Strong father-child relationships and other positive childhood experiences, adverse childhood experiences, and sexual risk factors for HIV among young adults aged 19-24 years, Namibia, 2019: A Cross-sectional Study.

doi:10.21203/rs.3.rs-1930490/v1

Background

Understanding what childhood factors influence HIV acquisition risk among young adults, especially young women, is critical as they are disproportionately affected by the global HIV epidemic. Adverse and positive childhood experiences (ACEs and PCEs, respectively), including strong parent-child relationships, may influence HIV acquisition risk among youth (19–24 years) living in sub-Saharan African countries.

Methods

Using cross-sectional data from the 2019 Namibia Violence Against Children and Youth Survey, we assessed the associations between each of 4 PCEs (including having a strong father-child relationship, strong mother-child relationship, or strong caregiver monitoring and supervision, and ever attending secondary school) and ≥ 3 ACEs with 7 individual sexual HIV risk factors, through sex-stratified multivariable hierarchical models. Interaction terms between ≥ 3 ACEs and the relevant PCE were included in each model. For significant interaction terms, multivariable analyses were done stratifying among those with and without the PCE.

Results

Strong father-child relationships were inversely associated with 2 HIV risk factors among women (lifetime transactional sex [OR 0.4, 95% CI 0.2–0.7] and recent age-disparate sexual relationship [OR 0.3, CI 95% 0.2–0.5]) and significantly interacted with having ≥ 3 ACEs for 3 HIV risk factors among women and 1 among men. Among women without strong father-child relationships, having ≥ 3 ACEs was positively associated with not knowing a partner’s HIV status (OR 1.7, 95% CI 1.7–2.4) or infrequently using condoms (OR 1.4, 95% CI 1.0-2.1) in the past year, and ever having an STI (OR 2.3, 95% CI 1.2–4.6); among men without strong father-child relationships, ≥ 3 ACEs was positively associated with having multiple sexual partners in the past year (OR 3.5, 95% CI 1.9–6.4). Conversely, among women and men with strong father-child relationships, experiencing ≥ 3 ACEs was either not significantly, or inversely, associated with those risk factors. The other PCEs were significantly associated with ≤ 1 HIV risk factor and had no significant interaction terms.

Conclusion

Among youth in Namibia, strong child-father relationships may reduce HIV acquisition risk and mitigate the effect of childhood adversity on this risk. Improving parent and caregiver support may be an important strategy to reduce the impact of childhood adversity and aid global HIV epidemic control.

HIV

sexual health

adolescents and young adult health

adverse childhood experiences

positive childhood experiences

fathers

Reducing the HIV burden and incidence among adolescents and young adults, particularly girls and young women given their disproportionate risk in high HIV-incidence countries, is essential to curbing the global HIV epidemic [1]. In 2019, 410,000 adolescents and young adults aged 10-24 were newly infected globally [2]. In Namibia, where HIV/AIDS was the number one cause of death and disability (measured using DALYs or disability adjusted life years) among the general population in 2019 [3], adolescents and young adults aged 15-24 account for approximately 19.1% of the population, 10.4% of all people living with HIV, but 31.4% of new HIV infections annually [4]. Understanding what factors influence the risk of HIV acquisition among adolescents and young adults, especially girls and young women, and implementing interventions targeting these factors, can help improve their well-being, and reduce the overall HIV burden and incidence in Namibia.

Heterosexual intercourse is a key mode of HIV transmission and has helped propagate the HIV epidemics in Namibia and other sub-Saharan African countries [5]. Sexual risk factors associated with HIV acquisition include behaviors such as engaging in transactional sex [6, 7], infrequently using condoms [8], having multiple sexual partners [9, 10], not knowing a sexual partner’s HIV status [11], and having age-disparate sexual relationships with substantially older partners [12, 13]. Other sexual HIV risk factors including sexual health-related outcomes are also independently associated with HIV acquisition, such as having a non-HIV STI [14, 15] and experiencing sexual violence in adulthood [16].

Earlier experiences in childhood and adolescence may influence sexual HIV risk later in life. Adverse childhood experiences (ACEs) are potentially traumatic events that occur in childhood and can increase the risk of adverse health behaviors and poor health outcomes in adolescents and adults [17], including HIV acquisition and associated sexual risk factors. Studies demonstrate an association between ACEs and sexual HIV risk factors in adulthood, including sexual risk behaviors [18-21], having an STI [22, 23], and experiencing sexual violence in adulthood [24]; however, most of these studies did not disaggregate by sex. Data on the sex-specific associations between ACEs and sexual HIV risk factors are limited but important, because young men and women may respond to ACEs differently [25] and carry different HIV risk profiles [26] that can significantly influence the interventions that may help reduce their HIV acquisition risk. Furthermore, published data on the prevalence and impact of ACEs, and their association with HIV acquisition risk, is generally lacking in many sub-Saharan African countries, including Namibia.

In contrast to ACEs, positive childhood experiences (PCEs), which include factors like safe, stable, and nurturing relationships and environments [27], can reduce the risk of adverse health behaviors and poor health outcomes in adolescents and adults [28, 29]. PCEs may not only be protective against adverse health outcomes, but they may also mitigate the harmful effects of ACEs on long-term health among those who have experienced childhood adversity [30-33]. Most of the evidence on PCEs is related to their impact on mental health; however, studies have subsequently demonstrated a beneficial effect on sexual health [34-36]. PCEs, in particular strong parental relationships and secondary school attendance and completion, are associated with reduced levels of sexual risk behaviors among young adults in sub-Saharan Africa [34-36] . More evidence is needed to understand the sex-specific influence of PCEs on HIV sexual risk and how PCEs may mitigate the effect of ACEs on HIV sexual risk among young men and women.

