CONTRIBUTING FACTORS TO ADOLESCENTS’ HIGH HIV AND AIDS PREVALENCE

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CHAPTER TWO: LITERATURE REVIEW

 INTRODUCTION

In the previous chapter, the researcher discussed the gap that exists in literature on HIV and AIDS interventions that were based on each of three existing models; the Theory of Planned Behaviour, the Information Motivation Behaviour Skills Models and the Social Ecology Theory. In this chapter, the researcher reviewed the relevant literature, the theoretical framework as well as the conceptual framework that were employed to carry out this study.

CONTRIBUTING FACTORS TO ADOLESCENTS’ HIGH HIV AND AIDS PREVALENCE

There are various factors that contribute to HIV infection including risk-related behaviours, biological, health as well as social factors. Causes of the HIV and AIDS epidemic may be attributed to multiple infections, lack of a cure for HIV and AIDS and poverty (Mnguni, 2012). Although antiretroviral therapy (ART) prolongs life expectancy, there was, between 2012 and 2017, an increase in the number of people living with HIV and AIDS in South Africa (UNAIDS, 2017a; Statistics South Africa, 2017). While ART addresses the life expectancy of infected persons, it does not prevent new HIV infections. The objectives of the 2016 United Nations conference in Durban (UNAIDS, 2016a) and the world AIDS day 2016 were to prevent HIV and AIDS prevalence (World Health Organisation, 2016b; UNAIDS, 2016b). The target of the world AIDS day is to end the transmission of HIV by 2030 (World Health Organisation, 2016b; UNAIDS, 2016b). This target can only be reached if effective programmes are put in place not only to treat individuals living with HIV and AIDS, but to prevent new infections. The researcher explored the contributing factors to adolescent‟s high HIV and AIDS prevalence as perceived by some learners in Gauteng province of South Africa. Consequently, this study developed a new multifaceted theoretical model from these identified factors that contribute to adolescents‟ high HIV and AIDS prevalence that may be used to design interventions to prevent HIV infection amongst adolescents.
As mentioned previously, there are presently no curative measure for HIV and AIDS. More so, despite numerous interventions there is an unacceptable increase in adolescents HIV and AIDS prevalence in Gauteng province of South Africa. It becomes imperative to prevent new HIV infections or reinfection of HIV amongst adolescents in Gauteng province of South Africa. In addition, each of the three models emphasises specific factors that contribute to adolescents‟ high prevalence of HIV and AIDS, but are silent on other important aspects. Consequently, the researcher explored all determinants of HIV infection amongst adolescents in order to develop a new model that could address HIV infection prevention. The researcher therefore reviewed relevant literature on factors contributing to adolescents‟ high HIV and AIDS prevalence using the following sub headings: risk related behaviour, health factors, social factors and knowledge factors.

Risk related behaviour

Risk related behaviours are behaviours adolescents may engage in that could increase their susceptibility to HIV and AIDS. Such behaviours include unprotected sex, more than one sexual partners, transactional sex and alcohol and drug use.

