Sexual health indicators among young adults living with perinatally-acquired HIV in france, a gender-stratified comparison with their peers in the general population

Abstract

Background

Comprehensive understanding of sexual health among young adults living with perinatally-acquired HIV (PHIV) is needed. We compared sexual health indicators among PHIV adults aged 18 to 25 and their peers in France, using a gender-stratified analysis.

Methods

Data were drawn from baseline questionnaires of 284 PHIV participants in the ANRS-COVERTE-CO19 cohort, enrolled from 2010 to 2015, and from the Baromètre Santé surveys (BS), nationally representative cross-sectional surveys conducted in 2010 and 2016 (BS10 N = 2,899 and BS16 N = 1,633 respectively). For each sexual health indicator, standardized rates among PHIV participants were compared with the pooled weighted rates for their peers from the general population. Where indicators differed, logistic regression was performed to assess associations between these indicators and three HIV-specific variables. Analyses were carried out separately by gender.

Results

PHIV participants showed similar results for current romantic relationship, previous sexual experiences, same-sex sexual partners, age at first intercourse, and condom use at first sexual intercourse were also similar. Prevalence for use of means to avoid pregnancy was lower among PHIV participants of both genders. PHIV women were less likely to report a satisfactory sex life (86% vs. 94%) and more likely to report voluntary abortion (16% vs. 12%). HIV disclosure was associated with a higher likelihood of reporting current romantic relationship in women (aOR 4.40 [1.94–9.95]) and satisfactory sex life in men (aOR 4.68 [1.29–17.04]).

Conclusions

PHIV participants demonstrated similar results regarding most of the sexual health outcomes. However, PHIV women reported less sex life satisfaction and more voluntary abortion.

Trial registration

The COVERTE study received approval from the CPP III (n°2738). For the BS surveys, the CNIL approved each survey (n°915589).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-025-24542-x.

Introduction

In France, national HIV incidence and undiagnosed HIV prevalence were estimated to be 0.17‰ (or 6607 adults) and was 0.64‰ (or 24,197 adults) in 2014 [1, 2] with the highest incidence occurring in men who have sex with men [2]. Implications of living with HIV are multiple, such as “lifelong integration of care”, stigma, and discrimination [3]. For children and adolescents, the latest French data available indicated that around 1500 children were living with perinatally acquired HIV (PHIV) in 2012 [4] and that 581 children under 15 years of age were newly diagnosed with HIV from 2010 to 2021, most of them born in sub-Saharan Africa [5]. As these children reach adolescence, they face particular challenges in their sexual and romantic relationships, such as the fact that they are carriers of a sexually transmitted disease [6–9]. Findings from two large cross sectional studies in Uganda among PHIV adolescents in 2008 and 2014, showed that one third to half of them were currently in a relationship, one third have had sexual intercourse, around one third reported consistent condom use, and more than two thirds of them who intend to have children in the future [10, 11]. Transitioning to adulthood holds challenges as they move to adult healthcare services [12], while achieving academic and professional milestones [13] and developing intimate relationships [14, 15] with critical decisions around disclosure of their HIV status to be made [16, 17]. Most of the studies that have compared sexual health indicators among PHIV young individuals and their peers take place in the United States, have focused on adolescents rather than young adults, with indicators such as having already had sex, age at first intercourse, and condom use [18]. Lower or similar prevalence of sexual intercourse was found among PHIV participants compared to their peers [19–22]. The mean age at first sexual intercourse was similar [19–22], as were the proportions of people who had engaged in sexual intercourse with a condom over their lifetime [19, 22]. Few studies have compared indicators such as contraceptive use [20, 22, 23], pregnancy [20, 22–24], and one study reported comparative data on romantic life [21]. To our knowledge, there is no comparative data among PHIV young adults on abortion, and sex life satisfaction. Yet, we need data on many sexual health indicators to appropriately address sexual health among PHIV young individuals [25].

Our objectives were twofold: first, to compare sexual health indicators collected between 2010 and 2016 of PHIV young adults living in France to those for their peers in the French general population with a gender-stratified analysis; second, in same temporal and geographic context, to study whether characteristics specific to living with HIV were associated with these sexual health indicators.