This cross-sectional analysis aims to understand how exposure to ACEs and PCEs may influence the occurrence of different sexual HIV risk factors among young adults in Namibia. The analysis has four objectives: (1) to compare the prevalence of six ACEs, four PCEs, and seven sexual HIV risk factors between young men and women; (2) to assess the sex-stratified associations between having ≥3 ACEs and the occurrence of each sexual HIV risk factor; (3) to assess the sex-stratified multivariable associations between exposure to each PCE and occurrence of each sexual HIV risk factor; and (4) to assess if and how having each PCE moderates, or potentially mitigates, the sex-stratified association between having ≥3 ACEs and each sexual HIV risk factor. Understanding these associations and relationships can help inform policy and programmatic efforts to reduce the risk of HIV acquisition among adolescents and young adults in high burden settings and aid HIV epidemic control.

Background and Objectives of Namibia VACS

This study was a secondary analysis of the 2019 Namibia Violence Against Children and Youth Survey, or Namibia VACS. The Namibia VACS was a cross-sectional, nationally representative multistage geographically clustered household survey of adolescents and young adults aged 13 to 24 years[37]. The standard VACS design and methodology have been described elsewhere [38]. Eligible participants for the Namibia VACS included females and males who lived in selected households in Namibia, were between 13 and 24 years, and spoke Afrikaans, English, Khoekhoegowab, Oshiwambo, Otjiherero, RuKwangali, or siLozi. Children unable to participate due to severe intellectual or physical disability (hearing or speech impairments) were excluded. Trained interviewers administered standardized questionnaires face-to-face to the head of each household and male or female participants [39]. The participant questionnaires inquired about the following topics: demographics, parental and familial relationships, and education status; lifetime and recent exposures to physical, emotional, and sexual violence; disclosure of violence experiences; knowledge and utilization of services; witnessing violence in the home or community; and risk-taking behaviors and health outcomes. In addition to the interviews, voluntary HIV testing was offered to participants 14 years and older in accordance with Namibia Ministry of Health and Social Services (MoHSS) guidelines [40].

Sampling

The Namibia VACS was led by the Government of Namibia, specifically the Ministry of Gender Equality, Poverty Eradication and Social Welfare (MGEPESW), the Ministry of Health and Social Services (MoHSS), and the Namibia Statistics Agency (NSA), with financial support from the President’s Emergency Plan for AIDS Relief (PEPFAR), and implementation and technical support from the US Centers for Disease Control and Prevention (CDC) and the International Training and Education Center for Health (I-TECH) at University of Washington (UW). The survey design followed a three-stage clustered sampling approach that included the random selection of geographic sampling units or enumeration areas, households in each sampling unit, and an eligible individual in each household. A split-sample approach was also followed, where different sampling units were selected for male and female participants to prevent retaliatory violence between opposite sex perpetrators and their survivors of violence [41, 42]. This approach also yielded separate estimates for males and females. Namibia VACS was implemented nationwide; however, adolescent girls and young women were oversampled in certain regions with high HIV prevalence, specifically Khomas, Oshikoto, and Zambezi, to provide regional estimates to inform HIV and violence prevention programming in these regions.

Ethical Procedures

Namibia’s MoHSS Research Ethics Committee and CDC’s Institutional Review Board reviewed and approved the study protocol. For participants under 18, permission was obtained from a parent or guardian and assent from the participant. For participants 18 years or older or minors 16 years and older who had a child, were married under civil law, or who were heads of households, informed consent was obtained directly from the participant.

In addition to the split sample approach, strategies to protect participant privacy, confidentiality, and safety included voluntary, private, and one-on-one interviews. Additionally, in accordance with WHO guidelines [42], VACS was presented as a general youth health and wellness survey to everyone including during the informed consent process with the heads of household and caregivers of the participants; only participants and interviewers were aware that the interview focused on the participant’s previous violence experiences.

All participants were provided with lists of health and social services in their local area, and specific participants who were identified to be highly vulnerable were offered direct referral to a social worker through MGEPESW. For those identified to be in acute danger, an immediate action plan was enacted. The United Nations International Children’s Emergency Fund (UNICEF) supported the development, training for, and implementation of the response plan through case management processes. For those who were diagnosed with HIV during the survey, I-TECH and MoHSS coordinated their immediate linkage with HIV treatment and care services.

Study Sample

This secondary analysis of data from the 2019 Namibia VACS included all young men and women who participated in the Namibia VACS and who were aged 19–24 years at the time the survey was conducted. Age 19 years was chosen as the cut-off to help ensure that the childhood exposures (ACEs and PCEs) occurred before most of the outcomes or sexual HIV risk factors, particularly those assessing sexual behaviors and experiences occurring in the previous 12 months.

Measures

Outcomes

Seven dichotomous sexual HIV risk factors, or risk factors related to sexual health and associated with HIV acquisition, were included in this analysis:

(1) unknown HIV status of recent sexual partner in past 12 months - participant had at least one sexual partner in past 12 months whose HIV status was unknown to the participant, i.e., participant both denied ever getting tested with partner and denied that partner ever disclosed his or her HIV status;

(2) lifetime transactional sex – participant reported ever having sex in exchange for material support, or things that he or she “needs such as money, gifts or other things that are important;”

(3) infrequent condom use in past 12 months - participant reported only sometimes or never using a condom with at least one sexual partner in past 12 months, excluding those participants who both reported being married or living with someone as being married and reported only having one sexual partner in past 12 months;

(4) multiple sexual partners in past 12 months – participant reported having more than one sexual partner in the past 12 months;

(5) age-disparate sexual relationship in past 12 months - participant reported having a sexual relationship in the past 12 months with a partner who was older than the participant by 10 or more years;

(6) STI in lifetime – participant reported ever being diagnosed with a sexually transmitted infection or ever having a genital sore or ulcer; and

(7) sexual violence during adulthood – participant reported experiencing sexual violence on or after age 18 years.