Unprotected sex

In this study, unprotected sex may be described as absence of use of protection during sex. It is worthy to note that some protected sex may only prevent pregnancy instead of HIV. In this study, the researcher focused on unprotected sex as it relates to prevention of HIV and AIDS that is, sex without the use of condoms amongst adolescents. Avert.org (2017) defined unprotected sex as engaging in vaginal, anal or oral sex without the use of a condom. Avert.org (2017) indicated that unprotected sex can expose adolescents to HIV infection but advocated that using condoms during sex is the best way to prevent HIV and AIDS. Consequently, the best way to prevent sexual transmission of the virus is for adolescents to use male and female condoms (UNAIDS, 2015b).
In spite of the free provision of male and female condoms, adolescents still engage in unprotected sex for various reasons. Firstly, lack of access to condoms may inspire adolescents to engage in unprotected sex. In some countries, including South Africa, Nigeria, America and United Kingdom, adolescents can access condoms distributed by their governments (USAID.gov, 2016; Ratna, Nardone, Hadley & Brigstock-Barron, 2015; Charania, Crepaz, Guenther-Gray, Henny, Liau, Willis & Lyles, 2011; Ham & Bennish, 2009). However, the problem of networks for sustained distribution may pose a hindrance to adolescents accessing condoms in a country like Nigeria (USAID.gov, 2016). In effect, in Sub Saharan African countries where condom distribution networks are not reliable, adolescents who desire to engage in protected sex may need to purchase condoms. However, learners from poor socioeconomic backgrounds may lack the finances to purchase condoms. More so, adolescents from high economic backgrounds may not readily have the time to purchase condoms when they desire to have protected sex. Consequently, these adolescents who practise unprotected sex could be susceptible to HIV.
In addition, South African adolescent high school learners are expected to go to clinics to collect condoms to practise protected sex. However, Ham and Bennish (2009) recommended that condoms should be distributed at high schools if adolescents are expected to use condoms. In another study, Tanser (2006) reported that the cost of transportation coupled with the distance to condom distribution sites prohibit some adolescents from accessing free condoms at government clinics. These authors therefore advocated that the Department of Health should include schools as part of their distribution centres (Ham & Bennish, 2009). In essence, high school learners may easily access condoms from their schools. In this study therefore, the social and economic factors that influence adolescents accessing condoms were explored in order to propose how best adolescents could access condoms.
Secondly, lack of consistent and correct use of condoms prohibit some adolescents from practising protected sex. In this study, consistent use of condoms could be regarded as reliable use of condoms during sexual intercourse. Mondal and Shitan (2013), referred to the effective use of condoms as accurate use of condoms. In another study, these scholars found that approximately forty five percent of adolescents in rural communities in South African use condoms, however, they lack consistent and regular condom use (Awotidebe, Philips & Lens, 2014). In effect, even some adolescents who live in countries were condoms are provided may lack skills to effectively use condoms while some may lack condom negotiation skills (Jemmott et al., 2007). Furthermore, lack of regular use of condoms as well as the inability to negotiate for condom use may increase adolescents‟ susceptibility to HIV infection. This researcher therefore, investigated all factors that participants reported that may prevent adolescents from regularly and correctly using condoms. In addition, the researcher proposed a new multifaceted theoretical model that maybe be used to address consistent condom use, condoms use skills and condom negotiation skills during HIV preventive intervention.

Number of sexual partners

The number of sexual partners some adolescents have may influence their susceptibility to HIV and AIDS. Some adolescents may have one sexual partner while some may have more than one sexual partner. Adolescents who engage in sex with HIV negative single sexual partner is not exposed to the virus through sexual intercourse. However, adolescents who engage in sex with multiple sexual partners may be exposed to the virus (Johnston, O’Malley, Bachman, Schulenberg, Patrick & Miech, 2017). In their study, Awotidebe et al. (2014) established that forty-two percent of adolescents in two South African rural communities engage in sexual intercourse with more than one sexual partner. In another study, Singh and Patra (2012) found that in Tanzania, women aged between 15-49 years who have five or more sexual partners‟ have a higher risk of contracting the virus than women who have a single sexual partner. The researcher developed a new multifaceted theoretical model that may be used to design HIV preventive interventions that will encourage adolescents to reduce their sexual partners to a single sexual partner.

Transactional sex

In this study, the researcher defined transactional sex as sexual intercourse in exchange for money, material goods and support. In this study, transactional sex may be used interchangeably with economic sex. In their study, Bradburn, Wanje, Pfeiffer, Jaoko, Kurth and McClelland (2017) classified individuals who practise economic sex as sex workers. Although this researcher categorised sex workers under risk related behavioural factors, in essence transactional sex is motivated by economic circumstances. Hence, economic sex may also be categorised under economic factors since it is always financially motivated. This further explains that certain determinants of HIV infections amongst adolescents may have dual or multiple reasons which could be neglected if models used to design HIV interventions focus on a singular model. However, in this study, the researcher explored risk behavioural as well as economic determinants of HIV infection amongst adolescents.

