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Behavioral, Biological, and Demographic Risk and Protective Factors for New HIV Infections Among Youth in Rakai, Uganda

Santelli, John S. MD, MPH*; Edelstein, Zoe R. MS, PhD; Mathur, Sanyukta MHS, DrPH*; Wei, Ying MS, PhD; Zhang, Wenfei MS, PhD; Orr, Mark G. PhD§; Higgins, Jenny A. MPH, PhD; Nalugoda, Fred MHS, PhD; Gray, Ron H. MBBS, MSc, MFCM#; Wawer, Maria J. MD, MHSc, FRCP#; Serwadda, David M. MBChB, MSc, MMed, MPH

JAIDS Journal of Acquired Immune Deficiency Syndromes: July 1st, 2013 - Volume 63 - Issue 3 - p 393–400
doi: 10.1097/QAI.0b013e3182926795
Epidemiology and Prevention

Background: Prevalence of HIV infection is considerable among youth, although data on risk factors for new (incident) infections are limited. We examined incidence of HIV infection and risk and protective factors among youth in rural Uganda, including the role of gender and social transitions.

Methods: Participants were sexually experienced youth (15–24 years old) enrolled in the Rakai Community Cohort Study, 1999–2008 (n = 6741). Poisson regression with robust standard errors was used to estimate incident rate ratios (IRR) and 95% confidence intervals (CI) of incident HIV infection.

Results: HIV incidence was greater among young women than young men (14.1 vs. 8.3 per 1000 person-years, respectively); this gender disparity was greater among teenagers (14.9 vs. 3.6). Beyond behavioral (multiple partners and concurrency) and biological factors (sexually transmitted infection symptoms), social transitions such as marriage and staying in school influenced HIV risk. In multivariate analyses among women, HIV incidence was associated with living in a trading village (adjusted IRR (aIRR) = 1.48; 95% CI: 1.04 to 2.11), being a student (aIRR = 0.22; 95% CI: 0.07 to 0.72), current marriage (aIRR = 0.55; 95% CI: 0.37 to 0.81), former marriage (aIRR = 1.73; 95% CI: 1.01 to 2.96), having multiple partners, and sexually transmitted infection symptoms. Among men, new infections were associated with former marriage (aIRR = 5.57; 95% CI: 2.51 to 12.36), genital ulceration (aIRR = 3.56; 95% CI: 1.97 to 6.41), and alcohol use (aIRR = 2.08; 95% CI: 1.15 to 3.77).

Conclusions: During the third decade of the HIV epidemic in Uganda, HIV incidence remains considerable among youth, with young women particularly at risk. The risk for new infections was strongly shaped by social transitions such as leaving school, entrance into marriage, and marital dissolution; the impact of marriage was different for young men than women.

*Heilbrunn Department of Population and Family Health, Mailman School of Public Health;

HIV Center for Clinical and Behavioral Studies;

Department of Biostatistics;

§Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY;

Department of Women's Studies, University of Wisconsin–Madison, Madison, WI;

Rakai Health Sciences Program, Uganda Virus Research Institute, Entebbe, Uganda; and

#Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD.

Correspondence to: John S. Santelli, MD, MPH, Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, 60 Haven Avenue, B-2, New York, NY 10032 (e-mail:

Supported by NIH/NIHCD (5R01HD061092) and NIH/NIMH training grant to Z. R. Edelstein (T32-MH19139).

Presented at XIX International AIDS Conference, July 2012, Seattle, WA, CROI 2011.

The authors have no conflicts of interest to disclose.

Received October 24, 2012

Accepted March 13, 2013

© 2013 Lippincott Williams & Wilkins, Inc.