Globally, boyish bodies (aged 15–24 years) are estimated to annual for 41% of new HIV infections amid adults of changeable age (aged 15–49 years).1 About 80% of these new infections are amid bodies alive in sub-Saharan Africa (SSA).1 Boyish girls in SSA are added acceptable to be alive with HIV than their macho peers.1Adolescent girls in SSA frequently abode behaviors activated with HIV, such as inconsistent condom use. For instance, in Nigeria, beneath than bisected of ually alive bachelor changeable adolescents (aged 15–19 years) appear they had anytime acclimated condoms.2 Amusing risks such as abandon can additionally accord to acute vulnerability to the accretion and manual of HIV, and abstracts abide that abode abandon amid boyish girls in SSA, as in added regions of the world. In Ghana, 30% of girls appear arrogant adventures at animal debut, including affected .3 In Liberia and Nigeria, 13% and 7% of girls, respectively, age-old 15–19 years accept accomplished animal violence. Despite these individual-level and structural-level risks for HIV, girls in SSA accept bound admission to animal and changeable bloom services. About 60% of unmarried, ually alive boyish girls age-old 15–19 years in SSA are not application a avant-garde contraceptive method.4 Across countries, including Sierra Leone, Nigeria, Niger, Ghana, and Mali, added than 90% of girls age-old 15–19 years accept never accustomed an HIV test.5,6
Concurrent with the challenges faced by girls in SSA are the vulnerabilities accomplished by amateur who advertise throughout the world. Amateur who advertise are not authentic as workers by the Joint United Nations Programme on HIV/AIDS.7 Some studies accept asked developed changeable workers (FSW) attendant questions about back they started affairs . FSW who started affairs as amateur alter from those who started as adults in their sociodemographic characteristics, behavioral and amusing risks for HIV, and admission to services. In demographics, FSW in North America who started affairs as adults alter from those who started as amateur in their education8,9 and clearing status.8 Studies from assorted settings accept apparent that women who started affairs afore the age of 18 years are added acceptable to accept HIV than those who started as adults.10,11 Behaviors associated with HIV, such as inconsistent condom use with clients, accept been apparent to be added accustomed amid those who started affairs as amateur compared to those who started as adults.12 The accord amid biologic addiction and admission of affairs as a accessory or an developed has assorted in antecedent studies.8,10,13 In accession to individual-level risks for HIV, FSW who started affairs as amateur are affected to amusing and structural risks, including violence. Assorted studies accept activate that FSW who were physically or ually abused as accouchement were acceptable to accept started affairs at boyish ages.8,9,14,15 Despite the vulnerabilities associated with affairs as a accessory and the risks faced by girls in SSA, there accept been almost few studies of girls who advertise in SSA16–18 compared to the cardinal of studies on this affair in Asia12,19–30 and the Americas.8–10,13–15,31–38
In West and Central Africa (WCA), area HIV is concentrated amid key populations such as FSW, an assay into the adventures of girls who advertise is decidedly warranted. Pooled HIV prevalence amid FSW in WCA is estimated to be 34.9%.39 An estimated 330,000 changeable adolescents amid the ages of 10 and 19 years in WCA are alive with HIV.1 The bartering animal corruption of accouchement and boyish trafficking accept additionally been appear in the WCA region.40 Burkina Faso is a country in West Africa belted by Ghana, Benin, Togo, Cote d’Ivoire, and Mali. Pooled HIV prevalence amid FSW in Burkina Faso was activate to be 45.8% in a analytical assay of assay from the region.39 Demographic and Bloom Survey abstracts announce that 0.9% of girls age-old 15–19 years in Burkina Faso are alive with HIV.41 There are several behavioral and amusing factors that may accord to HIV accretion amid these girls in Burkina Faso.41 In the country, 61.2% of women age-old 18–24 years appear they had animal action afore the age of 18 years.41 Amid girls age-old 15–19 years, 36.8% had with a nonmarital noncohabitating accomplice in the accomplished 12 months, including 3.6% who had assorted partners.41 In the aforementioned study, 46.4% acclimated a condom at aftermost with a nonmarital noncohabitating partner.41 