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I. PROGRAM RESOURCES
1. Case Studies in Global School Health Promotion: From Research to Practice
2. Curricula Review of Emergency Plan Centrally-Funded HIV Prevention Programs for Youth
3. Guide to Implementing Family Skills Training Programmes for Drug Abuse Prevention
4. Handbook on the Optional Protocol on the Sale of Children, Child Prostitution and Child Pornography
5. One Billion Dollars for U.S. International Family Planning Assistance
6. Preventing HIV with Young People: the Key to Tackling the Epidemic
7. Silent Suffering: The Psychosocial Impact of War, HIV and Other High-risk Situations on Girls and Boys in West and Central Africa
8. Skillz Magazine: Football for an HIV-Free Generation
9. Yemen Cross-Sectoral Youth Assessment: Final Report
10. YouthLens Series Numbers 28-30
II. RESEARCH SUMMARIES
1. Conceptions of mental health among Ugandan youth orphaned by AIDS
2. Determinants of transitions to first sexual intercourse, marriage and pregnancy among female adolescents: evidence from South Nyanza, Kenya
3. Disco funerals: a risk situation for HIV infection among youth in Kisumu, Kenya
4. Early initiation of sexual activity: a risk factor for sexually transmitted diseases, HIV infection, and unwanted pregnancy among university students in China
5. Evaluation of Berhane Hewan: a program to delay child marriage in rural Ethiopia
6. Facilitating health-enabling social contexts for youth: qualitative evaluation of a family-based HIV-prevention pilot programme
7. Gender differences in university students' HIV/AIDS-related knowledge and sexual behaviours in Malawi: a pilot study
8. Gender dynamics and sexual norms among youth in Mali in the context of HIV/AIDS prevention
9. Gender factors associated with sexual abstinent behaviour of rural South African high school going youth in KwaZulu-Natal, South Africa
10. Ideologies of sexuality, menstruation and risk: girls' experiences of puberty and schooling in northern Tanzania
11. Impact of post-abortion family planning services on contraceptive use and abortion rate among young women in China: a cluster randomised trial
12. Incidence of HIV and sexually transmitted infections and risk factors for acquisition among young methamphetamine users in northern Thailand
13. The influence of early sexual debut and sexual violence on adolescent pregnancy: a matched case-control study in Jamaica
14. Is education the link between orphanhood and HIV/HSV-2 risk among female adolescents in urban Zimbabwe?
15. Multiple sexual partnership mediates the association between early sexual debut and sexually transmitted infection among adolescent and young adult males in Nigeria
16. Sexual violence and reproductive health among youth in Port-au-Prince, Haiti
17. Young mothers, first time parenthood and exclusive breastfeeding in Kenya
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I. PROGRAM RESOURCES
1. Case Studies in Global School Health Promotion: From Research to Practice (2009, 408 pages, divided into numerous small files between 50 and 300 KB)
A growing body of research identifies strong links between children's health, social, and educational outcomes. Research also points to the reciprocal benefits of access to quality education on individual and family health status. In response to these findings, the World Health Organization developed the concept of the health-promoting school (HPS). This book, available for purchase, provides readers with examples from more than two dozen countries (representing urban and rural areas in developing and developed nations) that outline the strategies taken to implement HPS programs in individual schools, municipalities, and nations.
Organization: Education Development Center
Contact: CAldinger@edc.org
2. Curricula Review of Emergency Plan Centrally-Funded HIV Prevention Programs for Youth (2009, 24 pages, 226 KB)
This paper reports on an evaluation of the strengths and weaknesses of curricula used by centrally-funded President's Emergency Plan for AIDS Relief programs that focus on abstinence and "be faithful" messages for youth.
Organization: Measure Evaluation Project
Contact: measure@unc.edu
3. Guide to Implementing Family Skills Training Programmes for Drug Abuse Prevention (2009, 64 pages, 884 KB)
This curriculum, available in six languages, is designed primarily for preventing drug abuse among young people. However, many of the family and parenting skills discussed -- such as providing security, trust, and warmth in parent-child relationships; developing structure in family life; and using appropriate discipline practices and sufficient limit-setting -- are applicable in other settings. The guide also provides practical advice on training staff, recruiting families, and program monitoring and evaluation.
