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Honors Thesis

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The Role of Education in Women’s Disparities in Access to HIV Mitigation in Sub-Saharan Africa
Heidi Breanne Karns
Healthc...
Introduction
The prevalence of HIV in sub-Saharan Africa is the highest in the world. In 2013 there were
25.8 million peop...
administered through schools systems, those who are uneducated have not received adequate
information about HIV prevention...
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  1. 1. The Role of Education in Women’s Disparities in Access to HIV Mitigation in Sub-Saharan Africa Heidi Breanne Karns Healthcare Management & Policy Senior Dr. Kosali Simon Professor School of Public and Environmental Affairs Faculty Mentor Abstract: Many studies have evaluated the role of gender inequalities and women’s disproportionate risk of HIV compared to men. My thesis aims to assess women’s equity in access to HIV mitigation in sub-Saharan Africa. I focused my research efforts on three countries: Swaziland, Kenya, and Cameroon. I chose these countries because they have the highest prevalence of HIV among countries in their region, and they are countries for which data is available. Swaziland (Southern Africa) has a 26.5% HIV prevalence rate, Kenya (East Africa) has a 6.1% prevalence rate, and Cameroon (West Africa) has a 4.5% prevalence rate (AVERTa, 2014). I hypothesize that women who receive higher levels of education will have greater access to HIV prevention and alleviation services, and will therefore be less likely to contract HIV or better capable of managing the disease. The analysis reveals a strong correlation between increased educational attainment and HIV testing and access to test results in women of each country. This pattern may also reflect the idea that educational attainment is associated with wealth. Additionally, women of all educational backgrounds are equally likely to receive information about HIV testing sites. Among men and women there are far more people who know where to be tested than there are people who have actually been tested. Overall low utilization of HIV testing resources is likely the result of stigma rather than accessibility. Differences in resource utilization between countries may reflect differences in the administration of these resources.
  2. 2. Introduction The prevalence of HIV in sub-Saharan Africa is the highest in the world. In 2013 there were 25.8 million people in the region living with the virus; this number alone represents 70% of all people in the world who have HIV although SSA is only home to 13% of the world’s population (The Henry J. Kaiser Family Foundation [Kaiser Family Foundation], 2015). HIV exacerbates existing poverty in SSA. It is estimated that in some sub-Saharan countries HIV/AIDS reduces economic growth by 1% each year. HIV multiplies the cost of business operations through employee absenteeism, lower productivity, and large turnovers. Some companies also bear the costs of healthcare, funeral benefits, and pension funds for their employees. Large labor costs and reduced revenues resulting from the epidemic make these countries less desirable to industry and investment (AVERT, 2014c). High unemployment resulting from decreased industry can also influence HIV transmission in certain populations. For example, some women resort to trading sexual favors as a source of income (AVERT, 2014b). The healthcare industry is especially burdened by the HIV epidemic. In 2006 more than 50% of all hospital beds in the region were occupied by people with HIV-related illnesses. This immense need for healthcare services is unmet due to large shortages of healthcare professionals. Many healthcare providers are unable to work because of the role HIV plays in their personal lives; some stay home to care for family members, while others have died or are too ill to work. Additionally, the hazard of HIV exposure is especially relevant among healthcare professionals because they are regularly exposed to blood and other bodily fluids. The consistent use of universal precautions and increased awareness of the modes of HIV transmission are essential for preserving the already small healthcare workforce. Demanding workloads and poor pay also contribute to the shortage of healthcare professionals as some choose to seek work in developed countries (AVERT, 2014c). Inadequate healthcare infrastructure impedes the administration and effectiveness of HIV relief. In addition to constraining economic growth and development, the virus has fiscal implications on individuals and families as well. Many families become financially burdened when the primary income earner dies or becomes too ill to work. The expensive medical costs associated with the disease often force these families further into poverty. Soon they must rely on home- based care, causing other income earners to forfeit earnings in order to care for their loved-ones at home. Financial pressures become compounded when the family household is headed by a female after the death of her spouse. Certain cultural views make it difficult for women to maintain ownership of land and livestock, putting these women and their families in greater threat of poverty. The role of children within the family dynamic is also changing as a result of the epidemic. Children are often removed from school simply because uniforms and fees become unaffordable, and the child’s potential to generate income for the family becomes a priority (AVERT, 2014c). Children who do not attend school are limited in their ability to gain marketable skills and break the cycle of poverty. As many HIV intervention programs are
  3. 3. administered through schools systems, those who are uneducated have not received adequate information about HIV prevention and transmission. In addition to missing HIV education, children are also put at greater exposure to HIV if the work in which they participate involves commercial sex. Women around the world (particularly between the ages of 15-24) are most vulnerable to HIV. Each year there are 380,000 new HIV infections among women in this age group, signifying 60% of all new cases among young people. Disparate infection rates among men and women is especially apparent in sub-Saharan Africa as 80% of all young women living with HIV globally live in this region (AVERT, 2014d). Because sub-Saharan Africa experiences disproportionately high rates of HIV compared to the rest of the world, and women experience higher rates than men, women in the region are among the most at-risk of any subpopulation in the world. Women represent 57% percent of the 25.8 million people in SSA who are living with HIV (AVERT, 2014d). HIV in women in SSA can be linked to many patriarchal societies in the region. Women do not have the same access as men in terms of education, employment, and healthcare, and as a result, often do not have the autonomy to make their own medical decisions regarding their sexual and reproductive health (AVERT, 2015b). Background Institutional Research In sub-Saharan Africa HIV transmission occurs mainly through sex between men and women (Ramjee & Daniels, 2013). Other key indicators of transmission are infrequent and irregular use of condoms, child marriages, sex work, gender inequalities and violence against women, and polygamy (AVERT, 2015b). Swaziland has the highest prevalence of HIV worldwide (26.5%) with 200,000 people currently living with the virus. Life expectancy in this country is among the lowest in the world at only 48.9 years. Because HIV is most common among the working–age population (ages 15-49), children under the age of 14 now embody more than a third of the population, and an estimated 104,026 children are classified as orphaned or vulnerable (OVC) (AVERT, 2014b). There are nearly 1.6 million people living with HIV in Kenya, making the epidemic the fourth- largest in the world. In contrast to Swaziland, Kenya’s HIV epidemic equally affects people in all stages of life including children, adults, and the elderly. Despite the generalization of HIV infections across generations, children are still in danger of becoming OVC. In 2013 there were 1.1 million children orphaned by HIV/AIDS (AVERT, 2015a). In Cameroon 660,000 people live with HIV. Like Kenya, the HIV epidemic in Cameroon affects all generations equally, but children are at risk of becoming orphaned by the disease. In 2014 25% of all orphans in Cameroon were children orphaned as a result of AIDS deaths (National AIDS Control Committee, 2010; PEPFAR, 2015). Another special consideration of the HIV epidemic in Cameroon is the large variation in prevalence rates across different regions. The
