Women's Empowerment and HIV Testing Uptake: A Meta-analysis of Demographic and Health Surveys from 33 Sub-Saharan African Countries

Knowledge and attitude to HIV pre exposure prophylaxis among women in five sub-Saharan African countries: a multilevel model analysis of population-based survey 2021-2022

BACKGROUND

HIV Pre-Exposure Prophylaxis (HIV PrEP) may help reduce the rate of HIV infection among women in sub-Saharan Africa (SSA). This study aimed to assess women's knowledge and attitudes toward PrEP, a crucial component of HIV prevention, using nationwide data. It is the first study of its kind conducted in five SSA countries: Burkina Faso, Ghana, Côte d'Ivoire, Kenya, and Tanzania. The primary objective was to examine women's knowledge and attitudes toward PrEP for the prevention of HIV infection, as well as to explore individual- and community-level factors associated with it.

METHODS

The current study utilized the 2021/22 demographic and health survey datasets from five African nations, namely Burkina Faso, Côte d'Ivoire, Ghana, Kenya, and Tanzania. The analysis was performed using Stata 17. A weighted sample of 77,052 women of reproductive age participated in the survey. Univariate and multivariable multilevel logistic regressions were conducted to assess parameters related to knowledge and attitudes toward PrEP in these countries. In both the univariate regression and the final model, the significance of variables was determined using P values of ≤ 0.2 and < 0.05.

RESULTS

Overall, only about 13.88 (95% CI: 13.64,14.12) of women had knowledge and attitudes toward HIV PrEP. The highest (34.29%) and lowest (5.61%) values were observed for Kenya and Tanzania respectively. Higher rates of knowledge, and attitude toward HIV PrEP among women were independently associated with age 25-34 years old (AOR = 1.52, 95% CI:1.41,1.64), and 35-49 years old (AOR = 1.56, 95% CI:1.43,1.69), primary education level (AOR = 1.79,95% CI:1.65,1.95), and secondary/higher education level (AOR = 2.92, 95% CI: 2.67,3.20), richer (AOR = 1.14, 95% CI:1.02,1.27), and richest (AOR = 1.21, 95% CI:1.06,1.37), employed women (AOR = 1.82, 95% CI:1.65,1.99), had media exposure (AOR = 1.49,95% CI:1.40,1.59),knowledge of modern contraception (AOR = 2.62, 95% CI: 1.94,3.43), had at least one ANC visit (AOR = 1.99, 95% CI:1.47,2.69), gave birth at health institutions (AOR = 1.17, 95% CI: 1.02,1.37), ever had given birth (AOR = 1.53, 95% CI: 1.41,1.66), female household heads (AOR = 1.24, 95% CI:1.17,1.31), rural women (AOR = 0.83, 95% CI: 0.76,0.89). Similarly, women from communities with high ANC coverage (AOR = 1.84, 95% CI: 1.61,2.11), high community mass media exposure (AOR = 1.62, 95% CI: 1.39,1.88), and high community wealth level (AOR = 1.48, 95% CI: 1.30,1.68), and women from the high illiteracy rate community (AOR = 0.71, 95% CI: 0.61,0.82) showed statistically significant associations with the outcome variable in the final model.

CONCLUSIONS

Less than one-seventh of women exhibited knowledge of and positive attitudes toward HIV PrEP. All stakeholders involved in HIV/AIDS prevention and control have recognized the significance of the factors mentioned above. Enhancing maternal health services, such as promoting institutional delivery, contraception, antenatal care (ANC), and women's empowerment, alongside harnessing the power of media and embracing these transformative changes, will contribute to a greater understanding of and more favorable attitudes toward HIV PrEP within the population.

The Association of Women's Empowerment with HIV-Related Indicators: A Pooled Analysis of Demographic and Health Surveys in Sub-Saharan Africa

BACKGROUND

Women's empowerment is an important factor for HIV prevention, but the association with HIV-related indicators has never been quantified. In this study, we examined the association between women's empowerment and selected HIV-related indicators.

