Introduction
HIV/AIDS remains a public health concern in sub-Saharan Africa (SSA) (World Health Organization [WHO], 2018). Global statistics reveal that approximately 37 million people were infected with HIV in 2017, of which nearly 2 million were newly infected cases (WHO, 2018). To further reduce the cases of HIV each year, efforts to improve comprehensive knowledge on HIV in various populations, especially the young and sexually active population, have been intensified, yet with little success (Badru et al., Reference Badru, Mwaisaka, Khamofu, Agbakwuru, Adedokun and Pandey2020). Adolescent girls and young women (AGYW) in SSA are at higher risk of contracting HIV than their male peers as a result of early marriage, which predisposes them to HIV acquisition (Mavhu et al., Reference Mavhu, Rowley, Thior, Kruse-Levy, Mugurungi, Ncube and Leclerc-Madlala2018). Hence, there is a need to focus health education and HIV prevention strategies on this vulnerable group (UNAIDS, 2016; Saul et al., Reference Saul, Bachman, Allen, Toiv, Cooney and Beamon2018).
Unprotected sex is among several factors that account for new HIV infections among AGYW (Wang et al., Reference Wang, Alva and Wang2012; Sathiyasusuman, Reference Sathiyasusuman2015; Mwale & Muula, Reference Mwale and Muula2018). Also, lack of comprehensive knowledge on HIV has been identified as one of the critical factors contributing to the surge in the incidence of new cases of HIV among AGYW (Siziya et al., Reference Siziya, Muula and Rudatsikira2008; Darteh, Reference Darteh2020). Other factors, including mass media exposure and having attained a secondary or higher level of education, have been found to be predictors of comprehensive HIV knowledge among AGYW (Darteh, Reference Darteh2020). Comprehensive HIV knowledge is low among AGYW in Ghana, and is predicted by marital status, education, region and exposure to mass media (Darteh, Reference Darteh2020). However, a study in Malawi found a high level of comprehensive HIV knowledge among AGYW, depending on age, level of education, wealth index, mass media exposure and employment status (Mandiwa et al., Reference Mandiwa, Namondwe and Munthali2021).
In SSA, AGYW’s ability to negotiate for safer sex has been a major problem associated with HIV incidence since men are regarded as being more influential and domineering when it comes to sexuality decision-making (Saul et al., Reference Saul, Bachman, Allen, Toiv, Cooney and Beamon2018; Darteh, Reference Darteh2020). In light of this, the Sustainable Development Goal (SDG) 5 focuses on gender equality to enhance AGYW’s control in reproductive issues, attitudes and their overall ability to negotiate for safer sex with their male partners (Exavery et al., Reference Exavery, Kanté, Jackson, Noronha, Sikustahili and Tani2012; Darteh et al., Reference Darteh, Dickson and Doku2019). In SSA, interventions such as comprehensive sex education, the promotion of condom use, Determined, Resilience, Empowered, AIDS-free, Mentored and Safe (DREAMS), among others, aim to enhance AGYW’s control in reproductive issues and these efforts are making some progress (Saul et al., Reference Saul, Bachman, Allen, Toiv, Cooney and Beamon2018). Several socioeconomic and cultural factors, including place of residence, marital status, age and educational level, have been found to be associated with AGYW’s ability to negotiate for safer sex (Exavery et al., Reference Exavery, Kanté, Jackson, Noronha, Sikustahili and Tani2012; Darteh et al., Reference Darteh, Doku and Esia-Donkoh2014; Ameyaw et al., Reference Ameyaw, Appiah, Agbesi and Kannor2017).
Evidence suggests that HIV knowledge enhances an individual’s ability to negotiate for safer sex, which in turn is linked to a reduction in HIV incidence (De Coninck et al., Reference De Coninck, Feyissa, Ekström and Marrone2014). For instance, an AGYW who has knowledge about HIV and asks a partner who has contracted or been exposed to HIV to use a condom may be less likely to become infected with the virus. Despite the established link between comprehensive HIV knowledge and safer sex negotiation, and how this contributes to a reduction in HIV incidence, little research attention has been given to this phenomenon in SSA. To the best of the authors’ knowledge, there is limited evidence regarding the association between comprehensive HIV/AIDS knowledge and safer sex negotiation among AGYW in SSA. Therefore, this study aimed to examine the association between comprehensive HIV/AIDS knowledge and safer sex negotiation among AGYW in SSA using data from the Demographic and Health Surveys (DHSs). The findings of the study could help inform policy formulation in the sub-region in order to reduce the incidence of HIV/AIDS and unintended pregnancies.