  4. 4. four North-West regions experience the highest prevalence rates of HIV: North West (8.7%), East (8.6%), Yaunde (8.3%), and South West (8%). Extreme North and North regions have the lowest prevalence of HIV in the country at 2% and 1.7%, respectively (Denis & Lenora Foretia Foundation, 2013; National AIDS Control Committee, 2010). The governments of each of these countries have sponsored a variety of initiatives to reduce the impact of HIV. Preventative efforts taken by the governments include condom promotion and distribution, behavior change campaigns, promotion of Prevention of Mother-to-Child- Transmission (PMTCT) and voluntary medical male circumcision (VMMC), among others. The Swazi government has also responded to high rates of HIV by enacting legislation that protects at-risk groups, most notably young women. In September 2012 the Swazi government acknowledged the association between child marriage and HIV infections, and passed the Child Protection and Welfare Act which prohibits the marriage of girls under the age of 16. In addition to preventative services, the government has also taken steps to provide treatment to those who already live with the disease. Since 2003 the government has worked to provide free nationwide antiretroviral treatment. Before the World Health Organization changed their eligibility guidelines in 2013, Swaziland was one of five sub-Saharan countries to achieve universal access to treatment meaning more than 80% of those in need of treatment received it. Currently, all antiretroviral drugs available in Swaziland are domestically funded. Less reliance on international donors improves the long-term sustainability of these antiretroviral treatment programs (AVERT, 2014b). Despite the government’s significant strides in providing antiretroviral treatment, adherence to ART is compromised by practices of traditional medicine. The use of witch craft as a means of healing from disease is a common practice in Swaziland, and many people resort to traditional health practitioners for HIV treatment. Witch-doctors and modern healthcare professionals generally have conflicting ideas as to what constitutes appropriate treatment. To accommodate to the popular use of traditional medicine and to expand access and adherence to modern treatments, the Ministry of Health began including these traditional healers as a part of alleviation efforts. Other factors that impede HIV mitigation in Swaziland involve government officials and other influential leaders undermining these government sponsored prevention efforts. For example, King Mswati has been commended for encouraging discussion of HIV/AIDS in Swaziland, however he contradicts himself with his sexual practices. The King currently has 14 wives in accordance with the Swazi tradition of polygamy (AVERT, 2014b). The National AIDS Control Council (NACC) is the entity that governs HIV relief in Kenya. In addition to condom distribution, PMTCT and VMMC the government has also focused on improving and expanding the provision of HIV testing and counselling services including, “provider initiated testing and counselling (PCT), outreach testing and counselling, home-based testing and counselling (HBT) as well as integration of HTC in antenatal care, sexually transmitted infections (STI) and sexual and reproductive health services”. In addition to promoting testing and counselling, the government is also working to make available universal
  5. 5. access to antiretroviral treatment. Kenya was also one of the five sub-Saharan countries to achieve universal access to ART before WHO amendments to eligibility requirements. Sustaining these government sponsored resources is compromised by a heavy reliance on external funding. Currently, 70% of the funding for HIV alleviation, including antiretroviral treatment, comes from external donors. The remaining funding come from government contributions (17%) and private spending (13%). Sustainability is also threatened due to the increasing costs of the HIV response. Costs are projected to rise 114% by 2020, creating a $1.75 billion gap in funding. In preparation for these increasing costs, the Kenyan government has established the High Level Steering Committee for Sustainable Financing. The committee plans to create a trust fund of private resources to recoup the funding gap (AVERT, 2015a). The Cameroon government is coordinating the efforts of internal and external agencies to expand the national response to the HIV epidemic. The Cameroon Baptist Convention Health Services (CBCHS) is an internal faith-based organization that exists to alleviate poverty, facilitate medical experience and training, offer spiritual services, and provide HIV/AIDS prevention and treatment (Cameroon Baptist Convention Health Services [CBCHS], 2014a). The CBCHS AIDS Care and Prevention Program (ACP) incorporates a holistic approach to prevention and treatment efforts. ACP components include: community AIDS education; PMTCT; orphan care; support groups for people living with HIV; antiretroviral treatment; tuberculosis support; palliative care; women’s health programs; and nutrition services (CBCHS, 2014b). The government is also working to improve access to ART by offering free antiretroviral drugs to those who need them (National AIDS Control Committee, 2010). Additionally, Cameroon is joining the Accelerating Children’s HIV/AIDS Treatment (ACT) Initiative. ACT is a two year program meant to increase antiretroviral treatment in children (PEPFAR, 2015). Despite efforts by the government to expand access to antiretroviral drugs, only 23% of adults aged 15 or older are taking these drugs (National AIDS Control Committee, 2010). The President’s Emergency Plan for AIDS Relief (PEPFAR) is one of the external agencies helping to reduce the impact of the disease in Cameroon. PEPFAR goals for the country include: “preventing mother-to-child transmission of HIV; scaling-up access to HIV prevention, care and treatment among those most in need, particularly key and priority populations; supporting health systems strengthening with a focus on improving health information systems, human resources for health, laboratory and blood safety systems, and supply chain management; and strengthening the continuum of care and treatment and ensuring linkages in the delivery of HIV prevention, care, and treatment across all levels of care.” (U.S. President’s Emergency Plan for AIDS Relief [PEPFAR], 2015). Although each the countries’ governments have played a large role in promoting and sponsoring HIV prevention and treatment, certain obstacles continue to limit the effectiveness of these initiatives. HIV is attached to stigma, and those who reveal their positive HIV status are often ostracized from the community and excluded from family gatherings and activities. Many people do not want to know their HIV status and will choose not to be tested out of fear that they will be rejected by family and friends if they are positive for HIV. Those who are aware of their status will often keep the information secret, some not even sharing it with their sexual partners
  6. 6. (AVERT, 2015b). Technical challenges that impede HIV mitigation in each of the countries include: cost of medical treatment and distance to facilities; limited infrastructure; lack of capacity in treatment clinics resulting from workforce shortages and limited resources; and the tendency of people to visit traditional healers instead of certified health professionals (AVERT, 2014b). Women in SSA are especially affected by the limitations of access to HIV testing and treatment as is seen in the higher prevalence rates among women compared to men. In Swaziland women account for two out of three newly reported cases of HIV. Among the population aged 15 and older, the prevalence of HIV is 15.3% percent in women, and only 6.3% in men (AVERT, 2014b). Polygamy and child marriage are common cultural practices in Swaziland that influence high infection rates among women. Polygamy involves multiple sexual partners, and a woman’s submissive role, especially in regard to sex, makes it difficult for her to negotiate condom use. A 2011 report revealed that 15% of men between the ages of 15-49 reported having more than one sexual partner in the past 12 months compared to less than 3% of females. Intergenerational relationships between older men and young women is related to HIV infections in women between the ages of 15-24. Since 2007 the number of women in this age group who have reported having unsafe sex with men who are at least 10 years older has risen from 7% to 14%. Young women are also susceptible to the virus through acts of sexual violence, with one in three women reporting experiences of sexual violence before the age of 18 (AVERT 2014b, AVERT 2015b). In Kenya 6.9% of women have HIV compared to 4.2% of men. Additionally, women between the ages of 15-24 have HIV prevalence rates nearly three times higher than those of men in the same age group; HIV prevalence in this demographic is 3% for women and 1.1% for men. As in Swaziland, young women in Kenya often marry early and to older men, compromising their ability to negotiate safe sex practices even when they know the possibility of contracting HIV. In addition to child-marriage practices influencing higher rates of HIV infections among young women in Kenya, the 2014 Demographic Health Survey found that young women are less knowledgeable about HIV transmission compared to men of the same age group. The survey shows that only 54% of women ages 15-24 could correctly identify methods of HIV prevention compared to 64% of men in the same age group (AVERT, 2015a). HIV also disproportionately affects women in Cameroon. In Cameroon women represent three in five (60%) people living with HIV. Moreover, 70% of all people between the ages of 15-24 who have HIV are women (National AIDS Control Committee, 2010). Literature Review Women and HIV A report in AIDS Research and Therapy evaluates many studies on women’s vulnerability to HIV in sub-Saharan Africa. The research concludes that the epidemic is dynamic, involving many issues. The report considers the biological, cultural, socioeconomic, behavioral and structural factors that increase women’s risk of HIV in SSA (Ramjee & Daniels, 2013).