Methods

Study design

In order to compare PHIV participants to their peers in the general population, we used baseline data from the ANRS COVERTE-CO19 cohort (COVERTE) (N = 284) and data Baromètre Santé surveys (BS), as identical or very similar questions were used. Since PHIV participants were included for the 2010–2015 period, we used data from both 2010 BS survey (N = 2,899 18 to 25-year-old participants) and 2016 BS survey (N = 1,633 18 to 25-year-old participants).

Data sources and study population

The participants included in the COVERTE study (N = 284) were recruited from 2010 to 2015 in 64 public hospital pediatric and adult units in France. Inclusion criteria were: age 18 to 25 years at inclusion, diagnosis with HIV before 13 years of age, affiliation to a social security system, signed consent form. Only data from self-administered questionnaires at inclusion were used for this study.

The Baromètre Santé surveys (BS) are regular, national, cross-sectional telephone surveys, conducted on a representative sample by the French Public Health Agency [26]. Data assessing health knowledge, behaviors including sexuality and socio-demographic characteristics were collected in the BS surveys via computer-assisted telephone interview procedures. Sampling weights were computed to take into account the unequal probability sampling design, with a post-stratification approach to adjust for age, gender, educational level, size of residential area (and number of inhabitants in the household for BS16). For BS10, data were post stratified for the national census of 2008. For BS16, data were post stratified for the national census of 2012.

Methods of the COVERTE study and the Baromètre Santé surveys are described in more detail in supplementary material 1 (S1). Flow chart is demonstrated in Fig. 1.

Fig. 1.

Flow chart of PHIV participants and their peers from the general population

Characteristics and sexual health indicators

Characteristics

Five demographic variables were collected: gender with two possible answers (male or female), age, education, living with partner and country of birth (mainland France or not).

Sexual health indicators

Current romantic relationship

Participants were asked whether they currently had a girlfriend/boyfriend/spouse(COVERTE study and BS16 survey) or whether there was someone with whom they currently had a steady romantic relationship (BS10 survey). Participants were not asked whether they were engaging in sexual activity outside their current romantic relationship.

Previous sexual intercourse

Participants were asked whether they ever had sexual intercourse during their life.

Age at first intercourse

If they ever had sexual intercourse, participants were asked at what age.

Condom use at first intercourse

Participants were asked: “Was a condom been used? “, with answers being dichotomized.

Means to avoid pregnancy at first intercourse

In another separate question, participants of both genders were asked the same question: “Was any means been used to prevent pregnancy? “ and if they had, what mean(s) have been used (condoms being a possible response). Sexual orientation was not assessed.

Pregnancy and voluntary abortion

Female participants were asked whether they had ever been pregnant and whether they had ever had a voluntary abortion.

Satisfactory sex life

Answers to the question “How would you describe your sex life?” were dichotomized into satisfactory (very satisfactory and somewhat satisfactory) or not (not very satisfactory and not satisfactory at all).

Sexually active

Participants were asked whether they had had sexual intercourse in last month.

Same-sex sexual partner 

Participants were asked whether they had had a same-gender sexual partner at least once in their lifetime.

Exposure and counfouders

Exposure

For the first objective comparing indicators of sexual health among PHIV to those among their peers in the general population, the main exposure was living with perinatally acquired HIV or not.

For the second objective studying the association between certain sexual health indicators and HIV-specific exposures (among PHIV participants), we focused on self-reported current HIV viral load status (undetectable or not), disclosure of HIV status to partner(s) (“never” if no disclosure to any current or former partner, whether romantic or sexual partner, or “yes” if at least once), and history of having previously experienced HIV-related stigma (yes or no).

Confounders

For the first objective, six demographic variables were taken into account: gender (male or female), age (18–21 years or 22–25 years), educational level (completed high school diploma or not), perceived financial situation, living with partner or not, and country of birth (mainland France or not).

For the second objective, potential confounders were taken into account using the following binary variables: own accommodation (‘living with friends or own home, or student accommodation”) or not (“living with parents or family, or living with a foster family, living in a shelter home, or therapeutic apartment”); perceived financial situation as comfortable (“comfortable or going well”) or not (“you have to be careful or you find it hard to manage or you can’t manage without going into debt”); distressing family events (parental separation/divorce or illness of the mother/father, disability or serious accident or death of the mother/father death, or other significant family event) or not; at suicidal risk (whether they had thought about or attempted suicide in the last 12 months) or not.

