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Higher gender equality is associated with many human immunodeficiency virus HIV preventive behaviors, including HIV testing. However, there are no studies examining gender equality and HIV self-testing. We examined the associations between gender equality and couples' uptake of HIV self-testing among heterosexual couples expecting in central Kenya.
This analysis used data Oral sub for women and couples a HIV self-testing randomized intervention trial among pregnant women attending antenatal care and their male partners. The primary exposures were gender equality measured by the male partner's attitudes toward intimate partner violence, and the woman's report on her household decision making powerand the primary outcome was couples' uptake of HIV self-testing.
Generalized linear mixed models framework was used to for site-level clustering. In comparison to male partners reporting high acceptance of intimate partner violence, couples with male partners reporting medium acceptance odds ratio, 2. Gender equality measured by decision making power was not associated with couples' uptake of HIV self-testing. This study is the first of its kind to examine the association between gender equality and couples' HIV self-testing.
Higher gender equality, especially within sexual relationships, has been associated with many human immunodeficiency virus HIV preventive behaviors, including condom use, reduced partner concurrency, use of preexposure prophylaxis, use of HIV antiretroviral treatment, and decreased involvement in other sexually risky behaviors. A literature review assessing gender equality and sexual and reproductive health found that women who face violence within their relationship were less likely to access HIV testing services.
However, these studies were assessing HIV testing, traditionally accomplished in Kenya by Oral sub for women and couples of rapid blood tests in health clinics. This is the first study of its kind to study gender equality and how it is associated with couples' uptake of HST. To address this question, we used data from a randomized controlled trial of an HST intervention among heterosexual couples expecting in central Kenya.
Our aim was to identify the associations between gender equality measured by decision making power and attitudes toward intimate partner violence [IPV] and uptake of the couples' HST. We hypothesized that higher gender equality will be associated with higher uptake of HST by couples.
This analysis uses data from a HIV self-testing randomized intervention trial that was conducted in 14 separate clinics within 5 counties in central and eastern Kenya between July and February Women could participate in the study if they were at least 18 years old and pregnant, and attending antenatal clinic ANC for the first time in this pregnancy.
The women also had to have reported contact with their male partner not necessarily the father of the child at least once per week, believe their male partner was either HIV-negative or had unknown status at recruitment, and report that their male partner had not tested for HIV in the past 3 months before the study. If the women were concerned about a potential for violence from their male partner due to the topic of HIV testing, they were excluded due to safety concerns, but very few women were excluded for this reason.
Women were randomized into 1 of 3 arms after providing informed consent and completing a baseline questionnaire. Arm 1 was based on the standard Kenyan Ministry of Health card that invites the male partner to come to the Oral sub for women and couples clinic for a discussion on family health but did not mention HIV in the card.
Arm 2 included an enhanced invitation card that described not only family health, but the benefits of the male partner testing for HIV to prevent mother-to-child transmission of HIV. It is standard to test the woman for HIV as part of ANC care, but were given 2 kits to have the option of testing as a couple with their male partner. The women were interviewed 3 months after the baseline interview to assess the status of HIV testing for the male partner since the baseline interview, and the method of testing e. The male partners were also contacted at 3 months after the female baseline interview, and they were administered a questionnaire including variables from both the female baseline and the female 3-month follow-up surveys if they consented for an interview.
For this analysis, only the data from Arm 3 the intervention arm were used. At the time of the original trial, HST kits were not yet approved for use in Kenya, so the only way to acquire these kits was through participation in the RCT. Therefore, because the primary outcome in this current analysis was the use of HST kits, we limited the analysis to participants in the intervention arm, because participants in the control arms had no way of acquiring these kits.
The 2 primary exposure variables used in this study are 2 markers of gender equality—decision making power as assessed by the female, and attitudes toward IPV as reported by the male's personal attitudes. Decision making power was measured by the woman's report for the validated Household Decision Making Scale, a 3-item scale regarding the woman's decision making in 3 areas: visiting family or relatives, major household purchases, and daily household needs. During data analysis, each response to the 3 questions was dichotomized, and took on a value of 0 if the decision was made by her male partner or someone else, and a value of 1 if the woman reported that the decision was made by either herself or tly with her male partner.
An index was created by summing those 3 dichotomized responses to assess the level of decision making power by the female partner. This index took on a value of 0 if the woman made no decisions by herself or tly no decision making power1 if she made 1 or 2 decisions by herself or tly low decision making powerand 2 if she made all 3 decisions by herself or tly high decision making power. Attitudes toward IPV was measured by the male partner's report for the validated Violence Domain of the Gender Equitable Men Scale, a 5-question scale regarding hypothetical violence toward women, with answers of either agree score of 1 or disagree score of 3.
This binary variable took on 2 values: either couples' tested together using the HST kits, or they did not which included either testing together by other means or not testing together. Covariates included age of both the man and woman categorized from a continuous variable based on distributional balance Oral sub for women and couples, education primary or lower, or secondary or higheremployment status self-employed, employed for wages, or othermarital status currently married or not currently marriedHIV testing by the woman tested for HIV before or had notmale partner's alcohol and drug use currently using or not currently usingequality in earnings the proportion of household expenses met by the woman's earnings: none, less than a third, a third to a half, and more than halfand wealth index a composite measure of a household's cumulative living standard constructed by the International Demographic and Health Surveys Program.