  7. 7. Certain physiological and hormonal factors influence women’s susceptibility to HIV compared to men. Because the mucosal lining of the female genitalia covers a larger surface area than that of men’s, women are exposed to the virus and other sexually transmitted infections (STIs) for longer periods of time during intercourse. The vaginal tissue is also prone to tearing and other injury during intercourse, further increasing the possibility of the virus’ entry into the body. The report also acknowledges the association between sexually transmitted infections (STIs) and HIV (Ramjee & Daniels, 2013). Engaging in unprotected sexual activities not only increases the chances of acquiring an STI, but also of contracting HIV. Having an STI increases the likelihood of contracting HIV as openings in the skin caused by sores facilitates the virus’ entry into the body (Centers for Disease Control and Prevention [CDC], 2015). Women who have a sexually transmitted infection are likely to have prolonged exposure to HIV because STIs often occur in women without symptoms; women go undiagnosed and untreated for longer periods of time. The results of an observational study conducted by the authors coincides with this theory. The study evaluated four clinical sites in sub-Saharan Africa to determine the prevalence of STIs in association with HIV rates in the region. The four clinical sites included Durban and Hlabisa (South Africa), Lusaka (Zambia) and Moshi (Tanzania). The study found that women who lived in regions that had high rates of HIV were more likely to be diagnosed with an STI. The study specifically found that women who sought treatment at the South African clinics were three times more likely to have an STI than those in the Zambian and Tanzanian sites. Other studies looking at HIV/STI rates in South Africa suggest a connection between the prevalence of STIs and the incidence of HIV (Ramjee & Daniels, 2013). The study proposes that certain biological hormones, including progesterone, are related to risk of HIV infection in women. Injectable contraceptives, some of which contain progesterone, are a common and widely used birth control method among women in sub-Saharan Africa. Some research that has been done on the injectable contraceptive, depot medroxyprogesterone acetate (DMPA), suggests that the contraceptive enables transmission of the virus in those women who use it. Other studies provide contrary evidence to this claim. In response to research disputes in regard to DMPA, the World Health Organization recommends that women who are using the injectable birth control also use condoms to prevent infection with the virus and other STIs. Studies in Uganda, Rwanda and Zimbabwe indicate the impact of certain hormones in the transmission of HIV. Hormones released in the body during pregnancy, most notably oestrogen and progesterone, may cause pregnant women to become more susceptible to the virus. Abnormally high levels of these particular hormones can “cause changes in the structure of the genital mucosa or cause immunological changes, such as an increase in mucosal lymphoid aggregates or hormone-induced overexpression of co-receptors associated with HIV infection”. Other research done on the effect of hormones in the transmission of the virus suggest women are more likely to acquire HIV seven to ten days after ovulation (Ramgee & Daniels, 2013). Societal norms that govern relationships between men and women make women more vulnerable to HIV and other sexually transmitted infections. In patriarchal societies in sub-Saharan Africa
  8. 8. men are encouraged to pursue many sexual relationships and to display their dominance in sexual activity. There is an expectation that wives submit to having sex with their husbands as a woman is seen as the property of her husband, and sex his marital right. For example, in Malawi, marital rape is not recognized as consensual sex is assumed within a marriage. The cultural expectation of men to display their masculinity through sexual activity leads to polygamous relationships and child marriages. Women often marry at a young age to much older men, and young brides are typically not the first of their husband’s wives. Studies show that women who marry young are less likely to receive a formal education. As many intervention programs are administered through schools, those who do not receive an education are not exposed to these interventions and do not hear messages about prevention and safe sex practices. For example, many reports have documented an association between higher levels of education and the consistent and proper use of condoms. Lack of knowledge of safe-sex practices in conjunction with male dominance in sexual activity makes it increasingly difficult for women to negotiate safe sex practices. Research from various sources support the theory that expanding access to education for young girls will decrease their predisposition of HIV. Child marriages leads to earlier sexual debut, a behavior that has been linked to precarious sexual practices. Various studies in Africa have shown that engaging in sexual activity at an early age is associated with susceptibility to HIV. Those who have sex at an early age are more likely to have many partners and are less likely to use contraceptives, including condoms. A survey conducted in South Africa found that of women between the ages of 15-24, 7.8% had sex by the age of 14. In Uganda the government has responded to the HIV epidemic by encouraging young people to postpone sexual activity. This behavior change is thought to have led to the decline in HIV incidence in Uganda in recent years. Other behavior campaigns in countries across sub- Saharan Africa work to encourage fidelity and monogamous relationships. These behavioral campaigns are credited for the decrease in HIV infection rates in Kenya, Zimbabwe, Cote d’Ivoire, Malawi, and Ethiopia (Ramjee & Daniels, 2013). Studies also show that there are higher incidence rates of HIV among those with a low socioeconomic status. Additionally, research from SSA, Asia, and Latin America suggest in countries of high income inequality there are higher prevalence rates of HIV. Greater rates of HIV among the impoverished is linked to apathy of disease transmission. Those who live in poverty are more concerned with finding a means to support themselves and their families than protecting themselves from disease. Various studies on the link between poverty and HIV rates find that low socioeconomic status is associated with participation in unsafe sexual behaviors, including: earlier sexual debut; lower use of contraceptives, including condoms; having sex with many partners; first sexual experience is non-consensual; participation in transactional sex; and greater exposure to sexual violence (Ramjee & Daniels, 2013). Married women are also financially dependent on their husbands as men often head the household and have sovereignty in decisions regarding the distribution of the family’s resources and finances. Financial dependency not only puts women at risk of HIV, but also suggests
  9. 9. women may not have the same access to HIV testing and prevention services as they do not have the resource needed to pay for these services (Ramjee & Daniels, 2013). Economic disparities in countries across the world make women vulnerable to poverty, and they are typically forced to engage in transactional sex to as a means of sustaining their livelihoods. Sex workers are among those most subjected to HIV. It is reported that female sex workers are 13.5 times more likely to have HIV than women who do not engage in transactional sex. Also, 15% of HIV cases in women are attributable to female sex work. Transactional sex is a common practice in sub-Saharan Africa as women resort to offering sexual services in order to make a living, and young girls are pressured to engage in sexual activities with older men to receive money and other gifts that will help to support their families. HIV transmission through female sex work is most notable in SSA with 98,000 out of 106,000 worldwide HIV deaths related to FSW (Ramjee & Daniels, 2013). Women of low socioeconomic status are prone to sexual violence, and violence against women is a contributing factor in the transmission of HIV and STIs in women. Young, uneducated, and poor women are among those most likely to experience an act of sexual violence. Intimate partner violence is associated with drug and alcohol use, early sexual debut, multiple sexual partners, transactional sex, and low use of contraceptives. Several studies have found that intimate partner and gender-based violence are related to HIV infections in women in SSA. A South African study reports that of all new cases of HIV in women, 12% are linked to sexual violence. A Ugandan study also found that violence against women increased their risk of HIV infection by 55% (Ramjee & Daniels, 2013). Other cultural practices influence high HIV rates in widowed and young women. In Malawi, Kenya, Zambia, and Botswana a widow is seen as unclean after the death of her husband. In order to be cleansed the woman must participate in cleansing rituals led by the elders of the community, and must engage in an unprotected sexual act. It is believed that the entrance of semen into the woman’s body will cleans her and make her once again eligible for marriage. The elders of the community choose a man to perform the sexual act. In most cases this man has previously engaged in cleansing rituals and has had unprotected sex with other widows in the community. This practice facilitates the transmission of HIV in this sub-population and makes widowed women vulnerable to HIV infection. Sexual cleansing rituals are also thought to be a cure for HIV; it is believed that having sex with a virgin will cure the disease (Ramjee & Daniels, 2013). The practice of ‘dry sex’ in which drying agents are inserted into the vagina also result in disease transmission in women. The practice dries the mucosal lining of the vagina, increasing friction and causing tearing. Although tears in the vaginal tissue likely expose women to HIV, there have been no studies confirming the role of dry sex in the rapid spread of the virus in the region (Ramjee & Daniels, 2013).