Analysis strategy

All analyses were performed on STATA version 17.0 [27], separately for women and men, and using the survey options with the sampling weights taken into account. All tests were two-sided with a type-1 error set at 5%.

For the first objective, national prevalence of each sexual health indicator was estimated from the two pooled BS surveys, taking into account the sampling weights of each survey. Prevalence of each sexual health indicator for PHIV participants was estimated in the COVERTE study using direct standardization based on the distribution of age of the pooled BS surveys (18–21 years or 22–25 years). To compare the prevalence of each sexual health indicator according to PHIV status, multivariate logistic regression models were run using each sexual health indicator as a dependent variable and PHIV status as the main exposure, adjusted only for age at first (p* in Table 2), then adjusted for educational level, living with partner, financial situation, and country of birth (p** in Table 2). Sexual health indicators associated with PHIV status with a p-value below 0.20 and including at least ten events per variable were the only indicators considered for further analyses in the second objective.

Table 2.

Comparison of sexual health indicator prevalence among PHIV young adults (baseline data from the COVERTE study) and their peers from the general population (BS surveys), using direct standardization and multivariate logistic regression

	Women				Men
	PHIV N = 154	Without HIV N = 2,301			PHIV N = 130	Without HIV N = 2,231
	Std % [95%CI]a	% [95%CI]b	p*	p**	Std % [95%CI]a	% [95%CI]b	p*	p**
Current romantic relationship	58 [49–65]	64 [62–66]	0.33	0.39	42 [33–51]	52 [49–54]	0.19	0.60
Previous sexual intercourse	82 [75–87]	85 [83–87]	0.48	0.67	83 [76–89]	87 [86–89]	0.55	0.50
First intercourse :
Mean age***	17.4 [17.1–17.7]	16.9 [16.8–17.0]	0.08		16.3 [15.9–16.7]	16.3 [16.2–16.4]	0.63
Condom use	93 [86–97]	87 [84–89]	0.06	/c	94 [87–97]	87 [86–89]	0.15	/c
Means to avoid pregnancy	76 [67–82]	89 [87–91]	< 0.01	0.34	71 [61–79]	90 [88 − 981]	< 0.01	0.11
Pregnancy	27 [19–36]	26 [23–29]	0.70	< 0.01
Voluntary abortion	16 [11–25]	12 [10–15]	< 0.01	< 0.01
Satisfactory sex life	86 [79–92]	94 [91–95]	0.01	0.05	82 [73–89]	88 [85–91]	0.12	0.15
Sexually active	75 [67–82]	66 [62–70]	0.06	0.33	57 [47–66]	61 [57–65]	0.46	0.29
Same-sex sexual partner	5 [3–11]	6 [5–7]	0.91	/c	4 [1–9]	4 [3–5]	0.80	/c

PHIV Living with perinatally acquired HIV, BS Baromètre Santé, COVERTE ANRS COVERTE-CO19 cohort, CI Confidence interval, Std Standardized, p p value, ND No data

^aPrevalences were standardized for age distribution of the two Baromètre Santé surveys

^bProportions were weighted to take into account the sampling design (unequal inclusion probabilities) and post-stratification to adjust for age, gender, educational level, size of residential area (and number of inhabitants in the household for 2016 BS survey)

^cNumbers were too small for further analysis

^*Using multivariate logistic regression adjusted on age distribution (Coverte vs the two pooled BS surveys) for categorical variables, using Student t-tests for continuous variables

^**Using multivariate logistic regression adjusted on (Coverte vs the two pooled BS surveys): age distribution, education level, living with partner, financial situation, born in mainland France

^***Using Student test

For the second objective, only data from PHIV participants were used. A multivariable logistic regression model was run for each sexual health indicator selected in the first objective to study its associations with the three HIV-specific exposures (self-reported HIV viral load status, disclosure of HIV status to partner(s) and experiences of HIV-related stigma), adjusted for age and the potential confounding factors described above whenever a p-value < 0.20 was found for their association with the indicator in univariate analyses. As for some indicators, the ratio of the number of events per independent variables in the multivariate model ranged from five to ten [28], exact logistic regression models were also run as sensitivity analysis [29]. Missing values in covariates (up to 12%) were handled using multiple imputations by chained equation with 5 imputed datasets [30].

