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Dissertation
Understanding HIV among adolescent mothers in East and Southern Africa: a multilevel and Bayesian spatial analysis
Doctor of Philosophy (Ph.D.), Drexel University
Jun 2025
DOI:
https://doi.org/10.17918/00011043
Abstract
HIV transmission in East and Southern Africa (ESA) occurs predominantly among young people (aged 15-24 years). Among adolescents (15-19 years), girls account for 90% of all new HIV infections and adolescent mothers are at higher HIV risk than non-parenting adolescent girls. However, as adolescent mothers have been largely overlooked in HIV prevention research, gaps in knowledge regarding how individual, relational, and structural (e.g., urbanization) HIV risk factors impact adolescent mothers' HIV risk remain. Specifically, there are differences in adolescent mothers' relationship configurations, and yet no studies have examined how the co-occurrence of relational factors impact adolescent mothers' vulnerability to HIV using a typological approach. Further, most HIV studies on adolescent mothers in ESA use a single-level approach to describe HIV risk as opposed to applying a multilevel framework to explore multilevel HIV risk factors. Moreover, there is spatial variability in adolescent HIV diagnosis. And yet, where adolescent mothers are most at-risk have been underexplored. This dissertation applied a spatial and multilevel framework to investigate HIV among adolescent mothers across ESA. The specific aims are to: 1) identify and characterize typologies of adolescent mothers' sexual relationships in ESA, 2) examine associations between multilevel factors and adolescent mothers' positive HIV diagnoses in ESA, and 3) detect HIV spatial features and examine structural factors of HIV prevalence variation within Eswatini, as a case study. To address these aims, this dissertation uses (1) secondary data from the Population-based HIV Impact Assessment (PHIA), which includes 3,410 adolescent mothers (aged 15-19 years old); and (2) publicly available structural-level data, from Malaria Atlas Project. In Aim 1, we use multilevel latent class analysis (MLCA) to describe adolescent mothers' sexual relationships by identifying latent classes at the relationship and PHIA community-level. In Aim 2, we utilize Bayesian hierarchical modeling to examine the associations between multilevel risk factors and positive HIV diagnosis among adolescent mothers across ESA. And for Aim 3, we employ Bayesian spatial smoothing to map inkhundla-level HIV prevalence among adolescent mothers in Eswatini and detect spatial features of HIV prevalence. When examining adolescent mothers' relationships, MLCA results suggest three typologies: married with minimal transactional sex, unmarried peer partnership, and working and high transactional sex, with the majority of adolescent mothers' relationships labeled as: married with minimal transactional sex. Age, schooling, having multiple partners, and living in a low-wealth household were associated with relationship typologies. Further, PHIA communities were equally split into two classes: high age-disparate marriage and low marriage communities; urbanicity and proportion of low wealth households were associated with PHIA community-level latent classes. In examining the impact of multilevel factors on positive HIV diagnosis among adolescent mothers, there was strong evidence that being in school, married with minimal transactional sex (compared to all other relationship typologies) and not living in a low wealth household were associated with lower odds of positive HIV diagnosis. Further, living in an urban community, low-marriage community (compared to high-age-disparate-marriage community), or community with high gender inequity or child marriage rates were associated with higher odds of positive HIV diagnosis. Conversely, living in a community with all unpartnered adolescent mothers, a higher proportion of low wealth households or greater motorized travel time to nearest healthcare facility were associated with lower odds of positive HIV diagnosis. When estimating and mapping HIV prevalence among adolescent mothers at the inkhundla-level in Eswatini, we identified one hot spot, five cold spots, one low-high outlier, and three high-low outliers. Further, results suggest higher population viral suppression was associated with lower HIV prevalence among tinkhundla with low gender inequity in labor market participation, but not for tinkhundla with high gender inequity. This dissertation addresses several research gaps on adolescent mothers' HIV risk in ESA. Our findings highlight the need to implement and evaluate targeted combination interventions that address school return, employment opportunities and high-risk characteristics associated with relationship typologies, particularly in high HIV-burdened areas.
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Details
- Title
- Understanding HIV among adolescent mothers in East and Southern Africa
- Creators
- Luwam Teklemariam Gebrekristos
- Contributors
- Félice Lê-Scherban (Advisor)
- Awarding Institution
- Drexel University
- Degree Awarded
- Doctor of Philosophy (Ph.D.)
- Publisher
- Drexel University; Philadelphia, Pennsylvania
- Number of pages
- xiii, 103 pages
- Resource Type
- Dissertation
- Language
- English
- Academic Unit
- Dana and David Dornsife School of Public Health; Epidemiology and Biostatistics; Drexel University
- Other Identifier
- 991022058736404721