Demographics

Three sociodemographic variables were included in this analysis: (1) age - dichotomous variable including 19–21 and 22–24; (2) region of residence – 4-level variable including Khomas, Zambezi, Oshikoto, and other; and (3) financial insecurity – dichotomous variable distinguishing those who reported not having enough money for either food, “the most important things such as clothing, school fees, or medical care”, or both, and those who reported having enough money for all these items.

Exposures - Aces

Six dichotomous ACEs measures occurring before 18 years old were included in this analysis:

(1) experienced physical violence, defined as if an intimate partner; peer; parent, adult caregiver, or relative; or another adult in the community did any of the following:

slapped, pushed, shoved, shook, or intentionally threw something at participant;
punched, kicked, whipped, or beat participant with an object;
strangled, smothered, burned intentionally, or tried to drown participant; or
threatened or hurt participant with a knife, panga, gun, or other weapon;

(2) experienced emotional violence, defined as any of the following:

if a parent, adult caregiver, or other adult relative (i) told participant he or she was not loved, or did not deserve to be loved; (ii) said that they wished participant had never been born or were dead; or (iii) ridiculed or put participant down
if an intimate partner (i) insulted, humiliated, or made fun of participant in front of others; (ii) kept participant from having money; (iii) tried to keep participant from seeing or talking to family or friends; (iv) kept track of participant by demanding to know where he or she is and what he or she was doing; or (e) made threats to physically harm participant
if a peer (i) made participant get scared or feel really bad because peer was calling participant names, saying mean things, or saying they didn’t want participant around; (ii) told lies or spread rumors about participant; or (iii) kept participant out of things on purpose, excluded participant from their group of friends, or completely ignored participant;

(3) experienced sexual violence, defined as any of the following:

being touched in a sexual way without participant’s permission, including “fondling, pinching, groping, or touching” on or around his or her sexual body parts;
being physically forced to have sex against his or her will and when sex did occur;
being physically forced to have sex but sex didn’t occur;
being pressured to have sex through harassment and threats, and sex did occur;

(4) witnessed physical violence in community - participant witnessed someone get attacked outside the home;

(5) witnessed physical violence in home - participant witnessed father or step-father hit, punch, or kick mother or step-mother or vice-versa, or participant witnessed parent punch, kick, or beat siblings;

(6) became an orphan - at least one parent deceased prior to the participant becoming 18 years old.

A cumulative ACE score or indicator was also calculated for each participant and included two groups – those who experienced 0, 1, or 2 ACEs and those who experienced ≥ 3 ACEs. These two groups were chosen in order to compare the associations between high levels of adversity and lower levels of adversity in childhood. Two groups were chosen instead of three groups (e.g., 0 ACEs, 1–2 ACEs, and ≥ 3 ACEs) to facilitate interpretation of the interaction between PCEs and ACEs and understand the potential role PCEs have in moderating the association between high levels of adversity and sexual HIV risk factors.

Exposures – Pces

Four dichotomous PCEs measures were included in this analysis:

(1) attending or completing secondary school – participant reported having attended or completed secondary school by the time of the survey;

(2) having a strong mother-child relationship (under 18);

(3) having a strong father-child relationship (under 18);

Strong father/mother-child relationship is defined as a participant reporting that, while he or she was under 18, the participant both had an easy time talking to his or her biological father/mother and was close to his or her biological father/mother;

(4) strong caregiver monitoring and supervision - participant reported that the person he or she had the closest relationship with (either mother, father, or other caregiver) knew “a lot” about at least one of the following while participant was under 18: (a) who participant’s friends were; (b) how participant spent money; (c) where participant went after school; (d) where participant went at night; or (e) what participant did in his or her free time.

Data Analysis

First, the prevalence of the demographic variables, sexual HIV risk factors, ACEs, and PCEs were estimated and compared among males and females using chi-square tests (p-value < 0.05). Second, bivariate analyses were conducted to calculate crude odds ratios (OR) assessing the associations between the sexual HIV risk factors with the individual ACEs and PCEs and the cumulative ACEs score, i.e., having ≥ 3 ACEs, compared to 0–2 ACEs, among men and women (p-value < 0.05). Third, multivariable logistic regression analyses assessed the association between having ≥ 3 ACEs (compared to 0–2 ACEs) and each sexual HIV risk factor, adjusting for demographics (age, region of residence, and financial insecurity).

Fourth, multivariable logistic regression analyses assessed the association between each PCE and each sexual HIV risk factor. In this step, for each sexual HIV risk factor (dependent variable), four models were constructed. Each model included the ACEs variable, the three demographic variables, one of the four PCEs, and an interaction term between the cumulative ACEs indicator and the PCE under consideration. All multivariable analyses were stratified by sex; the determination to stratify by sex was made a priori in order to assess sex-based differences in the associations. This hierarchical analytic approach was taken rather than combining all the ACEs and PCEs into one model due to limitations in sample size. For all multivariable analyses, a Bonferroni correction was applied and alpha = 0.01 was used instead of 0.05 (five models were used for each of the ACE-sexual risk factor associations). Fifth, for all interaction terms that had p-value < 0.01 in the previous step, stratified multivariable analyses were conducted, if sample size permitted, to assess the associations between having ≥ 3 ACEs (compared to 0–2 ACEs) and the HIV sexual risk factor stratified by those with, and those without, the PCE under consideration.