Knowledge accompanying to HIV amid those age-old 15–19 years is low in Burkina Faso: 54.7% of girls knew that attached animal action to 1 antiseptic accomplice could abate the accident of HIV, and beneath than bisected (45.5%) knew that application condoms could abate the risk.41 Additionally, admission to animal and changeable bloom casework is low.41 Alone 44.3% of girls knew a antecedent of accepting condoms, and about 95% of ually alive girls had never accustomed an HIV test.6,41 In accession to behavioral risks and poor admission to services, girls in Burkina Faso additionally face amusing risks such as violence. For example, 15% of girls appear arrogant adventures at animal debut.3
Burkina Faso is a source, destination, and alteration country for trafficking of adults and children.42 This includes assorted definitions of trafficking: amateur who advertise but do not accede themselves to accept been forced, amateur who are affected to advertise , and adults who are affected to advertise . Bartering animal corruption of Burkinabe accouchement aural Burkina Faso has additionally been reported.40 A abstraction was conducted with 243 girls amid the ages of 13 and 17 years who awash in Ouagadougou.43 Added than bisected had college than a primary academy education. The afterlife of 1 or both parents was cited as a acumen for affairs by 15.6% of the sample. The majority (62.6%) appear their allegiance as Burkinabe. About 7% lived alfresco of Burkina Faso afore advancing to Ouagadougou. Beneath than 2% had been affected to advertise by a pimp or accession else. Condom use was added accepted compared to boyish girls in Burkina Faso in general. Added than 90% of the sample consistently acclimated condoms with clients. Amid those who did not consistently use condoms, about one third said the acumen was because the applicant refused. Admission to HIV testing was aerial compared to girls in Burkina Faso in general, but contraceptive use was low. Added than 80% had anytime been activated for HIV. Slightly added than one division acclimated contraceptive methods added than condoms. Added than 30% had an exceptionable abundance afore they started affairs . The abstraction participants additionally had adventures with animal violence. Added than one division had been ually abused afore they started affairs . The admeasurement of FSW who started affairs beneath the age of 18 years in Burkina Faso and the admeasurement to which their adventures alter from those of women who started affairs as adults are unknown.
Given the vulnerabilities associated with affairs as a minor, the aerial HIV prevalence amid FSW in Burkina Faso, and the risks appear by boyish girls who advertise in Burkina Faso, the cold of this abstraction was to investigate the structural determinants of bloom associated with the alpha of affairs as a accessory amid FSW in Burkina Faso.
In Ouagadougou and Bobo-Dioulasso, Burkina Faso from January to July 2013, FSW were recruited through respondent-driven sampling (RDS). This adjustment was called to aggregate rigorous, adumbrative abstracts from a hard-to-reach population.44 Ten “seeds” (7 in Ouagadougou and 3 in Bobo-Dioulasso) apery altered ages, apprenticeship levels, conjugal statuses, languages, and HIV statuses, and who met accommodation criteria, were called to activate associate recruitment. FSW whose gender assigned at bearing was female, who were at atomic 18 years old, acquired the majority of their assets in the accomplished 12 months from affairs , lived in the abstraction burghal for the accomplished 3 months, had a accurate RDS coupon, and provided accounting a accord in French or bounded accent (Moore, Dioula, etc.) were acceptable to participate. Participants completed an interviewer-administered questionnaire, accustomed pretest and posttest HIV counseling, and were activated for HIV and syphilis. They accustomed macho condoms, condom-compatible lubricants, HIV apprenticeship materials, and advice apropos absolute services. Anniversary actor additionally accustomed 2000 XOF (currency cipher for the West African CFA franc; about 4 USD) for busline agreement for anniversary abstraction appointment and 1500 XOF per associate (for up to 3 peers) recruited to be allotment of the study. The Johns Hopkins Bloomberg Academy of Accessible Bloom Institutional Assay Board and the Bloom Assay Ethics Committee (CERS) of Burkina Faso accustomed this study. The FSW affiliation in both cities provided ascribe to the assay aggregation throughout the study.
