Forced Sexual Initiation and Early Sexual Debut and Associated Risk Factors and Health Problems Among Adolescent Girls and Young Women — Violence Against Children and Youth Surveys, Nine PEPFAR Countries, 2007–2018

Adolescent girls and young women aged 13-24 years are disproportionately affected by HIV in sub-Saharan Africa (1), resulting from biologic, behavioral, and structural* factors, including violence. Girls in sub-Saharan Africa also experience sexual violence at higher rates than do boys (2), and women who experience intimate partner violence have 1.3-2.0 times the odds of acquiring HIV infection, compared with those who do not (3). Violence Against Children and Youth Survey (VACS) data during 2007-2018 from nine countries funded by the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) were analyzed to estimate prevalence and assess factors associated with early sexual debut and forced sexual initiation.† Among adolescent girls and young women aged 13-24 years who ever had sex, the prevalence of lifetime sexual violence ranged from 12.5% to 49.3%, and forced sexual initiation ranged from 14.7% to 38.9%; early sexual debut among adolescent girls and young women aged 16-24 years ranged from 14.4% to 40.1%. In multiple logistic regression models, forced sexual initiation was associated with being unmarried, violence victimization, risky sexual behaviors, sexually transmitted infections (STIs), and poor mental health. Early sexual debut was associated with lower education, marriage, ever witnessing parental intimate partner violence during childhood, risky sexual behaviors, poor mental health, and less HIV testing. Comprehensive violence and HIV prevention programming is needed to delay sexual debut and protect adolescent girls and young women from forced sex.

for minors, safeguards to protect privacy and confidentiality of participants, and referrals to postviolence care as needed. § CDC and in-country Institutional Review Boards approved study protocols. ¶ This report examines lifetime experiences of sexual violence, early sexual debut, and forced sexual initiation among adolescent girls and young women aged 13-24 years in Eswatini,** Haiti, Kenya, Malawi, Nigeria, Tanzania, Uganda, Zambia, and Zimbabwe, using 2007-2018 data from VACS. † † Lifetime sexual violence included ever experiencing 1) unwanted sexual touching, 2) unwanted attempted sex, 3) pressured or coerced sex, or 4) physically forced sex. Early sexual debut was defined as first sexual intercourse at or before age 15 years among adolescent girls and young women aged 16-24 years who had ever had sex with or without violence. Forced sexual initiation was defined as pressured, coerced, or physically forced first sex among adolescent girls or young women aged 13-24 years who had ever had sex. Orphan status was defined as having one or both parents deceased before the 18th birthday. Weighted prevalences of lifetime sexual violence, early sexual debut, and forced sexual initiation were estimated for each country using SAS (version 9.4; SAS Institute); prevalences were weighted to the most recent census or population projections to account for the multistage cluster design and nonresponse. Multiple logistic regression models were fit to the data combined across all countries to examine the odds of forced sexual initiation and early sexual debut by demographic characteristics and childhood experiences and health problems and behaviors. These models included a fixed effect for country and accounted for survey design, including stratification and clustering, and were adjusted to control for age and marital status.
Prevalence of lifetime sexual violence among adolescent girls and young women varied across countries, ranging from 12.5% (Zimbabwe) to 49.3% (Eswatini) ( Table 1). Among those who had ever had sex, the prevalence of forced sexual initiation ranged from 14.7% (Zimbabwe) to 38.9% (Malawi) and early sexual debut ranged from 14.4% (Zimbabwe) to 40.1% (Nigeria). Among adolescent girls and young women who had ever had sex, the odds of having experienced forced sexual initiation were elevated among those aged 13-15 years (adjusted odds ratio [aOR] = 1.77), those who experienced nonpenetrative sexual violence during childhood (aOR = 2.38) and who experienced emotional violence during childhood (aOR = 1.44) ( Table 2). Odds were lower among those who were ever married or cohabitating (aOR = 0.47) and those who never attended school (aOR = 0.56). The odds of early sexual debut were higher among adolescent girls and young women aged 16-19 years (aOR = 3.29), those who had no education (aOR = 5.16) or less than primary education (aOR = 2.19), were ever married or cohabitating (aOR = 3.03), or who had witnessed parental intimate partner violence before age 18 years (aOR = 1.31). The odds of forced sexual initiation or early sexual debut did not differ by orphan status, childhood physical violence, or witnessing violence in the community during childhood.
Compared with adolescent girls and young women who did not experience forced sexual initiation, those who did had elevated odds of engaging in transactional sex § § during the past 12 months (aOR = 1.6), infrequent condom use during the past 12 months (among those who were never married) (aOR = 1.7), ever having had an STI (aOR = 1.6), experiencing one or more (aOR = 2.8) and two or more (aOR = 2.6) types of violence during the past 12 months, having recent moderate or severe mental distress (aOR = 1.6), and ever having suicidal thoughts (aOR = 2.1) ( Table 3). Compared with those who did not experience early sexual debut, those who did had increased odds of having multiple sexual partners during the past 12 months (aOR = 1.7), infrequent condom use among those who were ever married (aOR = 2.1) or never married (aOR = 1.9), having recent moderate or severe mental distress (aOR = 1.5), and ever having attempted suicide (among those who ever thought of suicide) (aOR = 2.1). The odds were lower for ever having been tested for HIV (aOR = 0.4) and having been tested during the past year (aOR = 0.5). The odds § § Sex in exchange for money, favors, or material support. of alcohol abuse did not differ among those who did and did not experience forced sexual initiation or early sexual debut.