METHODS

We used the latest Demographic and Health Surveys that included HIV testing among other biomarkers of 31 countries in sub-Saharan Africa. Empowerment was measured by the Survey-based Women's EmPowERment (SWPER) index and was compared to the HIV-related indicators: HIV status, HIV testing (ever and in the past 12 months), condom use at last high-risk sex, the ability to ask the partner to use a condom, and the ability to refuse sex.

RESULTS

208,947 women were included in the analysis, of whom 100,924 (48%) were considered highly empowered and 21,933 (10%) as lowly empowered. There was no association between empowerment and HIV status (OR = 1.12, 95% confidence interval [CI] 0.98-1.28). Highly empowered women were more likely to have ever been tested for HIV (OR = 1.67, 95% CI 1.60-1.74) but less likely to have been tested for HIV in the past 12 months (OR = 0.92, 95%CI 0.88-0.96). Highly empowered women were more commonly able to ask the partner to use a condom (OR = 1.69, 95% CI 1.63-1.75) and to refuse sex (OR = 1.78, 95%CI 1.72-1.85).

CONCLUSIONS

Women's empowerment does not seem to be linked to HIV status, but it is strongly associated with a woman's ability to make decisions about their sexual behavior. Empowering women and young girls has the potential to contribute toward achieving the United Nations' goal of ending AIDS by 2030.

HIV testing among women of reproductive age in 28 sub-Saharan African countries: a multilevel modelling

BACKGROUND

Human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) remains one of the most significant public health challenges globally, particularly in sub-Saharan Africa (SSA). Although HIV testing is a vital step for both prevention and treatment, its uptake is still low in SSA. We therefore examined HIV testing in SSA and its individual/household and community factors among women of reproductive age groups (15-49 y).

METHODS

Demographic and Health Survey data collected between 2010 and 2020 from 28 SSA countries were used for this analysis. We analysed the coverage of HIV testing and individual/household and community factors on 384 416 women in the reproductive age groups (15-49 y). Bivariate and multivariable multilevel binary logistic regression analysis were conducted to select candidate variables and to identify significant explanatory variables associated with HIV testing and the results were presented using adjusted odd ratios (AORs) at 95% confidence intervals (CIs).

RESULTS

The pooled prevalence of HIV testing among women of reproductive age in SSA was 56.1% (95% CI 53.7 to 58.4), with the highest coverage found in Zambia (86.9%) and the lowest in Chad (6.1%). Age (45-49 y; AOR 0.30 [95% CI 0.15 to 0.62]), women's education level (secondary; AOR 1.97 [95% CI 1.36 to 2.84]) and economic status (richest; AOR 2.78 [95% CI 1.40 to 5.51]) were some of the individual/household factors associated with HIV testing. Similarly, religion (no religion; AOR 0.58 [95% CI 0.34 to 0.97]), marital status (married; AOR 0.69 [95% CI 0.50 to 0.95]) and comprehensive knowledge of HIV (yes; AOR 2.01 [95% CI 1.53 to 2.64]) were significantly associated individual/household factors for HIV testing. Meanwhile, place of residence (rural; AOR 0.65 [95% CI 0.45 to 0.94]) was found to be a significant community-level factor.

CONCLUSION

More than half of married women in SSA have been tested for HIV, with between-country variations. Both individual/household factors were associated with HIV testing. Stakeholders should therefore consider all above-mentioned factors to plan an integrated approach to enhancing HIV testing through health education, sensitization, counselling and empowering older and married women, those with no formal education, those who do not have comprehensive HIV/AIDS knowledge and those in rural areas.

Women's decision-making capacity and its association with comprehensive knowledge of HIV/AIDS in 23 sub-Saharan African countries

BACKGROUND

Globally, Human Immunodeficiency Virus (HIV) that causes Acquired Immunodeficiency Syndrome (AIDS) remains a public health problem with a higher burden in sub-Saharan African countries. Though the coverage is low in sub-Saharan Africa (SSA), comprehensive knowledge about HIV is vital for preventing and controlling the transmission of the virus. Women's decision-making power is significantly linked with the knowledge and use of healthcare services. However, there is no available evidence on women's decision-making capacity and comprehensive knowledge of HIV. Therefore, this study investigated the association between women's decision-making capacity within households and comprehensive knowledge of HIV/AIDS in SSA.