The check included a attendant catechism apropos the age at which participants started affairs for money. The catechism asked, “Approximately how old were you the aboriginal time you provided animal acts in barter for money?” This connected capricious barometer age in years was dichotomized for this assay to announce whether a actor started affairs afore age 18 years or at age 18 years or beforehand (the age of acknowledged majority in Burkina Faso).
The check included capacity such as sociodemographic characteristics, animal rights violations, animal behavior, bloom account access, and changeable health. Variables were included in the assay based on associations of affairs as a accessory in antecedent studies from added geographic regions.
Age in years was a connected capricious based on the question, “How old are you?” Apprenticeship was a absolute capricious based on the question, “What is the accomplished akin of apprenticeship you accept completed?” that was dichotomized such that commutual beneath than primary academy was coded as 0 and commutual primary academy or college was coded as 1. Parents’ afterlife was adjourned based on a catechism that asked, “Are both of your parents living?” An clearing capricious was created based on the question, “In what country were you born?” This capricious was coded as 0 for those who were built-in in Burkina Faso and 1 for participants who were built-in in Ghana, Benin, Togo, Ivory Coast, Nigeria, Cameroon, or any added country.
Length of time affairs was a connected capricious based on a catechism that asked, “Approximately how abounding years in absolute accept you been affairs for money?” Participants were asked, “What were the affidavit you started affairs ? I will apprehend you several accessible reasons. For each, amuse acquaint me if it was a acumen you started affairs .” Women could accept added than 1 reason. Participants who answered “yes” to “Someone talked me into it/pressured me,” or “I was affected adjoin my will (By forced, I beggarly physically affected or apprenticed into affairs ),” or both were advised to be affected or pressured to alpha affairs . Sex assignment area was adjourned through a catechism that asked, “Where do you accept with clients? I will apprehend you a account of accessible places. For anniversary one, amuse acquaint me whether you accept with audience there or not.” Participants could accept added than 1 location. Locations included clandestine home, bar or club, clandestine party, brothel, artery or esplanade or accessible garden, clandestine vehicle, auberge or bedfellow house, or added (specify).
Two behavioral accident questions were examined. Noninjection biologic use was a angled capricious based on the question, “Have you anytime acclimated any biologic that you did not inject and that was not assigned to you for bloom reasons? (These can accommodate marijuana, banga, glue, delicate cocaine, narcotics, or added drugs).” Participants were additionally asked, “In the aftermost 12 months, accept you had anal ?”
To appraise risks accompanying to animal behaviors with clients, participants were asked, “In the aftermost 12 months, accept there been added bodies brought to accept with you than what had been discussed with the client?” Applicant abatement of condoms was adjourned by a catechism that asked, “In the aftermost 12 months, has a applicant agreed to accept with a condom but again removed it or beneath later?” Participants who answered “Yes, in the aftermost 12 months” or “Yes, but not in the aftermost 12 months” were aggregate calm for the analysis. We adjourned whether participants had afterwards a condom because a applicant offered added money based on a catechism that asked, “Now anticipate about the aftermost time a condom was not acclimated back you had l or anal with a new client. Why wasn’t a condom acclimated at that time? I will apprehend some accessible reasons, and for anniversary one amuse acquaint me whether that acumen applies to your bearings or not.” Participants could accept added than 1 reason. The capricious was coded as 1 for who answered “yes” to “The applicant offered added money not to use a condom.” A agnate catechism was asked about approved audience who offered added money not to use a condom. Condom agreement adversity was abstinent by the question, “In general, how difficult or accessible is it for you to use or advance application a condom with a approved client?” The 5 acknowledgment options ranged from “very difficult” to “very easy.”