Methods
Data and study sample
The study used data from the DHSs conducted between 2010 and 2019 across 30 countries in SSA. Specifically, data from the women’s recode files were used. The DHS is a nationally representative household survey that is conducted in more than 85 low- and middle-income countries worldwide. It focuses on essential indicators including comprehensive HIV/AIDS knowledge and safer sex negotiation (Corsi et al., Reference Corsi, Neuman, Finlay and Subramanian2012). Respondents for the DHS are selected using a two-stage sampling approach stratified by rural and urban locations, which ensures that the data are nationally representative (Corsi et al., Reference Corsi, Neuman, Finlay and Subramanian2012). For details of the DHS sampling process, see Seidu et al. (Reference Seidu, Darteh, Kumi-Kyereme, Dickson and Ahinkorah2020). A total of 37,364 AGYW (15–24 years) who had complete information on all the variables of interest were included in this study. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement informed the study design (Von Elm et al., Reference Von Elm, Altman, Egger, Pocock, Gøtzsche and Vandenbroucke2007). Table 1 gives a detailed description of the countries, survey years and study sample. The datasets for the DHS can be accessed freely at https://dhsprogram.com/data/available-datasets.cfm
Table 1. Countries, survey years and study sample of adolescent girls and young women in sub-Saharan Africa
Outcome variable
The outcome variable was ‘safer sex negotiation’. This was derived as a composite variable from two questions, ‘Can you ever refuse sex with your partner?’, and ‘Can you ever ask your partner to use a condom during sex?’ Responses to these questions were ‘yes’ or ‘no’. For the purposes of this study, respondents who answered ‘yes’ to at least one of the two questions were considered to be able to negotiate for safer sex and were assign the code ‘yes’ and otherwise as ‘no’.
Main explanatory variable
The main explanatory variable was ‘comprehensive knowledge on HIV/AIDS’. This is defined as correctly knowing two ways to prevent HIV transmission and rejection of the three most common misconceptions about HIV (Ochako et al., Reference Ochako, Ulwodi, Njagi, Kimetu and Onyango2011). This variable was measured by asking each woman whether or not she agreed with the following five statements: (a) Consistent use of condoms during sexual intercourse can prevent HIV transmission; (b) Limiting sex to just one uninfected faithful partner can prevent HIV transmission; (c) A healthy-looking person can have HIV; (d) A person can get HIV through mosquito bites; (e) A person can get HIV by sharing food with an HIV-infected person (Ochako et al., Reference Ochako, Ulwodi, Njagi, Kimetu and Onyango2011; Agegnehu et al., Reference Agegnehu, Geremew, Sisay, Muchie, Engida and Gudayu2020; Darteh, Reference Darteh2020). A composite score based on the correct answers to the preceding questions was used to derive a ‘comprehensive knowledge on HIV/AIDS’ score, which was dichotomously coded as ‘Yes’ = 1 (correctly responding to all five questions) and ‘No’ = 0 (incorrectly responding to at least one of the questions).
Control variables
Eleven control variables were considered, broadly clustered into individual level and contextual variables. Individual level variables included age, occupational status, marital status, educational level, frequency of reading newspapers, frequency of listening to the radio, frequency of watching the television, condom use and number of current sexual partners. Contextual variables were wealth index and type of place of residence. These variables were not determined a priori; but were instead based on parsimony, theoretical relevance and practical significance with safer sex negotiation (Bharat et al., Reference Bharat, Mahapatra, Roy and Saggurti2013; Atteraya et al., Reference Atteraya, Kimm and Song2014; Sunmola et al., Reference Sunmola, Mayungbo, Fayehun, Opayemi and Morakinyo2018).
