HIV Infection Among Adolescent Girls and Young Women in Sub-Saharan Africa: Philosophical Perspectives of Sociostructural Risk Factors

Background

Human immunodeficiency virus (HIV) infection is a major global public health challenge,^[1,2] affecting mostly vulnerable subpopulations and societies.^[3,4] Adolescent Girls and Young Women (AGYW) in Sub-Saharan Africa are disproportionately affected by HIV infection.^[5,6] Sub-Saharan Africa accounted for 25.6 million of the 38.4 million people living with HIV (PLHIV) globally in 2021.^[7] In the same year, AGYW aged 15–24 years comprised 63% of all new HIV infections in Sub-Saharan Africa^[2] and were twice as likely to be living with HIV compared to their male counterparts.^[2] AGYW in different countries of Sub-Saharan Africa face unique HIV risk challenges, including early marriages, gender-based violence, stigma, and limited access to education and healthcare.^[8–12] The higher risk of HIV infection among AGYW aged 15–24 years is attributed to different sociostructural factors^[12–16] varying by geographical context.^[10,17,18] Sociostructural risk factors are elements that affect HIV infection outcomes at the individual, relationship-based, community, and societal levels. These broader social and structural dimensions serve as enabling or constraining factors that directly or indirectly influence AGYW behaviors in relation to HIV infection.^[19] Past studies have revealed that understanding and improving contextual knowledge of philosophical perspectives of sociostructural risk factors among AGYW aged 15–24 years is essential in predicting and addressing new HIV infections.^[20,21] However, it is unclear how philosophical aspects of sociostructural risk factors (independent variable) influence HIV infection outcomes (dependent variable) among the AGYW aged 15–24 years in the different countries of Sub-Saharan Africa,^[5,22–24] yet this specific knowledge is needed to address age-gender inequalities in HIV infection risk reduction.^[25] Hence, this review aimed to provide a deep understanding of the philosophical perspectives of sociostructural risk factors influencing HIV infection outcomes among AGYW in order to guide the development and implementation of targeted interventions to reduce new HIV infection in Sub-Saharan Africa.

Objective

This literature review considered sociostructural risk factors including socioeconomic and structural elements associated with HIV infection, in order to characterize drivers of HIV risk across various socioecological levels.^[19] HIV Infection refers to a viral infection that is transmitted via exposure to infected body fluids such as semen, blood, breast milk, and vaginal fluids, and its outcome is measured as a positive or negative new HIV diagnosis. The review utilized various philosophies to explore the sociostructural risk factors of HIV infection among AGYW.^[22–24] It examines how AGYW acquires and transmits HIV infection and as well as strategies for prevention, highlighting the importance of understanding these factors. The review’s exploratory question was, “What philosophical perspectives of sociostructural risk factors influence the acquisition and transmission of HIV infection among AGYW aged 15–24 years in Sub-Saharan Africa?”

Scope

This review explores the philosophical aspects relating to sociostructural risk factors of HIV infection from June 1981, when improvements in HIV knowledge regarding clinical course and epidemiology began to November 2023, focusing on the philosophical understanding of these factors as a measure to reduce HIV infection among AGYW.

Search Strategy

This paper generated data from scholarly sources including published academic literature, mainly peer-reviewed papers, and books on the HIV risk factors and HIV infection outcomes among AGYW. Several online information sources provided necessary secondary data by utilizing search terms such as philosophical, perspectives, sociostructural, risk, risk factors, factors, infection, infections, AGYW, aged, 15-24, adolescent, adolescents, young women, and HIV infection outcomes. Various search engines including PubMed, Google Scholar, Medline and Open Access journals were used to generate literature used to describe the philosophical perspectives of sociostructural risk factors. Additionally, relevant articles were found using backward searching by examining the references of found articles, and through forward searching: by locating newer articles that included the original cited paper. The review focused on classical philosophical perspectives of HIV infection among AGYW, highlighting contributions, limitations, differences, and gaps in knowledge.

Study Selection

The researchers analyzed the literature on HIV-related outcomes and explored the sociostructural risk factors and HIV infection outcomes among AGYW in Sub-Saharan Africa. Secondary data on philosophical perspectives of sociostructural risk factors (independent variables) and HIV infection outcomes (dependent variable) among AGYW were selected. The inclusion criteria considered in this study were: the research was published in the English language; the study was conducted between June 1981 and November 2023; the article focused on sociostructural risk factors; the article focused on HIV-related outcomes; and the article related to the philosophical perspectives of HIV infection among AGYW. Studies were excluded if they did not specifically focused on HIV infection, sociostructural risk factors, and philosophical perspectives.