Organization: UNODC
Contact: youthmail@unodc.org
4. Handbook on the Optional Protocol on the Sale of Children, Child Prostitution and Child Pornography (2009, 74 pages, 336 KB)
The Convention on the Rights of the Child, the main international instrument for protecting children's rights, is supplemented by two optional protocols. One addresses the sale of children, child prostitution, and child pornography, and the other the involvement of children in armed conflict. This handbook addresses the former issue. The publication describes the genesis, scope, and content of the protocol and provides examples of measures taken by governments to fulfill their obligations under this protocol.
Organization: UNICEF Innocenti Research Centre
Contact: florence@unicef.org
5. One Billion Dollars for U.S. International Family Planning Assistance (2008, 4 pages 571 KB)
This policy brief discusses the need for increased funding for family planning and provides brief examples of how this can improve the health of youth. It also examines historical funding trends for family planning.
Organization: Advocates for Youth
Contact: www.advocatesforyouth.org
6. Preventing HIV with Young People: the Key to Tackling the Epidemic (2009, 32 pages, 3.6 MB)
This report describes the current state of the HIV epidemic, the key challenges faced by adolescents and young people, and UNICEF's response in each region.
Organization: UNICEF UK, Unite for Children, Unite against AIDS
Contact: https://www.unicef.org.uk/contact/contact_hub_home.asp
7. Silent Suffering: The Psychosocial Impact of War, HIV and Other High-risk Situations on Girls and Boys in West and Central Africa (2009, 64 pages, 4.8 MB)
English
French
The regions of West and Central Africa are home to an ever-growing number of children who live on the streets, who are trafficked and exploited as cheap labor, who are neglected or sexually abused, or who are forced into combat in a civil war. To learn more about the impact of these circumstances on children, researchers conducted a study in which they interviewed more than 1,000 children and adolescents in Burkina Faso, Sierra Leone, Liberia, Togo, and Cameroon. The study also included an intervention component for children who were determined to be in critical situations.
Organization: Plan International, FHI
Contact: waro.ro@plan-international.org
8. Skillz Magazine: Football for an HIV-Free Generation (8 pages, 2 MB)
Skillz magazine features international soccer stars as well as young Africans who are making a difference in their communities and leading the fight against HIV and AIDS.
Organization: Football for an HIV Free Generation
Contact: http://www.f4hivfree.com/learn/game/contact.html
9. Yemen Cross-Sectoral Youth Assessment: Final Report (2008, 133 pages, 2 MB)
The Yemen Stability Initiative works with disaffected, disenfranchised vulnerable youth ages 15-24 through programs to increase their civic participation, life skills competence, health, and livelihood opportunities and to help them combat violent extremism.
Organization: Education Development Center, Inc. (EDC)
Contact: http://www.edc.org/contact
10. YouthLens Series Numbers 28-30 (2009, 4 pages each, approximately 185 KB)
This series, produced by the Interagency Youth Working Group (IYWG), focuses on new research and programs related to various topics affecting youth. The three new briefs in the series are:
- Number 28. Communicating with Youth: Using the Internet and Mobile Phones in Reproductive Health Programs -- discusses the advantages and challenges of using these technologies, how mobile phones and the Internet can be used to their best advantage, and what evidence exists about the effectiveness of this technology in youth programs.
- Number 29. HIV-Infected Youth -- discusses the need to provide HIV-infected youth with age-appropriate care and treatment, psychosocial support, and reproductive health counseling.
- Number 30. Hormonal Methods of Contraception for Youth -- discusses the impact that hormonal contraceptives can have on adolescent health.
Organization: Family Health International/IYWG
Contact: youthwg@fhi.org
II. RESEARCH SUMMARIES
1. Conceptions of mental health among Ugandan youth orphaned by AIDS. Harms S, Kizza R, Sebunnya J, et al. S. Afr J AIDS Res 2009;8(1):7-16.
This paper reports on a qualitative study that comprehensively describes the experience of orphanhood and its impact on mental health from the perspective of Ugandan youths. The authors conducted interviews with a purposeful sample of 13 youths (ages 12 to 18) who had lost one or both parents to AIDS illness and who were also affiliated with a nongovernmental organization providing support to orphans. The orphaned youths experienced significant ongoing emotional difficulties following the death of their parent(s). The youths in this study were unfamiliar with the term "mental health"; however, they easily identified factors associated with good or poor mental health. In general, good mental health was associated with social conduct that is culturally appropriate. Poor mental health was perceived as a form of madness or insanity and it was associated with a loss of basic life necessities, such as access to food, education, or shelter. The youths also identified factors that promote more successful orphans. The findings of this study suggest that Western terminologies and symptom constellations in the Diagnostic and Statistical Manual IV may not be applicable in an African cultural context.
