Monica A. Magadi

A multilevel analysis of the determinants of high-risk sexual behaviour in sub-Saharan Africa.

A number of authors have identified multiple concurrent sexual partnerships by both men and women to lie at the root of the HIV/AIDS epidemic in sub-Saharan Africa. This study applies multilevel models to Demographic and Health Survey data collected during 2003-2008 in 20 sub-Saharan African countries to examine the influence of social and cultural context on involvement with multiple sexual partnerships in the region, above and beyond the effects of individual characteristics. The findings provide support for the ecological argument that health behaviours are shaped and determined by societal conditions, in addition to the effects of individual and household characteristics. Involvement with multiple sex partners is most prevalent in societies in which sexual norms are widely permissive and where polygyny is common. Individual autonomy is substantial and attitudes towards sexuality are more liberal among men and women who live in communities in which sexual norms are widely permissive. Men and women who are most likely to have multiple sex partners in the sub-Saharan region are those who initiated sexual activity earlier and those who have the individual attributes (e.g. young age, urban residence, education, media exposure and working for cash and away from home) that bring to them more rights and/or decision-making autonomy, but not necessarily more financial resources and economic security (mostly among women). On the other hand, involvement with multiple partners is determined by cultural norms (i.e. permissive sexual norms) and social change (i.e. mass education, expansion of cash employment). The findings suggest a number of opportunities for more effective policy and programmatic responses to curb the prevalence of multiple partnerships in sub-Saharan Africa.

Onset of sexual activity among adolescents in hiv/aids-affected households in sub-Saharan Africa

This paper examines the effect of orphanhood and HIV status of adults in a household on onset of sexual activity among adolescent girls and boys aged 15-17 years in sub-Saharan Africa. Multilevel logistic regression models were applied to pooled Demographic and Health Surveys data from nineteen countries of sub-Saharan Africa where HIV test data were collected during 2003-2008 from nationally representative samples of men and women of reproductive age. The results highlight increased vulnerability among adolescent boys and girls living in households where an adult is infected with HIV, and adolescent boys who are paternal orphans. On average, adolescent boys and girls living in households where at least one adult is HIV-positive have about 25% higher odds of having initiated sexual activity compared with their counterparts of similar characteristics in households where no adult is HIV-positive. Furthermore, adolescent boys who are paternal orphans have about 25% higher odds of having initiated sexual activity than their non-orphan counterparts of similar individual characteristics. Further analysis reveals that household circumstances relating to living arrangements and poverty are important pathways through which household HIV/AIDS status is linked to adolescent sexual debut. The findings underscore the importance of international efforts in the sub-Saharan Africa region to address the plight of other children in HIV/AIDS-affected households, beyond orphans.

A multilevel analysis of the determinants of HIV testing in Zimbabwe: evidence from the demographic and health surveys

Introduction Zimbabwe is still burdened with HIV epidemic and the government has an ambitious aim in the post-2015 era to end the AIDS epidemic by 2030. To achieve this, the government has set up the 90-90-90 strategic milestones to be achieved by 2020. It is daunting task to increase HIV testing uptake from current estimate of 56%to 90% to meet these targets. The current government’s initiative requires an understanding of determinants of HIV testing. Objectives The specific objectives of this study are to: (i) identify the individual and community-level determinants of HIV testing, focussing on predisposing, enabling and perceived need factors (PREP); and (ii) establish gender differences. Material and Methods We applied multilevel logistic regression models to nationally-representative samples of 17,797women and 14,587 men from the 2005/6 and 2010/11 Zimbabwe Demographic and Health Surveys to examine the determinants of HIV testing. Results HIV testing uptake increased significantly between 2005/6 and 2010/11, especially for women (females OR=5.60; males OR=2.57). Most PREP factors associated with HIV testing are largely consistent with patterns in Southern Africa (e.g. higher uptake by women and those who are wealthier), but unique patterns have also emerged. In particular, results reveal important gender differences: rural residence is associated with lower uptake of HIV testing for women (OR=0.74) but higher for men (OR=1.16); community wealth is a more important factor in enabling HIV testing than household wealth for women, but the converse is true for men; and individual-level, rather than community-level stigma is important for women, while for men, it is community-level stigma that is important. Conclusion Observed gender disparities in determinants of HIV testing calls for gender specific response. Couple-oriented HIV counselling and testing services where men accompany their spouse to HIV screening during pregnancy may help increase HIV testing uptake for males and reduce gender disparities.