Torture was adjourned by the question, “Have you anytime been bent by someone?” The analogue of ache was larboard to participants’ interpretation. Affected was abstinent by a catechism that asked, “Have you anytime been affected to accept back you did not appetite to? (By forced, I beggarly physically forced, apprenticed to accept , or penetrated with an object, back you did not appetite to).”
Participation in HIV-related talks or affairs was adjourned by a catechism that asked, “In the aftermost 12 months, accept you alternate in any talks or affairs about HIV/AIDS?” Uptake of HIV testing was adjourned by the question, “Have you anytime been activated for HIV infection?” Responses included “No,” “Yes, once,” and “Yes, added than once.” Exceptionable abundance (among those who appear they had anytime been pregnant) was abstinent by the question, “Have you anytime had a abundance that was unwanted/unplanned? What I beggarly by that is, at the time back you activate out you were pregnant, you did not appetite or intend to be abundant then.”
Women who self-reported they started affairs for money afore age 18 years were compared with those who started at age 18 years or beforehand application χ2 statistics for absolute variables and t tests for connected variables. Variables that were decidedly accompanying to captivation in affairs afore age 18 years in the bivariate assay (P < 0.05) were advised for admittance in multivariate analyses. Separate multivariate logistic regressions were conducted for anniversary burghal to appraise correlates of the alpha of affairs beneath age 18 years. Because antecedent studies of developed FSW activate that at the time they completed the questionnaire, those who started affairs as amateur were decidedly boyish than those who started as adults,30 we controlled for age at the time of the questionnaire. Control variables added than age were not acclimatized for because the ambition was to appraise the accord absolute of age of abounding factors accompanying to aboriginal admission of affairs rather than to admeasurement absolute paths through which aboriginal admission of affairs is accompanying to risks. Separate models advised the age-adjusted accord amid anniversary covariate and aboriginal admission of affairs . All estimates appear are not RDS-weighted. Analyses were conducted application Stata 13.1 (Statacorp, College Station, TX).
As apparent in Table 1, the beggarly age at the time of the check was lower amid aboriginal initiates (21.7 years in Ouagadougou and 25.0 years in Bobo-Dioulasso) than afterwards initiates (26.4 years in Ouagadougou and 32.6 years in Bobo-Dioulasso). Beneath than bisected of participants completed primary academy or higher. Apprenticeship levels were college amid those who started affairs as adults compared to those who started as amateur in Ouagadougou (50.9% vs. 35.5%). In Bobo-Dioulasso, a greater allotment of women who started affairs as amateur appear that 1 or both of their parents had died. In Ouagadougou, afterwards adjusting for age, aboriginal initiates were added than alert as acceptable to abode both of their parents had died compared to afterwards initiates. About one fifth of women in both cities were built-in alfresco Burkina Faso (28.9% in Ouagadougou and 17.8% in Bobo-Dioulasso), and women who started affairs as adults were added acceptable to be from accession country. The allotment of FSW participants who started affairs as amateur was 31.2% in Ouagadougou and 24.4% in Bobo-Dioulasso. Amid aboriginal initiates, the beggarly age of starting was 15.9 years in Ouagadougou and 15.7 years in Bobo-Dioulasso, admitting amid afterwards initiates, the beggarly age of starting was 22.2 years in Ouagadougou and 25.6 years in Bobo-Dioulasso. In both cities, the beggarly cardinal of years affairs did not decidedly alter amid those who started at beforehand or boyish ages.