METHODS

We derived data from the 2010 to 2020 Demographic and Health Surveys of 23 sub-Saharan African countries for the analysis. Using Stata version 14, both bivariate logistic regression and multivariate multilevel logistic regression analyses were used to examine the association between women's decision-making capacity and comprehensive knowledge of HIV/AIDS at p ≤ 0.05. Results were reported using adjusted odds ratios (aOR) with their respective 95% confidence interval (CI).

RESULTS

The pooled results show that comprehensive HIV/AIDS knowledge among married women in the studied countries was 35.5%, from 18.3% in Chad to 77.1% in Rwanda. Regarding sub-regional distribution, comprehensive knowledge of HIV/AIDS in Southern Africa was 73.2%, followed by East Africa (52.4%), West Africa (43.6%), and Central Africa (35.5%). The study showed higher odds of comprehensive knowledge of HIV/AIDS among married women who had decision making power (yes-aOR = 1.20, 95% CI; 1.16-1.25) compared to those who had no decision-making power. Age, women and partner's level of education, place of residence, exposure to media, HIV testing status, community socio-economic status, parity, religion, and distance to health facilities also had significant association with comprehensive HIV/AIDS knowledge.

CONCLUSIONS

Comprehensive knowledge of HIV/AIDS in SSA is low but varies per country. Married women with decision-making capacity were more likely to have comprehensive knowledge of HIV compared to those with no decision-making capacity. Therefore, comprehensive knowledge of HIV/AIDS can be increased through enhancing women's decision-making capacities, strengthening employment opportunities, socioeconomic capacities and creating awareness through media. Moreover, improving access to health care facilities working closely with religious leaders, can be considered to increase coverage of comprehensive knowledge of HIV among married women in SSA.

Between a Rock and a Hard Place: How poverty and lack of agency affect HIV risk behaviors among married women in 25 African countries: A cross-sectional study

Background

Gender inequality and poverty exacerbate the burden of HIV/AIDS among women in Africa. AIDS awareness and educational campaigns have been inadequate in many countries and rates of HIV testing and adherence to condom use remains considerably low, especially among married women. We investigate whether higher HIV knowledge is equally effective in lowering risky behaviors among groups of women with different levels of wealth and agency.

Methods

Pooled data on 113 151 adult married women from Demographic and Health Surveys (DHS) in 25 African countries was used (2010 to 2016). Agency was defined as women’s ability to refuse sex and ask her partner to use a condom, plus have a role in decision making in household spending and health-related issues. The lowest tertile of DHS wealth index defined poverty. Questions about HIV prevention and mother-to-child transmission were used to create a scale for knowledge (0-5). Use of condom, HIV testing, absence of sexually transmitted disease (STD), and having one partner were dependent variables. Regression models investigated the effect of agency and knowledge as predictors of behaviors. Separate additional models were run to measure associations of each behavior with knowledge scores on groups of women divided by agency and poverty. Analyses were adjusted for demographic factors, history of pregnancy, wife-beating attitude, and country dummies.

Results

Significantly higher risk and lower level of protective factors exist for poor women who lack agency. Knowledge had positive associations with a better score in behavior, higher rate of condom use and testing for HIV both among poor and not poor women. When examining compound effects of agency and poverty, absence of agency reduces the positive effect of knowledge on lowering STD rate and overall behavior score among poor women. It also nullifies the effect of knowledge on condom use in both wealth groups.

Conclusion

Knowledge of HIV does not exert its potential protective effect when women live in poverty compounded with lack of agency. Success of anti-HIV programs should be tailored to dynamics of risk and sociocultural and economic context of target populations.