2. Determinants of transitions to first sexual intercourse, marriage and pregnancy among female adolescents: evidence from South Nyanza, Kenya. Magadi MA, Agwanda AO. J Biosoc Sci 2009;41(3):409-27.
This study investigates the determinants of adolescent transitions in South Nyanza, a socioeconomically deprived setting in Kenya where adolescent reproductive health is a particular concern. The analysis is based on Cox regression of timing of first sexual intercourse, first marriage, and first pregnancy, using data from a survey of 1,247 females aged 12-19 years. The results show that higher household socioeconomic status and educational attainment are associated with delayed onset of all three transition events. Furthermore, mother's higher educational attainment is protective for initiation of sexual intercourse, while rural residence is protective for pregnancy. Other protective factors include communication with parents or with fellow girlfriends. However, discussing sexual matters with boyfriends, high internal locus of control, and gender bias are associated with early onset of the three transition events.
3. Disco funerals: a risk situation for HIV infection among youth in Kisumu, Kenya. Njue C, Voeten HA, Remes P. AIDS 2009;23(4):505-9.
This study examines the so-called "disco funeral" phenomenon in Kisumu, Kenya, whereby community members, including adolescents, congregate at the home of a deceased person for several days, accompanied by music and dancing. The authors conducted a cross-sectional qualitative study to explore whether attendance at disco funerals put youth at risk of HIV and other sexually transmitted infections (STIs). The researchers conducted 44 in-depth interviews with male and female adolescents aged 15-20 years and observed during six disco funerals. They found that disco funerals were an important place for young people to hang out and that the events increased the opportunities for youth to meet and engage in (risky) sexual activities. Many adolescents reported having casual sex on these occasions, sometimes with multiple partners, and mostly without condoms. Some girls were forced into sex, and there were several accounts of gang rape. Sex in exchange for money was reported frequently. Drugs and alcohol seemed to facilitate unprotected, multiple-partner, coerced, and transactional sex. HIV interventions urgently need to include outreach to youth who attend disco funerals and should link with parents and funeral organizers to reduce risk situations.
4. Early initiation of sexual activity: a risk factor for sexually transmitted diseases, HIV infection, and unwanted pregnancy among university students in China. Ma Q, Ono-Kihara M, Cong L, et al. BMC Public Health 2009;9(Article No.111):8 p.
This study explored any association between the timing of the initiation of sexual activity and sexual behaviors and risks among university students in China. Data were derived from a cross-sectional study on sexual behavior among university students conducted in Ningbo municipality at the end of 2003. Students completed a self-administered, structured questionnaire. Of 1,981 sexually active male students, 1,908 (96.3%) completed the item for timing of the initiation of sexual activity and were included in analyses to compare the association between this timing and sexual behavior and risks. Compared with late initiators, male early sexual initiators had a significantly higher risk profile, including a significantly higher proportion reporting non-regular partners (i.e., casual or commercial partners), multiple partners, diagnosis with an STI, partner history of pregnancy, partner history of induced abortion, and less condom and oral contraceptive use. Multivariate analyses confirmed the increased likelihood of these risks in early initiators versus late initiators, other than partner type during the last year. The authors conclude that sex-education strategies should be focused on an earlier age, should include advice on delaying the age of first sexual activity, and should target young people who continue to take sexual risks.
The full text is available (248 KB).
5. Evaluation of Berhane Hewan: a program to delay child marriage in rural Ethiopia. Erulkar AS, Muthengi E. Int Perspect Sex Reprod Health 2009;35(1):6-14.
Berhane Hewan was a pilot project conducted in 2004-2006 that aimed to reduce the prevalence of child marriage in rural Ethiopia through a combination of group formation, support for girls to remain in school, and community awareness. A quasi-experimental research design with baseline and endline surveys was used to measure changes in social and educational participation, marriage age, reproductive health knowledge, and contraceptive use. Chi-square tests, proportional hazards models, and logistic regressions were conducted to assess changes associated with the project. The intervention was associated with considerable improvements in girls' school enrollment, age at marriage, reproductive health knowledge, and contraceptive use. Particularly among girls aged 10-14, those exposed to the program were more likely than those in the control area to be in school at the endline survey (odds ratio, 3.0) and were less likely to have ever been married (0.1). However, among girls aged 15-19, those in the intervention area had an elevated likelihood of having gotten married by the endline (2.4). Sexually experienced girls exposed to the intervention had elevated odds at endline of having ever used contraceptives (2.9).
