- Women living in sub-Saharan Africa are more affected by HIV/AIDS than any other population in the world. Two-thirds of all new HIV infections worldwide occur in sub-Saharan Africa and over 60% of these infections are in women. Indeed, 70% of
all women globally who are infected with HIV reside in this region (UNAIDS, 2006).
If women are already infected with HIV, unprotected sex puts them at risk of
transmitting the virus to a partner or to an unborn child. It also puts them at risk of
becoming superinfected with different HIV strains, including HIV strains that are
already resistant to HIV drugs (Little et al., 1999; Hecht et al., 1998; Flaks, Burman,
Gourley, Rietmeijer, Cohn, 2003; Kozal et al., 2006). HIV infected women also need
to be concerned with adherence to their antiretroviral therapy (ART) regimen. Lack of
adherence to drug regimens puts women at risk of poor HIV treatment outcomes such
as drug resistance (Chesney, 2003).
When used consistently and correctly, male condoms are the most effective
method of protection against HIV for sexually active persons (Stone, Timyan, Thomas,1999). Women, however, may be unable to negotiate the use of a male condom
because strong gender-based power differentials and conservative social and cultural norms often make this decision completely up to a man (Gupta, 2002; Cohen, 2004).
The constraints on a woman’s ability to reduce her risk have led to concerns about the use of individual based models for HIV/AIDS behavior in women. These models often fail to acknowledge the relationship factors and the social, cultural and economic
contexts that influence women’s behavior.
These concerns with inadequate models of HIV risk reduction for women have resulted in the publication of numerous articles proposing social-structural, also
referred to as structural and environmental, models of HIV/AIDS risk reduction for
women (Parker et al., 2002; O’Leary & Martins, 2000; Parker et al., 2000; Sumartojo,2000; Sweat & Denison, 1995; Decosas, 1996; Farmer, 2003; Turshen, 1998; Tawil et al., 1995; Lurie et al., 2004). This study, therefore, sought to use social-structural variables in exploring women’s HIV-related risk behaviors in a sub-Saharan Africa setting, Uganda, in East Africa.
Although much is known about structural and environmental approaches to HIV prevention among HIV negative women, little is known about the potential application of this approach to studying sexual risk behaviors and adherence to ART among HIV infected women. The overall aim of the study was to examine associations between social-structural variables (e.g., poverty, gender power dynamics) and two outcome variables: history of unprotected sex and self-reported adherence to ART among HIV infected women enrolled in drug therapy programs. Data were collected using structured interviews with 377 HIV infected women in four different HIV/AIDS treatment programs in Kampala and Masaka, Uganda. A major finding of the study was that few women in the sample were sexually active(34%), partly due to the high proportion of non-sexually active widows (49%). The majority of sexually active women reported condom use at last sex act (75%) and
disclosure of their HIV status to a main partner (78%). In multivariate analysis condom use at last sex act was strongly predicted by the need to borrow food to survive (OR=5.440, 95% CI 1.237, 23.923, p<.05), possibly indicating that women engaging in sexual exchange for food are more likely to use condoms. Forced, coercive or survival sex was significantly associated with the number of meals missed per week due to lack of food (OR=1.130, 95% CI 1.125,
1.526, p<.005). In addition, married women compared to unmarried women were three
times more likely to have experienced forced, coercive or survival sex (OR=2.911,
95% CI 1.234, 6.87, p<.05).
Because married women are considered to be relatively more economically stable,
the findings that missing meals due to lack of food and married marital status are both
associated with forced, coercive or survival sex, when adjusted for other factors,
support the conclusion that both impoverished women and women with access to more resources can be at risk. Alternately, married women may not have as ready access to
resources as is usually assumed and could also be engaging in sexual exchange
behavior and borrowing food to get by. In either case, married women are probably more likely than their unmarried
counterparts to experience large gender power differentials, despite their economic
resources, that limit their ability to use condoms. Indeed, for all women in the study,
the structural equation modeling (SEM) model fitting analyses indicated that genderbased
power may be a more important predictor than economic security of women’s
sexual risk behaviors. Neither factor was, however, predictive of ART adherence in
this study sample.
In summary, findings suggested that sexual exchange for food and other assistance
is probably common and likely driven by economic deprivation. On the contrary,
results indicated that sexual exchange is not necessarily linked with risky behaviors
such as lack of condom use. There is evidence of increased risk for married women in the study, especially the risk of forced, coercive or survival sex. The complex
interactions between poverty, hunger, marital status, gender-based power and different HIV/AIDS risk behaviors should be further examined in order to inform the
implementation of HIV/AIDS programs designed for women.