behav. 2017;21(5):1417–28.Google Scholar
  31. 31.
    Ross DA, Changalucha J, Obasi AI, Grosskurth H, et al. Biological and behavioural impact of an adolescent sexual health intervention in Tanzania: a community-randomized trial. AIDS. 2007;21(14):1943–55.Google Scholar
  32. 32.
    Nöstlinger C, Jasna L, Sabrina B-K, Obong’o C, Eric W, Buvé A. Translating primary into ‘positive’prevention for adolescents in Eastern Africa. Health Promot Int. 2015;31(3):653.Google Scholar
  33. 33.
    Dutwin D, Lavrakas P. Trends in telephone outcomes, 2008–2015. Surv Pract. 2016;9(3):1–9.Google Scholar
  34. 34.
    Jemmott JB 3rd, Jemmott LS, Fong GT. Abstinence and safer sex HIV risk-reduction interventions for African American adolescents: a randomized controlled trial. JAMA. 1998;279(19):1529–36.Google Scholar
  35. 35.
    Rotheram-Borus MJ, Lee MB, Murphy DA, et al. Efficacy of a preventive intervention for youths living with HIV. Am J Public Health. 2001;91(3):400.Google Scholar
  36. 36.
    De Cock KM, Jaffe HW, Curran JW. The evolving epidemiology of HIV/AIDS. AIDS. 2012;26(10):1205–13.Google Scholar
  37. 37.
    Mbalinda SN, Kiwanuka N, Eriksson LE, Wanyenze RK, Kaye DK. Correlates of ever had sex among perinatally HIV-infected adolescents in Uganda. Reprod Health. 2015;12(1):96.Google Scholar
  38. 38.
    Birungi H, Mugisha JF, Obare F, Nyombi JK. Sexual behavior and desires among adolescents perinatally infected with human immunodeficiency virus in Uganda: implications for programming. J adolesc Health. 2009;44(2):184–7.Google Scholar
  39. 39.
    Toska E, Cluver LD, Hodes R, Kidia KK. Sex and secrecy: how HIV-status disclosure affects safe sex among HIV-positive adolescents. AIDS care. 2015;27(sup1):47–58.Google Scholar
  40. 40.
    Masatu MC, Kazaura MR, Ndeki S, Mwampambe R. Predictors of risky sexual behavior among adolescents in Tanzania. AIDS Behav. 2009;13(1):94–9.Google Scholar
  41. 41.
    Homsy J, Bunnell R, Moore D, et al. Reproductive intentions and outcomes among women on antiretroviral therapy in rural Uganda: a prospective cohort study. PLoS ONE. 2009;4(1):e4149.Google Scholar
  42. 42.
    Pettifor AE, Van Der Straten A, Dunbar MS, Shiboski SC, Padian N. S Early age of first sex: a risk factor for HIV infection among women in Zimbabwe. AIDS. 2004;18(10):1435–42.Google Scholar
  43. 43.
    Mkandawire P, Tenkorang E, Luginaah IN. Orphan status and time to first sex among adolescents in northern Malawi. AIDS Behav. 2013;17(3):939–50.Google Scholar
  44. 44.
    Juma M, Alaii J, Bartholomew LK, Askew I, Van den Borne B. Risky sexual behavior among orphan and non-orphan adolescents in Nyanza Province, Western Kenya. AIDS Behav. 2013;17(3):951–60.Google Scholar
  45. 45.
    Thurman TR, Brown L, Richter L, Maharaj P, Magnani R. Sexual risk behavior among South African adolescents: is orphan status a factor? AIDS Behav. 2006;10(6):627–35.Google Scholar
  46. 46.
    Puffer ES, Drabkin AS, Stashko AL, Broverman SA, Ogwang-Odhiambo RA, Sikkema KJ. Orphan status, HIV risk behavior, and mental health among adolescents in rural Kenya. J Pediatr Psychol. 2012;37(8):868–78.Google Scholar
  47. 47.
