From policy to practice: uptake of pre-exposure prophylaxis among adolescent girls and young women in United States President's Emergency Plan for AIDS Relief-supported countries, 2017-2020.

BACKGROUND: The US President's Emergency Plan for AIDS Relief's (PEPFAR) first implemented pre-exposure prophylaxis (PrEP) for HIV prevention through the Determined, Resilient, Empowered, AIDS-Free, Mentored and Safe (DREAMS) partnership in 2016. PrEP is a critical intervention to achieve the main objective of DREAMS, reducing new HIV infections among 15-14 year old adolescent girls and young women (AGYW) in 15 high HIV burdened countries. METHODS: We describe uptake of PrEP among AGYW in PEPFAR. Most PrEP programs screened persons who tested HIV-negative for eligibility and offered PrEP as part of combination prevention with follow-up, including repeat HIV testing and counseling, at 3-month intervals. Platforms providing comprehensive services for AGYW were also leveraged. We examined two PEPFAR monitoring indicators, using the FY20Q4 Monitoring, Evaluation, Reporting (MER) indicator dataset to assess progress in PrEP uptake, and descriptive narratives to understand successes and challenges from fiscal year 2017 to 2020. To assess coverage, we calculated the PrEP to Need ratio (PnR) using a published methodology. RESULTS: From FY2017 to FY2020, 576570 total clients initiated PrEP and the number of PEPFAR countries offering PrEP doubled from 12 to 24. Of 360073 (62% of total) initiations among women, 52% were among AGYW with steady increases from year to year. Among all AGYW, 20-24-year-old women represented a significantly higher proportion of PrEP initiators than adolescents (15-19years) (64 versus 36%, P  < 0.05). Of all 186985 PrEP initiations among AGYW, 99% were in DREAMS countries. Barriers, such as low demand and adherence, were addressed through outreach efforts, including mobile sites, use of technology to educate and support AGYW, media campaigns, and engaging peers in program implementation. We saw a 2.5-fold increase in PrEP uptake among AGYW from 2018 to 2019; by 2020, all DREAMS countries were implementing PrEP. However, PrEP coverage among AGYW in DREAMS countries remains low (PnR range: 0-4.1); only two have a PnR greater than 1 where there were more PrEP users than new HIV diagnoses. CONCLUSION: PrEP uptake among AGYW has grown since 2016; however, challenges remain. Tools to improve adherence are needed to improve PrEP persistence among AGYW. National policies to facilitate greater PrEP uptake among adolescents would be beneficial. A greater need for PrEP in DREAMS countries is evident and if realized, will contribute to epidemic control.

Multipurpose prevention technologies for sexual and reproductive health: mapping global needs for introduction of new preventive products.

OBJECTIVES: Worldwide, women face sexual and reproductive health (SRH) risks including unintended pregnancy and sexually transmitted infections (STIs) including HIV. Multipurpose prevention technologies (MPTs) combine protection against two or more SRH risks into one product. Male and female condoms are the only currently available MPT products, but several other forms of MPTs are in development. We examined the global distribution of selected SRH issues to determine where various risks have the greatest geographical overlap. STUDY DESIGN: We examined four indicators relevant to MPTs in development: HIV prevalence, herpes simplex virus type 2 prevalence (HSV-2), human papillomavirus prevalence (HPV) and the proportion of women with unmet need for modern contraception. Using ArcGIS Desktop, we mapped these indicators individually and in combination on choropleth and graduated symbol maps. We conducted a principal components analysis to reduce data and enable visual mapping of all four indicators on one graphic to identify overlap. RESULTS: Our findings document the greatest overlapping risks in Sub-Saharan Africa, and we specify countries in greatest need by specific MPT indication. CONCLUSIONS: These results can inform strategic planning for MPT introduction, market segmentation and demand generation; data limitations also highlight the need for improved (non-HIV) STI surveillance globally. IMPLICATIONS: MPTs are products in development with the potential to empower women to prevent two or more SRH risks. Geographic analysis of overlapping SRH risks demonstrates particularly high need in Sub-Saharan Africa. This study can help to inform strategic planning for MPT introduction, market segmentation and demand generation.

