Reply

To the Editors: We thank Dr. Hodson and Dr. Bewley for their insightful review and for raising important concerns surrounding the use of specific terminologies in research and public health programs. We acknowledge the importance of their concerns and how standard terminologies in epidemiology and public health can shape our understanding and interpretation of quantitative results—and, as Dr. Hodson et al suggest, belie the underlying complexity that give rise to the observations. Dr. Hodson et al raise the question of whether condom use should be considered a behavioral factor as we categorized it in the analyses or whether it should be seen as structural factor. We used traditional conceptual frameworks of HIV acquisition to generate the “domains” under which each vulnerability was categorized.1,2 However, and as outlined within each of these traditional frameworks, individuals' behaviors, their reaction to situations, their health, and general well-being are embedded in the structural context of society, politics, and geography and often influenced by the social interactions with others in the immediate environment.2–4 Indeed, although condom promotion and condom use are often considered a behavioral component within comprehensive HIV prevention programs, such behavioral components are intrinsically linked and delivered as part of larger structural interventions.5–7 We recognize the limitations of categorizing and grouping vulnerabilities that comprise a nonlinear and complex ecology of risk and the challenges of separating out structural factors, which influence nearly all factors proximally associated with HIV acquisition. Dr. Hodson et al also challenge our use of the term “early sexual debut” and the acronym “adolescent girls and young women (AGYW).” In this article, we are using standard and, as far as possible, deliberately neutral terms and language because we lack the lived experience to contextualize and judge the experiences of the individuals in our survey beyond what was asked of participants in the survey. As Dr. Hodson et al note, these terms are not new, and many others have used the term previously in the HIV literature. We chose to use the term “early sexual debut” only in the context of referencing other researchers' study findings because this was the terminology they had used in their own writings.8–10 For our study and when referencing our findings, we chose to use the term “first sexual experience,” which as Dr. Hodson identifies, is a more neutral term. In our study, as Dr. Hodson et al highlight, a strikingly high proportion of AGYW reported a coerced or forced first sexual experience. The use of a neutral term (first sexual experience) is not meant to minimize the significance of these early first sexual experiences. Our use of the acronym “AGYW” was selected to represent the age of participants in our study, which ranged from ages 14–24 years. The World Health Organization classifies adolescence as individuals between the ages of 10–19 years and young people up to age 24 years.11 Accordingly, we used this definition to reference study participants as AGYW—an acronym commonly used in the national and international literature and public health reports.12–15 In conclusion, we recognize that terminology can be limiting when trying to describe the full experience of AGYW and the context in which they live. However, we hope that the striking numbers presented in our study call attention to the unmet sexual and reproductive health needs of AGYW and can help further shape HIV and sexual and reproductive health programs and policies. Programs designed to reach this young population should be comprehensive in nature and include interventions focused on empowerment and agency.3 As demonstrated in Van Banvel's research, agency among adolescent girls selling sex is more limited as compared to their more mature counterparts. However, despite this, agency is present among adolescent girls, and we should recognize their agency and promote further empowerment.16 Most importantly, as Dr. Hodson et al astutely point out, our findings of a high prevalence of very early vulnerabilities experienced in childhood and adolescence signal the need for structural interventions that can reduce these risks, and we emphasize this need in the discussion of our article.

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