  10. 10. Stigma is a factor that prevents people from being tested, and thus receiving treatment for HIV. Women are especially likely to experience fear of knowing their HIV status. HIV stigma suggests a positive test result is associated with a woman’s promiscuity and infidelity. Women who receive a positive test result are more likely to be ostracized from their families and communities, and may lose their jobs. Studies also show that women who have HIV are more likely to be discriminated against in the healthcare setting. Women who have HIV have reported being denied healthcare services, having their patient confidentiality breached, receiving judgmental treatment, and not receiving informed consent for certain medical procedures (Ramjee & Daniels, 2013). Although there are growing interventions and increasing availability of HIV prevention, testing and treatment, the optimal utilization of these resources among women is questioned. For example, although male condoms are generally the most effective and easily accessible of all HIV prevention methods, women do not generally have to ability to negotiate condom use. To improve women’s ability to protect themselves from getting the virus, female-initiated prevention methods are being researched and tested. One such method is the use of microbicides. Microbicides help to prevent the transmission of HIV through “actions such as membrane disruption activity, prevention of virus attachment to target cells, and buffering agents”. Although many researchers believe that microbicides can be effective at a cellular level in preventing HIV, the benefits of the drug’s use are limited in sub-Saharan Africa. Testing of the drug in the region has been met with limited success due to poor adherence from those women participating in the studies. Other microbicides which incorporate the use of antiretroviral agents have also been evaluated. The efficacy of one such microbicide containing tenofovir was studied in South Africa. The use of the vaginal gel was associated with a 39% decrease in the rate of HIV transmission in women. Those women who used the gel appropriately and consistently where those most likely to benefit from its use. Again, the value of the microbicide was found to be limited by poor adherence. Studies on microbicides suggest that other interventions will not be successful unless more is understood of African women’s social, cultural and traditional roles (Ramjee & Daniels, 2013). Studies on couples with one partner having a positive HIV status and one a negative HIV status have showed a decrease in HIV acquisition when the negative partner was given an oral pre- exposure prophylaxis. If the negative partner took oral tenofovir as a prophylaxis they were 67% less likely to get HIV from their partner. Negative partners who took tenofovir and emtricitibine (Truvada) were 75% less likely to acquire the virus. However, another study in east and southern Africa looking at the effect of Truvada in preventing HIV transmission between couples did not support the drug’s efficacy. This study was compromised due to poor adherence in study subjects. Other studies on the use of antiretroviral therapy in the prevention of HIV transmission between couples have shown that when the positive partner receives ART the negative partner is less likely to get the disease. This study reports that the use of ART for prevention in disease transmission is 96% effective. The results of these studies suggest that the most successful interventions target both sexual partners together (Ramjee & Daniels. 2013).
  11. 11. Educational Attainment and HIV Another study in AIDS evaluates trends in educational attainment and its association to HIV rates in developing countries. The original report was published in 2001 and contained data from the pandemic before 1996. The report found that in most studies conducted in sub-Saharan Africa during this time there was no association between level of education and HIV infection. Some studies evaluated in the report showed that those with advanced levels of education had higher HIV infection rates. This was suspected to be linked to greater socioeconomic status which gives people the ability to travel, and thus expand their network of sexual interactions. The study was updated and published again in 2008, and used data obtained between 2001 and 2006. The updated analysis of this trend reveals that over time those who have lower levels of education have become more prone to contracting the virus while those with higher levels of education have become less susceptible. It is hypothesized by the authors that the trend has reversed because those with higher socioeconomic status had better access to the growing public health responses to the epidemic. Additionally, because HIV interventions are delivered in schools, it is suspected that those who have greater access to education are more likely to come into contact with these preventative efforts and adopt healthier behaviors (Hargreaves et al., 2008) The study was conducted in the same way each time. HIV research from a variety of biomedical databases and medical journals were analyzed and those with certain characteristics were included in the study. Articles selected for the study were those that “reported original data comparing individually measured educational attainment and HIV status” in populations no smaller than 300 people and that best represent the general population (Hargreaves et al., 2008). Research that focused only on at-risk populations were excluded from study. Articles were only reviewed if the data had been analyzed appropriately, adjusting for locality (urban/rural), age, and sex of study participants. Among the articles that describe the relationship between education and HIV infection, data collected and deemed appropriately analyzed before 1996 include data from 32 different populations, and data collected after 1996 include data from 40 populations. Together the study includes 200,000 individuals from 11 countries (Hargreaves et al., 2008). The authors first compared rates of HIV among those with the highest levels of education to those with the least education. The authors categorized levels of education into two to five categories, either measured by years of school attended or the grade achieved. The authors then identified cross-sectional data of the same populations to study trends in HIV rates between the most and least educated over time. The data used in the report include age-stratified and time- series analyses (Hargreaves et al., 2008). Data before 1996 reveal that higher educational attainment was associated with greater probability of HIV infection. This discovery was found in 15 of the 32 populations evaluated before 1996. Contrary findings are show in those populations evaluated after 1996. Only five out of 40 populations studied after 1996 show higher HIV rates in those with higher education
  12. 12. levels, while seven of the 40 populations (one in 32 before 1996) saw a reduction in the rate of HIV among the most educated. Similar results were found from a variety of studies conducted in different countries and populations during the same time periods. 