6. Facilitating health-enabling social contexts for youth: qualitative evaluation of a family-based HIV-prevention pilot programme. Paruk Z, Petersen I, Bhana A. Afr J AIDS Res 2009;8(1):61-8.
This paper reports on an evaluation of a cartoon-based intervention aimed at preventing HIV in adolescents and delivered to multiple family groups in South Africa over 10 sessions. Semi-structured interviews with nine women who participated in the intervention were used to understand participants' perceptions of how the family-based HIV-prevention program had helped them address issues. Findings indicate that at an individual level, the women interviewed had experienced an improved sense of empowerment, both as parents and as women. They also reported increased social support for effective parenting. At a collective level, the women reported that the program had helped them to exert better informal social controls within the community, as well as to increase their social leverage and participation in community organizations.
7. Gender differences in university students' HIV/AIDS-related knowledge and sexual behaviours in Malawi: a pilot study. Ntata PR, Muula AS, Siziya S, et al. SAHARA J 2008;5(4):201-5.
The authors conducted a cross-sectional study among first-year university students in Malawi to determine distributions of HIV/AIDS-related knowledge and sexual behaviors. A total of 314 (199 male and 115 female) students were eligible to participate, and of these 221 (70.4%) participated in the survey. Generally, levels of HIV/AIDS-related knowledge were similar between sexes. Overall, 68.9% of students of both sexes felt that they knew enough about HIV/AIDS. Altogether, 83.3% of students reported that they knew where to access HIV testing on campus, but only 19.0% reported that they knew their HIV status. Some 60.3% of students who had never been tested intended to have an HIV test. A history of having ever been tested was not associated with sex. Most (68.4%) students felt that they were not at risk of acquiring HIV infection. Overall, 66.8% of students knew where to get a condom on campus, and 38.7% stated that they knew exactly how to use it. About half (52.6%) of the students used a condom at last vaginal sexual intercourse. Having multiple sex partners in the last 12 months was reported by 40.4% of students.
8. Gender dynamics and sexual norms among youth in Mali in the context of HIV/AIDS prevention. Boileau C, Vissandjee B, Nguyen V-K, et al. Afr J Reprod Health 2008;12(3):173-84.
The authors conducted 10 focus groups and 16 individual interviews to explore sexual norms among youth in Bamako. Premarital sex, multiple partnering, condom use, and transactional sex were discussed. The findings suggest that young people's sexual norms are shaped by kin or authoritative elders as well as by external influences coming from Western culture. Sexual norms are differentially constructed by men and women and contradict those of older generations. Views on premarital sex, condom use, and transactional sex generated controversy among men and women, as well as among more sexually conservative or progressive youth. However, there was general rejection of multiple partnerships.
9. Gender factors associated with sexual abstinent behaviour of rural South African high school going youth in KwaZulu-Natal, South Africa. Dlamini S, Taylor M, Mkhize N, et al. Health Educ Res 2009;24(3):450-60.
To develop tailored health education messages, the authors conducted a cross-sectional study investigating the choice by rural South African high school students to be sexually abstinent. All Grade 9 learners from one class at each of 10 randomly selected rural high schools participated. The Integrated Model for Motivational and Behavioural Change was used to elicit attitudes, social influences, self-efficacy, and intentions toward sexual abstinence. Chi-square and t-tests were used for bivariate analysis. In total, 454 learners, mean age 16.7 years (standard deviation 1.41; range 14-20 years), participated, of whom 246 (54.2%) were female. Compared to learners who were not abstinent (n = 202), abstinent learners (n=252) were significantly more often female (P < 0.005), younger (16.5 years versus 17.1 years, P < 0.005), and drank less alcohol (P < 0.005). Abstaining girls believed that their friends and parents think that they should abstain from sex, that their friends abstained from sex, and that abstinence helped them to mature emotionally. Abstinent boys expressed intentions to abstain from sex until marriage. Different abstinent messages are needed for boys and girls to address the different patterns of behavior observed.
