India-US collaboration to prevent adolescent HIV infection
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A secondary goal is to scale up the knowledge base and research capacities of both Indian and American social scientists to develop and implement innovative, culturally appropriate, effective and sustainable HIV/AIDS prevention and treatment programmes. The results of this study represent the first of several formative research projects in support of these two goals.
The overall objective was to gain insight into diverse family perspectives on the feasibility and acceptability of a family-based adolescent HIV prevention programme for rural Indian families. The proposed intervention is distinct from previous prevention approaches in that parents will be targeted as agents of change who can provide their adolescents with the guidance, information and strategies necessary to reduce their risk of HIV infection.
To date, we know of no family-based adolescent HIV-prevention programmes for rural Indian youth. The majority of adolescent prevention programmes have tended to target adolescents via peer models or school-based programmes [7-9], or have focused predominantly on urban areas. As a result, relatively little is known about the familial and contextual factors that might promote or hinder the success of a family-based HIV prevention intervention for rural youth.
This study focused on adolescents aged 14 to 18 years old and their families who reside in a rural community near Mumbai and Pune in Maharashtra. Rural adolescents in Maharashtra were targeted for several reasons. First, Maharashtra continues to bear a disproportionately high burden of HIV cases in India [2]. In addition, research with rural youth in Maharashtra suggests that HIV knowledge is low. For example, in a study with rural Maharashtran girls and women aged 15 to 24 years old, only 49% indicated that they were aware of AIDS and only 60% reported that AIDS could be avoided [10].
Sexual behaviour remains the leading cause of HIV infection in India [11], and complex factors underlie rural youth’s vulnerability to HIV. In Maharashtra, many rural young men migrate to cities, particularly Mumbai, in search of economic opportunities. While they are in urban areas, young men may have sexual relationships with women, including sex workers [12]. When male migrants return to their rural homes to marry and begin families, this migration creates a bridge for HIV infection. In addition, studies have also documented high rates of unprotected anal intercourse among rural men who have sex with men [13].
Although male adolescents report higher rates of sexual activity than females, female adolescents are also vulnerable to HIV. A complex combination of factors related to increased biological susceptibility, low levels of education, poverty and gender inequality heighten vulnerability for many females [8]. Many young women in Maharashtra do not complete secondary school. Some young women enter early marriages or commercial sex work, and gender inequality creates power differences that create formidable barriers to consistent condom use. Among young people aged 15 to 24 years, the number of women with HIV/AIDS is estimated to be almost twice that of young men [14]. Taken together, these factors suggest that rural adolescents are a vulnerable group of young people.
A growing body of research conducted with young people in developing contexts indicates that parents can influence the sexual decision making of their adolescent children [15-17]. These findings are consistent with the large body of literature from the US, which has found that parents can influence an adolescent’s sexual debut [18], condom use [19] and acquisition of STIs [20]. Additionally, a number of parent-based interventions evaluated in the US show that parents can reduce adolescent sexual risk behaviour when given appropriate information and parenting strategies [21-23].
Despite widespread support for the influence of parents on adolescent sexual behaviour, parent-based approaches to preventing adolescent HIV infection in India are rare. Indian culture is often characterized as having strong norms against open discussions of sexual behaviour [24], and Indian families are said to engage in indirect communication about sex [25]. At the same time, many Indian parents are concerned about their children becoming infected with HIV [26,27] and want to help their children make appropriate decisions regarding marriage [27,28].
Research also indicates that Indian adolescents are influenced by their parents. For example, a study in Uttaranchal observed that many young men attributed premarital sex to low levels of parental control and supervision [26]. In addition, a recent study with youth in Pune found that young people were more likely to talk with their parents about romantic relationships than they were with their peers [28]. Moreover, females who reported high levels of parental closeness were less likely to form romantic relationships [28].
Our study is distinct from previous research in several ways. First, it focused on families and parent-adolescent communication about HIV/AIDS as a means of preventing sexual risk behaviour and reducing adolescent vulnerability to HIV. Although the family has been the focus of interventions to help Indian persons living with HIV/AIDS, less research has focused on the family as a way to reduce adolescent vulnerability to HIV/AIDS. Open discussions about sexual behaviour are perceived as taboo in Indian culture [8,24,29]. As a result, relatively little is known about family communication about HIV/AIDS and how best to design a family-based intervention to prevent adolescent HIV infection.
We conducted exploratory research with families to generate insight into an understudied topic in the HIV/AIDS prevention literature. Previous research has tended to interview individual family members, i.e., adolescents [8,10]. In contrast, we conducted focus groups with mothers, fathers, and adolescent males and females in order to obtain a more comprehensive understanding of family perspectives on preventing adolescent HIV infection. In addition, interviewing multiple family members provided insight into possible biases in perceptions versus actual behaviour with respect to parent-adolescent communication about HIV/AIDS.
Finally, a strength of the study is the collaboration and integration of Indian and US perspectives into the development of study protocols and a family-based intervention to prevent adolescent HIV infection.
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