Social and structural vulnerability to HIV infection in Uganda: A multilevel modelling of AIDS indicators survey data, 2004-2005 and 2011

Introduction: Sub Saharan Africa (SSA) continues to exhibit inequalities in HIV epidemic. As of 2017, about 69.5% of people living with HIV, 64% of new infections and 73% HIV-related deaths were in SSA. Most HIV research conducted in the continent has focused on individual-level factors. Objectives: This research identifies social and structural factors that increase vulnerability to HIV; and estimates the effect of community-level factors in increasing vulnerability to HIV infection. Methods: Multilevel binary logistic regression is applied to 39,766 individual cases with HIV test results obtained in 887 clusters of Uganda HIV/AIDS Indicators Survey conducted in 2004-2005 and 2011. Findings: After controlling for individual-level factors, living in a community with a higher proportion of wealthy households (Average Odds Ratio=1.07, CI [1.03–1.11], with more former married individuals (AOR=1.21, CI [1.09–1.33]), with a higher proportion of people drunk with alcohol before unsafe sex (AOR=1.11, CI [1.05–1.18]), and living in a community where a higher proportion of people believe it is okay for a woman to ask her sexual partner to use a condom (AOR=1.08, CI [1.02–1.15]) was significantly associated with being HIV positive. However, living in a community where a higher proportion of men practiced polygamy was associated with reduced vulnerability to the risk of HIV infection (AOR=0.91, CI [0.85–0.98]). Conclusion: Community factors influence vulnerability to the risk of HIV infection in Uganda. Immediate efforts to prevent HIV infection need to focus on community awareness about the influence of these factors, and long-term efforts need to address the broader determinants of these practices.

[1]  M. Magadi.  Understanding the urban‐rural disparity in HIV and poverty nexus: the case of Kenya , 2016, Journal of public health.

[2]  E. Dumbili,et al.  The Politics of Alcohol Policy in Nigeria: A Critical Analysis of How and Why Brewers Use Strategic Ambiguity to Supplant Policy Initiatives , 2014 .

[3]  S. Kapiga,et al.  Systematic review and meta-analysis: prevalence of alcohol use among young people in eastern Africa , 2014, Tropical medicine & international health : TM & IH.

[4]  Suzanna C. Francis,et al.  Factors Associated with Problem Drinking among Women Employed in Food and Recreational Facilities in Northern Tanzania , 2013, PloS one.

[5]  L. Bekker,et al.  Changing patterns in HIV/AIDS stigma and uptake of voluntary counselling and testing services: The results of two consecutive community surveys conducted in the Western Cape, South Africa , 2013, AIDS care.

[6]  D. Durevall,et al.  Economic Inequality and HIV in Malawi , 2012 .

[7]  M. Magadi.  The Disproportionate High Risk of HIV Infection Among the Urban Poor in Sub-Saharan Africa , 2012, AIDS and Behavior.

[8]  G. Reniers,et al.  Polygyny, Partnership Concurrency, and HIV Transmission in Sub-Saharan Africa , 2012, Demography.

[9]  A. Gibbs,et al.  Combined structural interventions for gender equality and livelihood security: a critical review of the evidence from southern and eastern Africa and the implications for young people , 2012, Journal of the International AIDS Society.

[10]  J. Seeley,et al.  Addressing the structural drivers of HIV: a luxury or necessity for programmes? , 2012, Journal of the International AIDS Society.

[11]  J. Parkhurst.  HIV prevention, structural change and social values: the need for an explicit normative approach , 2012, Journal of the International AIDS Society.

[12]  Ashley M. Fox.  THE HIV–POVERTY THESIS RE-EXAMINED: POVERTY, WEALTH OR INEQUALITY AS A SOCIAL DETERMINANT OF HIV INFECTION IN SUB-SAHARAN AFRICA? , 2012, Journal of Biosocial Science.

[13]  D. Antai,et al.  Traumatic physical health consequences of intimate partner violence against women: what is the role of community-level factors? , 2011, BMC women's health.

[14]  J. Parkhurst,et al.  Addressing social drivers of HIV/AIDS for the long-term response: Conceptual and methodological considerations , 2011, Global public health.

[15]  M. Magadi,et al.  A multilevel analysis of the determinants and cross-national variations of HIV seropositivity in sub-Saharan Africa: Evidence from the DHS☆ , 2011, Health & place.

[16]  I. Obot,et al.  Botswana alcohol policy and the presidential levy controversy. , 2011, Addiction.

[17]  S. Zondo,et al.  Why do some South African ethnic groups have very high HIV rates and others not? , 2011, African journal of AIDS research : AJAR.

[18]  S. Ennett,et al.  It's not just who you are but where you live: an exploration of community influences on individual HIV status in rural Malawi. , 2011, Social science & medicine.