This analysis was done using SAS (version 9.4; SAS Institute) accounting for the complex survey design (including survey weight, cluster, and strata).

Descriptive analysis

Of the 4,211 girls and young women who completed the Namibia VACS (89% overall response rate), 2,046 (49%) were 19–24 years old and eligible for this analysis; and of the 980 boys and young men who completed the VACS (84% overall response rate), 467 (48%) were 19–24 years old and eligible for this analysis. Sociodemographic characteristics were similar among men and women. Over half of eligible young adults were aged 19–21 years. Over two thirds (68%) of young adults experienced financial insecurity, i.e.not having enough money for either food and/or other essential items like schooling or clothes (Table 1).

Table 1

Demographics and sexual HIV risk factors among young adults 19–24 years old in Namibia
Indicator	Female		Male		Total
	N	Weighted Prevalence % (95% CI)	N	Weighted Prevalence % (95% CI)	N	Weighted Prevalence % (95% CI)
Demographics
Age	2046		467		2513
19–21		55.0 (51.5–58.6)		57.8 (51.8–63.8)		56.5 (52.9–60.1)
22–24		45.0 (41.4–48.5)		42.2 (36.2–48.2)		43.5 (39.9–47.1)
Region of residence	2046		467		2513
Khomas		21.6 (16.5–26.6)		16.2 (6.7–25.8)		18.7 (14.3–23.1)
Oshikoto		10.5 (7.9–13.1)		9.2 (0.5–17.8)		9.8 (5.5–14.1)
Zambezi		5.6 (4.3-7.0)		4.8 (0.0-10.2)		5.2 (2.5–7.9)
Other		62.3 (54.3–70.3)		69.8 (57.5–82.1)		66.3 (60.8–71.7)
Financial insecurity	2012	63.7 (57.9–69.5)	464	71.8 (65.4–78.3)	2476	68.0 (63.8–72.3)
Outcomes
Didn’t know HIV status of at least one sexual partner in past 12 months***	1972	18.1 (14.9–21.3)	445	29.3 (23.7–34.9)	2417	24.0 (20.6–27.5)
Ever had transactional sex	1999	3.4 (2.1–4.7)	462	2.6 (1.2–4.1)	2461	3.0 (2.0–4.0)
Multiple sexual partners in past 12 months***	1975	7.1 (5.1–9.2)	445	24.6 (20.2–29.1)	2420	16.4 (13.2–19.6)
Infrequent or no condom use in past 12 months***	1961	38.2 (34.1–42.3)	442	21.2 (17.0-25.5)	2403	29.2 (25.6–32.8)
Sexual partner in the past 12 months who is older by ≥ 10 years***	1889	3.7 (2.2–5.3)	435	0.4 (0.0-0.8)	2324	1.9 (1.1–2.8)
History of STI in lifetime	2034	7.2 (5.2–9.2)	467	9.0 (5.6–12.4)	2501	8.1 (5.9–10.4)
Experienced sexual violence in adulthood (18 yrs old to present)	2027	9.6 (7.2–12.0)	464	7.3 (3.5–11.0)	2491	8.3 (6.0-10.7)
*chi-square p-value < 0.05
** chi-square p-value < 0.01
*** chi-square p-value < 0.001
N = unweighted sample size in sex-stratum or total sample

Not knowing the HIV status of at least one sexual partner and using condoms infrequently in the past 12 months were common sexual HIV risk factors (24% and 29%, respectively) among all young adults in Namibia aged 19–24 years. Significantly more young women than men used condoms infrequently in the past 12 months (38% vs 21%, p < 0.001) and had an age-disparate sexual relationship with a partner who was older by 10 years or more in the past 12 months (3.7% vs 0.4%, p < 0.001). Conversely, more young men than women did not know the HIV status of at least one sexual partner in the past 12 months (29% vs 18%, p < 0.001) and had more than one sexual partner in the past 12 months (25% vs 7%, p < 0.001, Table 1).

Approximately 79% of young adults in Namibia have had at least one ACE and 26% have had 3 or more ACEs, with no significant differences between men and women. Significantly more women, however, experienced sexual violence than men (11% vs 6%, p < 0.05), whereas significantly more men experienced physical violence (39% vs 31%, p < 0.05) and witnessed physical violence in the community (60% vs 49%, p < 0.05, Table 2). The prevalence of experiencing emotional violence (9%), witnessing violence in the home (37%), and being an orphan (29%) were not significantly different between men and women. Attending or completing secondary school was the most prevalent PCE among men and women (86%). Women were more likely than men to attend or complete secondary school (91% vs 82%, p < 0.01), while men were more likely than women to have a strong father-child relationship (55% vs 43%, p < 0.01; Table 2).