Ethics declarations

The COVERTE study received approval from the Ethics Committee of Ile de France III (n°2738). For the BS surveys, the French National Commission for Computer Data and Individual Freedom (CNIL) approved each survey (n°915589). This research adhered to the Declaration of Helsinki. Informed consent was obtained from all individual participants included in the study.

Results

Participants characteristics

Socio-demographic characteristics are presented in Table 1. PHIV participants’ complete data are described in supplementary material 2 (S2).

Table 1.

Baseline characteristics of PHIV young adults (baseline data from the COVERTE study) and standardized comparison with their peers from the general population (BS surveys)

	Young women			Young men
	PHIV N = 154		Without HIV N = 2,301	PHIV N = 130		Without HIV N = 2,231
	% [95%CI]	Std % [95%CI]a	% [95%CI]b	% [95%CI]	Std % [95%CI]a	% [95%CI]b
Aged 18–21 years (among 18–25)	60 [52–68]	52	52 [49–54]	60 [51–68]	52	52 [50–55]
Completed high school diploma	53 [45–60]	55 [47–62]	65 [62–67]	41 [33–49]	42 [34–51]	55 [52–57]
Living with partner	20 [14–27]	22 [16–29]	27 [25–29]	11 [6–17]	12 [7–19]	18 [16–20]
Born in mainland France	69 [62–76]	70 [63–77]	90 [88–92]	67 [59–75]	68 [60–76]	90 [88–91]
Uncomfortable financial situation	53 [45–61]	53 [45–61]	36 [34–38]	55 [46–64]	54 [45–63]	34 [32–36]
Has own accomodation	34 [26–42]			28 [20–36]
Distressing family events	87 [80–91]			76 [68–83]
At suicidal risk	26 [20–34]			13 [8–20]
Detectable viral load, self-reported	39 [31–47]			29 [22–39]
HIV status disclosure to partner(s)	57 [49–65]			54 [44–63]
Experience of HIV-related stigma	33 [26–41]			23 [16–31]

PHIV Living with perinatally acquired HIV, BS Baromètre Santé survey, COVERTE ANRS COVERTE-CO19 cohort, CI Confidence interval, Std Standardized

^aProportions were standardized for age distribution of the two Baromètre Santé surveys, using mean standardized weights per standard strata

^bProportions were weighted to take into account the sampling design (unequal inclusion probabilities) and post-stratification to adjust for age, gender, educational level, size of residential area (and number of inhabitants in the household for the 2016 BS)

First objective: comparison of sexual health indicators prevalence (Table 2)

After standardization for age distribution, although PHIV participants of both genders exhibited similar prevalence for condom use at first sexual intercourse, and lower prevalence of using means to avoid pregnancy at first sexual intercourse. However, this difference was not significant after further adjustment on education level, living with partner, financial situation, and born in mainland France.

PHIV women were more likely to report voluntary abortion and less likely to describe their sex life as satisfactory. These differences remained significant after further adjustment. PHIV men tended to report poorer sex life satisfaction than their peers.

Second objective: associations between sexual health indicators and HIV-specific variables, among PHIV participants (Table 3)

Table 3.

Association between sexual health indicators and three HIV-specific experiences among PHIV participants in the COVERTE study at baseline using multivariable logistic regression

	Romantic relationship		Satisfactory sex life		Sexually active
	PHIV young women (N = 150)	PHIV young men (N = 121)	PHIV young women (N = 119)	PHIV young men (N = 94)	PHIV young women (N = 123)	PHIV young men (N = 104)
	aOR [95% CI]	aOR [95% CI]	aOR [95% CI]	aOR [95% CI]	aOR [95% CI]	aOR [95% CI]
Detectable viral loada	1.97 [0.93–4.43]	1.10 [0.45–2.78]	1.27 [0.52–2.76]	0.52 [0.27–1.65]	0.79 [0.31–1.98]	1.20 [0.44–3.29]
HIV disclosure	4.40 [1.94–9.95]	2.24 [0.96–5.24]	2.14 [0.85–5.35]	4.68 [1.29–17.04]	3.06 [1.09–8.57]	0.63 [0.26–1.54]
HIV-related stigma	0.54 [0.24–1.27]	0.83 [0.31–2.20]	1.08 [0.45–2.63]	1.48 [0.43–5.10]	0.52 [0.19–1.46]	0.86 [0.27–2.72]

Adjustment for age, educational level, perceived financial situation,distressing family event, own accommodation and mental health

AOR Adjusted Odds Ratio, CI Confidence Interval, PHIV Living with perinatally acquired HIV

^aDetectable viral load was self-reported

Three sexual health indicators were selected: romantic relationships, sex life satisfaction, and sexually active.

