Do Risky Sexual Behaviors Mediate the Association Between Non-Consensual First Sex and HIV Among a National Sample of Sexually Active Women in Lesotho?

Sexual violence, especially non-consensual first sex (NCFS) has profound impact on women's risk to HIV infection, a link that can be partly explained by subsequent risky sexual behavior (RSBs) later on in life and yet has been limitedly explored. Using a national sample of 4286 women aged 15 to 49 years from Lesotho Population-based HIV Impact Assessment, we explored the mediation effect of RSBs on the association between history of NCFS and HIV infection among women in Lesotho. We first employed multivariate logistic regression to estimate the associations between NCFS and HIV infection; and then used generalized structural equation modeling (GSEM) to determine the mediation effect of RSBs (casual sex, multiple sexual partners and condom use) on this association, while adjusting for cluster sampling design of the survey. About 16.8% of the women had a history of NCFS, and logistic regression results showed a significant positive association between NCFS and HIV positive status (AOR: 1.24; 95% CI [1.02, 1.49]). From the GSEM, all the RSBs were significant mediators of the link between NCFS and HIV positive status; whereby casual sex (AOR: 1.17; 95% CI [1.00, 1.35]) and multiple sexual partners (AOR: 1.91; 95% CI [1.81, 2.02]) were full mediators, while condom use (AOR: 0.91; 95% CI [0.89, 0.92]) showed partial mediation. Multiple lifetime partners showed to have highest total mediation effect (AOR: 2.13; 95% CI [1.84, 2.41]). The results indicated that NCFS is linked to HIV infection indirectly through RSBs. Therefore, HIV prevention interventions targeting victims of NCFS would greatly contribute in reducing risk of HIV infections among women in Lesotho.