Statistical analyses
Data analyses were conducted using Stata version 14.0 (Stata Corporation, College Station, TX, USA). The first step was the determination of the prevalence of safer sex negotiation and comprehensive knowledge on HIV/AIDS among the respondents in each of the 30 sub-Saharan African countries surveyed. Next, the relationship between the explanatory and control variables and the outcome variable (safer sex negotiation) was analysed using Pearson’s chi-squared test. This was followed by the use of a multivariable binary logistic regression to examine the association between comprehensive knowledge and HIV/AIDS and safer sex negotiation among the respondents. Finally, the association between comprehensive knowledge on HIV/AIDS and safer sex negotiation in each of the 30 countries was assessed using logistic regression models. The results of the regression analysis are presented as crude odds ratios (CORs) and adjusted odds ratios (AORs) at 95% confidence intervals (CIs).
The women’s sample weight (v005/1,000,000) was applied to correct for over- and under-sampling and the survey command (svy) in Stata was used in both the chi-squared and regression analyses to account for the complex survey design and generalizability of the findings. According to Hatt and Waters (Reference Hatt and Waters2006), pooling data can bring about broader results that are ‘often obscured by the noise of individual data sets’. To calculate the pooled values, further adjustment was needed to account for the variability in the number of individuals sampled in each country. This was accomplished using the weighting factor 1/(A*n c /n t ), where A is the number of countries that asked a particular question, n c is the number of respondents in a country c and n t is the total number of respondents over all countries asked the question (Peng et al., Reference Peng, Hight-Laukaran, Peterson and Perez-Escamilla1998).
Results
Prevalence of comprehensive HIV/AIDS knowledge and safer sex negotiation
The overall prevalence of safer sex negotiation among AGYW in the 30 sub-Saharan African countries was 74.9%, ranging from 47.7% in Mali to 99.1% in Namibia (Figure 1). The overall prevalence of comprehensive HIV/AIDS knowledge in the 30 countries in SSA was 41.6%, with the highest in Rwanda (74.3%) and lowest in Congo (15.0%) (Figure 2).
Figure 1. Prevalence of safer sex negotiation among AGYW in 30 countries in SSA.
Figure 2. Prevalence of comprehensive knowledge on HIV/AIDS among AGYW in 30 countries in SSA.
Distribution of safer sex negotiation by knowledge on HIV/AIDS and other covariates
Table 2 presents the results of the bivariate analysis of comprehensive HIV/AIDS knowledge, control variables and safer sex negotiation among AGYW in SSA. A larger proportion (80.1%) of respondents with comprehensive knowledge on HIV/AIDS had safer sex negotiation than those with no comprehensive knowledge on HIV/AIDS (71.3%). More than three-quarters of women aged 20–24 (76.5%) had higher safer sex negotiation than those aged 15–19 (70.3%). A higher proportion of women who were working (77.2%) had safer sex negotiation than those who were not working (71.0%). Those who were cohabiting (88.4%), who had secondary or higher education (85.0%), were in the richest wealth quintile (81.6%), resided in urban areas (81.3%), were exposed to newspapers (97.8%), radio (88.3%) and television almost every day (89.8%) and who used condoms (93.4%) had higher proportions of safer sex negotiation. Finally, women who had a single current sexual partner (74.2%) had a higher proportion of safer sex negotiation than those with multiple current sexual partners (68.9%).
Table 2. Bivariate analysis of safer sex negotiation, comprehensive HIV/AIDS knowledge and selected covariates of adolescent girls and young women in sub-Saharan Africa
Association between comprehensive knowledge on HIV/AIDS and safer sex negotiation
Table 3 presents the binary logistic regression analysis on the association between comprehensive knowledge on HIV/AIDS and safer sex negotiation among AGYW in SSA. As shown in Model II, women who had comprehensive knowledge on HIV/AIDS were more likely to have safer sex negotiation compared with those who had no comprehensive knowledge on HIV/AIDS (AOR=1.31, 95% CI: 1.22–1.41). In addition, women who had comprehensive knowledge on HIV/AIDS were more likely to have safer sex negotiation in Congo, Congo DR, Gambia, Guinea, Liberia, Ethiopia and Malawi.