Alcohol and drug use

Alcohol and drugs use do not have a direct impact on adolescents‟ high HIV and AIDS prevalence but the behaviour adolescents engage in after using alcohol and drugs may increase their exposure to the virus. Ferreira-Borges, Rehm, Dias, Babor and Parry (2016) indicated that in Sub Saharan Africa, alcohol use influences diseases including HIV infection. More so, these researchers found that the use of alcohol is a risk factor that influences the desire to engage in unprotected sexual intercourse (Rehm, Shield, Joharchi & Shuper, 2012). In addition, Kiene, Simbayi, Abrams, Cloete, Tennen and Fisher (2008) established that average or high consumption of alcohol prior to sex may influence unprotected sex amongst HIV infected individuals in Cape Town, South Africa. Kiene et al. (2008) also found that these intoxicated HIV positive individuals may engage in sexual intercourse with HIV negative individuals or people they do not know their HIV status. Moreover, during their study, these researchers established that HIV infected persons transmitted the virus to their uninfected sexual partners (Kiene et al., 2008). This implies that alcohol may influence the judgement of individuals to engage in unprotected sex. Consequently, alcohol may increase exposure to HIV and AIDS transmission.
Drug use may increase adolescents’ risk related behaviour including their susceptibility to HIV infection. Akanle, Adesina and Adebayo (2015) indicated that teenagers are inspired by their peers to use drugs. In addition, Mayer, Colfax and Guzman (2006) established that drug use may contribute to incorrect use of condoms as well as unprotected sex exposing adolescents to the virus. This study aimed at finding all determinants of risk related behaviour that may expose adolescents to HIV and AIDS in order to develop a combined theory that could be used for HIV preventive.

Health factors

The only health factor that was described is contact with HIV contaminated blood.

Contact with HIV contaminated blood

Some adolescents could intentionally or accidentally come into contact with HIV contaminated blood which exposes them to HIV infection. Adolescents who use drugs may share injection needles for drugs. Sharing of injection needles for drugs may expose some adolescents to HIV. Fisher, Misovich, Kimbel and Weinstein (1999) found that forty percent of their participants shared injection needles for drugs even though they were HIV positive.
Moreover, HIV contaminated blood could expose adolescents to the pandemic during blood transfusions, contact with blood without gloves and sharing of sharp objects (Center for Disease Control, 2018; UNAIDS, 2017d; Mbakwem-Aniebo, Ezekoye, & Okonko, 2012). UNAIDS (2017d) advised that blood that is used in transfusions should be properly screened for HIV infection to prevent transmission of the virus. More so, relief workers should protect themselves from contact with blood to avoid exposure to the pandemic (UNAIDS, 2017d). In addition, the use of unsterilised sharp objects may expose adolescents to the virus (Mbakwem-Aniebo et al., 2012). In this study, the researcher, proposed a new multifaceted theoretical model that could be used to design HIV preventive interventions to discourage behaviour that could bring how adolescents come into contact with HIV and AIDS infected blood.