Understanding the urban-rural disparity in HIV and poverty nexus: the case of Kenya

Background The relationship between HIV and poverty is complex and recent studies reveal an urban‐rural divide that is not well understood. This paper examines the urban‐rural disparity in the relationship between poverty and HIV infection in Kenya, with particular reference to possible explanations relating to social cohesion/capital and other moderating factors. Methods Multilevel logistic regression models are applied to nationally‐representative samples of 13 094 men and women of reproductive age from recent Kenya Demographic and Health Surveys. Results The results confirm a disproportionate higher risk of HIV infection among the urban poor, despite a general negative association between poverty and HIV infection among rural residents. Estimates of intra‐community correlations suggest lower social cohesion in urban than rural communities. This, combined with marked socio‐economic inequalities in urban areas is likely to result in the urban poor being particularly vulnerable. The results further reveal interesting cultural variations and trends. In particular, recent declines in HIV prevalence among urban residents in Kenya have been predominantly confined to those of higher socio‐economic status. Conclusion With current rapid urbanization patterns and increasing urban poverty, these trends have important implications for the future of the HIV epidemic in Kenya and similar settings across the sub‐Saharan Africa region.

Socioeconomic Status and Vulnerability to HIV Infection in Uganda: Evidence from Multilevel Modelling of AIDS Indicator Survey Data

Background There is controversy on the association between socioeconomic status (SES) and HIV infection. Some evidence claims higher SES is negatively associated with HIV infection while others report the reverse. Objectives To examine the association between SES and HIV infection in Uganda and to examine whether the SES-HIV relationship varies by gender, rural-urban place of residence, and time (2004-2005 and 2011) in Uganda. Methods Multilevel analysis was applied to 39,766 individual cases obtained in 887 clusters of Uganda HIV/AIDS Indicators Survey conducted in 2004-2005 and 2011. Results Household wealth is associated with increased vulnerability in the general population and in rural areas. Compared with no educational attainment, secondary or higher education is associated with reduced vulnerability to the risk of HIV infection by 37% in the general population. However, this effect was stronger in urban than rural areas. Besides individual-level factors, unobserved community factors too play an important role and account for 9% of unexplained variance after individual-level factors are considered. Conclusion Household wealth increases vulnerability but education reduces it. The social environment influences vulnerability to HIV infection independent of individual-level factors. HIV/AIDS awareness targeting sexual practices of wealthy individuals and those with primary-level educational attainment together with improving educational attainment and addressing contextual factors influencing vulnerability to HIV infection are necessary strategies to reduce HIV infections in Uganda.

Multilevel determinants of teenage childbearing in sub-Saharan Africa in the context of HIV/AIDS

Abstract This paper examined national variations and multilevel determinants of teenage childbearing in sub‐Saharan Africa (SSA) in the context of HIV/AIDS using data from recent Demographic and Health Surveys conducted in 29 countries of SSA. Results showed significant community and national variations in teenage childbearing, partly explained by socio‐economic and HIV/AIDS context. At community level, lower HIV/AIDS stigma, higher wealth and female education were associated with lower teenage childbearing. However, national socio‐economic status had an intricate relationship with teenage childbearing. Higher national GDP per‐capita was generally associated with higher teenage childbearing, and this relationship was stronger in lower HIV prevalence countries. HighlightsHigher community wealth and female education are associated with lower teenage childbearing.Evidence of higher teenage childbearing in communities of higher HIV prevalence, testing coverage or HIV/AIDS stigma.Relationship between national GDP per‐capita and teenage childbearing moderated by HIV prevalence.Positive association between national GDP per‐capita and teenage childbearing stronger in lower HIV prevalence countries.

