HIV Risk Assessment and Risk Reduction Strategies in the Context of Prevailing Gender Norms in Rural Areas of Cabo Delgado,Mozambique

Abstract

Since minimal information exists on how individuals work within existing social norms to reduce HIV risk, this study explored the specific factors influencing men and women to reduce their HIV risk in the face of prevailing gender norms in rural villages of Cabo Delgado, Mozambique. Qualitative data were gathered from 160 participants through 29 in-depth interviews to explore gender norms, HIV risk determinants, and risk reduction responses. Results were analyzed using adaptations of grounded theory and constant comparative analysis. Men and women who actively take measures to decrease their risk of HIV infection associate a partner’s acceptance of condom use and an HIV test as confirmation of emotional intimacy in the relationship. Other factors influencing risk reduction efforts include various levels of influence from family or peers, prior experience, relationship dynamics, and a reflection of broader personal outcomes.

Introduction

Socially prescribed gender roles often create power imbalances between men and women which in turn influence both HIV risk and prevention strategies. Studies conducted in Mozambique suggest the existence of widespread gender disparities in the social realm, such as a lack of access to HIV services and on the economic front, including minimal income generating opportunities, both of which can adversely affect HIV risk, particularly for women. ^1,2 Based on studies from South Africa, power inequalities in a relationship influenced the extent to which a woman was able to effectively negotiate safe sexual practices with her partner. ^3,4 Even when women had knowledge of HIV prevention, they identified the unsafe sexual behavior of their partner as HIV risk factors over which they had limited control and power. ^5,6

Partner selection and motivations for entering a relationship are closely intertwined with the manifestation of gender norms and HIV risk. In studies conducted in Nigeria and South Africa, risk assessment among youth was based on partner appearance and personality ^7,8 with condoms generally used with self-identified risky partners. ⁹ Protection against HIV is often foregone in relationships due to trust, love, desire to conceive, or emotional intimacy. ^10,11 Condom use has been linked to relationship duration, value, exclusivity, and communication with a partner based on findings from studies in Mozambique and Ghana. ^12,13 Trust is an important feature in relationships and often determines whether individuals will engage in risk reduction strategies, with condoms and an HIV test used most often when a partner’s trust is not easily ascertained. ¹⁴ Some men and women in Mozambique and elsewhere use protection but do so based on relationship type, with condoms generally used with casual rather than with primary partners. ^15,16

There is vast evidence on the mechanisms through which gender inequalities enhance HIV acquisition, yet minimal investigation has been conducted on how men and women within situations of gender inequalities negotiate risk reduction strategies which this study sought to address.

Study Setting

The study took place in rural villages of Mahate (~2706 inhabitants), Bilibiza (~4,056 inhabitants), Mieze (~4,109 inhabitants), and 25 de Junho (~4,034 inhabitants) in Cabo Delgado, Mozambique. ¹⁷ On the gender-related Development Index, Mozambique ranked 145 of 155 countries, indicating substantial disparities between men and women as measured through a healthy life, literacy, and standard of living. ¹⁸ Based on the 2009 AIDS Indicator Survey, the HIV prevalence rate among individuals aged 15 to 49 years was 9% in Cabo Delgado compared to 12% nationally. There are gender differences across HIV indicators in the province, with more men than women having knowledge of preventing HIV acquisition. Although many individuals have never had an HIV test, the rate for men in Cabo Delgado who had a test is much higher than that of women. ¹⁹

Methods

A qualitative design was employed using a 2-pronged approach: (a) 16 group discussions with 160 participants (age ranges between 15 and 68 years) and (b) 29 in-depth interviews. The group discussions helped elicit information on the definition of gender norms and assess HIV knowledge levels and its behavioral determinants. Respondents for the group discussion were selected based on purposive and nonrandom sampling and separated according to gender and marital status initially and then brought together for further probing. Two local research assistants, a man and woman were hired and trained in conducting group sessions and interviews in indigenous language. Individuals for in-depth interviews were drawn from group discussions (usually 1-2 per group) based on the following criteria: (1) demonstration of gender-balanced attitudes, beliefs, or practices or (2) stated measures, actions, or strategies to reduce HIV risk, with preference given to those individuals where the 2 criteria intersected. Since it was difficult to keep track of respondents who fulfilled both criteria simultaneously during the group session, only 1 of the 2 criteria was deemed sufficient to select an individual, with linkages to the other criterion explored in more detail during the interviews. The research adapted techniques from grounded theory to analyze the data using (a) line-by-line coding of all transcripts based on prior research as well as in vivo codes, (b) focused coding to subsume the initial 120 codes into more frequent and salient codes, and (c) thematic coding to help compare key codes across narratives (ie, risk assessment, partner categorization, gender roles, and responses). Constant comparative analysis, developed from grounded theory, was used to compare and contrast coded themes across gender and age groups. Interviews were digitally recorded and translated from local language into Portuguese by the research assistants and then into English by the lead researcher. The constant review of data, continuous debriefs with the research assistants, and detailed notes helped increase the validity of the findings. Ethics approval for the study was obtained from the London School of Hygiene and Tropical Medicine.