Declaration
Ethics Clearance Certificate
Dedication 
Acknowledgements
Abstract 
Language Editor 
List of abbreviations 
List of Figures
List of Tables 
CHAPTER ONE: INTRODUCTION 
1.1 PROBLEM STATEMENT
1.2 RATIONALE
1.3 ASSUMPTIONS ABOUT INTERVENTION APPROACHES AND BEHAVIOUR .
1.4 AIMS AND OBJECTIVES
1.5 RESEARCH QUESTIONS AND SUB-QUESTIONS
1.6 THE RESEARCHER AS A RESEARCH INSTRUMENT
1.7 SCOPE OF THE STUDY
1.8 LIMITATIONS OF THE STUDY
1.9 CONCEPT CLARIFICATION
1.10 CONCLUDING REMARKS
CHAPTER TWO: LITERATURE REVIEW 
2.1 INTRODUCTION
2.2 CONTRIBUTING FACTORS TO ADOLESCENTS’ HIGH HIV AND AIDS PREVALENCE
2.2.1 Risk related behaviour
2.2.2 Health factors
2.2.3 Social factors
2.2.4 Knowledge factors
2.3 THEORETICAL APPROACH TO THE STUDY
2.3.1 The Theory of Planned Behaviour
2.3.2 The Information Motivation Behaviour Skills Model
2.3.3 The Social Ecology Theory
2.3.4 The three models in relation to HIV and AIDS
2.3.5 How these three models are used during HIV interventions
2.3.6 Grounded Theory
2.4 CONCEPTUAL FRAMEWORK OF THE STUDY.
2.4.1 Introduction
2.4.2 The overlap of the three models
2.5 CONCLUDING REMARKS
CHAPTER THREE: RESEARCH METHODOLOGY 
3.1 INTRODUCTION
3.2 RESEARCH METHODOLOGY AND PARADIGMS
3.3 SAMPLING AND SAMPLING DESCRIPTION
3.4 SUMMARY OF PARTICIPANTS IN THE STUDY
3.5 METHODOLOGY FOR RESEARCH SUB QUESTIONS
3.6 INSTRUMENT DESIGN AND TRUSTWORTHINESS
3.7 DATA COLLECTION AND ANALYSIS
3.8 ETHICS
3.9 CONCLUDING REMARKS
CHAPTER FOUR: RESULTS, ANALYSIS AND DISCUSSION
4.1 INTRODUCTION
4.2 INITIAL CODES, FOCUSED CODES AND CONCEPTUAL CATEGORIES DERIVED FROM
COMPARATIVE ANALYSIS OF INCIDENTS
4.3 CONCEPTUAL CATEGORY 1: RISK BEHAVIOURAL FACTORS
4.4 CONCEPTUAL CATEGORY 2: SEXUAL ABUSE
4.5 CONCEPTUAL CATEGORY 3: HEALTH FACTORS
4.6 CONCEPTUAL CATEGORY 4: SOCIAL FACTORS
4.7 CONCEPTUAL CATEGORY 5: KNOWLEDGE FACTORS
4.8 SITUATING THE DATA IN THE CONTEXT OF EXISTING THEORIES
4.9 CONCLUDING REMARKS
CHAPTER FIVE: FINDINGS AND DISCUSSION
5.1 INTRODUCTION
5.2 REVISITING THE RESEARCH QUESTIONS OF THE STUDY
5.3 FACTORS PARTICIPANTS RECOGNISED IN THE THEORY OF PLANNED BEHAVIOUR THAT WERE PERCEIVED TO CONTRIBUTE TO HIGH HIV AND AIDS PREVALENCE AMONGST
ADOLESCENTS
5.4 FACTORS PARTICIPANTS RECOGNISED IN THE INFORMATION MOTIVATION BEHAVIOUR
SKILLS MODEL THAT WERE PERCEIVED TO CONTRIBUTE TO HIGH HIV AND AIDS PREVALENCE AMONGST ADOLESCENTS
5.5 FACTORS PARTICIPANTS RECOGNISED IN THE SOCIAL ECOLOGY THEORY THAT WERE
PERCEIVED TO CONTRIBUTE TO HIGH HIV AND AIDS PREVALENCE AMONGST ADOLESCENTS
5.6 FACTORS PARTICIPANTS RECOGNISED THAT WERE EXCLUDED FROM THE THREE
MODELS THAT WERE PERCEIVED TO CONTRIBUTE TO HIGH HIV AND AIDS PREVALENCE
AMONGST ADOLESCENTS
5.7 FACTORS PARTICIPANTS ASSOCIATE WITH CONTRIBUTING TO HIGH HIV AND AIDS PREVALENCE THAT COULD BE USED TO DEVELOP A NEW MULTIFACETED THEORETICAL MODEL TO INFORM HIV AND AIDS INTERVENTION
5.8 CONCLUDING REMARKS
CHAPTER SIX: CONCLUSION
6.1 INTRODUCTION
6.2 SUMMARY OF FINDINGS
6.3 LIMITATIONS OF THE STUDY
6.4 RECOMMENDATIONS
6.5 TESTING OF RESULTS
6.6 CONTRIBUTION TO PRACTICAL AND THEORETICAL KNOWLEDGE
6.7 SUGGESTIONS FOR FURTHER RESEARCH
6.8 CONCLUSION
7. REFERENCES 
8. APPENDICES
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