13 populations in five countries in sub-Saharan Africa report similar findings. The populations analyzed include: one population in Malawi, two in Tanzania, three in Uganda, six in Zambia and one in Zimbabwe. Each of the populations saw a decrease in HIV prevalence rates among the most educated, but the circumstances of these trends varied by population. For example, decreasing prevalence rates were seen “in rural (but not urban) Kangera, Tanzania; females (but not males) from Masaka, Uganda; antenatal clinic users in Fort Portal, Uganda and in Manicaland, Zimbabwe; and among urban (but not rural) populations in Zambia” (Hargreaves et al., 2008). Additionally, the decreased relative prevalence of HIV seen in Karonga, Malawi during the 1990s was associated with an increase in prevalence in the least educated, not a decrease in prevalence among the most educated. Rises or stabilization of HIV prevalence among the least educated in Zimbabwe and Zambia contributed to the changing relative prevalence. Masaka, Uganda, was the only population in which there was a reduction in prevalence among both the most and least educated. In general, HIV incidence and prevalence rates reveal that after 1996 the trends began to change to no association or decreased risk among the most educated (Hargreaves et al., 2008). Analyses modifying for age (populations under 30 years old) were available for 35 populations in sub-Saharan Africa after 1996. These analyses show that there was no association between level of education and HIV among males or females between the ages of 15-24 in Kisumu, Kenya and Ndola, Zambia. However, there was a decrease in HIV infection rates found among the most educated women between the ages of 15-24 in Yaounde, Cameroon; there was no clear association between HIV and level of education among men of the same age group. In contrast, in Cotonou, Benin, there was a decrease of HIV in men with higher levels of education between the ages of 15-24, but no association between women of the same age group. In Manicaland, Zimbabwe it was reported that the most educated women between the ages of 15-24 were the least likely to acquire HIV, while there was no association among men aged 17-29. Finally, in Mwanza, Tanzania ever having attended school was associated with decreased infection in men aged 15-19, but no association in women of the same age group (Hargreaves et al., 2008). Time-series analyses of the most and least educated young people were also included in the report. In Masaka, Uganda between 1989-90 and 1999-2000, there was no association between level of education and HIV among men aged 18-29 years old. The same study showed that among females of the same age group there was no association in 1989-90, but in 1999-2000 there was a decrease in HIV infection in young women who had higher levels of education (Hargreaves et al., 2008). In Fort Portal, Uganda in 1991-94 there was no association among those aged 15-24 who attended antenatal clinics, but by 1995-1997 it was reported that there were lower rates among the most educated of antenatal attendees aged 15-24. However, another study looking at HIV infection rates in antenatal attendees aged 15-24 in Zambia show that there was higher rates in
  13. 13. those with higher education levels in 1994, 1998 and 2002. Differences in trends between studies evaluating HIV in antenatal attendees may be explained by surveys only capturing responses from those pregnant women who attended these clinics. Capturing data in this way excludes responses from those who are sexually inactive and those who do not attend clinics because they are unable to pay for the services (which is assumed to be those who are uneducated). This explains why antenatal clinic data shows higher rates of infection among the most educated (Hargreaves et al., 2008). Time-series data that captures differences in HIV rates among the most and least educated living in rural and urban settings were also included in the study. A study in Zambia shows that among males aged 15-24 who lived in a rural setting, there was no association between level of education and HIV each year of the study (1995, 1999, 2003). No association was found among males aged 15-24 who lived in an urban setting in 1995 and 1999, however, 2003 data show there were less HIV infections in those who had higher levels of education. The Zambian study also revealed trends in women who lived in rural and urban settings. In Zambian women aged 15-24 who lived in a rural setting there was no association between level of education and HIV in 1995 and 2003, but data from 1999 show that these women with the highest level of education were more likely to have an infection. There was no association among women of the same age group who lived in urban areas in 1995 and 1999, but 2003 data show that lower rates were found in women who were among the most educated (Hargreaves et al., 2008). As opposed to studies conducted before 1996, those conducted afterwards largely showed a decrease of HIV infection among the most educated men and women. The analyses reveal that as HIV prevalence was decreasing among the most educated, prevalence was increasing in the least educated even when overall population prevalence was decreasing. These findings in conjunction to one another suggest that post-1996 HIV infections in sub-Saharan Africa have been occurring disproportionately in the least educated. It is also possible that differences in infection rates among the most and least educated is much greater because differences in HIV prevalence are slow to change in response to rises in incidence (Hargreaves et al., 2008). Poverty and HIV An article in Croatian Medical Journal evaluates the role of poverty in the transmission of HIV across sub-Saharan Africa. The report acknowledges that the region is home to 70% of the world’s poorest, with 60% living below the United Nation’s established poverty line of one United States dollar a day. The article discusses sexual trade, polygamy and child marriages of the poor as contributing factors of rapid disease transmission in the region. Each of these factors has been acknowledge in several studies (including Ramjee & Daniels’) as behaviors that are directly related to HIV/AIDS. The study examines illustrations in 20 poverty stricken countries in sub-Saharan Africa as an assessment of the effect of poverty on growing HIV rates (Dzimnenani, 2007).
  14. 14. Many studies have reported that those who live in poverty are more vulnerable to HIV infection. Poverty is of particular threat to women because of social inequities that make women less capable of financial stability and more reliant on men. The behaviors of the poor, rather than reduced access to HIV education, are what proliferate the rate of transmission in this population. It is believed that although these people hear messages about HIV prevention, protecting themselves from the deadly virus is of low priority given the circumstances of their every-day lives. Additionally, even if messages are understood some people lack the resources to adopt healthier behaviors (Dzimnenani, 2007). Those who do not possess monetary wealth typically do not have other assets or the skills needed to achieve financial stability. As HIV/AIDS is associated with costly medical care and treatment, even people with an abundance of resources experience diminishing of their finances as a result of infection with the virus. Those who do not have assets to begin with are especially ill-equipped to deal with financial pressures posed by the disease (Dzimnenani, 2007). Worsening economic conditions in many countries in the region have made commercial sex common place in sub-Saharan Africa. For example, in Zimbabwe, men are forced to travel long distances to places of work and do not see their wives for long periods of time. Some men tend to develop transactional sexual relations with women in the cities in which they work. In some cases this leads to divorce, and wives are forced to resort to commercial sex as a means to earn an income for themselves and their children. In many poor communities transactional sex is accepted as a way of improving living standards (Dzimnenani, 2007). Other cultural expectations and lack of alternative occupational opportunities for women influence growth of the commercial sex industry. Transactional sex is a major factor in the HIV/AIDS pandemic. Women who engage in sexual transactions, a dangerous behavior in and of itself, are less likely to care about protecting themselves from HIV transmission by using protective measures. It is also understood that women who are engaging in commercial sex are not as financially well off as the men who are paying for these services, so there is an expectation that the men provide condoms. Additionally, men are willing to pay much more for sex that does not involve the use of a condom. Knowing that they will receive more money, some women do not negotiate condom use during transactional sex (Dzimnenani, 2007). Poverty also exposes children to sexual exploitation. The Integrated Regional Information Network, a news agency that reports on humanitarian issues, reported that in Kenya female children of poor rural families are often taken out of school and sent to larger cities to trade sexual favors in order to support their families. Without receiving an education or marketable skills these children often have a difficult time exiting the sex market into their adult years. Those who do often face discrimination from their families and communities (Dzimnenani, 2007).