Family environments and the relationship context of first adolescent sex: Correlates of first sex in a casual versus steady relationship.

Limited research has examined how family environments are associated with the relationship context of first sex, an important indicator of reproductive health risk. We use data from the 1997 National Longitudinal Survey of Youth to assess the association between the family environment - parent-parent relationships, parent-adolescent relationships, and family structure - and relationship context of first heterosexual sexual intercourse, distinguishing between the transition to first sex in serious and casual relationships. Twenty-five percent of females and 43% of males who had sex by age 18 did so in a casual relationship. All dimensions of the family environment were linked to the relationship context of first sex. Notably, higher parental monitoring was associated with a reduced risk of transitioning to first sex in a casual relationship versus no sex, and greater family routines were associated with a reduced risk of transitioning to sex in a steady relationship versus having no sex, for males and females. A strong maternal-adolescent relationship was associated with a reduced risk of first sex in a casual relationship but only for males. Additionally, in two-parent families, a strong father-adolescent relationship was associated with reduced risk of transitioning to casual sex, but only for females. Pregnancy and STI prevention programs should work with parents to foster positive parent-adolescent relationships, to become aware of their adolescents' activities and to recognize that parents are important models for adolescent relationship behaviors.

Pesticide exposure and child neurodevelopment: summary and implications.

Widely used around the world, pesticides play an important role in protecting health, crops, and property. However, pesticides may also have detrimental effects on human health, with young children among the particularly vulnerable. Recent research suggests that even low levels of pesticide exposure can affect young children's neurological and behavioral development. Evidence shows a link between pesticides and neonatal reflexes, psychomotor and mental development, and attention-deficit hyperactivity disorder. Implications include a need for improved risk assessment and health histories by clinicians, greater education at all levels, more common use of integrated pest management, and continued policy and regulatory strategies to mitigate the effects of and the need for pesticides.

Risky adolescent sexual behaviors and reproductive health in young adulthood.

CONTEXT: Little research links adolescent risk behaviors to reproductive health outcomes beyond adolescence, although young adults--men and women in their early 20s--bear a disproportionate burden of STDs and unintended childbearing. METHODS: To assess whether individuals who engaged in risk behaviors during adolescence had increased risk of negative reproductive health outcomes in young adulthood, data from Waves 1-4 of the National Longitudinal Study of Adolescent Health on 5,798 sexually active respondents were analyzed. Logistic and multinomial logistic regressions examined associations between risk behaviors (cumulatively and individually) and each of three outcomes. RESULTS: Four in 10 youth reported at least three risk factors during adolescence. Women who were exposed to an increasing number of risks had an elevated likelihood of having had multiple sex partners in the last year, rather than none (relative risk ratio, 1.3); having had an STD (odds ratio, 1.1); and having had an intended or unintended birth, as opposed to no birth (relative risk ratio, 1.1 for each). Inconsistent contraceptive use and having had multiple partners, a non-monogamous partner or a non-romantic partner were associated with reporting multiple partners in the last year; inconsistent use, sexual debut after age 16 and not discussing contraception with a partner were associated with having any birth. CONCLUSIONS: Teenagers' sexual behaviors have both short-term and long-term consequences, and interventions that focus on multiple domains of risk may be the most effective in helping to promote broad reproductive health among young adults.

Relationship characteristics and contraceptive use among young adults.