Results

Conceptualizing HIV/AIDS Risk

In accordance with HIV/AIDS data ¹⁷ on the key causes promulgating transmission in Mozambique, respondents indicate that low condom use in conjunction with men and women having multiple sexual partners contributes to the heightened spread of HIV/AIDS in their areas:

HIV/AIDS increases because people have many partners and they change women or men, these people have no control. We know we must use condoms but we don’t want to use it.—group of married men

Among both men and women, there is a widespread and pervasive fear of getting an HIV test due to the health consequences of an HIV-positive status or fear of being abandoned.

Others refuse to go and do a test, they are afraid that if the partner discovers this they are going to leave them.—group of married women

We fear going to the GATV (voluntary counseling and testing site) and being told that we have HIV/AIDS. I am afraid to get tested, when you are told that you are HIV positive that is where you want to hang yourself.—group of unmarried men

There are also many noted barriers to condom use among respondents including perceptions that condoms are responsible for the spread of HIV and a belief that condoms reduce pleasure during sex. Phrases such as “taste of sex” highlight the perceived interference of condoms in promoting pleasurable sexual activity.

Women don’t want to use condoms, they think it has the virus and they want to have sex without condoms to feel the taste of sex, we men also refuse.—group of married men and women

Many young men identify low levels of trust in a partner as a determinant of condom use. In such cases, condoms are used with women who are sought primarily for sexual enjoyment and who are generally not trusted by men vis-à-vis pregnancy prevention and disease acquisition. Many men also place the onus and responsibility of using protection on women even though they acknowledge that risky behaviors are practiced by both sexes.

Sometimes I use condoms with girlfriends who I don’t trust and those that I have fun with to prevent pregnancy and disease, but there are very few times I use a condom.—group of unmarried men

Women are responsible for forcing men to use a condom. Women must always use it because they don’t know if a man has [HIV/AIDS] or not.—group of married men and women

Women are often held responsible for suggesting condom use with their partner, which can be difficult to do when they feel powerless. Many women feel uncomfortable suggesting condom use because of its association with prostitution. Even in cases where women did try, men made convincing counterarguments to relinquish its use.

Here nobody prevents HIV/AIDS because we don’t like using condoms, when someone uses it we think that they are a prostitute.—group of married men and women

Sometimes us women, when we meet a boyfriend, he soon asks us to have sexual relations, he does not accept having sex with a condom, he speaks to us until we are convinced and soon we accept it.—interview with a female, 23 years, divorced

Consistent Adherence to Risk Reduction Strategies

There are some men and women who consistently engage in HIV risk reduction behavior with different partners regardless of the relationship status or gender views. These individuals engage in multiple risk reduction strategies including abstinence, abandonment, HIV testing, and/or condom use across a variety of partner types to minimize HIV acquisition.

Some women will undergo an HIV test with new partners as a way of ascertaining HIV status but also as a means to assess a partner’s emotional bond. Despite fears of HIV testing in the study population, 1 respondent uses an HIV test with casual partners to mitigate distrust; while with a boyfriend, it helps determine the extent of emotional intimacy he has for her. Though now widowed, this respondent admits a strong influence from her husband and acknowledges “I always obeyed everything that he told me . . . he started getting the HIV test and then always took me,” a practice she has carried on with all her subsequent partners. The respondent states that “since my husband’s death, I feel I am suffering, I just stay at home and wait for my family to help me,” a scenario which could lead to financial dependency on men and make it difficult to enact risk reduction strategies. Yet, it is the result of her husband’s actions which influences the respondent to insist on getting tested across all partner types:

If I don’t know a man’s behavior, I ask him to go to the hospital so we can get an HIV test and know our health status. If I am away and leave my boyfriend, when I return, we must get a test before we continue with our love. If he really loves me he will agree to get a test done, if not then he does not want me.—interview with a female, 45 years, widowed

Similar to the association of an HIV test with a partner’s love, some women will leave a relationship if their partner refuses to use a condom. Condom use acceptance is closely tied with emotional intimacy, which contrasts the widely practiced use of condoms with partners who cannot be trusted or where there is a lack of intimacy. In the following case, a respondent feels women in the community do not have much power to negotiate anything. She nonetheless took measures to abandon a previous marriage because of a husband’s infidelity and is also adamant about her decision to use condoms in all new relationships to prevent unwanted pregnancy and HIV:

When you have women with no power to talk, they practice sexual relations in any manner. We depend on men for money so it is tough without a man. With my first husband, he had other women and I didn’t like that so I left . . . I keep condoms and tell my partner that he is not able to be with me if he doesn’t use it, if he understands we will use it, if he refuses he can leave.—interview with a female, 38 years, divorced