  15. 15. Polygamy and child marriages are often the result of poverty and influence higher HIV transmission in women. Polygamy is a social practice meant to display male status, and is also used as a means to help widows and orphans to escape poverty. In some countries in sub- Saharan Africa it is believed that the less economically advantaged women should be wed and cared for financially by a husband. Parents of young girls will often arrange marriages between their children and older financially established men as a strategy for attaining wealth. The strategy is also used by orphanage caregivers who find it difficult to care for so many children, especially in areas where there are large numbers of orphans due to the HIV epidemic. The WHO reported that poverty increases the likelihood that a woman will be married at a young age as female children are seen as a burden on the family’s resources. Additionally, families are encouraged to marry their daughters at a young age because the younger the bride, the larger the dowry paid to the family. Studies consistently show that young women who come from impoverished families are more likely to marry at a young age. It was reported in one study that in Cote d’Ivoire young women from the 20% poorest households were three times more likely to marry early compared to wealthier women of the same age group. Similar data were shown in the 20% poorest households in Senegal; there, young women were four times more likely to marry early (Dzimnenani, 2007). Early marriage is also practiced because it is believed that marrying at a young age decreases a woman’s exposure to HIV and other sexually transmitted infections. However, evidence suggest otherwise. Studies show that young brides who marry older men are more susceptible to HIV transmission than if they were to marry men closer to their own age. On average, older husbands are more likely to have HIV. A study conducted in Kisumu, Kenya found that of those men married to younger women, 30% had HIV compared to 11.5% of those men who had sexual relationships with women of the same age. Similar data was found in Ndola, Zambia. Of men who were married to younger women, 31.6% had HIV while only 16.8% of boyfriends were living with the virus (Dzimnenani, 2007). Method My hypothesis is that women who have achieve higher levels of education will be more likely to access and utilize HIV mitigation resources. I will establish differences in access by comparing data between countries, women and men, and women of different levels of education. Assessing differences between Swaziland, Kenya, and Cameroon will reveal existing trends in women’s access, and may suggest strengths and weaknesses in each countries’ administration of alleviation efforts. The analysis will first describe the differences in educational attainment between countries, between men and women in each of the countries, and between women of different countries. The second part of the analysis will evaluate differences in access to HIV/AIDS mitigation between countries, between men and women in each country, and between women of different educations. The variables that are used to measure access are: whether (1) a person has been
  16. 16. tested for HIV/AIDS, (2) knows where to get tested, and (3) received the results of their last HIV/AIDS test. The final part of the analysis will evaluate women’s access in relation to their educational attainment. This section of the analysis will evaluate different trends in women by country and by educational attainment. The analysis includes correlations between educational attainment and the variables of access in each of the countries. Decisions of contraceptive use among women who have different educations will be also assessed. This component of the analysis will compare reported decision-makers for contraceptive use between countries and among women of different educational backgrounds. Data The main variables that I will evaluate as a part of my research include: level of education, HIV/AIDS mitigation resources, and the reported decision maker for contraceptive use. For each dataset the case identification variable (CASEID) is used to uniquely identify survey respondents and their responses to the survey questionnaire. The definitions of these variables are described by the Standard Recode Manual for DHS V and VI, and are included in Appendix B of this document. To account for differences in research methodologies and to facilitate data comparisons across surveys, the Demographic and Health Survey Program uses a recode file, or standardized questionnaire format, for those countries participating in DHS phases. Each DHS phase includes unique variables, so comparing data using different DHS phases comes with limitations. Data on Swaziland and Kenya were retrieved using DHS V format, while data on Cameroon uses DHS VI. In order to compare surveys it was essential to identify those variables of interest that each survey measures. For purposes of my research I used the Individual Women’s and Men’s Data- Individual Recode (IR) files for each dataset. These recode files have one record for every woman or man eligible to participate in the survey. Therefore the unit of analysis is either the woman or man (The Demographic and Health Surveys Program [DHS], n.d.). Additionally, each survey was conducted in different years. The Swaziland survey was administered in 2006-2007, the Kenya survey in 2008-2009, and the Cameroon survey in 2011 (USAID, 2013). The differences between years may not comprehensively account for economic or political changes in each country, however the data is collected within a span of ten years so these differences are assumed to be negligible. Results and Analysis The following data analysis refers to figures in Appendix A. Figure 1 shows the percent of people in each country who have achieved at least a primary education.
  17. 17. Educational attainment is comparable by country, but is highest in Swaziland followed by Kenya and Cameroon. The finding that educational attainment is highest in Swaziland shows that better availability of education is not necessarily associated with lower HIV prevalence as Swaziland has the highest prevalence of HIV among the three countries (26.5%). Figure 2 compares the percentage of men and women in each country who have attained at least a primary education. The data mostly reflect the trend that access to education is highest in Swaziland followed by Kenya and Cameroon. In each of the countries, men have slightly better access to education than women. This data provides commentary on women’s roles in sub-Saharan African culture. It may also suggest why women in the region are more susceptible to poverty. Figure 3 shows the difference in educational attainment of women in each country. The data measures those women in each country who have completed at least a primary education. Swaziland has the highest percentage of women who have some level of education (91.72%) which reflects the trend that education is more available in Swaziland than the other two countries. Figure 4 shows the difference in access to HIV/AIDS mitigation by country. The data measures the percent of men and women who have (1) ever been tested for HIV/AIDS, (2) know a place to get tested, (3) and got the results of their last test. Kenya has the highest percent of people who have ever been tested, know a place to get tested, and got the results of their last test. This contradicts the theory that people with better access to education also have better access to testing as Swaziland has the highest educational attainment among the three countries. However, educational attainment and access in all three categories is lowest in Cameroon; this finding supports the theory. The contrary findings may suggest differences in the administration of these services in each of the countries. For example, Kenya may have a more comprehensive administration of these resources compared to Swaziland and Cameroon. Another thing to note about the graph is that in all three countries, there are many more people who know where to be tested than there are people actually being tested for HIV/AIDS. This indicates that although people are hearing messages of HIV prevention and relief, many are still choosing not to be tested. Taboo and stigma related to HIV/AIDS, and poverty in the region may be factors deterring people from being tested. One thing to consider for future research is differences in the availability of HIV mitigation in rural and urban locations, and the associated burden on the impoverished.