CONTEXT: Young adults have high rates of unintended childbearing and STDs, yet little research has examined the role of relationship characteristics in their contraceptive use. METHODS: Data collected from the 2002-2005 rounds of the National Longitudinal Survey of Youth yielded a sample of 4,014 dating relationships among sexually active 18-26-year-olds. Bivariate analysis and multivariate logistic and multinomial logistic regressions assessed associations between relationship characteristics and contraceptive use at last sex. RESULTS: In three-quarters of the relationships, respondents had used some method at last intercourse; respondents in 26% of the relationships had used a condom only, in 26% a hormonal method only and in 23% dual methods. Compared with respondents in relationships in which first sex occurred within two months of starting to date, those who first had sex before dating were more likely to have used any method at last sex (odds ratio, 1.4), particularly condoms or dual methods (relative risk ratio, 1.5 for each). The relative risk of using a hormonal method only, rather than no method or condoms only, increased with relationship duration (1.01) and level of intimacy (1.1-1.2). Discussing marriage or cohabitation was associated with reduced odds of having used any method (0.7) and a reduced relative risk of having used condoms alone or dual methods (0.6 for each). Increasing levels of partner conflict and asymmetry were also linked to reduced odds of any method use (0.97 and 0.90, respectively). CONCLUSIONS: Prevention programs should address relationship context in contraceptive decision making, perhaps by combining relationship and sex education curricula to foster communication and negotiation skills.

Family Structure History: Links to Relationship Formation Behaviors in Young Adulthood.

Using data from three waves of the National Longitudinal Study of Adolescent Health (N=4,538), we examine the intergenerational link between parental family structure history and relationship formation in young adulthood. We investigate: (a) first, whether parental family structure history is associated with young adults' own relationship formation behaviors; (b) second, which dimensions of family structure history are most predictive of children's later relationship formation behaviors; and (c) third, if the association between family structure history and young adulthood relationship formation differs by gender. Our findings provide evidence of an intergenerational link between parent relationship histories and their offspring's own relationship formation behaviors in young adulthood, over and above confounding factors.

High-Risk Subsequent Births Among Co-Residential Couples: The Role of Fathers, Mothers, and Couples.

This study examines predictors of a cumulative measure of high-risk births, rather than single risks separately, as in prior research. Using the Early Childhood Longitudinal Study-Birth Cohort survey, we incorporate data from fathers and mothers to assess characteristics associated with births subsequent to a focal child's birth within high-risk circumstances. Components of a high-risk birth include: high-parity, very closely-spaced, or births to unmarried couples, unhappy couples, or couples in high-conflict relationships. Both fathers' and mothers' pregnancy intentions affect whether couples have a subsequent high-risk birth. The odds of a high-risk subsequent birth, relative to no birth and to a low-risk birth, are more than twice as high if only the father intended the birth of the previous child rather than if the child was intended by both the mother and father. High-risk subsequent births are much more likely among couples where the prior child was high risk and where family income was low, and lower where both father and mother had lived with both biological parents. Findings highlight the importance of father data in fertility research.

Older sexual partners during adolescence: links to reproductive health outcomes in young adulthood.

CONTEXT: Sex at a young age with an older partner has been linked to poor reproductive health outcomes during adolescence, but minimal research has examined the influence of teenagers' having an older sexual partner on reproductive health outcomes during the transition to young adulthood. METHODS: Logistic regression and contrast analyses of three waves of data from the National Longitudinal Study of Adolescent Health were used to examine whether individuals who had had sex before age 16 with a partner at least three years their senior were at increased risk of becoming teenage or unmarried parents or of contracting an STD by young adulthood. RESULTS: Ten percent of females and 2% of males had had early sex with an older partner. These females were more likely to acquire an STD as young adults than were those whose riskiest relationship was before age 16 with a similar-aged partner (odds ratio, 2.1) or at age 16 or later with a similar-aged or older partner (2.4 and 2.6, respectively). For males, having sex before 16, regardless of partner age, was associated with an elevated STD risk (odds ratio, 1.9), although controlling for relationship history characteristics attenuated the association. CONCLUSIONS: Adolescents, particularly young adolescents, should be made aware of the potential risks associated with having older sexual partners. In particular, program providers should be alerted that females who engage in early sexual activity with older partners are at especially high risk of experiencing adverse reproductive health consequences.