Women who started affairs as amateur were added acceptable to abode behavioral accident factors for HIV and ually transmitted infection such as anal in the accomplished 12 months [Ouagadougou age-adjusted allowance arrangement (aaOR): 2.44, 95% aplomb breach (CI): 1.32 to 4.51]. They were added acceptable to abode barriers to condom use. For example, aboriginal initiates were added acceptable to abode audience removed condoms (Ouagadougou aaOR: 1.83, 95% CI: 1.11 to 3.01; Bobo-Dioulasso aaOR: 2.34, 95% CI: 1.35 to 4.08). FSW who started affairs as amateur were added acceptable to abode the aftermost time they did not use a condom with a new applicant (Bobo-Dioulasso aaOR: 3.04, 95% CI: 1.53 to 6.05) or a approved applicant (Ouagadougou aaOR: 2.34, 95% CI: 1.23 to 4.47; Bobo-Dioulasso aaOR: 2.37, 95% CI: 1.29 to 4.36) was because the applicant paid added not to use a condom. In Bobo-Dioulasso, aboriginal initiates were beneath acceptable to abode it was somewhat accessible (aaOR: 0.15, 95% CI: 0.05 to 0.50) or actual accessible (aaOR: 0.15, 95% CI: 0.05 to 0.45) to use or advance application a condom with a approved client. In accession to these behavioral accident factors, FSW who started affairs as amateur were added acceptable to face amusing and structural risks. Affairs beneath age 18 years was associated with violence, including ache (Bobo-Dioulasso aaOR: 2.21, 95% CI: 1.28 to 4.20) and affected (Ouagadougou aaOR: 2.54, 95% CI: 1.53 to 4.23). Those who started affairs back they were amateur were beneath acceptable to accept abounding HIV-related services, including talks or affairs (Bobo-Dioulasso aaOR: 0.56, 95% CI: 0.33 to 0.97) or accept been activated for HIV assorted times anytime (Ouagadougou aaOR: 0.50, 95% CI: 0.26 to 0.94) (Table 2).
Although several studies comparing aboriginal and afterwards admission of affairs accept been conducted in Asia and the Americas, our abstraction is one of the aboriginal studies on this affair in the West African context. In this study, 27.8% of FSW abstraction participants sampled in Ouagadougou and Bobo-Dioulasso, Burkina Faso started affairs as minors. This is constant with studies from added countries that accept activate amid 10% and 40% of FSW accomplished affairs afore age 18 years.8,10,35 Compared to afterwards initiators, aboriginal initiators had beneath apprenticeship and were added acceptable to be orphaned. Those who started affairs as amateur had added behavioral accident factors for HIV, including client-related barriers to condom use. They additionally were added acceptable to acquaintance amusing and structural vulnerabilities, including bound admission to bloom casework and violence. Women who started affairs as amateur were added acceptable to accept been affected or pressured to advertise but were beneath acceptable to accept been built-in alfresco Burkina Faso.
In Ouagadougou, FSW who started affairs as amateur were added acceptable to abode both their parents had died. As in added studies,9 apprenticeship akin was abnormally accompanying to affairs as a minor. Taken together, these allegation advance that orphans and accessible children, including those who accept alone out of school, may be at acute accident for affairs during boyhood and experiencing the associated abrogating furnishings of this situation. Interventions abroad in SSA such as banknote transfers and amusing abutment accept been apparent to abate transactional amid boyish girls and could be advised for the blockage of the bartering animal corruption of girls in Burkina Faso.45,46 The allegation from the present abstraction that alone about one third of FSW who started affairs as amateur had completed primary academy or college adverse with allegation from a antecedent abstraction of girls who awash in Ouagadougou in which added than bisected had college than a primary academy education.43 This may betoken that girls with college apprenticeship levels who advertise as amateur may be added able to stop affairs as adults through agency such as award addition application than those with lower apprenticeship levels.
A antecedent abstraction of amateur who advertise in Burkina Faso activate that about all participants consistently acclimated condoms with clients.43 However, in the present research, as studies in Asia12 and North America35 accept found, affairs as a accessory in Burkina Faso was associated with challenges in application condoms with clients. FSW who authorize patterns of caught with audience as amateur because of bound adeptness to accommodate condom use may abide these behaviors in adulthood.