10. Ideologies of sexuality, menstruation and risk: girls' experiences of puberty and schooling in northern Tanzania. Sommer M. Cult Health Sex 2009;11(4):383-98.
This paper examines girls' experiences of menstruation, puberty, and schooling in northern Tanzania. The major question explored was how the onset of menses and puberty may be affecting girls' school participation, given societal implications and potentially discriminatory school environments. The methodology included a comparative case study using in-depth interviews and participatory research with young women living in urban and rural Kilimanjaro. Along with findings about how menstrual onset creates challenges for girls attending school, other findings emerged about the significant gaps in girls' knowledge about body changes, sexual health, and HIV/AIDS.
11. Impact of post-abortion family planning services on contraceptive use and abortion rate among young women in China: a cluster randomised trial. Zhu JL , Zhang W-H, Cheng Y, et al. Eur J Contracept Reprod Health Care 2009;14(1):46-54.
In this cluster-randomized trial, eight matched pairs of hospitals were certified by centralized randomization to offer either a "simple" family planning service package (provision of limited information and referral to existing family planning services) or a more comprehensive package (consisting -- in addition to the simple package -- of individual counseling, free provision of contraceptive materials, and involvement of the male partner). Women undergoing abortion were followed up for six months, and data were collected in two rounds, before and after the intervention. The authors followed a total of 2,336 women younger than 25 years (555 before and 555 after the simple intervention package; 634 before and 592 after the comprehensive intervention package). Both packages increased use of any contraceptive method, but the comprehensive approach also increased use of more effective methods and showed better compliance. The rates of unwanted pregnancies and repeat abortions were somewhat reduced for both packages, with no significant statistical difference between them.
12. Incidence of HIV and sexually transmitted infections and risk factors for acquisition among young methamphetamine users in northern Thailand. Sutcliffe CG, Aramrattana A, Sherman SG, et al. Sex Transm Dis 2009;36(5):284-9.
This study enrolled methamphetamine users aged 18 to 25 years in a 12-month randomized behavioral intervention trial in Chiang Mai, Thailand in 2005. Behavioral questionnaires were administered at visits every three months, and biologic specimens were collected at baseline and 12 months to test for common STIs (chlamydia, gonorrhea, HSV-2, and HIV). Poisson regression with robust variance was used to determine risk factors for incident STIs. Overall, 12.7% of 519 participants acquired at least one STI. Chlamydia was the most common (10.6%), followed by HSV-2 (4.0%), gonorrhea (2.9%), and HIV (0.6%). Risk factors for both men and women included self-reported incarceration and having a casual sex partner during follow-up, and having a prevalent STI at baseline. Additionally, among women, having two or more heterosexual partners, and among men, having a greater frequency of drunkenness were risk factors for STI acquisition. The authors concluded that although HIV incidence is low in this population, incidence of other STIs is high compared with previous studies of young Thai adults.
13. The influence of early sexual debut and sexual violence on adolescent pregnancy: a matched case-control study in Jamaica. Baumgartner JN, Geary CW, Tucker H, et al. Int Perspect Sex Reprod Health 2009;35(1):21-8.
The authors conducted structured interviews with 15- to 17-year-old females -- 250 who were currently pregnant and 500 sexually experienced, but never-pregnant, neighborhood-matched controls. Bivariate and multivariate analyses were used to examine associations between adolescent pregnancy and early sexual debut, sexual coercion or violence, and sexual risk-taking behaviors. Greater proportions of pregnant youth than of their never-pregnant peers reported having had first sex by age 14 (54% vs. 41%), a first sexual partner who was five or more years older (33% vs. 20%), or multiple partners (63% vs. 50%). A greater proportion of never-pregnant youth had used contraceptives at first sex (88% vs. 80%). Almost half (49%) of all young women reported ever having experienced sexual coercion or violence. Compared with controls, pregnant youth had greater odds of having had an older partner at first sex and believing contraception is a woman's responsibility (odds ratios, 1.3 and 2.1, respectively), and had lower odds of ever having experienced sexual violence and thinking that it is important to protect oneself against pregnancy (0.5 and 0.2, respectively). An interaction between early sexual debut and multiple partners was found. Having had multiple partners was associated with pregnancy only for youth with early sexual debut. Encouraging adolescents to delay sexual debut and reduce their number of sexual partners may help prevent unintended pregnancies. Experiences of sexual coercion and violence were common among both groups, highlighting the need to address gender-based violence at the community level.