Some women value the companionship of a partner, yet are determined to ward off the risk of HIV infection through multiple risk reduction efforts including condom use, getting an HIV test, and maintaining a relationship with only 1 man at a time. Consistent with other women, the respondent below feels that a partner’s refusal to use condoms indicates his lack of interest in her and the relationship. The respondent also gets an HIV test with all new partners in an effort to regulate her body and ensure a negative status. Although the respondent has assets from her now deceased husband and is able to generate an income: “I have two houses that my husband left for me and I get money from the rental of the house,” she still places value on a man’s role to provide resources. This stance, however, does not interfere with the desire to respect herself and control her body:

With this one friend, he has good behavior, he helps me when I need it, if he stops me from using a condom then he doesn’t like me, and I do not need him. Whenever I am with a man I get an HIV test to control my body. When I have a partner we stay together, people will never say that I change men, I am a person of respect, I still have not had a disease.—interview with a female, 50 years, widowed

Younger unmarried women report fearing HIV as a result of the uncertainty associated with the infection rather than feeling at any direct risk. Parental guidance and self-determination have been pivotal factors to ensure these young women not only finish their education but abide to a prevention strategy of avoiding sex until marriage. A future husband’s refusal to get an HIV test provides some insight into the type of behavior a woman can expect in the marriage:

I fear HIV/AIDS but do not feel at risk. If a man wants to have sex with me I will not accept, first we have to get married . . . Before we get married, we must get an HIV test, if he refuses to get an HIV test he will have to leave me . . . My mother gives me moral strength to go to school and says education is the future of tomorrow.”—interview with a female, 15 years, unmarried

Young men are overcoming norms that encourage condom use with outside women and instead believe that partner agreement to condom use is a sign of trust and love, consistent with the accounts of women. With strong influences from an uncle, the young man below uses a condom in all sexual encounters to avoid pregnancy and prevent disease. A woman who agrees to use protection, which is generally linked to notions of distrust in the study setting, is instead embraced by this man who believes it represents a woman who exhibits “good behavior”:

I was always told by my uncle that we have a disease with no cure and that without prevention I will die early, he told me if I can’t stay with only one girlfriend I must use a condom… When I get a girl I use a condom, if she refuses I leave and look for another one who will follow my example to avoid things like pregnancy and disease.—interview with a male, 20 years, unmarried

Prior experience with a girlfriend’s unfaithful behavior can motivate men to abandon the relationship and dissociate themselves from the “contaminated” behavior of others. Even though the respondent below believes that all “decisions should be made by a man because he is the head of the house,” he acts on these thoughts and takes action to minimize any potential HIV risk, and in doing so overcomes peer barriers discouraging condom use in sexual encounters with a primary partner:

She was my only girlfriend, but she behaved badly with my friend and for that I left her, I didn’t want to be contaminated . . . Yes I always use a condom, there are others with girlfriends who say that I cannot use a condom with my principal girlfriend, but I use it with all women.—interview with a male, 20 years, unmarried

Discussion

Consistent with other research from Mozambique and a variety of settings in sub-Saharan Africa and beyond, this study found that power imbalances in relationships determine whether women will discuss safer sex. ^{1,20 –22} Many leading gender and human sexuality theorists ^{23 –26} highlight the coexistence of multiple forms of masculinity and femininity which can transcend sexes based on experiences. Such notions were reaffirmed in this study in the context of HIV risk reduction where at times, men reconstructed widely accepted forms of masculinity, such as the display of power by insisting on the use of protection with partners across various relationship types. Similarly, women redefined norms of femininity (ie, passivity and dependence) by removing themselves from risky situations through self-efficacious actions.

This research found that emotional intimacy, past experience, relationship dynamics as well as peers and family influence risk reduction efforts among men and women, however, some of these factors can also exacerbate HIV risk. As noted in previous studies, peer influence is usually grounded in prevailing gender and social norms and can have either a positive ^12,27 or a negative effect on health practices. ^28,29 Some unmarried men in this study are questioning peer advice to engage in sex with multiple women and instead always use protection to protect their primary partner. Family influence has a very positive bearing on men and women to pursue less risky sexual situations as also noted in studies from South Africa. ^30,31 Unmarried men are influenced by family members encouraging them to remain monogamous and abiding by family advice to engage in condom use. Parental advice also plays a key role in influencing unmarried women to remain abstinent in order to prevent disease acquisition or to complete school. Individuals in this study associate a partner’s acceptance of risk reduction strategies as enforcement of emotional intimacy, highlighting shifting norms on safe sexual behavior.

Findings support widespread literature highlighting that gender disparities can place individuals in situations of heightened HIV risk, ^{32 –34} however, they also suggest that these disparities do not inhibit men and women from responding to perceived risk. There are some factors that are specific to individual cases such as relationship dynamics, family advice, and past experience, which in turn affect both risk and risk reduction. Recognizing how such factors influence behavior modification toward reduced risk should broaden their use including through the sharing of individual experiences with others via peer-to-peer approaches. Complementing this, concerted efforts should also link risk reduction with other outcomes salient to the population such as the desire to be a respected member of society as this may influence behavior and hold more intrinsic value than the resulting reduction in HIV risk.