Table 2

Adverse (ACEs) and Positive Childhood Experiences (PCEs) among young adults 19–24 years old in Namibia
Indicator	Female		Male		Total
	N	Weighted Prevalence % (95% CI)	N	Weighted Prevalence % (95% CI)	N	Weighted Prevalence % (95% CI)
ACEs (before age 18 years)
Experienced physical violence*	2015	30.6 (26.4–34.8)	453	39.4 (32.7–46)	2468	35.3 (31.6–39)
Experienced sexual violence*	2032	10.9 (8.3–13.5)	467	6.1 (3.3-9.0)	2499	8.3 (6.4–10.3)
Experienced emotional violence	1977	10.6 (7.8–13.4)	458	7.0 (4.6–9.3)	2435	8.7 (7.0-10.3)
Witnessed physical violence in community*	1997	49.1 (44.7–53.5)	451	60.2 (52.5–67.9)	2448	55 (50.2–59.8)
Witnessed physical violence at home	1991	35.9 (31.5–40.3)	449	38.8 (31.8–45.8)	2440	37.4 (33.5–41.4)
Orphan status	1915	32.5 (27.7–37.4)	446	26.4 (21.3–31.5)	2361	29.3 (25.7–32.8)
≥ 1 ACEs	2037	77.2 (73.3–81.1)	467	81.0 (75.3–86.7)	2504	79.2 (75.7–82.7)
≥ 3 ACEs	2037	25.5 (21.4–29.5)	467	26 (19.9–32)	2504	25.7 (22.4–29.1)
PCEs (before age 18 years)
Education Status: Completed or attended secondary school**	2032	90.6 (87.7–93.5)	467	81.8 (76-87.7)	2499	85.9 (82.4–89.4)
Strong mother-child relationship (before 18 years)	1950	68.0 (64.0-72.1)	461	74.7 (69.0-80.5)	2411	71.7 (67.9–75.5)
Strong father-child relationship (before 18 years)**	1864	42.5 (37.0–48)	447	55.3 (49.6–61.0)	2311	49.6 (45.7–53.4)
Caregiver monitoring and supervision (before 18 years)	2002	64.0 (59.5–68.4)	459	67.3 (60.4–74.1)	2461	65.7 (61.5–70.0)
*p-value < 0.05
**p-value < 0.01
N = unweighted sample size in sex-stratum or total sample size

Bivariate Association Between Aces, Pces, And Sexual Hiv Risk Factors

Experiencing three or more ACEs, compared to experiencing 0–2 ACEs, was significantly associated with 5 sexual HIV risk factors among men and 4 risk factors among women (S1 Table). Completing or attending secondary school was significantly associated with 2 sexual HIV risk factors among women and 1 risk factor among men. Having a strong father-child relationship was significantly associated with 4 sexual HIV risk factors among women and 2 risk factors among men. Having a strong mother-child relationship was significantly associated with 1 sexual HIV risk factor among women and 3 risk factors among men. Strong caregiver monitoring and supervision was significantly associated with 3 sexual HIV risk factors among women and 1 risk factor among men (S2 Table). Bivariate associations could not be assessed for the age-disparate sexual relationship among men given the low prevalence of this risk factor among men.

Multivariable Associations Between Cumulative Aces Score, Individual Pces, And Sexual Hiv Risk Factors

After adjusting for demographic variables, having ≥ 3ACEs, compared to having 0––2 ACEs, was significantly associated for 3 of the 7 sexual HIV risk factors among women―lifetime transactional sex (OR 4.2, 95% CI 2.0-8.7; Table 3), having an age-disparate sexual relationship in the past 12 months (OR 2.0, 95% CI 1.2–3.3), and experiencing sexual violence in adulthood (OR 2.9, 95% CI 1.7–5.1). Among men, having ≥ 3 ACEs was only significantly associated with not knowing partner’s HIV status (OR 2.1, CI 95% 1.4–3.1, Table 4). Multivariable associations could not be determined for three sexual HIV risk factors among men―lifetime transactional sex, having an age-disparate sexual relationship in the past 12 months, and experiencing sexual violence in adulthood―given the limited prevalence of these reported risk factors among men and failure of models to converge.

Table 3

Multivariable associations between sexual HIV risk factors, ≥ 3 ACEs, and individual PCEs among young women
	Adjusted OR (CI 95%)
	Don’t know partner’s HIV status in past 12 months	Lifetime transactional sex	Multiple sexual partners in past 12 months	Infrequent condom use in past 12 months	Lifetime STI	SV at 18 years or older	Sexual partner in the past 12 months who is older by ≥ 10 years
Exposure
ACEs 3 or more (ref: <3 ACEs)¹	1.1 (0.8–1.5)	4.2 (2.0-8.7)***	2.2 (1.2-4.0)*	1.0 (0.6–1.7)	1.5 (0.8–2.8)	2.9 (1.7–5.1)***	2.0 (1.2–3.3)**
Attended or completed Secondary school²	0.6 (0.4–0.9)*	0.6 (0.2–1.8)	0.7 (0.2–2.1)	0.8 (0.4–1.6)	0.6 (0.2–1.5)	0.6 (0.3–1.2)	0.2 (0.1 0.5)***
Strong relationship with mother²	0.9 (0.6–1.4)	0.8 (0.4–1.6)	0.5 (0.3–0.9)*	0.9 (0.6–1.3)	0.9 (0.6–1.5)	0.8 (0.5–1.3)	0.5 (0.2–1.4)
Strong relationship with father²	n/a³	0.4 (0.2–0.7)**	1.5 (1.0-2.2)	n/a³	n/a³	0.9 (0.6–1.4)	0.3 (0.2–0.5)***
Caregiver monitoring and supervision²	1.2 (0.9–1.5)	1.5 (0.5-4.0)	1.4 (0.9-2.0)	0.8 (0.6-1.0)*	3.0 (1.6–5.7)**	2.3 (1.2–4.6)*	0.8 (0.3–2.1)
*p-value < 0.05
**p-value < 0.01
***p-value < 0.001
¹adjusted for age, region of residence, and financial insecurity
²adjusted for age, region of residence, financial insecurity, and experiencing 3 or more ACEs
³interaction term for PCE variable and 3 or more ACEs variable is statistically significant (p-value < 0.01).