Data Extraction

The review used database querying and text pattern matching to capture key characteristics of published studies based on information in journal articles and reports. For example, “PubMed was searched using the terms ‘sociostructural risk factors’ and ‘HIV infection outcomes’ from 1981 through November 2023. Data concerning the study goal, a synopsis of the research content, philosophical perspectives of sociostructural risk factors, HIV infection outcomes, and a summary of each study’s characteristics were gathered from the articles. Information extracted for each research primarily focused on the sociostructural risk of acquisition and transmission of HIV infection, the target population of AGYW, human behavior, HIV infection outcomes, and study conclusion summaries.

Two authors separately assessed each of the identified research articles to ascertain eligibility and performed data extraction for the current study. Any inconsistencies between the two authors were discussed and a consensus was reached. The authors developed a complete and accurate table of study descriptions and outcomes and counted various features among the manuscripts’ findings and conclusions, as indicated in Figure 1 and Table 1.

Close

Figure 1:

PRISMA flow diagram for identification of studies via databases.

Export to PPT

Synthesis of Evidence

African Ubuntu philosophy

Ubuntu is a Zulu word or a Nguni Bantu philosophy meaning “humanity.”^[30] Since the 1950s, when Ubuntu philosophy came into use,^[31] it has been used to explore and inform numerous societal phenomena for reducing HIV risk among youth within and outside of Africa.^[32,33] Ubuntu’s philosophy on education was applied to develop African education and HIV prevention efforts, aiming to decolonize them from Western educational philosophies.^[34] In the predominantly Buganda’s Central region, Sylvia Nagginda, the current “Nnabagereka” translated as the “Queen of Buganda,”^[35] emphasizes HIV prevention education for girls and promotes cultural values that make a good mother or woman in Buganda, including abstinence from premarital sex and stigma reduction among PLHIV.^[36] These values of Ubuntu in the Buganda ethic attest to the sociostructural risks of HIV infection among the AGYW.

Ubuntu philosophy was found not to be universally applicable to all cultures.^[37] The copying of every traditional practice among the AGYW including lesbianism contributed to increased immorality and laziness that made AGYW think they could achieve higher wealth freely and continue to erode the Uganda society values.^[38]

Philosophy of realism

The philosophy of realism has been used in health research since the 6th century BC and continues to influence new thinking and behavior of individuals to date.^[39]

Realism philosophy was critical to the assessment of practical and logical truth about actual risk behaviors of AGYW and their correlation with HIV infection because realism tends toward an actual view of a situation. Realism philosophy focuses typically on synthesizing only quantitative studies, answering questions about “what works at the expense of understanding how, in what context, and for whom’’,^[40,41] and is linked to sociostructural risk factors of HIV infection such as sexual and HIV stigma.^[42] Realists view the world as consisting of strata or layers of reality which may interact with other layers to produce new mechanisms^[39] that trigger behavioral change for HIV infection.^[42]

Philosophy of holism

The term “Holism” is a philosophical perspective based upon ideas that the whole is more than the sum of its constitutive parts, so the reduction of the whole to its constitutive elements eliminates some factors that manifest only when the entity is perceived as a whole.^[43] In 1926, the theory of “holism” and its application in explaining health risk behaviors was described as the idea that natural systems such as physical, biological, or social and their properties should be viewed not as a collection of parts, but as integrated wholes.^[44]

The modern English term “health” recognizes the essential connection with holism and synergy is generated through the interaction of parts but it does not exist if we take parts alone.^[43]

The philosophy of holism has been used to influence health policies in Canada by harmonizing the socio-political landscape and healthcare financing.^[45] Holistic caring involves taking care of the patient as a whole body, which involves the physical, social environment, psychological, cultural, and religious beliefs.^[46] On the other hand, some philosophers have argued that there is a clear distinction between body and mind, and the separation of body, mind, and spirit shapes attitudes toward health.^[47]

Philosophy of health

The World Health Organization (WHO) definition of health as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity” has been criticized by philosophers since its inception on April 7, 1948, despite being intuitive and accessible to a large audience.^[48] It is not necessarily researchable across health disciplines, and without a common definition of health, important communications from patients to doctors, from subjects to researchers, and from researchers to collaborators can become fragmented or lost in translation.^[49] There have been several countersuggestions, arguing for a revised description of health that supports a more holistic understanding of a phenomenon involving complex and interrelated factors,^[45,49] hence giving rise to the philosophy of health.

