Functional Disability, Violence, HIV Status, and Risk Factors for HIV Among Adolescent Girls and Young Women — Eswatini, 2022

Abstract

Eswatini has made substantial progress responding to its HIV epidemic and reducing violence against children. However, adolescent girls and young women with disabilities might be at increased risk for experiencing violence and for HIV infection, compared with those without disabilities. Data from the 2022 Eswatini Violence Against Children and Youth Survey were analyzed to compare HIV infection and violence-related measures by functional disability status (e.g., difficulties in performing functional activities such as seeing, walking, or communicating) among adolescent girls and young women. In 2022, in Eswatini, 14.0% of adolescent girls and young women aged 13–24 years had a reported functional disability. Compared with those without a functional disability, adolescent girls and young women with a functional disability had higher lifetime prevalences of experiencing sexual, physical, and emotional violence. They were also more likely to know where to seek help for experiences of violence. After adjusting for sociodemographic characteristics, HIV testing and infection status, HIV risk factors, sexual risk behaviors, and HIV treatment and prevention services did not differ by functional disability status. Prioritizing accessible, disability-inclusive prevention programs and services might help reduce experiences of violence among adolescent girls and young women with disabilities. Partnering with disability-led and disability-serving organizations and directly with adolescent girls and young women with disabilities to plan and implement programs and services that are disability-inclusive could help ensure that adolescent girls and young women with disabilities are aware of and can access these resources.

Introduction

Eswatini has made substantial progress in HIV epidemic control and in reducing violence against children (1,2). However, certain populations remain particularly vulnerable to HIV infection and violence. Adolescent girls and young women in Eswatini are disproportionately affected by HIV, with an estimated prevalence of HIV infection among those aged 15–24 years (11.0%) that is more than three times that among male peers (3.4%) (2). Adolescent girls and young women with disabilities are particularly at risk for violence and HIV infection because of physical or communication barriers to accessing HIV prevention, testing, and treatment services, in addition to economic vulnerabilities, exclusion from education, and discrimination (3–5). This report describes self-reported functional disability prevalence (difficulties in performing functional activities [e.g., seeing, walking, or communicating]) (6) and the association with HIV and violence-related measures among adolescent girls and young women aged 13–24 in Eswatini. Findings could be used to improve service delivery and better understand the risks and needs of adolescent girls and young women with disabilities.

Methods

Data Source

Data from 6,318 adolescent girls and young women aged 13–24 years who participated in the 2022 Eswatini Violence Against Children and Youth Survey (VACS) were analyzed (female response rate = 90.1%). VACS is a cross-sectional, nationally representative household survey of persons aged 13–24 years that collects data on experiencing violence, HIV infection, and risk and protective factors for violence and HIV infection (1). Participation in VACS is voluntary, and for participants aged 13–17 years, parental permission and assent from the participant are obtained; for those aged ≥18 years, participant consent is obtained. Sex-matched interviewers conduct the interviews and record responses electronically using tablets. Forty-nine persons with severe disabilities or challenges in understanding or responding to questions were excluded. A comprehensive response plan and referral protocol was in place for participants who needed referrals during or after the survey, including those who recently experienced violence (1).

Disability Measures

Functional disability status was assessed using a modified version of the Washington Group on Disability Statistics Short Set (WG-SS) on Functioning questionnaire (6) (Supplementary Table, https://stacks.cdc.gov/view/cdc/176833#tabs-3). This analysis considered adolescent girls and young women to have a disability if they responded, “some difficulty,” “a lot of difficulty,” or “cannot do at all” to at least one question assessing six domains of current functioning: vision, cognition, mobility, self-care, independent living,* and communication.^† Because the ability to hear an interviewer is required for participation in an interviewer-administered survey, the WG-SS question on hearing was not included in the Eswatini VACS.

Violence-Related Measures

Violence-related measures included lifetime experiences of sexual, physical, and emotional violence; knowledge of a place to go for help for experiences of violence and to seek help for sexual and physical violence; having sought professional services for sexual and physical violence; and having received professional services for experiences of sexual and physical violence.

HIV Testing, Prevention, and Treatment Measures

HIV testing and infection status measures included ever having been tested for HIV infection, tested positive for HIV, and knowing one’s HIV infection status. HIV status was ascertained either via self-report of a previous positive HIV test result or positive rapid HIV test result at the time of the VACS interview. HIV testing was offered using the national HIV rapid testing algorithm (1). HIV prevention measures and treatment included knowledge of and ever having taken pre-exposure or postexposure prophylaxis, and among adolescent girls and young women living with HIV, being on antiretroviral therapy and viral load suppression.

HIV Infection Risk Factors and Sexual Risk Behaviors

HIV risk factors and sexual risk behaviors included lifetime experience of transactional sex, ever having symptoms or received a diagnosis of a sexually transmitted infection, forced sexual initiation, early sexual debut; and any of the following during the previous 12 months: multiple sexual partners, infrequent condom use (sometimes or never using condoms), positive or unknown HIV status of sex partners, sex partners who were ≥5 years older than the respondent, partners who ever refused to wear a condom, and fear of experiencing violence from disclosure of HIV status if the respondent received a positive HIV test result. Because of complex skip patterns used in VACS (i.e., each respondent could receive a different sequence of questions based on prior responses), indicator denominators might differ. All measures were dichotomized (i.e., yes or no) and self-reported during face-to-face interviews.