Among PHIV women, having disclosed their HIV status to a partner was associated with a greater likelihood of a current romantic relationship and a greater likelihood of being sexually active. Among PHIV men, having disclosed their HIV status to a partner was also associated with a greater likelihood of sex life satisfaction.

Results using exact multivariate logistic regression provided similar results. Numbers of participants in each modality of the sexual health indicators and of the HIV specific experiences among PHIV participants are shown in supplementary material (S3).

Discussion

Our study is one of the few studies outside the USA with comprehensive comparative data on various sexual health indicators among PHIV young adults compared to their peers in the general population [18]. PHIV participants demonstrated similar results regarding most of the sexual health outcomes. However, although reporting of condom use at first sexual intercourse was similar, PHIV participants were less likely to report use of means to avoid pregnancy at first sexual intercourse. Furthermore, PHIV women were more likely to report voluntary abortion, and less likely to report a satisfactory sex life. Multivariate analysis showed that PHIV participants who ever disclosed their HIV status to a partner were more likely to report a current romantic relationship, and among men, to report a satisfactory sex life.

We were surprised to observe that although condom use was similar at first sexual intercourse, PHIV participants in our study were less likely to report use of means to avoid pregnancy. One explanation might be that they considered condom as a means of contraception. Birungi et al. reported that 57% of PHIV young adults reported male condom as contraception [31]. Another explanation might be that, unlike their peers, one of PHIV adolescents’ main concern was to prevent HIV transmission, as suggested by some findings of qualitative studies [8, 17]. Further studies should explore the link between viral load status and the use of means to avoid pregnancy, as well as PHIV participants’ level of concern regarding pregnancy and regarding HIV transmission, now that the awareness of the Undetectable = Untransmittable (U = U) slogan [32] has potentially increased [8, 17, 33]. Indeed PHIV participants were included from 2010 to 2015 (before the U = U slogan) and may not have all been aware that “those who are virally suppressed cannot transmit the virus to others” even without condoms [34].

We observed gendered differences. Unlike men, PHIV women reported lesser sex life satisfaction than their female peers and more abortions. Another cross-sectional study conducted in United Kingdom among PVIH young women reported high rates of pregnancy terminations [35]. As suggested by a recent review, these differences could be understood through the lens of intersectionality [25]. This concept was described by Crenshaw in the late 80s as a way of understanding how power is distributed [36]. Looking closer at our female PHIV participants’ characteristics, they are at the intersection of being young, being women and living with HIV since childhood and, as Watkins-Hayes said, “the resulting reduced social and economic power limits their abilities to dictate the terms of sexual relationships” [37].

We found a positive association between HIV disclosure and current romantic relationship in both genders. One explanation might be that a loving relationship facilitates disclosure or that disclosure leads to romantic relationship when it has not resulted in rejection. But the relationship might also be reversed, with some PHIV participants postponing romantic relationship in order to avoid disclosure and protect themselves from stigma and rejection, as reported by some qualitative studies [38, 39]. Our study did not explore whether PHIV young adults would differ from their peers in the general population regarding casual sexual relationships; this could be an area of future research.

