HIV/AIDS Knowledge and Testing amongst Young People (MICS 5 Indicators 9.1 and 9.6)
It is not certain as to why there are a relatively a greater number of young persons within the middle horizontal strip of the study area who have comprehensive knowledge about HIV (MICS 5 Indicator 9.1 and MDG Indicator 6.3) than of people in the northern and southern flanks. However, better knowledge about HIV is likely to be associated with both urban dwelling and more education (49, 50). More educational opportunities as well as urban dwelling tend to be concentrated in the same middle horizontal strip of the study area. Nevertheless, the percentage of young persons with comprehensive HIV knowledge in the study area is generally low, ranging from 4–9%. This implies a need to improve HIV-related education in the study area, particularly in the northern and southern flanks.
From the mapping of SAEs of MICS 5 Indicator 9.6 shown in Fig. 3B, not only is the percentage of young persons who have tested for HIV in the last 12 months and know the results very low (3.6–12.4%), places with exceptionally poor testing for HIV are also revealed. This indicates that while the study area will benefit from universal improvement in the coverage of HIV testing for sexually active young persons, localities with exceptionally low records of HIV testing (3.6–6.3%) should be targeted for prioritised provision of HIV testing services as well as awareness creation (1).
The suggested urban advantage (shown in Fig. 3) is plausible for a number of reasons, including relatively higher health literacy and better accessibility of HIV services in comparison to rural areas (51, 52). This indicates that rural areas should be given prioritised attention for HIV/AIDS-related interventions. Furthermore, higher levels of both education and wealth quintiles are associated with remarkable increases in both Indicators 9.1 and 9.6. Together with urban residence, wealth and education are key markers of socioeconomic advantage. As these have been shown to be greatly associated with better knowledge of, as well as more testing for, HIV amongst young people, poor knowledge of HIV and a lack of HIV testing amongst sexually active young people can be considered matters of disadvantage in respect of socioeconomic status. This supports studies which show that even though highly educated and/or well-off people are more likely to engage in risky sexual behaviours (such as keeping multiple sexual partners), they also tend to both be more health-literate and practise safe sex, thereby being less prone to HIV infection than are poor and/or less educated people (49, 50, 53). Theoretically, there is a complex relationship between risky sexual behaviours and both schooling and wealth, which also varies by gender (16). Nevertheless, the spatial and social disaggregation of these indicators suggests socio-spatial inequalities that are worth investigating further in subsequent studies.
Multiple Sexual Partnerships and Condom Use amongst Young People (MICS 5 Indicators 9.14 and 9.15)
Small-area estimates of MICS 5 Indicators 9.14 and 9.15 (shown in Fig. 5A and Fig. 5B respectively) indicate that even though a large proportion of the young population in the study area had had multiple sexual partners in the last 12 months, a good percentage of these had used a condom during their last sexual intercourse with a non-regular partner. However, the observed spatial patterns in Fig. 5A and Fig. 5B suggest an inverse relationship between multiple sexual partnerships and condom use amongst young persons in the study area. For instance, relative to other senatorial districts, a smaller proportion of young persons in Kogi Central have multiple sexual partners, while a greater percentage of them reported having used a condom during their last sexual intercourse with a non-regular partner. Conversely, Kogi East, which records a high proportion of multiple sexual partnerships among young people, is also the senatorial district with a relatively low proportion of condom use during their last sexual intercourse with a non-regular partner. This shows that although there is a need to improve sex education and HIV/AIDS-related healthcare/screening services in the study area, this is particularly more crucial in Kogi East to ensure that the higher proportion of multiple sexual partnerships are matched with safe-sex practices.
Despite the increased sexual partnerships associated with higher levels of education depicted in Fig. 5, these are matched with more reports of regular usage of condoms (51, 53). In fact, 84.8% of this population had used a condom during their last sexual affair with a non-regular partner, compared to 12.6% of young people with primary education who reported having used a condom during a similar sexual affair. This shows that although more educated young people tend to be more exploratory regarding having sex with multiple sexual partners, they are also more cautious in practising safe sex (by using a condom with non-regular partners) than are their less educated peers (52, 54). This suggests a need for more sex education for young people with secondary education or lower. For young people aged 15–24 years, a key reason for increased multiple sexual partnerships with higher education is that time in higher education and beyond is often associated with more liberty/autonomy, being away from the restrictions of parents or guardians (55, 56). Apparently, the educational level of young people is likely to be directly correlated with age. Results show that with increased age comes more tendency towards sex with multiple sexual partners amongst young people; however, a greater proportion of non-teenage young people (42.1% and 43.8% for ages 20–22 and 23–24 respectively) reported having used a condom during their last sexual affair with a non-regular partner in comparison to the proportion of teenage young people (23.5% and 30.6% for ages 15–17 and 18–19 respectively) reporting the usage of condoms. This is consistent with extant empirical literature, which suggests that awareness of safe-sex practices is positively related to age, education, and socioeconomic status (57). As with having a higher level of education, post-teenage young people are likely to be more autonomous than teenage young people, since they may no longer be subject to as many parental restrictions as those imposed on teenagers (55, 56). Despite this, they tend to be twice as likely to practise safe sex as teenage young people. Thus, teenage young people should be prioritised for HIV-related interventions, especially on the need for safer sexual behaviour.