Table 4

Multivariable associations between sexual HIV risk factors, ≥ 3 ACEs, and individual PCEs among young men
	Adjusted OR (95% CI)
	Don’t know partner’s HIV status in past 12 months	Lifetime transactional sex	Multiple sexual partners in past 12 months	Infrequent condom use in past 12 months	Lifetime STI	SV at 18 years or older	Sexual partner in the past 12 months who is older by ≥ 10 years
Exposure
ACEs 3 or more (ref: <3 ACEs)¹	2.1 (1.4–3.1)**	n/a⁴	1.7 (1.0-2.8)	2.2 (1.1-4.0)*	1.7 (1.2–2.6)*	n/a⁴	n/a⁴
Attended or completed Secondary school²	0.7 (0.5-1.0)	n/a⁴	0.7 (0.3–1.6)	0.2 (0.1–0.6)*	0.8 (0.3–1.8)	n/a⁴	n/a⁴
Strong relationship with mother²	0.8 (0.4–1.5)	n/a⁴	0.6 (0.4–1.1)	0.7 (0.4–1.3)	0.4 (0.2–0.8)**	n/a⁴	n/a⁴
Strong relationship with father²	1.0 (0.7–1.3)	n/a⁴	n/a³	1.0 (0.6–1.6)	0.7 (0.4–1.2)	n/a⁴	n/a⁴
Caregiver monitoring and supervision²	0.6 (0.3-1.0)	n/a⁴	1.1 (0.7-2.0)	1.1 (0.6–2.2)	1.1 (0.5–2.2)	n/a⁴	n/a⁴
*p-value < 0.05
**p-value < 0.01
¹adjusted for age, region of residence, and financial insecurity
²adjusted for age, region of residence, financial insecurity, and experiencing 3 or more ACEs
³interaction term for PCE variable and 3 or more ACEs variable is statistically significant (p-value < 0.01).
⁴Sample size too small to model

After adjusting for demographics and having ≥ 3 ACEs, several PCE and sexual HIV risk factor associations were statistically significant for both young men and women. Among women, having a strong father-child relationship was significantly associated with decreased odds of lifetime transactional sex (OR 0.4, 95% CI 0.2–0.7) and decreased odds of having a recent age-disparate sexual relationship (OR 0.3, CI 95% 0.2–0.5); experiencing strong caregiver monitoring and supervision was associated with increased odds of ever having an STI (OR 3.0, 95% CI 1.6–5.7); and attending or completing secondary school was significantly associated with decreased odds of having an age-disparate sexual relationship in the past 12 months (OR 0.2, CI 95% 0.1–0.5; Table 3). Among men, having a strong mother-child relationship was significantly associated with decreased odds of ever having an STI (OR 0.4, 95% CI 0.2–0.8, Table 4). .

Interactions between having a strong father-child relationship and having ≥ 3 ACEs were statistically significant for 4 of the sexual HIV risk factors – 3 among women (Table 3) and 1 among men (Table 4) - and required stratified analyses (Table 5). Among women who did not have strong relationships with their father in childhood, experiencing ≥ 3 ACEs was associated with increased odds of not knowing a partner’s HIV status in the past 12 months (OR 1.7, 95% CI 1.7–2.4), increased odds of infrequently using condoms in the past 12 months (OR 1.4, 95% CI 1.0-2.1), and increased odds of ever having an STI (OR 2.3, 95% CI 1.2–4.6). Conversely, among women who had strong relationships with their fathers in childhood, these associations were nullified or inverted - experiencing ≥ 3 ACEs was associated with decreased odds of not knowing a partner’s HIV status in the past 12 months (OR 0.6, 95% CI 0.3-1.0), decreased odds of infrequently using a condom in the past 12 months (OR 0.6, 95% CI 0.4–0.9), and decreased odds of ever experiencing an STI (OR 0.3, 95% CI 0.1-1.0). Among men who did not have strong relationships with their fathers in childhood, experiencing ≥ 3 ACEs was associated with increased odds of having multiple sexual partners (OR 3.5, 95% CI 1.9–6.4); while among men who did have strong relationships with their father, experiencing ≥ 3 was associated with decreased odds of having multiple sexual partners (OR 0.9, 95% CI 0.4–1.9).

Table 5

Multivariable associations between sexual HIV risk factors and ≥ 3 ACEs stratified by father-child relationship status
			Experienced ≥ 3 ACEs
			OR and 95% CIs by stratum²
			Among those who had a strong relationship with one’s father	Among those who did not have a strong relationship with one’s father
HIV sexual risk factor	sex	p-value¹
Unknown HIV status of at least one sexual partner³	Female	0.002	0.5 (0.3-1.0)	1.5 (1.0-2.3)*
infrequent condom use³	Female	0.005	0.6 (0.4–0.9)**	1.4 (1.0-2.1)
STI in lifetime	Female	0.005	0.3 (0.1-1.0)	2.3 (1.2–4.6)*
Multiple sexual partners³	Male	0.004	0.9 (0.4–1.9)	3.5 (1.9–6.4)***
*p-value < 0.05
**p-value < 0.01
***p-value < 0.001
¹p-value for interaction term between having a strong paternal relationship) and having 3 or more ACEs
²adjusted for age, region of residence, financial insecurity
³in previous 12 months

Our analysis of 2019 Namibia VACS data suggest that strong parent-child relationships, particularly father-daughter relationships, may be protective and mitigate the negative impact that high levels of childhood adversity can have on HIV acquisition risk among young adults aged 19–24 in Namibia. Having a strong father-child relationship was found to be protective against ever having transactional sex and having a recent age-disparate sexual relationship among women and having a strong mother-child relationship was protective against being diagnosed with an STI among men. Furthermore, having a strong father-child relationship moderated the association between high levels of ACEs and 4 of the 7 sexual HIV risk factors in this analysis, 3 among women and 1 among men.