[19]  Michael Emch,et al.  Spatial and socio-behavioral patterns of HIV prevalence in the Democratic Republic of Congo. , 2010, Social science & medicine.

[20]  Susan Watkins,et al.  Polygyny and the spread of HIV in sub-Saharan Africa: a case of benign concurrency , 2010, AIDS.

[21]  R. Mikolajczyk,et al.  Time Trends and Regional Differences in the Prevalence of HIV Infection Among Women Attending Antenatal Clinics in 2 Provinces in Cameroon , 2009, Journal of acquired immune deficiency syndromes.

[22]  O. Uthman,et al.  Bmc International Health and Human Rights Factors Associated with Attitudes towards Intimate Partner Violence against Women: a Comparative Analysis of 17 Sub-saharan Countries , 2008 .

[23]  N. McGrath,et al.  Trends in marriage and time spent single in sub-Saharan Africa: a comparative analysis of six population-based cohort studies and nine Demographic and Health Surveys , 2009, Sexually Transmitted Infections.

[24]  S. Kapiga,et al.  Socioeconomic status and HIV seroprevalence in Tanzania: a counterintuitive relationship. , 2008, International journal of epidemiology.

[25]  P. Aggleton,et al.  Structural approaches to HIV prevention , 2008, The Lancet.

[26]  Jane G. Fortson.  The gradient in sub-saharan Africa: Socioeconomic status and HIV/AIDS , 2008, Demography.

[27]  S. Kapiga,et al.  Place matters: multilevel investigation of HIV distribution in Tanzania , 2008, AIDS.

[28]  S. Gabrysch,et al.  The role of context: neighbourhood characteristics strongly influence HIV risk in young women in Ndola, Zambia , 2008, Tropical medicine & international health : TM & IH.

[29]  H. Bang,et al.  The Association Between HIV Infection and Alcohol Use: A Systematic Review and Meta-Analysis of African Studies , 2007, Sexually transmitted diseases.

[30]  Shanti A. Parikh.  The political economy of marriage and HIV: the ABC approach, "safe" infidelity, and managing moral risk in Uganda. , 2007, American journal of public health.

[31]  D. Smith.  Modern marriage, men's extramarital sex, and HIV risk in southeastern Nigeria. , 2007, American journal of public health.

[32]  K. Peltzer,et al.  HIV/AIDS Risk Reduction Counseling for Alcohol Using Sexually Transmitted Infections Clinic Patients in Cape Town, South Africa , 2007, Journal of acquired immune deficiency syndromes.

[33]  Nawal M. Nour,et al.  Health Consequences of Child Marriage in Africa , 2006, Emerging infectious diseases.

[34]  Tabitha T. Langen.  Gender power imbalance on women's capacity to negotiate self-protection against HIV/AIDS in Botswana and South Africa. , 2005, African health sciences.

[35]  J. Fotso,et al.  Measuring socioeconomic status in health research in developing countries: Should we be focusing on households, communities or both? , 2005 .

[36]  M. Silberschmidt.  Men, male sexuality and HIV/AIDS: Reflections from studies in rural and urban East Africa , 2004 .

[37]  M. Hunter.  Masculinities, multiple-sexual-partners, and AIDS: the making and unmaking of Isoka in KwaZulu-Natal , 2004 .

[38]  S. Clark.  Early marriage and HIV risks in sub-Saharan Africa. , 2004, Studies in family planning.

[39]  G. Gupta.  How men's power over women fuels the HIV epidemic , 2002, British medical journal.

[40]  M. Silberschmidt.  Disempowerment of Men in Rural and Urban East Africa: Implications for Male Identity and Sexual Behavior , 2001 .

[41]  Brett Williams,et al.  Beyond the biomedical and behavioural: towards an integrated approach to HIV prevention in the southern African mining industry. , 1999, Social science & medicine.

[42]  AN Organising Framework.  INCORPORATING A STRUCTURAL APPROACH WITHIN COMBINATION HIV PREVENTION , 2013 .

[43]  L. Busani,et al.  Individual and area-based socioeconomic influences on HIV seroprevalence in Cameroon , 2013 .

[44]  Michael P. Arnold,et al.  Exploring the connections between HIV serostatus and individual, household, and community socioeconomic resources: evidence from two population-based surveys in Kenya. , 2012, Social science & medicine.

[45]  R. Bove,et al.  Polygyny and women's health in sub-Saharan Africa. , 2009, Social science & medicine.

[46]  A. Blanc,et al.  The changing context of sexual initiation in sub-Saharan Africa. , 2005 .

[47]  I. Wolffers.  Biomedical and development paradigms in AIDS prevention. , 2000, Bulletin of the World Health Organization.