Adolescents in Sub-Saharan Africa who live in HIV-affected households are more likely than their peers to initiate sexual activity.1 According to an analysis of Demographic and Health Survey (DHS) data collected in 2003–2008 from 19 countries, adolescents aged 15–17 who lived with at least one HIV-positive adult had 27% higher odds of having ever had sex than did adolescents who were not living with an HIV-positive adult (odds ratio, 1.3). However, unlike some prior research, the study did not find that orphans have an elevated risk of sexual activity, once poverty level and other household circumstances are taken into account.

Although considerable research has examined the vulnerabilities of children orphaned by AIDS, much less attention has been paid to those of children living with an HIV-positive household member. To address this gap in the literature, the researchers analyzed DHS data from 19 of the 21 Sub-Saharan countries with HIV-test data from 2003 to 2008 (the other two countries were excluded for technical reasons). Like all DHS surveys, these collected information from nationally representative samples of men and women of reproductive age; the current analysis was restricted to 22,620 adolescents aged 15–17.

In addition to questions on social and demographic characteristics, respondents were asked about their maternal and paternal orphanhood status; whether they were enrolled in school; their level of media exposure; the household’s possessions and amenities (from which information the DHS estimates household wealth); the sex of, the age of and their relationship to the household head; and whether they had ever had sex. Results of HIV tests administered to household members were used to classify adolescents according to whether they lived with an HIV-positive adult. The researchers constructed multilevel logistic regression models to assess the associations, stratified by sex, of living with an HIV-positive adult and of maternal or paternal orphanhood with the initiation of sexual activity.

Overall, 11% of respondents lived with an HIV-positive adult, though the proportion varied widely, ranging from 2% in Ethiopia to 44% in Swaziland. In the 10 countries for which data on orphanhood were available, 7% of respondents were maternal orphans; the proportion was lowest in Liberia (4%) and highest in Zimbabwe (17%). The proportion of adolescents who were paternal orphans was 13% in the pooled sample, and ranged from 11% in Liberia to 34% in Lesotho.

Thirty-two percent of adolescent females and 25% of adolescent males had ever had sex. Again, these proportions varied considerably across countries. For example, in Rwanda, 9% of females aged 15–17 had ever had sex, while this was true for 60% of their counterparts in Liberia. For males, the proportion was lowest in Ethiopia (3%) and highest in Côte d’Ivoire (52%).

In multilevel logistic regression analyses that adjusted for household circumstances (household wealth, adolescent’s relationship to head of household, and age and sex of household head) and other covariates, young women who lived with an HIV-positive adult had elevated odds of having had sex (odds ratio, 1.3). In addition, age was positively associated with having had sex (2.0 per year), while young women had reduced odds of having had sex if they were attending school (0.4), were Protestant rather than Catholic or orthodox (0.8), were not the head of their household (0.02–0.04), were in the richest wealth quintile rather than the poorest (0.7) or lived in a household in which the head was younger than 25 rather than aged 25–59 (0.8).

For males, the results of the regressions typically mirrored those for females. Age and living with an HIV-positive adult were associated with elevated odds of having ever had sex (odds ratios, 1.8 and 1.2, respectively), while being in school, not being a head of household and being in the richest wealth quintile were associated with reduced odds of having had sex (0.4–0.6). In addition, as levels of education and media exposure increased, so did the odds of males’ being sexually experienced (1.4–1.9); living in a household with a head who was aged 60 or older was also associated with elevated odds of having had sex (1.2). Although in intermediate regression models, paternal orphanhood was positively associated with males’ having had sex, the association was not significant when the authors adjusted for household circumstances.

Finally, regressions run on the full sample yielded results similar to those for males, albeit with some slight differences in odds ratios. The odds of having had sex were 27% greater among adolescents in households with an HIV-positive adult than among youth in other households (odds ratio, 1.3). In addition, being female was associated with elevated odds of having ever had sex (1.2), while being a maternal orphan was associated with reduced odds (0.8).

The researchers acknowledge several limitations. First, the data were cross-sectional; therefore, it was not possible to determine the temporal ordering of household HIV status and adolescent sexual debut. Second, orphanhood data were available for only about half of the included countries; however, supplemental analyses indicated that inclusion or exclusion of the orphanhood variable did not affect the other estimates. Finally, data limitations precluded exploration of regional or country-level associations. Despite these limitations, the researchers conclude that their findings support the argument that adolescents in HIV-affected households are vulnerable to sexual initiation and underscore “the importance of extending current efforts in the region to address the plight of other children in HIV/AIDS–affected households, beyond orphans.”—L. Melhado