HIV Risk Among Displaced Adolescent Girls in Ethiopia: The Role of Gender Norms and Self-Esteem

Background & Purpose: Globally, females between the ages of 15 and 24 are at disproportionately higher risk for HIV infections than any other gender and age cohort.  In Sub-Saharan Africa (SSA), which accounts for over seventy percent of the total global disease burden of HIV, this subgroup accounts for 25 percent of all new infections. Experiences of intimate partner violence (IPV), harmful gender norms, diminished personal agency, and age-disparate sex are some of the key factors that have been identified to explain the increasing rate of new infections among this population. For girls living in conflict settings, economic deprivation, disruption of health infrastructure, and strained community cohesion may exacerbate these risks.  Relatedly, adolescent girls suffer more self-blame and low self-esteem compared to male peers, potentially affecting their ability to negotiate protected sex.  While adolescent girls in SSA have been deemed a critical population to target in HIV elimination campaigns, few studies have quantified associations between gender norms, self-esteem, and HIV risk for girls, particularly in conflict settings.

Methods: This study used baseline data from the Creating Opportunities through Mentorship, Parental Involvement, and Safe Spaces (COMPASS) program, a cluster-randomized controlled trial implemented by the International Rescue Committee (IRC) in the Democratic Republic of Congo, Pakistan, and Ethiopia to establish foundations for healthy female transitions to adulthood in humanitarian crises.   Our analysis used a cross-sectional survey of South Sudanese refugee adolescents in three refugee camps in Benishangul-Gumuz Region, Ethiopia.  Inclusion criteria for adolescents were as follows (1) being 13 to 19 years of age; (2) being female; and (3) having verbal proficiency in Funj, Regarig, Ingessana Kulelek, or Maban.   Using bivariate and multivariate logistic regression, we examined the associations between HIV risk factors, gender norms, and self-esteem for female adolescent refugees from Sudan and South Sudan (n=919). 

Results: In multivariate models, adjusting for age and education, results showed girls who were more accepting of gender inequitable norms and IPV had greater odds of ever experiencing forced (OR 1.39, CI: 1.15-1.69; OR 1.64, CI: 1.41-1.90) or transactional sex (OR 1.28, CI: 1.05-1.55; OR 1.59, CI: 1.37-1.85) while also indicated higher rates of condom use (OR 1.65, CI: 1.16-2.36; OR 2.27, CI: 1.72-2.99) compared to girls who demonstrated less approval of gender inequality and IPV.   High self-esteem was associated with decreased odds of adolescent marriage (OR 0.95, CI: 0.92-0.97), age-disparate sex (OR 0.90, CI: 0.87-0.94), and transactional sex (OR 0.96, CI: 0.93-0.99).

Conclusions and Implications: Practitioners that aim to reduce HIV risk among adolescent girls in SSA, especially among displaced populations, should consider the influence of socially constructed gender norms and self-esteem on program effectiveness.  Findings, while nuanced, suggest that programs seeking to promote self-esteem among adolescents have the potential to reduce a range of HIV risk factors, from adolescent marriage to age disparate sex to transactional sex.  Our findings also support gender transformative programming in humanitarian contexts as a mechanism for increasing gender equity and eliminating IPV complacency thereby reducing key HIV factors of forced and transactional sex among adolescent girls.