These findings are novel as few studies have assessed how strong parental relationships can mitigate the effect of ACEs on HIV sexual risk. Evidence clearly demonstrates, however, that social protection and support, including strong parental support, prevents adolescent participation in behaviors associated with HIV-risk and decreases HIV acquisition risk [36, 43]. Some studies have linked the specific benefits of paternal support to reducing the risk of having many lifetime sexual partners or multiple partners in the past 12 months [36, 44]. A study from South Africa demonstrated that having a father in the home moderated and mediated the effects of their school-based intervention aimed at reducing the risk of sexual intercourse in the previous 3 months and unprotected intercourse among adolescents. Further work is needed to explore these associations and understand the mechanisms linking ACEs, strong relationships with parents and other primary caregivers, and HIV acquisition risk [45]..

Understanding which childhood experiences (e.g., strong paternal relationships) benefit young adults, and protect them from the negative effects of ACEs, is critical given the strong effect of ACEs on HIV acquisition risk. Indeed, our analysis detected significant associations between having ≥ 3 ACEs and increased odds of several sexual HIV risk factors among both men and women. The Namibia VACS clearly shows that childhood adversity is a common experience among young adults in Namibia. Nearly 3 out of 4 young women and over 4 out of 5 men in Namibia have had ≥ 1 ACE and 1 of 4 young adults have had ≥ 3 ACEs. Studies from other African countries have also reported consistently high prevalence of experiencing ≥ 1 ACE ranging from 75%-99% [19, 46–50]. In our analysis, prevalence of cumulative ACEs did not differ significantly by sex, but the prevalence of individual ACEs did. Previous studies from both outside and within sub-Saharan Africa have also corroborated our findings that girls and young women were more likely to experience sexual violence in childhood and boys and young men may be more likely to be exposed to community violence; on the other hand, while we demonstrated that young men and boys were more likely to experience physical violence, the findings from these previous studies were mixed [19, 46, 48, 49, 51–53].

Our analysis benefits from Namibia VACS’s large and nationally representative sample, its comprehensive and expert-based questionnaire, and its rigorous survey methodology that promotes privacy, confidentiality, and accuracy in responses. Nevertheless, limitations of the survey may hinder interpretation of our findings. First, recall and social desirability bias may have influenced our findings and altered the observed associations from the actual ones. Second, the cross-sectional data in this analysis cannot permit causal inferences between the exposure, ACEs and PCEs, and the outcomes, sexual HIV risk factors. Third, the present findings apply to youth living in households; the results cannot be generalized to children and young adults who are institutionalized, homeless, or unable to complete VACS due to disability. Fourth, the Namibia VACS did not collect data on all potential ACEs and therefore our analysis may underestimate the number of children exposed to other ACEs and the number of ACEs to which children in Namibia are exposed. Fifth, besides the question assessing caregiver support and monitoring, VACS do not collect substantive data role of key secondary caregivers in a child’s life including biological relatives like grandparents or unrelated caregivers like neighbors, family friends, or adopted parents. Lastly, the smaller sample size of male participants may have limited the power to detect significant associations in men; multivariable analyses could not be done for 3 of the 7 risk factors among men.

Two additional limitations exclusively related to the analysis may also hinder the interpretation of our findings. First, our analysis may be prone to type 1 statistical error given the numerous associations assessed, though our analysis used a Bonferroni correction to mitigate this limitation. Furthermore, this report’s main findings are supported by consistent associations among multiple sexual HIV risk factors; these multiple significant associations are less likely to be all due to statistical error. Second, variables other than demographics not included in this analysis due to sample size considerations may have confounded, mediated, or moderated the associations and influenced our findings. For example, mental health of the young adult may be an important mediator influencing the relationship between childhood experiences and HIV risk in young adulthood. Poor mental health has been shown to be associated with both high levels of ACEs and HIV risk factors among adolescents and young adults in Sub-Saharan Africa [46, 54–56]. Meinck et al. showed in their longitudinal study following adolescent girls aged 12–17 years in South Africa that mental health distress completely mediated the relationship between ACEs at baseline and increased HIV risk behaviors (including infrequent condom use in past year, lifetime sex while intoxicated, and more than 2 sexual partners in past year) at 1-year follow up [35]. Parental experience of ACEs may also be another important confounder in these relationships. The increased stress for parents who have experienced ACES may not be able to control their stress system and their parenting styles [57]. As a result, intergenerational effects of ACEs might be transmitted through common pathways such as parent mental health and unfavorable parenting practices [58].

Next steps should be considered to strengthen the evidence and better understand the negative effects of ACEs and positive effects of PCEs on the occurrence of sexual HIV risk factors in young adults in sub-Saharan Africa. Surveys examining violence against children could be expanded to incorporate more comprehensive information on ACEs and PCEs (as long as ethical and methodological requirements are met to ensure the risk of harm to the participant from asking violence-related questions is minimized)[42]. In regard to ACEs, surveys of violence among children like VACS could expand measurement of household challenges in childhood, especially parent and family member health and circumstances during childhood. Regarding PCEs, recent literature has attempted to create frameworks to holistically capture experiences in childhood that may lead to resilience. These new comprehensive approaches to understanding positive experiences, like the HOPE framework and the Benevolent Childhood Experiences scale, could influence future VACS questionnaire items [28, 59]. Future VACS could also include more questions about caregivers other than biological parents to assess whether these child-caregiver relationships are potential PCEs.

Other analytic approaches like multi-country analyses using VACS could also help further understand the association between ACEs and HIV risk and inform global HIV prevention efforts. Such analyses could leverage both VACS questionnaire items related to HIV and voluntary HIV testing data to assess other rarer outcomes that more directly assess HIV risk, like new or recent HIV diagnoses. Future studies may consider replicating this study using VACS data from other countries and other data sources to assess if the results observed in this study holds, particularly the potentially mitigating effect of parental relationships on the association between ACEs and HIV risk factors. Such efforts should aim to include relatively larger samples of male participants, such as also oversampling males in high HIV prevalence regions.