Some limitations need to be considered when interpreting our results. Firstly, the data collection methods were different between the two studies: PHIV participants were interviewed using a self-administered-questionnaire versus computer-assisted telephone interviews among their peers of the general population. Social desirability may have biased responses in the BS surveys. Nevertheless, we used the answers to very similar questions across the three surveys, maximizing comparability for our selected sexual health indicators. Secondly, standardization on age may be insufficient to take into account discrepancies between our two populations that could account for the observed differences concerning sexual health outcomes. For instance caregiver HIV status could influence the way sexuality is addressed within the family [39], as could AIDS orphanhood, which has been reported to be associated with increased sexual vulnerability among teenage women in Zimbabwe [40]. However, very few studies have compared sexual indicator prevalence among PHIV young adults and among their peers from the general population [21]. In addition, our analyses among PHIV participants considered some of these factors, for instance distressing family events or perceived financial situation. Thirdly, although PHIV participants’ data in this study were drawn from the largest multicenter cohort in France and were compared to a large sample of peers surveyed over the same period, the sample size remained limited, which may have prevented us from establishing certain associations. However, our results provide new insights into PHIV sexual health and confirm earlier findings. Fourthly, our data were not representative of all PHIV participants in France limiting the generalization of the results to all PHIV young adults living in France. Samwise data were collected in France, limiting generalization of the results to other regions. But we have provided comparative data on sexual health variables rarely reported in the literature. Finally, data were collected between 2010 and 2016, which may impact the generalizability of the findings to the present day. However, key aspects of their living conditions remain unchanged (e.g., migration, bereavement) as well as their behavior (e.g. use of means to avoid pregnancy at first sexual intercourse, voluntary abortion, or a satisfactory sex life), even after the emergence of the U = U slogan [34]. Moreover, some of our findings (e.g., lower sexual satisfaction) align with those of a French qualitative study conducted in 2022 [17], suggesting that certain factors shaping their experiences and decisions may persist over time.

Conclusion

Compared to their peers of the general population, PHIV participants living in France exhibited similar results concerning most of the studied sexual health indicators. However, PHIV participants of both genders were less likely to report means to avoid pregnancy at first sexual intercourse. There were gendered differences with PHIV young women reporting less sex life satisfaction and more voluntary abortion than their peers. To effectively meet the sexual health needs of PHIV young adults, we suggest that sexual health education programs target unwanted pregnancies and address the effects of intersectionality among PHIV young women.

Abbreviations

AIDS

Acquired Immunodeficiency Syndrome

ANRS

Agence Nationale de Recherche sur le SIDA, les hépatites virales et les maladies infectieuses émergentes

BS

Baromètre Santé

BS10

2010 Baromètre Santé survey

BS16

2016 Baromètre Santé survey

HIV

Human Immunodeficiency Virus

PHIV

living with Perinatal HIV Infection

Authors’ contributions

Nour Ibrahim: Conceptualization; Project Administration; Data curation; Formal analysis; Software; Investigation; Writing –original draft; Writing – Review & Editing; Visualization.Jean Bouyer: Conceptualization; Methodology; Supervision; Formal analysis; Visualization; Writing – review & editingCatherine Dollfus: Validation; Visualization; Writing – review and editing Jean-Paul Viard: Writing – review & editing Albert Faye: Writing – review & editing.Veronique Reliquet: Writing – review & editing.Cédric Arvieux: Writing – review & editing.Josiane Warszawski: Funding acquisition; Data curation; Conceptualization; Methodology; Supervision; Formal analysis; Visualization; Writing – review & editing.Alexandra Rouquette: Funding acquisition; Conceptualization; Methodology; Supervision; Formal analysis; Visualization; Writing – review & editing.

Funding

The ANRS COVERTE-CO19 cohort was supported by the ANRS Mie (Agence Nationale de Recherche sur le SIDA et les maladies infectieuses émergentes) [Award number: ANRS COVERTE-CO19; Grant Recipient: CESP INSERM U1018].

This work was supported by La Fondation pour la Recherche Médicale (FRM) [grant number FDM202006011199 to N.I.]. The first author received the FRM funding for her three-year PhD program.

Data availability

Data collected from the ANRS-COVERTE-CO19 cohort (deidentified participant data) can be made available after approval of a proposal addressed to the principal investigator ([josiane.warszawski@inserm.fr](mailto: josiane.warszawski@inserm.fr)). Data collected from the Baromètre Santé surveys (BS) are already available (deidentified participant data and data dictionary) upon request from Dr Delphine Rahib ([delphine.rahib@santepubliquefrance.fr](mailto: delphine.rahib@santepubliquefrance.fr)).

Declarations

Ethics approval and consent to participate

The COVERTE study received approval from the Ethics Committee of Ile de France III (n°2738). For the BS surveys, the French National Commission for Computer Data and Individual Freedom (CNIL) approved each survey (n°915589). This research adhered to the Declaration of Helsinki.

Informed consent was obtained from all individual participants included in the study.

Competing interests

The authors declare no competing interests.