title: Is early sexual debut a risk factor for HIV infection among women in sub-Saharan Africa? A systematic review.
abstract: OBJECTIVE
  In Africa, adolescent girls have high HIV risk. Early sexual debut may be a risk factor, although evidence has not been systematically compiled.
  
  
  METHODS
  A systematic review was conducted. Quantitative studies from sub-Saharan Africa with biologically confirmed HIV infection measures were included.
  
  
  RESULTS
  A total of 128 full texts were screened. Twenty-five met the inclusion criteria, most cross-sectional. Half of studies, and all with large sample sizes, reported significant bivariate associations. These remained significant in all three studies controlling for socio-demographic factors; both studies controlling for sexual activity duration and four of eight studies controlling for subsequent risk behaviour.
  
  
  CONCLUSIONS
  Higher-quality studies consistently find significant bivariate associations between early sexual debut and HIV. In some studies, the increase in women's HIV infection risk seems to result from women's later engagement in risky sexual behaviours, rather than being directly related to early onset of sexual debut. In other studies, the increase in risk did not seem to be due to specific behavioural risk characteristics of the respondents or their sexual partners, suggesting that the risk may relate more to the potential for biological factors, for example, genital trauma, or other factors that have not been captured by the studies in this review.
authors.affiliation: Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK. heidi.stoeckl@lshtm.ac.uk
authors.forename: Heidi
authors.initials: H
authors.lastname: Stöckl
authors.forename: Naira
authors.initials: N
authors.lastname: Kalra
authors.forename: Jantine
authors.initials: J
authors.lastname: Jacobi
authors.forename: Charlotte
authors.initials: C
authors.lastname: Watts
mesh_terms: D000293:Adolescent; D017954:Africa South of the Sahara / Q000453:epidemiology; D005260:Female; D015658:HIV Infections / Q000453:epidemiology* / Q000635:transmission*; D006801:Humans; D012309:Risk-Taking; D012737:Sex Factors; D012725:Sexual Behavior; D012959:Socioeconomic Factors