    Bauermeister JA, Elkington K, Brackis-Cott E, Dolezal C, Mellins CA. Sexual behavior and perceived peer norms: comparing perinatally HIV-infected and HIV-affected youth. J Youth Adolesc. 2009;38(8):1110–22.Google Scholar
  48. 48.
    Mburu G, Hodgson I, Kalibala S, et al. Adolescent HIV disclosure in Zambia: barriers, facilitators and outcomes. J Int AIDS Soc. 2014;17(1):18866.Google Scholar
  49. 49.
    Kidia KK, Mupambireyi Z, Cluver L, Ndhlovu CE, Borok M, Ferrand RA. HIV status disclosure to perinatally-infected adolescents in Zimbabwe: a qualitative study of adolescent and healthcare worker perspectives. PLoS ONE. 2014;9(1):e87322.Google Scholar
  50. 50.
    Folke C, Hahn T, Olsson P, Norberg J. Adaptive governance of social-ecological systems. Annu Rev Environ Resour. 2005;30:441–73.Google Scholar
  51. 51.
    Jukes M, Simmons S, Bundy D. Education and vulnerability: the role of schools in protecting young women and girls from HIV in southern Africa. AIDS. 2008;22:S41–56.Google Scholar
  52. 52.
    De Neve J-W, Fink G, Subramanian S, Moyo S, Bor J. Length of secondary schooling and risk of HIV infection in Botswana: evidence from a natural experiment. Lancet Glob Health. 2015;3(8):e470–7.Google Scholar
  53. 53.
    Maleche A, Day E. Traditional cultural practices and HIV: reconciling culture and human rights: Working Paper for the Third;2011.Google Scholar
  54. 54.
    Mavedzenge SMN, Doyle AM, Ross DA. HIV prevention in young people in sub-Saharan Africa: a systematic review. J Adolesc Health. 2011;49(6):568–86.Google Scholar
  55. 55.
    Airhihenbuwa CO, Dutta MJ. New perspectives on global health communication. In: Waisbord S, editor. Obregon (R). Hoboken: The handbook of global health communication. Wiley; 2012. p. 34–51.Google Scholar
  56. 56.
    Sieving RE, Eisenberg ME, Pettingell S, Skay C. Friends’ influence on adolescents’ first sexual intercourse. Perspect Sex Reprod Health. 2006;38(1):13–9.Google Scholar
  57. 57.
    Miranda-Diaz M, Corcoran K. “All my friends are doing it:” The Impact of the Perception of Peer Sexuality on Adolescents’ Intent to have Sex. J Evid-based Soc Work. 2012;9(3):260–4.Google Scholar
  58. 58.
    Sherr L, Cluver LD, Toska E, He E. Differing psychological vulnerabilities among behaviourally and perinatally HIV infected adolescents in South Africa—implications for targeted health service provision. AIDS Care. 2018;30(sup2):92–101.Google Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Sabrina Bakeera-Kitaka
    • 1
    • 2
    Email author
  • Tom Smekens
    • 3
  • Vicky Jespers
    • 3
  • Eric Wobudeya
    • 1
  • Jasna Loos
    • 3
  • Robert Colebunders
    • 4
  • Daniel Adipo
    • 5
    • 6
  • Adeodata Kekitiinwa
    • 1
  • Philippa Musoke
    • 2
  • Anne Buve
    • 3
  • Christiana Nöstlinger
    • 3
    • 7
  1. 1.Baylor-UgandaKampalaUganda
  2. 2.Department of Paediatrics and Child HealthMakerere UniversityKampalaUganda
  3. 3.Department of Public HealthInstitute of Tropical MedicineAntwerpBelgium
  4. 4.Global Health InstituteUniversity of AntwerpAntwerpBelgium
  5. 5.Kenya Medical Research InstituteKisumuKenya
  6. 6.IMPACT Research and Development Organization, Tuungane Youth ProjectKisumuKenya
  7. 7.Faculty of PsychologyUniversity of ViennaViennaAustria

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