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Age-disparate partnerships and incident HIV infection in adolescent girls and young women in rural South Africa

Stoner, Marie C.D.a; Nguyen, Nadiab; Kilburn, Kellya; Gómez-Olivé, F Xavierd,e; Edwards, Jessie K.c; Selin, Amandac; Hughes, James P.f,g; Agyei, Yawh; Macphail, Catherined,j,k; Kahn, Kathleend,e,i; Pettifor, Audreya,c,d

doi: 10.1097/QAD.0000000000002037

Objective: Adolescent girls and young women (AGYW) have a much higher risk of HIV infection than young men of the same age. One hypothesis for this disparity is AGYW are more likely to be in sexual partnerships with older men with HIV; however, evidence has been inconclusive.

Design: We used longitudinal data from a randomized trial in South Africa (HPTN 068) to determined whether partner age difference is associated with incident HIV infection in AGYW.

Methods: Age difference was examined continuously and dichotomously (≥5 years). We examined inverse probability of exposure weighted survival curves and calculated time-specific risk differences and risk ratios over 5.5 years of follow-up. We also used a marginal structural Cox model to estimate hazard ratios over the entire study period.

Results: Risk of HIV was higher in AGYW with an age-disparate partnership versus not and the risk difference was largest at later time points. At 5.5 years, AGYW with an age-disparate partnership had a 12.6% (95% confidence interval 1.9–23.3) higher risk than AGYW with no age-disparate partnerships. The weighted hazard ratio was 1.91 (95% confidence interval 1.33–2.74), an association that remained after weighting for either transactional or condomless sex, and after examining continuous age-differences.

Conclusion: Age-disparate partnerships increased risk of HIV infection, even after accounting for transactional sex and condomless sex. The relationship between age-disparate partnerships and HIV infection may be explained by increased exposure to infection from men in a higher HIV prevalence pool rather than differences in sexual behaviour within these partnerships.

aCarolina Population Center, University of North Carolina, Chapel Hill, North Carolina

bHIV Center for Clinical and Behavioral Studies at Columbia University at the New York State Psychiatric Institute, New York

cDepartment of Epidemiology, University of North Carolina, Chapel Hill, New York, USA

dMRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

eINDEPTH Network, Accra, Ghana

fDepartment of Biostatistics, University of Washington

gFred Hutchinson Cancer Research Center, Seattle, Washington

hSchool of Medicine, Department of Pathology, Johns Hopkins University, Baltimore, Maryland, USA

iEpidemiology and Global Health Unit, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden

jSchool of Health and Society, University of Wollongong, Wollongong, New South Wales, Australia

kWits Reproductive Health and HIV Research Institute, University of the Witwatersrand, Johannesburg, South Africa.

Correspondence to Marie C.D. Stoner, MPH, PhD, Carolina Population, University of North Carolina, 123 W Franklin St., Chapel Hill, NC 27599, USA. E-mail:

Received 5 June, 2018

Accepted 3 September, 2018

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