Table 3. Logistic regression on the association between comprehensive knowledge on HIV/AIDS and safer sex negotiation of adolescent girls and young women among countries in sub-Saharan Africa
Model II adjusted for age, occupational status, marital status, education level, frequency of reading newspapers, frequency of listening to the radio, frequency of watching the television, condom use, number of current sexual partners, wealth index and type of place of residence.
COR=Crude odds ratio; AOR: Adjusted odds ratio
Discussion
The results show that the prevalence of safer sex negotiation was high while that of comprehensive HIV/AIDS knowledge was low among AGYW in SSA in 2010 to 2019. There was also a significant association between comprehensive HIV/AIDs knowledge and safer sex negotiation among the study respondents.
Despite the high prevalence of safer sex negotiation, the widespread reports of gender inequalities, unequal sexual power relations, rising cases of child marriages and socio-cultural practices can serve as barriers to safer sex negotiation among AGYW in SSA (UNAIDS, 2016; George et al., Reference George, Amin, de Abreu Lopes and Ravindran2020; Melesse et al., Reference Melesse, Mutua, Choudhury, Wado, Faye, Neal and Boerma2020). These barriers could explain the low prevalence of comprehensive HIV/AIDS knowledge among AGYW in SSA (UNICEF, 2016; Shayo & Kalomo, Reference Shayo and Kalomo2019; McKinnon & Vandermorris, Reference McKinnon and Vandermorris2019). The high prevalence of safer sex negotiation in SSA reported in this study is, however, consistent with a previous study conducted in Ethiopia (De Coninck et al., Reference De Coninck, Feyissa, Ekström and Marrone2014). This could be attributed to the education level of the majority of the respondents in the present study, as most (72.5%) had completed at least primary education. Young women who are educated are more likely to be able to negotiate for safer sex compared with their counterparts who are not educated (De Coninck et al., Reference De Coninck, Feyissa, Ekström and Marrone2014). The low prevalence of comprehensive HIV/AIDS knowledge among AGYW in SSA found in this study is also consistent with the findings of previous studies (Idele et al., Reference Idele, Gillespie, Porth, Suzuki, Mahy, Kasedde and Luo2014; Asaolu et al., Reference Asaolu, Gunn, Center, Koss, Iwelunmor and Ehiri2016). A possible reason for this finding could be the place of residence of the respondents, as the majority (68.3%) were living in rural areas where access to comprehensive sex education is sometimes a problem (Secor-Turner et al., Reference Secor-Turner, Randall, Christensen, Jacobson and Loyola Meléndez2017).
The low prevalence of comprehensive HIV knowledge among AGYW in SSA implies that the global target of 90% by 2020 (UNAIDS, 2016) was not achieved as a result of the variations in the prevalence of comprehensive HIV/AIDS knowledge among the selected countries. For instance, while some countries (Rwanda, Kenya and Burundi) had a high prevalence of comprehensive HIV/AIDS knowledge, others (Congo, Benin and Ghana) had a low prevalence. This observation falls short of the intention of providing comprehensive sex education in the countries of SSA. The sub-region is still far from meeting the 95% target by 2030 given the slow progress so far.
A key finding of this study is the significant association between comprehensive HIV/AIDS knowledge and safer sex negotiation among AGYW in SSA. Specifically, those who had comprehensive knowledge of HIV/AIDS had higher odds of safer sex negotiation. Comprehensive HIV/AIDS knowledge resulted in higher safer sex negotiation in Chad and Congo DR in Central Africa; Gambia, Guinea and Liberia in West Africa; Ethiopia in East Africa; and Malawi in Southern Africa. However, it decreased safer sex negotiation among AGYW in Togo. A possible reason for this finding could be that in Togo, certain practices, such as intimate partner violence and physical violence against AGYW, prevent adolescent girls and young women from negotiating for safer sex despite their higher knowledge in comprehensive HIV/AIDS (Burgos-Soto et al., Reference Burgos-Soto, Orne-Gliemann, Encrenaz, Patassi, Woronowski and Kariyiare2014). This finding corroborates findings from a previous study in Ethiopia (De Coninck et al., Reference De Coninck, Feyissa, Ekström and Marrone2014). Comprehensive HIV/AIDS knowledge is widely reported to influence people’s sexual behaviour and sexual autonomy (Iqbal et al., Reference Iqbal, Maqsood, Zafar, Zakar, Zakar and Fischer2019). Also, this supports the Health Belief Model, which posits that gaining consciousness and knowledge about a health condition is the first step to informing the needed precaution (Becker, Reference Becker1974). It is therefore not a surprise that AGYW in SSA who had comprehensive HIV/AIDS knowledge were more likely to negotiate for safer sex.