  18. 18. Figures 5a-c show the difference in access to mitigation resources between men and women in each country. Showing these differences may highlight the successes and weaknesses of HIV interventions in these countries. In general, women are more likely to be tested for HIV/AIDS than men. This might be explained by women’s likelihood to attend a medical facility as a result of pregnancy. Women who attend antenatal clinics are tested for HIV as a part of the services they receive from the facility (Ramjee & Daniels, 2013). In Cameroon, women are less likely than men to be tested for HIV/AIDS. One question to ask in future research is whether antenatal clinics are less available to women in Cameroon than to women in Swaziland and Kenya. In the exception of Swaziland, women and men are equally likely to hear messages of HIV testing resources. This shows that HIV interventions in each country are successful at disseminating information to both men and women, but there are still barriers that exist that prevent people from being tested. In Kenya and Cameroon men and women who have been tested for HIV/AIDS are equally likely to receive their test results. Of those people who are tested for HIV/AIDS in Swaziland, men are more likely to receive their results than women. A potential explanation of this finding is that women who are diagnosed with HIV are often discriminated against in the healthcare setting. Another reason is that healthcare providers sometimes share a woman’s health information with her husband or closest male relative instead of her. A woman who is diagnosed with HIV may not ever receive that information, or may first hear it through her spouse (Ramjee & Daniels, 2013). Figure 6 shows differences in HIV testing, knowledge of testing sites, and access to test results of women in each country. The data show that women in Kenya are more likely to receive HIV testing and to have better access to test results than women in Swaziland and Cameroon. HIV mitigation is more obtainable in Kenya in general, so the fact that women in Kenya have better access to HIV resources is not surprising. The trend is similar among women in Cameroon. Mitigation is less attainable in Cameroon, so women in Cameroon generally have less access than women in Swaziland and Kenya. Figures 7a-c show differences in testing, knowledge of testing sites, and access to test results among women of different educations in all three countries. In each of the countries there is a trend of increased testing, knowledge of testing sites, and reception of test results with advanced educational attainment. Women who have higher educations are more likely to have been tested for HIV/AIDS, to know of places to get tested,
  19. 19. and to have access to their test results. This supports the hypothesis that advanced educational attainment is associated with improved access to and utilization of resources. Figures 8a-d describe differences in HIV testing rates among women of different education levels, and compares trends across countries. In each of the countries there is a strong positive correlation between higher levels of education and HIV testing in women. This data indicates that women who have higher education levels are more likely to be tested for HIV. Education is associated with greater wealth which may explain why women of higher educations are more likely to be tested. Women of lower socioeconomic status may not have monetary resources to access medical care and are therefore not tested, even if they know where to be tested. Additionally, women of lower socioeconomic status may rely on their spouse or another male relative to be tested. In many cases women must ask their husbands for money needed to pay the medical provider, and also must ask permission to go to a testing facility (Ramjee & Daniels, 2013). Figures 9a-d show the difference is women’s knowledge of HIV/AIDS testing sites, and compares trends in Swaziland, Kenya and Cameroon. There is a positive correlation between increased educational attainment and better knowledge of existing testing sites, but it is a weak correlation. This might indicate that, overall, women of all levels of education have similar knowledge of locations to be tested. This trend is seen in all countries. Figures 10a-d show differences in access to test results among women of different educational backgrounds in each of the countries. There is a strong positive correlation between higher educational attainment and access to test results in all three countries. This could be because women with higher levels of education are likely to have greater wealth and have improved access to testing in general. It may be more difficult for women of lower socioeconomic status to attend a testing center more than once in order to receive the results of her test, especially if she must ask her husband for money and permission. Figure 11 shows the difference in contraceptive decision makers in each country. The data is reported by women. In each of the countries the decision to use contraceptives is a joint decision between a woman and her sexual partner. Figures 12a-c show differences in contraceptive use among women of different education levels in each country.
  20. 20. The data show that in all countries women of all levels of education are more likely to make contraceptive decisions with their partners. This reflects the trends that, in general, women in each of the countries are more likely to make this decision jointly. It also provides commentary on the success of HIV prevention initiatives to target men and women as sexual partners. Overall, the findings show that access to basic education is not necessarily related to better access to and utilization of HIV resources, but increased educational attainment is. Additionally, although many people know of these resources there are still barriers that prevent optimal utilization. Differences in the strategies of government initiatives and the views of women in each of the countries should be further assessed to explain variations in utilization of these resources.
  21. 21. Bibliography AVERT (2015a, May 01). HIV & AIDS in Kenya. Retrieved from http://www.avert.org/professionals/hiv-around-world/sub-saharan-africa/kenya AVERT. (2014a, June 06). HIV and AIDS in sub-Saharan Africa. Retrieved from http://www.avert.org/hiv-aids-sub-saharan-africa.htm AVERT. (2014b, June 06). HIV & AIDS in Swaziland. Retrieved from http://www.avert.org/hiv-aids-swaziland.htm AVERT. (2015b, May 01). HIV & AIDS in Swaziland. Retrieved from http://www.avert.org/professionals/hiv-around-world/sub-saharan-africa/swaziland AVERT. (2014c, June 06). Impact of HIV and AIDS in sub-Saharan Africa. Retrieved from http://www.avert.org/impact-hiv-and-aids-sub-saharan-africa.htm AVERT. (2014d, June 06). Women and HIV/AIDS. Retrieved from http://www.avert.org/women-and-hiv-aids.htm Cameroon Baptist Convention Health Services. (2014a). About Us. Retrieved from http://www.cbchealthservices.org/html/about_us.html Cameroon Baptist Convention Health Services. (2014b). AIDS Care and Prevention Program. Retrieved from http://www.cbchealthservices.org/html/a_c_p.html Centers for Disease Control and Prevention. (2015, Oct. 14). STDs and HIV- CDC Fact Sheet. Retrieved from http://www.cdc.gov/std/hiv/stdfact-std-hiv.htm The Demographic and Health Surveys Program. (n.d). Dataset Types. Retrieved from http://dhsprogram.com/data/Dataset-Types.cfm Denis &Lenora Foretia Foundation. (2013, Dec. 01). HIV AIDS in Cameroon- An Update. Retrieved from http://www.foretiafoundation.org/hiv-aids-in-cameroon-an-update/ Dzimnenani Mbirimtengerenji, N. (2007). Is HIV/AIDS Epidemic Outcome of Poverty in Sub- Saharan Africa? Croatian Medical Journal, 48(5), 605–617. Hargreaves, J. R., Bonell, C. P., Boler, T., Boccia, D., Birdthistle, I., Fletcher. A.,… Glynn, J. R. (2008). Systematic review exploring time trends in the association between educational attainment and risk of HIV infection in sub-Saharan Africa. AIDS, 22(3), 403-414. doi: 10.1097/QAD.0b013e3282f2aac3
  22. 22. The Henry J. Kaiser Family Foundation. (2015, July 31). The Global HIV/AIDS Epidemic. Retrieved from http://kff.org/global-health-policy/fact-sheet/the-global-hivaids-epidemic/ National AIDS Control Committee. (2010, Sept.). The Impact of HIV and AIDS in Cameroon through 2020. Retrieved from http://www.healthpolicyinitiative.com/Publications/Documents/1250_1_Cameroon_EN_ Singles_Reduced_acc.pdf Ramjee, G. & Daniels, B. (2013). Women and HIV in Sub-Saharan Africa. AIDS Research and Therapy, 10, 30. doi: 10.1186/1742-6405-10-30 United States Agency for International Development. (2013, March 22). Standard Recode Manual for DHS 6. Retrieved from https://dhsprogram.com/pubs/pdf/DHSG4/Recode6_DHS_22March2013_DHSG4.pdf U.S. President’s Emergency Plan for AIDS Relief. (2015, Aug.). Partnering to Achieve Epidemic Control in Cameroon. Retrieved from http://www.pepfar.gov/documents/organization/203142.pdf