Women who started affairs afore age 18 years in this abstraction were beneath acceptable to accept anytime activated for HIV added than once. Age of accord behavior are potentially barriers to HIV testing amid amateur who advertise . Conflicting advice exists about minimum age of consent, affectionate permission, and acknowledgment of after-effects to parents in Burkina Faso.47 The HIV Counseling and Testing Bloom Provider Reference Manual states that HIV testing may be conducted for those age-old 14 years and aloft provided that they are abundantly mature.47 Added sources accompaniment that the minimum age of accord for HIV testing in Burkina Faso is 18 years, affectionate accord is appropriate for HIV testing of minors, and after-effects charge be appear to parents.47,48 Healthcare providers and amateur may be cryptic on what is permissible, which may absolute accouterment or uptake of HIV testing. Amateur who advertise may not appetite to seek affectionate permission for HIV testing because of abhorrence of advice their captivation in affairs . Because those who started affairs as amateur were added acceptable to accept been orphaned, affectionate accord for HIV testing afore age 18 years may not accept been an option. Additionally, laws accompanying to the bartering animal corruption of accouchement that are advised to assure amateur may accept the adventitious aftereffect of attached minors’ acknowledgment of captivation in affairs to healthcare providers for abhorrence of repercussions for themselves or their clients.
Violence was accession structural accident agency accomplished by those who started affairs as accouchement added than those who started as adults. Several studies from added regions accept activate boyhood concrete or animal corruption was accompanying to aboriginal admission of affairs .5,6,11,12 In Bobo-Dioulasso, compared to those who started affairs as adults, FSW who started affairs as amateur were added acceptable to accept accomplished affected both afore and afterwards they started affairs . This is constant with an beforehand abstraction of girls who awash in Ouagadougou that activate added than a division of participants had been ually abused afore they started affairs .43 Experiencing abandon has been apparent in added settings to be associated with abrogating health-related behaviors, such as decreased adeptness to accommodate condom use.49,50
The analogue of trafficking encompasses coercing, moving, or harboring bodies for the purpose of exploitation.51 Trafficking accompanying to affairs includes corruption of amateur or banishment adults adjoin their will.51 In this study, FSW who started affairs as adults were added acceptable to accept been built-in in accession country than those who started as minors, constant with studies from North America.10 In Burkina Faso, trafficking of both accouchement (eg, from Nigeria52) and adults is prevalent.42 In Bobo-Dioulasso, those who started as amateur were added acceptable to say they were affected or pressured to advertise than those who started as adults. This suggests an overlap in trafficking definitions. Amateur and adults who are affected to advertise adjoin their will may crave altered interventions and casework than those who alpha affairs for added affidavit such as abridgement of apprenticeship or bread-and-er opportunities.53
This abstraction has some limitations. As the abstracts are cross-sectional, causal inferences could not be made. Sample admeasurement was powered based on HIV prevalence but may not accept been ample abundant to ascertain differences in HIV/ually transmitted infection prevalence amid those who started affairs as amateur and those who started as adults. The abstracts are self-reported and may be accountable to amusing agreeableness bent and anamnesis bias. The sample included alone FSW aloft the age of 18 years, so we cannot accomplish inferences about girls who advertise as amateur and stop affairs afore age 18 years. Future studies in added countries in the WCA arena with a lower minimum age of accord to accept bloom casework and participate in assay afterwards affectionate permission may abode this gap. Despite these limitations, this abstraction adds advice from an understudied arena to the growing anatomy of all-around abstract on amateur who advertise .
Results from this abstraction announce that arrears affairs of is accustomed in Ouagadougou and Bobo-Dioulasso, Burkina Faso. Affairs beneath age 18 years in this ambience is accompanying to lower education, parents’ death, behavioral and amusing risks for HIV, and bound admission to bloom services. These allegation advance the charge to anticipate the bartering animal corruption of accouchement in Burkina Faso and accommodate casework such as HIV testing accurately acclimatized for amateur who advertise or FSW who started affairs during adolescence.
The authors would like to accurate their acknowledgment to the women who alternate in these studies and to the affiliation groups who provided basic ascribe throughout the studies. The authors additionally acknowledge the charge of all the abstraction aggregation members, afterwards whom this assay would not accept been possible.
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