Associations between Forced Sexual Initiation, Post-Exposure Prophylaxis and Subsequent Violence Experiences Among Displaced Young Women in Ugandan Urban Slums

Background: Displaced adolescent girls and young women (AGYW) face elevated HIV risk early in their sexual life course, often due to forced sexual initiations (FSIs) that mark the beginnings of cycles of violence. Yet scant evidence exists of FSI rates among displaced AGYW in Uganda or FSI’s association with violence experiences or utilization of post-exposure prophylaxis (PEP: effective for preventing HIV infection among sexual violence survivors). Addressing this knowledge gap could inform the development of trauma-informed violence response and HIV prevention interventions for AGYW in humanitarian contexts. Guided by Michau and colleagues’ framework for assessing causes of violence against AGYW at multiple ecological levels, this study poses three research questions focused on displaced AGYW in urban Kampala, Uganda: (1) At the individual level, what is the prevalence of FSI?; (2) At the interpersonal level, are there any associations between FSI and (a) non-partner violence and (b) recent intimate partner violence?; and (3) At the structural level, is FSI associated with knowledge, availability, and utilization of post-exposure prophylaxis (PEP)?

Methods: We conducted a community-based cross-sectional survey with a peer-driven sample of sexually active refugee/displaced AGYW (n=201) living in informal settlements in Kampala, Uganda. We assessed violence experiences of non-partner lifetime violence and intimate partner violence (IPV) using the revised conflict tactics scale–victimization. We also assessed PEP awareness, access, and uptake using the PEP availability and awareness of PEP availability scale. We conducted bivariate analyses to examine associations between FSI and PEP, and multivariable logistic regressions to examine associations between FSI and (a) non-partner physical and sexual violence and (b) recent sexual and physical IPV.

Results: Among participants, 35.8% (n=72) reported experiencing FSI. Of those 72 participants, 66.7% (n=48/72) had experienced lifetime non-partner sexual violence, 81.9% (n=59/72) had experienced lifetime non-partner physical violence, 35.2% (n=19/72) had experienced recent intimate partner physical violence, and 70.4% (n=38/72) had experienced recent intimate partner sexual violence. Among participants who experienced FSI, 5.6% (n = 4/72) reported awareness of PEP in their community, 5.6% (n = 4/72) reported knowing where to access PEP, and none reported past 3-month PEP access. Compared to AGYW who did not experience FSI, those who experienced FSI had increased odds of reporting non-partner lifetime physical violence (aOR 2.88, 95%CI=[1.33, 6.22]), non-partner lifetime sexual violence (aOR 13.22, 95%CI=[5.85, 29.88]), intimate partner physical violence (aOR 2.56, 95%CI=[1.12, 5.88]), and intimate partner sexual violence (aOR 2.31, 95%CI=[1.02, 5.20]).

Conclusions and Relevance: FSI among displaced AGYW appears common and associated with violence experiences. AGYW need multisectoral trauma-informed interventions that respond to FSI alongside other violence experiences; increase PEP knowledge availability, access and utilization; and, ultimately, reduce HIV exposure among displaced AGYW in Kampala, and potentially in humanitarian settings globally.