The philosophy of health asserts that “life is a reality and health is a universal value.” It proposes that “integrating principles of health begins with a common-sense definition of health that can also be upheld across existing naturalistic and holistic perspectives of health.”^[48] The naturalistic perspective defines health as physical, physiological, biological, or natural processes that are observable, tangible, and measurable with modern technology.^[50] The holistic perspective of health contends that holistic phenomena (vital goals, meaning, and purpose) play a central role in population health.^[51]

Gaps and future directions

Past studies exploring HIV risks among vulnerable subpopulations in Uganda were mostly conducted among female sex workers, men who have sex with men, fisher folks, and migrant subpopulations and considered adult populations (18–49 years).^[52–57] Other studies in Kenya and Zambia^[58,59] found age and gender differences in the risk of acquiring HIV. Altogether, these studies left a gap in terms of contextual and geographical settings. The review suggests that future empirical studies be conducted to examine sociostructural risk factors of HIV infection among AGYW aged 15–24 years in Uganda, in order to guide the development of contextual HIV prevention packages for AGYW.

Interpretation

The finding that most of the tenets of the philosophy of sexuality are linked to human sexuality for pleasure or reproduction among the AGYW implies that some of the tenets such as adultery, casual sex, and prostitution may influence HIV risky practices among the AGYW, as they are human beings who may use their body organs for pleasure and/or reproduction. Unfortunately, sexuality concerns have been found to be not of high priority in healthcare, and therefore may not be considered important in HIV risk assessment by healthcare professionals. This finding may contribute to the increased risk of HIV infections among the AGYW.

The finding that AGYW’s social values are profoundly ingrained in African Ubuntu traditions such as the social order of togetherness implies that Ubuntu is strongly rooted in positive behavioral change and togetherness across Africa. This knowledge may act as a recipe for the successful assessments of HIV risks among AGYW and help in redesigning of more effective HIV prevention interventions targeting AGYW in Sub-Saharan Africa.

The result indicates that the philosophy of realism typically appraises quantitative studies, answering questions about “what works” while neglecting the understanding of “how” and “in what context”, poses a limitation in exploring the context of HIV risk reduction interventions among the AGYW aged 15–24 years. Additional philosophies are necessary to generate new knowledge on sociostructural risk factors among AGYW, which can be helpful in designing targeted HIV prevention interventions.

The finding that the theory of “holism” should be viewed not as a collection of parts, but as integrated structure implies that HIV infection may be inextricably linked to other health problems that disproportionately affect AGYW, such as the sexual victimization, stigmatization, alcohol use, and sexually transmitted diseases, and therefore need to be explored holistically. The result emphasizes the importance of undertaking assessments of behavioral health risks for health promotion and disease prevention. Therefore, the philosophy of holism can be used in the assessment of sociostructural risk factors among AGYW for HIV prevention as a major component of public health.

The observation that the Philosophy of Health considers health as a universal value that can also be upheld across existing naturalistic and holistic perspectives suggests that the philosophy can be applied simultaneously to investigate naturalistic and holistic phenomena of sociostructural risk factors and HIV infection outcomes among AGYW.

Sociostructural risk factors have individual and societal effects due to their biological, behavioral, and social implications, and hence, the HIV infection is neither purely naturalistic nor purely holistic (value-laden); rather, it reflects an integration of natural and holistic phenomena appropriately explained in the philosophy of health.

Implications

National governments in Sub-Saharan Africa through their respective ministries of health, education, and gender should adopt targeted HIV prevention initiatives addressing philosophical perspectives of sociostructural risk factors in their national policy on the prevention of new HIV infections among AGYW in order to reduce HIV-related gender disparities and health inequities.

The national governments should strengthen the capacities of individuals, groups, and institutions to provide appropriate socioeconomic empowerment services to AGYW who require them in order to reduce their risk of new HIV infections.

Lastly, the study suggests that Ministers of Health, directors of hospitals, and district health officers should implement an integrated package of prevention services through health facilities and community-based health delivery structures including community health workers to achieve zero new HIV infections by 2030 among the AGYW in Sub-Saharan Africa.

Challenges and Recommendations

The limitations of this narrative literature review were the complete reliance on the previously published research and the availability of these studies using the methodology described in the search strategy (Section 2.1), the study selection criteria (Section 2.2), and the data extraction procedures (Section 2.3). Of the fifty-three original research assessed for eligibility in this literature review, forty-two were removed for non-compliance with the screening procedures. Consequently, their findings were excluded in the final analysis for the following reasons: Lack of focus on sociostructural risk factors (n = 9), absence of emphasis on HIV infection (n =12), and insufficient focus on philosophical perspectives (n = 21).

Further research in sociostructural HIV risk factors should be carried out to explore the biological, behavioral, and social practices since HIV infection reflects an integration of naturalistic and holistic phenomena.

Key Messages

• The philosophical perspectives of sociostructural risk factors are important for human immunodeficiency virus (HIV) prevention.

• Uganda’s national laws and policies on HIV/AIDS prevention should adopt philosophical perspectives necessary for targeted HIV risk reduction among adolescent girls and young women aged 15–24 years.

• Sociostructural risk factors are unique factors that influence population health.