Discussion
Sexual violence, forced sexual initiation, and early sexual debut were common among adolescent girls and young women in the nine countries examined. Increased odds of risky sexual behaviors among adolescent girls and young women who experienced forced sexual initiation and early sexual debut suggest that those with negative early sexual experiences are at increased risk for HIV acquisition. Forced sexual initiation was associated with having experienced violence during childhood and multiple types of recent violence, highlighting the complex interplay between early sexual experiences and violence. Association of forced sexual initiation and early sexual debut with recent mental distress, as well as with lifetime suicidal ideation and attempted suicide, indicate the deep and lasting impact of early or forced first sex on mental health.
These findings are consistent with previous studies showing that sexual violence, early sexual debut, and forced sexual initiation are associated with HIV acquisition and risky sexual behaviors (4,5). These findings also corroborate previous work relating recent violence with infrequent condom use and poor mental health (6) and underscore the need to provide postviolence care and mental health services for adolescent girls and young women to lower HIV risk (7). In these analyses, adolescent girls and young women who experienced early sexual debut had lower HIV testing rates despite higher HIV risk behaviors, indicating a need to reach girls who have early sexual debut for HIV testing services. These findings reinforce the importance of primary prevention of sexual violence and delayed sexual initiation as essential elements of HIV prevention and control (8).
The high prevalence of forced sexual initiation among the youngest members of this population who ever had sex demonstrates a need for sexual violence prevention programs to include girls aged <13 years. The following subgroups should be targeted for sexual violence prevention: in-school and never-married adolescent girls and young women, those who experienced sexual violence or emotional violence in childhood or forced sex, and families of adolescent girls and young women and their communities. In addition to encouraging girls to stay in school, programs might target adolescent girls and young women with primary education or less and those out of school, at risk for early marriage, and who witnessed parental intimate partner violence in childhood with programs to delay early sexual debut. Programs can adopt approaches from INSPIRE's seven strategies for ending violence against Abbreviation: VACS = Violence Against Children and Youth Surveys. * Lifetime sexual violence is defined as unwanted touching, unwanted attempted sex, pressured or coerced sex, or physically forced sex. For this analysis, lifetime sexual violence was examined for adolescent girls and young women aged ≤24 years. † Forced sexual initiation defined as first sexual intercourse was physically forced, pressured, or coerced, among adolescent girls and young women aged 13-24 years who had ever had sex. Definitions of pressured sex varied among countries. § Early sexual debut defined as first sex at aged ≤15 years among adolescent girls and young women aged 16-24 years who had ever had sex. ¶ Weights accounted for the multistage cluster sampling design (e.g., enumeration area, household, and household member), nonresponse, and calibration to a known population (i.e., the most recent census for Eswatini, Kenya, Tanzania, Uganda, and Zimbabwe; for the remaining countries, the country's population projections for the year of VACS data used). ** Formerly Swaziland.
children: implementation and enforcement of laws, norms and values, safe environments, parent and caregiver support, income and economic strengthening, response and support services, and education and life skills (9).
The findings in this report are subject to at least four limitations. First, data were self-reported, and are subject to recall bias. Second, slight variations in questions could contribute to differences in estimates across countries. Third, older data might not reflect recent changes in policies or programs. Finally, VACS only includes adolescent girls and young women living in households, so findings are not generalizable to those living in institutions or dormitories or to street youth.
Prevention of sexual violence and early sexual debut are key components of the comprehensive efforts of PEPFAR to control the HIV epidemic. In countries examined in this report, PEPFAR's Determined, Resilient, AIDS-free, Mentored, and Safe (DREAMS) partnership provides a core package of interventions to help prevent sexual violence and HIV acquisition among adolescent girls and young women. These interventions include community mobilization and norms change, school-based interventions, caregiver programs, social protection, social asset building, economic strengthening, sexual and reproductive health care including postviolence care, and access to preexposure prophylaxis (10). HIV prevention among girls aged 9-14 years includes evidence-based programs to prevent violence and risky sexual behaviors and strengthen family and community support (10). Although some reductions in new HIV infections among adolescent girls and young women have been achieved, HIV incidence among this population remains high compared with that in young men (1) and calls for increased efforts to protect this vulnerable population with multiple evidence-based approaches to HIV and violence prevention.

Summary
What is already known about this topic?
Early sexual debut (first intercourse at or before age 15 years) and forced sexual initiation are associated with increased risk behaviors for HIV acquisition, including transactional sex and multiple sexual partners, but studies are limited.
What is added by this report?
During 2007-2018, in nine countries funded by the U.S. President's Emergency Plan for AIDS Relief, 14.4% to 40.1% of adolescent girls and young women had early sexual debut. Among those with early sexual debut, the odds of having been tested for HIV was 40% lower and the odds of increased risky sexual behaviors were elevated.
What are the implications for public health practice?
Comprehensive violence and HIV prevention programs for adolescent girls and young women are needed to prevent early sexual debut and reduce the risk for HIV infection.  3. Prevalence of health outcomes and behaviors among adolescent girls and young women aged 13-24 years who had ever had sex,*