Date of Award

2019

Embargo Period

4-30-2024

Document Type

Dissertation

Degree Name

Doctor of Philosophy (PhD)

Department

Public Health Sciences

College

College of Graduate Studies

First Advisor

Jeffrey E. Korte

Second Advisor

Mulugeta Gebregziabher

Third Advisor

Anbesaw Selassie

Fourth Advisor

Michael Sweat

Fifth Advisor

Lauren Richey

Abstract

Gender equality refers to equal rights, responsibilities and opportunities for women and men. Equality between women and men is both a human rights issue and is necessary for sustainable societal development. However, in most sub-Saharan African societies, men have substantial power over women, and many national advancements in reproductive health, empowerment, and labor market participation have been impeded by gender inequality. Gender inequality has been correlated with intimate partner violence (IPV), which is in turn positively correlated with risk of HIV, and has also been associated with higher risk of HIV infection independent of IPV. Thus, factors that diminish gender inequality may decrease IPV and risk of HIV infection. Moreover, there is a lack of studies assessing factors predictive of gender equality in a pregnancy context. Compared to current blood-based methods of clinical HIV testing, HIV self-testing kits are a relatively new technology, and hold great potential to increase testing rates and HIV awareness, maintain patient privacy, and lead to both prevention of HIV and improved treatment. However, no studies have queried the correlation between relationship gender equality and HIV self-testing behavior. This dissertation research examined the relationships between individual social and economic factors related to decision-making power and personal attitudes towards IPV within heterosexual couples expecting a child. In addition, the work explored the correlation between relationship gender equality and HIV self-testing uptake. This study addressed these questions in four specific aims: 1. Identify social and economic predictors of low decision-making power and high acceptance of IPV within heterosexual couples expecting a child in central Kenya. 2. Determine the association between high gender equality (measured by high decision-making power and low acceptance of IPV) and couples’ uptake of HIV self-testing kits in central Kenya. 3. Identify social and economic predictors of low decision-making power and high acceptance of IPV within heterosexual couples expecting a child in south-central Uganda. 4. Determine the association between high gender equality (measured by high decision-making power and low acceptance of IPV) and male partners’ uptake of HIV self-testing kits in south-central Uganda. This study used data collected from two randomized controlled trials (RCTs) assessing the effectiveness of HIV self-testing kits to increase HIV testing for male partners of pregnant women in Kenya and Uganda (n=1,410 and n=1,618, respectively). We found, through Aims 1 and 3, that there are potential targets to improve specific social and economic variables associated with lower gender equality (e.g., to increase men and women’s education levels, equality in earnings between partners, and reduce HIV prevalence). Furthermore, interventions could be created for specific populations (e.g., targeted towards different religions or wealth status and married couples) to improve gender equality in heterosexual couples expecting a child in Kenya and Uganda. We found, through Aims 2 and 4, that there was no association between decision-making power and uptake of HIV self-testing, either as a couple (in Aim 2), or the male partner alone (Aim 4). There was also no association between male partner’s attitudes towards IPV and uptake of HIV self-testing from the male partner alone (Aim 4), but men with low acceptance of IPV were 2.5 times more likely to use the HIV self-testing kits as part of a couple compared to men with high acceptance of IPV (Aim 2), and in couples where the female partner had medium or low acceptance of IPV, the male partners were 1.76 and 1.82 times more likely to use the HIV self-testing kits than in couples where the female partner had high acceptance of IPV. Overall, this dissertation fills a gap in research on sociodemographic predictors of gender equality within a pregnancy context in Kenya and Uganda, and in research regarding the associations between gender equality and HIV self-testing uptake. Fighting the AIDS epidemic needs to involve efforts at all levels of the HIV continuum of care, as underscored by the 90:90:90 goal set forth by UNAIDS, in which 90% of all individuals living with HIV around the world should know their HIV status. This present work showing the importance of low acceptance of IPV in increasing HIV self-testing (both as a couple and the male partner alone) and discovering additional influences of HIV self-testing uptake are vitally important as we work towards achieving the first 90% of the tripartite goal.

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