  23. 23. Appendix A: Analysis Graphs Figure 1 Figure 2 91.85% 87.82% 84.87% 0 10 20 30 40 50 60 70 80 90 100 Swaziland Kenya Cameroon Percentofpeoplewhohavecompletedatleasta primaryeducation Countries in SSA Differences in Educational Attainment by Country 0 10 20 30 40 50 60 70 80 90 100 Swaziland Kenya Cameroon Percentage of men and women who have at least a primary education CountriesinSSA Differences in Educational Attainment Between Men and Women in Each Country Men Women
  24. 24. Figure 3 Figure 4 91.72% 85.29% 81.87% 0 10 20 30 40 50 60 70 80 90 100 Swaziland Kenya Cameroon Percentage of women who have completed at least a primary education CountreisinSSA Women's Educational Attainment by Country At least primary No Education 0 10 20 30 40 50 60 70 80 90 100 Ever been tested Know a place to get tested Did get results of test Percentofpeople Measures of Access Access to HIV Mitigation by Country Swaziland Kenya Cameroon
  25. 25. Figures 5a-c a) b) 0 20 40 60 80 100 Ever been tested for HIV/AIDS Know a place to get HIV/AIDS test Did get results of test Percentofpeople Measures of Access Differences in Access Between Men and Women in Swaziland Women Men 0 10 20 30 40 50 60 70 80 90 100 Ever been tested for HIV/AIDS Know a place to get HIV/AIDS test Did get results of test Percentofpeople Measures of Access Differences in Access Between Men and Women in Kenya Women Men
  26. 26. c) Figure 6 0 20 40 60 80 100 Ever been tested for HIV/AIDS Know a place to get HIV/AIDS test Did get results of test PercentofPeople Measures of Access Differences in Access Between Men and Women in Cameroon Women Men 0 10 20 30 40 50 60 70 80 90 100 Ever been tested for HIV/AIDS Know a place to get HIV/AIDS test Did get results of test Percentofpeople Measures of Access Women's Access to HIV Mitigation by Country Swaziland Kenya Cameroon
  27. 27. Figures 7a-c a) b) 0 10 20 30 40 50 60 70 80 90 100 Ever been tested know place to get tested got results of last test Percent of women MeasuresofAccess Swaziland Women's Acces to HIV/AIDS Mitigation by Lvl Education higher secondary primary no education 0 10 20 30 40 50 60 70 80 90 100 Ever been tested know place to get tested got results of last test Percent of women MeasuresofAccess Kenya Women's Access to HIV Mitigation by Lvl Education higher secondary primary no education
  28. 28. c) Figures 8a-d a) 0 10 20 30 40 50 60 70 80 90 100 Ever been tested know place to get tested got results of last test Percent of women MeasuresofAccess Cameroon Women's Access to Mitigation by Lvl Education higher secondary primary no education 0 10 20 30 40 50 60 70 80 90 100 Swaziland Kenya Cameroon Percentofwomenwhohavebeentested Countries in SSA Education and HIV Testing of Women in SSA no education primary secondary higher
  29. 29. b) c) R² = 0.805 0 10 20 30 40 50 60 70 80 90 100 no education primary secondary higher Percentofwomenwhohavebeentested Levels of Education HIV Testing of Swazi Women R² = 0.9402 0 10 20 30 40 50 60 70 80 90 100 no education primary secondary higher Percentofwomenwhohavebeentested Levels of Education HIV Testing of Kenyan Women
  30. 30. d) Figures 9a-d a) R² = 0.9545 0 10 20 30 40 50 60 70 80 90 100 no education primary secondary higher Percentofwomenwhohavebeentested Levels of education HIV Testing of Cameroonian Women 0 10 20 30 40 50 60 70 80 90 100 Swaziland Kenya Cameroon Percentofwomen Countries in SSA Education and Knowledge of Testing Sites of Women in SSA no education primary secondary higher
  31. 31. b) c) R² = 0.7021 0 10 20 30 40 50 60 70 80 90 100 no education primary secondary higher Percentofwomenwhoknowwheretogettested Level of Education Education and Knowledge of Testing Sites in Swazi Women R² = 0.7426 0 10 20 30 40 50 60 70 80 90 100 no education primary secondary higher Percentofwomenwhoknowwheretogettested Level of Education Education and Knowledge of Testing Sites in Kenyan Women
  32. 32. d) Figures 10a-d a) R² = 0.8523 0 10 20 30 40 50 60 70 80 90 100 no education primary secondary higher Percentofwomenwhoknowwheretogettested Level of Education Education and Knowledge of Testing Sites in Cameroonian Women 70 75 80 85 90 95 100 Swaziland Kenya Cameroon Percentofwomenwhogottestresults Countries in SSA Education and Women's Access to Test Results in SSA no education primary secondary higher
  33. 33. b) c) R² = 0.9209 0 10 20 30 40 50 60 70 80 90 100 no education primary secondary higher Percnetofwomenwhogottestresults Level of Education Education and Swazi Women's Access to Test Results R² = 0.8642 0 10 20 30 40 50 60 70 80 90 100 no education primary secondary higher Percnetofwomenwhohaverecievedtestresults Level of Education Education and Kenyan Women's Access to Test Results
  34. 34. d) Figure 11 R² = 0.9748 0 10 20 30 40 50 60 70 80 90 100 no education primary secondary higher Percentofwomenwhohaverecievedtestresults Level of Education Education and Cameroonian Women's Access to Test Results 0 10 20 30 40 50 60 70 80 90 100 mainly respondent mainly husband, partner joint decision other missing Percent of reported contraceptive decision-makers Reportedcontraceptivedecision-makers Women Report Contraceptive Decision-Makers in SSA Cameroon Kenya Swaziland
  35. 35. Figures 12a-c a) b) 0 10 20 30 40 50 60 70 80 90 100 mainly respondent mainly husband, partner joint decision other Percent of reported contraceptive decision-makers Reporteddecision-makers Swazi Women Report Contraceptive Decision- Maker higher secondary primary no edu 0 10 20 30 40 50 60 70 80 90 100 mainly respondent mainly husband, partner joint decision other missing Percent of reported contraceptive decision-makers Reporteddecision-makers Kenyan Women Report Contraceptive Decision-Maker higher secondary primary no edu
  36. 36. c) 0 10 20 30 40 50 60 70 80 90 100 mainly respondent mainly husband, partner joint decision other missing Percent of reported contraceptive decision-makers Reporteddecision-makers Cameroonian Women Report Contraceptive Decision- Maker higher secondar primary no edu
  37. 37. Appendix B: DHS Variables and Definitions CASEID In most surveys this is constructed by concatenating the cluster or sample point number, the household number and the respondent’s line number, but in some surveys this may be the questionnaire number taken from the front page of the questionnaire V106 Highest education level attended. This is a standardized variable providing level of education in the following categories: No education, Primary, Secondary, and Higher. V376 Reason the respondent does not intend to use a method of contraception in the future. BASE: All women not currently using a contraceptive method and not intending to use a method in the future (V362=5). This question is no longer part of the DHS VI core questionnaire, but the variable is kept in the DHS VI recode. V379 Source of any method of contraception is formed from a combination of responses. For current users of modern methods, it is the source of that method. For women who are not currently using a methods, it is a source from which they know they can obtain family planning methods, if they know any source. This is not in general part of the standard questionnaire since it is replaced with a multiple-choice question. However, it is left as a standard variable in case the question asked has only one answer. V467 Getting medical care for herself. In case where the respondent is sick, this set of questions give an answer to the major problems preventing her from getting medical advice or treatment. The questions pertaining to V467A, V467E, V467G, V467H and V467I are no longer part of the DHS VI core questionnaire, but the variables are kept in the DHS VI recode. V467A Knowing where to go V467B Getting permission to go V467C Getting money needed for treatment V467D Distance to the health facility V467E Having to take transport V467F Not wanting to go alone V467G Concern that there may not be a female health provider V467H Concern that there may not be a provider V467I Concern that there may not be drugs available V632 Women using contraception are asked who decided on the use of contraception V744 When wife’s beating or hitting is justified V744A Goes out without telling him V744B Neglects the children V744C Argues with him V744D Refuses to have sex with him V744E Burns food V781 Ever been tested for AIDS V783 Know a place to get AIDS test V828 Did get results for last test (USAID, 2013)

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