Other interesting patterns are also observable when Indicators 9.14 and 9.15 are disaggregated according to marital status, sex, and urban/rural dwelling. Being in non-committal relationships, many more single young people (44.7%) have had sex with multiple sexual partners in the last twelve months in comparison to their married peers (7.9%), as expected (58, 59). Furthermore, amongst married young people who have had an extramarital sexual partner in the last 12 months, the large majority (72.2%) reported having used a condom, compared to the proportion of single young people who reported having used a condom with their non-regular sexual partner in the same period (36.8%). For cultural and religious reasons, married young people in the study area are much less likely to engage in extramarital sex than are their single peers (60). Moreover, having a married regular sexual partner means that most married young people are not likely to be keenly searching for new sexual partners. Whenever such extramarital affairs happen, condoms are often used to prevent both pregnancy of the non-regular (female) partner as well as the transmission of an STI/STD to their married spouse.
It is unsurprising that a greater proportion of young males have had sex with a non-regular sexual partner (48.0%) in comparison to the proportion of females with multiple sexual partners in the last 12 months (31.9%) (61–63). This is because Nigeria, like many sub-Saharan African countries, is notoriously patriarchal, thus being culpable of hegemonic masculinity (64–66). This concept develops on ideas of patriarchy in explaining entrenched patterns of social practices (including actions and expectations) that perpetuate male dominance of females, often facilitated by culture, institutions, and political influence (67). Consequently, while females are highly discouraged from keeping multiple sexual partners for cultural reasons, males do not experience the same levels of restrictions, even when married (68, 69). Indeed, in many localities (including the study area), while it is taboo for married females to engage in extramarital sex, this is not the case for married males. It is, however, ironical that a higher proportion of married young males who reported having had sex with a non-regular partner in the last 12 months (48.4%) indicated having used a condom in such affairs, compared to the percentage of their female peers who reported having used a condom during their last sexual affair with a non-regular partner (21.0%) (70–72). This may be because in the study area there is a tendency for (married) females who have sex with non-regular partners to do so for a variety of transactional reasons (including in exchange for gifts or other favours from men), in which case they are less able to negotiate for safe sex (73–75). Consequently, young males are twice as likely to practise safe sex with a non-regular partner as females, thereby partly explaining why young females (aged 15–24 years) in sub-Saharan Africa are twice as likely as young males to have HIV (76). This suggests a need to promote safer-sex practices amongst young people, especially females, as well as to target empowerment interventions at women to make them less vulnerable (16).
In rural areas, more young people reported having had sex with a non-regular partner (41.1%) in the last 12 months, compared to their peers in urban areas who reported a similar practice (33.9%) (77). This suggests that young people in rural areas enjoy more autonomy than do their peers in urban centres, probably because of the very informal and communal nature of rural areas in the study area. With this comes an increased risk of HIV infection because people who become sexually active at a younger age are more prone to having multiple sexual partners in their lifetime, which is associated with a higher tendency towards indulging in other risky sexual behaviours (53, 58). This is, however, slightly at odds with the patterns recorded based on disaggregation by educational level, as a greater proportion of young people in urban areas are expected to possess higher education in comparison to their peers in rural areas. Despite more reports of having had sex with non-regular partners amongst young people in rural areas, a much lower proportion of these people do not use condoms in comparison to their peers in urban areas (77). While 67.5% of young people with multiple sexual partners in urban areas had used a condom during their last sexual intercourse with a non-regular partner, only 33.3% of young people in rural areas reported the usage of condoms. Thus, young rural dwellers are twice less likely than their urban peers to practise safe sex with a non-regular partner. In addition to poorer access to condoms in rural areas, this could indicate lower levels of sex education and, by extension, less awareness of safe-sex practices than in urban areas (49, 52). On the one hand, this suggests a need for increased sex education, condom accessibility, and the promotion of safe-sex practices in rural areas. On the other hand, being more vulnerable, rural areas should be targeted for increased accessibility to medical services related to the sexual health of young people, such as HIV/AIDS-related services as well as services for other STDs/STIs, such as relevant screenings/tests (1, 78).