In sharp contrast with the findings of this study, a systematic review by Zgambo et al. (Reference Zgambo, Kalembo and Mbakaya2018) showed that even though adolescents living with HIV/AIDS in SSA had comprehensive knowledge about the disease and knew their positive HIV status and its implications, they still engaged in risky sexual behaviours and could not negotiate for safer sex. Aboki et al. (Reference Aboki, Folayan, Daniel and Ogunlayi2014), in their study in Nigeria, also found an insignificant relationship between comprehensive HIV knowledge and safer sex negotiation among adolescents. The disparities in the findings could be the result of differences in the socio-demographic characteristics of the respondents sampled for the various studies. Perhaps certain socio-cultural practices and the dominant patriarchal culture, which often leads to the subordination of women in sexual relationships, exacerbates women’s inferiority and affords them little or no power, makes it difficult for even AGYW with comprehensive HIV/AIDS knowledge to negotiate for safer sex in SSA (Uchem & Ngwa, Reference Uchem and Ngwa2014; Madiba & Ngwenya, Reference Madiba and Ngwenya2017; Sikweyiya et al., Reference Sikweyiya, Addo-Lartey, Alangea, Dako-Gyeke, Chirwa and Coker-Appiah2020).
The study had its strengths and limitations. Its key strength is its use of nationally representative DHS data from 30 sub-Saharan African countries. The DHS data collection techniques and methodology follow best practices using experienced and well-trained data collectors, resulting in a high response rate across all countries. The study findings can therefore be generalized to all adolescent girls and young women in SSA. However, it used a cross-sectional study design, and as such causality could not be deduced. Also, the relationships established between the explanatory and outcome variables may vary over time.
In conclusion, this study found that the overall prevalence of safer sex negotiation among AGYW in SSA was relatively high in 2010–2019, but that of comprehensive HIV/AIDS knowledge was relatively low. Also, a strong statistically significant association was found between comprehensive HIV/AIDS knowledge and safer sex negotiation. These findings will inform policies and programmes in the sub-Saharan African region on the crucial role of comprehensive HIV/AIDS education and knowledge in increasing safer sex practice among AGYW. The study recommends that Togo addresses certain practices, such as intimate partner violence and physical violence against AGYW adolescent girls and young women in the country, which prevent them from negotiating for safer sex, despite their high knowledge in comprehensive HIV/AIDS. Lessons could be learnt from countries like Chad, Congo DR, Gambia, Guinea, Liberia, Ethiopia, and Malawi, which have scaled-up programmes and interventions targeted at enhancing safer sex negotiation among AGYW.
Acknowledgments
The authors are grateful to the MEASURE DHS project for giving free access to the original data.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.
Conflicts of Interest
The authors declare that they have no conflicts of interest. There are no financial, copyright, trademark or patent implications arising from this research and no organization has any vested interest in this research.
Ethical Approval
The DHS reports that ethical clearance was obtained from the Ethics Committee of ORC Macro Inc. and ethics boards of the partner organizations of the various countries, including the Ministries of Health. The DHS follows the standards for ensuring the protection of respondents’ privacy. ICF International ensures that the survey complies with the US Department of Health and Human Services’ regulations for the respect of human subjects. This study was a secondary analysis of the survey data and thus no further approval was required since the data is available in the public domain. Further information about the DHS data usage and ethical standards are available at http://goo.gl/ny8T6X. The authors assert that all procedures contributing to this study comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008.
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