HIV/AIDS and contraceptive use: Factors associated with contraceptive use among sexually-active HIV-positive women in Kenya.

OBJECTIVESnWith increased availability of antiretroviral therapy and improved survival for people living with HIV, more HIV-positive women are leading full reproductive lives. However, HIV-positive women have special contraceptive needs/concerns. This paper examines the individual and community-level HIV/AIDS factors associated with contraceptive use and compares predictors of contraceptive uptake between HIV-positive and HIV-negative women in Kenya.nnnSTUDY DESIGNnThe study is based on secondary analysis of cross-sectional data of a sample of 9132 sexually active women of reproductive age from the Kenya Demographic and Health Surveys collected in 2003 and 2008. Multilevel logistic regression models are used to examine individual and contextual community-level factors associated with current contraceptive use.nnnRESULTSnThe study provides evidence of lower contraceptive uptake among women living in high HIV-prevalence communities. It further reveals striking differences in factors associated with contraceptive uptake between HIV-positive and HIV-negative women. Education and the desire to stop childbearing are strongly associated with contraceptive uptake among uninfected women, but both factors are not significant among HIV-positive women for whom wealth is the most important factor. While HIV-negative women in the richest wealth quintile are about twice as likely to use contraceptives as their counterparts of similar characteristics in the poorest quintile, this gap is about sevenfold among HIV-positive women.nnnCONCLUSIONnThese findings suggest that having the desire and relevant knowledge to use contraceptives does not necessarily translate into expected contraceptive behavior for HIV-positive women in Kenya and that poor HIV-positive women may be particularly in need of increased access to contraceptive services.nnnIMPLICATIONSn• Study provides evidence of lower contraceptive uptake among women living in high HIV-prevalence communities in Kenya. • Results reveal striking differences in factors associated with contraceptive use between HIV-positive and HIV-negative women. • Poverty may be an impediment to contraceptive uptake among HIV-positive women in Kenya.

HIV/AIDS and contraceptive method choice : demographic and socio-economic correlates of contraceptive method choice among HIV-positive women practising family planning in Kenya

Introduction: As the generalized HIV epidemic in specific settings of sub-Saharan Africa continues to evolve, there is need for evidence-based response to address emerging challenges, which include enabling the large number of women living with HIV make informed choices to achieve their reproductive goals. Objectives: This paper seeks to (i) examine the effect of HIV/AIDS on contraceptive method choice among women using contraceptives in Kenya; and (ii) identify correlates of contraceptive method choice among HIV-positive women practising family planning. Material and Methods: We apply multinomial Logistic regression models to a sample of 3190 sexually-active women of reproductive age using contraceptives from the 2003 and 2008 Kenya Demographic and Health Surveys to examine the effect of HIV/AIDS on contraceptive method choice. The analysis of correlates of method choice among HIV-positive women is based on a sample of 255 HIV-positive women using contraceptives and involves bivariate cross-tabulations with Chi-Square tests. Result: Overall association between HIV status and contraceptive method choice is consistent with expected patterns, with women who are HIV-positive being more than twice as likely to use condoms rather than hormonal contraceptives, compared to their counterparts of similar characteristics who are HIV-negative (p<0.05). Among women infected with HIV, those who were previously tested for HIV were more likely to use condoms and less likely to use hormonal methods (p<0.05) than those who had never been tested. The higher use of condoms by HIV-positive women is only evident among those who had previously been tested for HIV. Significant correlates of contraceptive method choice among HIV-positive women include parity, marital status, age group, education and ethnicity. Overall trends suggest a notable shift from use of hormonal methods to condoms by HIV-positive women, but predominant use of hormonal methods (60%) and low use of condoms (23%) by HIV-positive young women aged 15-24 practising family planning is of potential concern. Conclusion: The findings have important implications for family planning policies/programs targeting young women living with HIV and underscore the need to intensify efforts towards improved HIV testing coverage to enable HIV-positive women make informed reproductive choices.