Data Analysis

Prevalence estimates were calculated for number of functional disabilities, functional disability status, and sociodemographic characteristics and HIV and violence-related measures by functional disability status. Rao-Scott chi-square tests were used to assess differences in sociodemographic characteristics by functional disability status, with p-values <0.05 considered statistically significant. Associations between functional disability status (independent variable) and HIV and violence-related measures (dependent variables) were assessed in separate unadjusted and adjusted logistic regression models, which generated prevalence ratios (PRs) comparing HIV and violence-related measures by disability status.^§ To adjust for potential confounders of the association between functional disability and the different measures, adjusted analyses controlled for sociodemographic variables that reflect potential social and environmental influences (age, education, food insecurity,^¶ orphan status,** marital status, and residence^††). To account for multiple statistical tests, a Bonferroni-corrected significance level of p<0.0017 was used for regression analyses. Survey weights were included for all analyses. Analyses were conducted using SAS (version 9.4; SAS Institute), accounting for the complex survey design. This activity was reviewed by CDC, deemed not research, and was conducted consistent with applicable federal law and CDC policy.^§§

Results

Functional Disability Prevalence

Among adolescent girls and young women aged 13–24 years in Eswatini, 14% have a self-reported functional disability, with 11.2% reporting one functional disability type and 2.8% reporting two or more types (Table 1). The most commonly reported functional disability domain was vision (6.7%).

Associations of Violence and HIV Measures with Functional Disability

No differences were observed in characteristics between adolescent girls and young women aged 13–24 years with versus without functional disability except more of those with a functional disability experienced food insecurity (67.0% versus 59.7%; p = 0.002) (Table 2). After adjusting for sociodemographic characteristics, adolescent girls and young women with a functional disability had a higher prevalence of experiencing lifetime sexual violence (adjusted prevalence ratio [aPR] = 2.0), physical violence (aPR = 1.7), and emotional violence (aPR = 2.2) versus those without a functional disability (Table 3). Adolescent girls and young women with versus without a functional disability were more likely to know of a place to go for help for experiences of violence (aPR = 1.2). Prevalence ratios of measures related to HIV testing and infection status, HIV risk factors, sexual risk behaviors, and HIV treatment and prevention services did not differ by disability status.

Discussion

In Eswatini in 2022, 14% of adolescent girls and young women aged 13–24 years had a self-reported functional disability. Those with a functional disability had a higher lifetime prevalence of experiencing sexual, physical, and emotional violence compared with those without a disability. These findings are consistent with previous studies that found a relationship between disability and experiencing violence (3,5). Adolescent girls and young women with versus without functional disabilities were also more likely to experience food insecurity, an economic vulnerability that might contribute to increased risk for experiencing violence (7). In addition, adolescent girls and young women with a functional disability were more likely to know where to go to seek help services for experiencing violence, potentially because of their increased likelihood of experiencing violence or engagement with health systems where violence referral services might be shared or co-located. However, the extent to which these services are accessible and disability-inclusive is unknown. An analysis of the 2018 Lesotho VACS identified relationships between disability and HIV and risk behaviors (5). However, in the current study, disability was not associated with HIV infection status or risk behaviors after adjusting for age, education, food insecurity, orphan status, marital status, and residence. Further investigation is needed to better understand how these factors might modify the relationship between disability and HIV infection status.

Increased prevalences of experiencing sexual, physical, and emotional violence among adolescent girls and young women with functional disabilities highlights the need for accessible and disability-inclusive prevention programming and services to promote continued progress in addressing violence in Eswatini. Preventing experiences of violence among adolescent girls and young women with disabilities aligns with efforts set forth by the Eswatini government (8,9) to advance the inclusion of persons with disabilities in violence prevention programs and services and ending violence, stigma, and discrimination.

Limitations

The findings in this report are subject to at least seven limitations. First, self-reported data might be subject to recall, social desirability, or other biases. Second, because VACS are cross-sectional surveys, results cannot be interpreted as being causal or directional. Third, the Bonferroni correction is conservative, and some significant findings might have been missed using the Bonferroni-corrected significance level (e.g., the relationship between disability and HIV infection status). Fourth, including “some difficulty” in the disability categorization might bias results toward the null, because adolescent girls and young women with lesser degrees of functional limitations were included as having a disability. Fifth, because of small response numbers, it was not possible to assess differences in outcomes by disability type or degree of functional limitation, which would be helpful for focusing interventions within a heterogeneous population. Sixth, exclusion of persons with severe disabilities or challenges in understanding or responding to questions might have limited the inclusion of persons with a high degree of functional limitations. Therefore, disability prevalence is an underestimate and results might not be generalizable to that population of adolescent girls and young women. Finally, since hearing disability was not assessed in the Eswatini VACS, adolescent girls and young women with only this disability type would have been excluded when assessing disability.

Implications for Public Health Practice

Understanding risk factors for experiencing violence by adolescent girls and young women with disabilities might help guide development and implementation of tailored violence prevention programs and services. Prioritizing accessible and disability-inclusive violence prevention programs and service delivery might help reduce experiences of violence among adolescent girls and young women with disabilities (5). In addition, violence prevention partners collaborating with disability-led and disability-serving organizations and directly with adolescent girls and young women with disabilities to plan and implement programs and services that are disability-inclusive could help ensure that adolescent girls and young women with disabilities are aware of and can access these resources.