14. Is education the link between orphanhood and HIV/HSV-2 risk among female adolescents in urban Zimbabwe? Birdthistle I, Floyd S, Nyagadza A, et al. Soc Sci Med 2009;68(10):1810-8.
This study explored the role of education in explaining the excess sexual risk previously documented among unmarried female orphans in urban Zimbabwe. School attendance and attainment were assessed by type of orphanhood, and for their association with markers of sexual risk (HIV and/or HSV-2 infection) among 743 participants drawn from a random sample of 15- to 19-year-old girls identified in a cross-sectional survey in Highfield, Harare in 2004. Multivariable logistic regression was used to assess the role of educational status in explaining the higher prevalence of adverse sexual outcomes among unmarried orphans compared to non-orphans, adjusting for possible confounders. Double orphans had significantly lower educational attendance and attainment than non-orphans. Maternal orphans had higher odds of school drop-out, although this association disappeared when adjusted for recent mobility. Educational status was strongly associated with HIV/HSV-2 risk, but explained only a small part of double orphans' sexual risk and did not explain the HIV/HSV-2 risk of maternal and paternal orphans. High overall levels of secondary school participation and school fee assistance provided to vulnerable families may have reduced the schooling disparities between orphans and non-orphans in Highfield. However, further efforts are needed to rectify the schooling inequities that persist, while additional research is needed to identify other socioeconomic and emotional factors driving orphans' sexual risk so that prevention and support programs can meet the needs of this growing population.
15. Multiple sexual partnership mediates the association between early sexual debut and sexually transmitted infection among adolescent and young adult males in Nigeria. Fatusi A, Wang W. Eur J Contracept Reprod Health Care 2009;14(2):134-43.
The study was cross-sectional analytical in design and involved 1,278 Nigerian males aged 15-24 years. Logistic regression was used in assessing the statistical relationship between early sexual debut (<16 years) and self-reported STIs (history of at least one of three symptoms -- painful urination, genital discharge, and genital ulcer/sore within the past 12 months), with demographic factors, sexual behaviors, and psychosocial measures controlled for. The prevalence of self-reported symptoms was 4.2% for genital discharge, 4.1% for painful urination, and 2.0% for genital sore/ulcer. Overall, 6.8% had STI symptoms. At bivariate analysis, early sexual debut (p = 0.021), multiple partners (p < 0.001), concurrent partners (p = 0.002), and sex with casual/commercial partners (p = 0.013) were associated with STIs. At multivariate analysis, early sexual debut (odds ratio [OR] = 2.12, 95% confidence interval [CI] = 1.17-3.84) remained significantly associated with STIs. Multiple sexual partnership (OR = 2.00, 95% CI = 1.13-3.52) was also significantly associated with STIs and is a mediator of the association between early debut and STI.
16. Sexual violence and reproductive health among youth in Port-au-Prince, Haiti. Gomez AM, Speizer IS, Beauvais H. J Adolesc Health 2009;44(5):508-10.
The authors examined sexual violence and reproductive health outcomes among sexually experienced youth in Port-au-Prince, Haiti, using the Priorities for Local AIDS Control methodology to identify participants in locations where sexual partnerships are formed. Their findings indicated that sexual violence is common and is significantly associated with condom use, pregnancy experience, and recent STI symptoms.
17. Young mothers, first time parenthood and exclusive breastfeeding in Kenya. Naanyu V. Afr J Reprod Health 2008;12(3):125-37.
This paper examines duration of exclusive breastfeeding among young mothers below 20 years of age as compared to older cohorts in Eldoret, Kenya. Additionally, the study focused on the effect of first-time motherhood and breastfeeding difficulties on exclusive breastfeeding. Results show that Eldoret mothers are aware of benefits of breastfeeding; nevertheless, the mean duration for exclusive breastfeeding in this sample was 2.4 months. Higher durations of exclusive breastfeeding are associated with increasing age and first-time motherhood. Predictably, breastfeeding difficulties bear a negative association with exclusive breastfeeding. While HIV is transmissible through breastfeeding, breastmilk remains a vital source of nourishment for infants in Sub-Saharan Africa. More research on mothering should examine the changing socioeconomic milieu and its influence on women's infant-feeding decisions.