Our findings can have significant programmatic and policy implications. They support the application of violence prevention strategies using technical packages like INSPIRE to improve the well-being of children, adolescents and young adults in Namibia and other countries in sub-Saharan African countries and reduce their HIV risk. INSPIRE is a set of seven evidence-based strategies recommended by WHO and partners to help end violence against children [60]. Our findings specifically highlight the importance of improving parent and caregiver support, one of the INSPIRE strategies, which aims to reduce harsh parenting practices and create close parent-child relationships by emphasizing non-violent discipline and close and effective communication[60]. Several programs have been implemented in Namibia and other countries intending to fulfill this strategy and help create strong parent-child relationships. For example, the Families Matter program is a community-based group intervention focused on improving parental knowledge, skills, and self-efficacy in communicating with adolescents about sexuality, safe sex practices, sexual violence, and ways to reduce their sexual and HIV risk. Evaluations of the program in Tanzania and Kenya have demonstrated increased and improved communication about sexual issues between adolescents and parents who completed the program [60, 61]. Parenting for Lifelong Health or ‘Sinovuyo Teen’ is a group-based parenting programs that includes both parents and their adolescents and emphasizes positive parenting using social learning principles. Studies of the program in South Africa have demonstrated that it is cost-effective and associated with several outcomes including improved positive parenting and discipline and reduced rates of childhood violence, poor mental health among caregiver and adolescents, and caregiver substance abuse [62–64].

Our findings also support the cross-disciplinary combination-prevention approach of DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe). DREAMS is a PEPFAR-supported partnership that implements evidence-based interventions aimed to help prevent HIV among adolescent girls and young women (AGYW). It was first implemented in Khomas, Zambezi, and Oshikoto in 2017 leading to VACS oversampling in those regions, and since has expanded to other high incidence areas in the country. DREAMS focuses on reducing the risk among both AGYW and their sexual partners, strengthening families through parenting and caregiver programs, and mobilizing communities for change [65]. In Namibia, DREAMS has partnered with the in-country NGO Lifeline/Childline Namibia to implement positive parenting training programs like Families Matter! to parents of DREAMS participants, strengthen parent-adolescent relationships, and to reduce HIV risk for AGYW[66].

This study demonstrates a negative association between strong parent-child relationships, particularly father-daughter relationships, on HIV acquisition risk in Namibia. In addition, we found that PCEs mitigated the association between childhood adversity and high-risk behaviors for HIV acquisition. While further research is needed, this study supports the important role strong parent-child relationships may have by building resilience, promoting positive health, particularly sexual health, and protecting many young adults from the negative health effects of the adversity that they experience in childhood. Understanding the role of these positive parental relationships and implementing socio-ecologic comprehensive strategies that include evidence-based positive parenting programs are critical to controlling the HIV epidemic and improving the well-being of children, adolescents, and young adults in Namibia.

Ethics Approval: Namibia’s Ministry of Health and Social Services Research Ethics Committee and CDC’s Institutional Review Board reviewed and approved the study protocol.

Consent to participate: For participants under 18, written consent was obtained from a parent or guardian and assent from the participant. For participants 18 years or older or minors 16 years and older who had a child, were married under civil law, or who were heads of households, written informed consent was obtained directly from the participant.

Consent for Publication: non-applicable

Funding: This research has been supported by the President’s Emergency Plan for AIDS Relief (PEPFAR) through US Centers for Disease Control and Prevention (CDC) under the terms of NU2GGH001430-05. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of CDC, PEPFAR, or the US government.

Availability of data and material: Data is available through request from the Together for Girls Partnership (https://www.togetherforgirls.org/request-access-vacs/)

Code availability: Code is available from corresponding author upon request.

Conflicts of Interest: The authors of this manuscript have no relevant conflicts of financial or non-financial interest to disclose.

Author Contribution Roles

NA conceptualized and designed the study; analyzed and interpreted the data; and drafted the manuscript.

FA and GM conceptualized and designed the study; analyzed and interpreted the data; drafted the manuscript; critically revised the manuscript for important intellectual content; and supervised the investigation.

LX, LC, and ES conceptualized and designed the study; analyzed and interpreted the data; drafted the manuscript; and critically revised the manuscript for important intellectual content

RC, JH, PP, NF, GO, AE, RK, HA, BN, and MM participated in interpreting the data and critically revised the manuscript for important intellectual content.

Acknowledgments: We would like to thank the President’s Emergency Plan for AIDS Relief (PEPFAR) for funding support. We would like to also thank all VACS Namibia field staff, participants, and their families and communities.

Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention or the US government.

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TableS1S2.docx

Strong father-child relationships and other positive childhood experiences, adverse childhood experiences, and sexual risk factors for HIV among young adults aged 19-24 years, Namibia, 2019: A Cross-sectional Study.

Status:

Version 1

Abstract

Background

Methods

Results

Conclusion

Introduction

Methods

Background and Objectives of Namibia VACS

Sampling

Ethical Procedures

Study Sample

Measures

Outcomes

Demographics

Exposures - Aces

Exposures – Pces

Data Analysis

Results

Descriptive analysis

Bivariate Association Between Aces, Pces, And Sexual Hiv Risk Factors

Multivariable Associations Between Cumulative Aces Score, Individual Pces, And Sexual Hiv Risk Factors

Discussion

Conclusion

Declarations

References

Supplementary Files

Status:

Version 1