HIV Risk, Prevention and Testing in Sub-Saharan Africa: Mixed Methods Analysis

Abstract

This thesis explores cultural, social and economic determinants of HIV risk across three settings in sub-Saharan Africa. I use mixed methods of inquiry to examine how these contextual features inform HIV transmission, testing, and prevention. My research is motivated by the growing appreciation that public health challenges require not only accurate and clear measurement, but a nuanced understanding of how health phenomena are perceived and how these perceptions shape individual behaviors and population health. To this end, the methodological tools and theoretical constructs to situate assessment within its particular social context are critical to an accurate diagnosis of the causes of important public health challenges. Paper 1 examines the extent to which conjugal relationship structure, in particular long-term unmarried partnering, is associated with HIV risk in KwaZulu-Natal South Africa. Using longitudinal panel data I estimate HIV incidence among, those who are not in conjugal relationships, those who are in long-term unmarried conjugal relationships, and those who are in married conjugal relationships. Although being married in a conjugal relationship is associated with a significant decrease in HIV risk, those in long-term, unmarried conjugal relationships experienced significantly increased HIV risk. Paper 2 explores how men in rural Malawi understand their access to and participation in HIV testing. Using qualitative analysis of data obtained from interviews, I contextualize the key factors men identify as important to how they rationalize non-testing and highlight the role that testing by partner proxy plays in how they weigh the pressures for and against testing. Paper 3 offers insight into the strategies that female commercial sex workers use to assess their own HIV risk, and how they apply this information in their participation in the commercial sex market in Kampala Uganda. Using qualitative analysis of data obtained through interviews, I propose a framework based on the strategies used by many sex workers to balance the risks and benefits associated with their work, in particular in navigating the condomless sex market. In each case, the study methodology and data selected complement existing knowledge to add theoretical insight. Individuals’ perception of their health risk, and their subjective assessment of the factors that they consider important, inform their navigation of the HIV risk environment.