Rasch modeling was performed in the original trial to create the wealth index, and then was Oral sub for women and couples into quartiles. SAS 9. Descriptive statistics were conducted with mean and SD for continuous variablesand proportions for categorical variables.
Cochran Mantel-Haenzel or Cochran-Armitage Trend tests were used for comparisons in bivariate analyses. Modeling was performed with a generalized linear mixed models framework to for clinic site-level clustering. The first set of analyses focused on gender equality as measured by attitudes toward IPV from the man's report, and the second set of analyses focused on gender equality as measured by decision making power from the woman's report as the primary exposure.
We ran sequential modeling for each set of analyses, first running unadjusted analysis, and then added sets of Oral sub for women and couples demographic variables and economic variables, and then all of the variables and behavioral variables. Written informed consent was obtained from all participants.
The current data analysis was performed on completely deidentified data and was deemed by the institutional review board of the Medical University of South Carolina to not be human subjects research. Overall, 1, women were enrolled and randomized into the study, with women enrolled and randomized into the intervention arm with the provision of the HST kitsand women were interviewed at the 3-month follow-up visit.
The original study attempted to reach all male partners in the intervention arm, and male partners were interviewed at the 3-month follow-up visit. Male partners were on average older than the women For women, the majority had a primary or lower education For the men, the majority had a secondary or higher education The variables that were ificantly different between male and female partners were age, education, religion, and employment. Overall, For decision making power, Those with low acceptance of IPV had 2. We did not find any statistically ificant for the association between decision making power with an index of decision making regarding major household purchases, daily household needs, and visiting family Oral sub for women and couples couples' uptake of HST, both with unadjusted and adjusted models.
In this study, we examined uptake of HST among heterosexual couples expecting in Kenya, where the pregnant women brought home 2 oral self-testing kits from ANC to present to her male partner for HIV testing. This study was conducted to examine the association between gender equality as measured by male partner's attitudes toward IPV, and woman's report of decision making power and uptake of HST uptake among these couples.
The decision making power index was not ificantly associated with couples' uptake of HST. However, among couples where the man had low acceptance of IPV, there was 2. Eighty-one percent of the participants tested together as a couple using the HST kits.
This high proportion underscores the promise of HST to increase testing rates, and corroborates other studies showing high acceptability of HST and high uptake of this testing method, 1314 including among male partners of pregnant women. Future research should examine the potential differences in HST uptake between more stable relationships, like these heterosexual primary partners expectingversus more casual sexual relationships. These show the benefits of appropriate attitudes regarding IPV on couples testing together using this new testing technology of HST.
Our suggest that if the male partner does not accept IPV, he may be more likely to be open for discussion within the partnership, and more willing to test for HIV with their female partner. Male partners less accepting of IPV may be more accepting of the scenario in which the pregnant female partner brings home self-testing kits from the clinic and initiates the discussion about HIV testing. If these individuals are more willing to test for HIV as a couple using these self-testing kits, and they do test positive, this could have important implications in reducing transmission of HIV between heterosexual partners in a relationship, and prevention of mother-to-child transmission of HIV.
Second, these findings highlight a potential dual intervention. A community-based HST study in Malawi found that fear of HIV discordant testunequal household gender roles, and couple dynamics were barriers for couples to self-test together. A community-level intervention trial in Uganda attempting to shift harmful social norms that promote gender inequality found that males in the intervention group, over a 1-year follow-up, were more likely to have an HIV test compared with controls.
There are several limitations in this study. This study population might be limited Oral sub for women and couples the generalizability of theas this analysis was limited to heterosexual couples expectingand women self-excluded from the original trial if they were concerned about IPV. Furthermore, IPV concerns or negative when offering self-testing could be different among the participants who were lost to follow-up, for which we have no data. However, the original trial had very high participation rates with very few women self-excluding due to IPV concerns.
There is also a limitation in the measurement of gender equality within this data. Gender equality cannot be generalized beyond how it is measured. In this study, gender equality was measured as attitudes toward IPV, and decision making power was measured by decision making regarding visiting family, major household purchases, and daily household Oral sub for women and couples. There could be other ways of measuring gender equality that were not captured in this analysis, including influences on HIV preventive behaviors like condom use or measures of relationship quality.
In summary, lower acceptance of IPV from the male partner of pregnant women in central Kenya is ificantly associated with more than double the odds of HST as a couple compared with couples in which the men had high acceptance of IPV. This study appears to be the first to investigate the relationship between gender equality and uptake of HST. The funding organizations had no role in this de of the original study, current analysis, interpretation of data, or manuscript writing. The authors declare that they have no conflict of interest. The original trial was approved by the institutional review board of the Kenya Research Medical Institute.
Written informed consent was obtained from all participants for the original trial. This article does not contain any studies with animals performed by any of the authors. The current data analysis was performed on completely de-identified data, and was deemed by the institutional review board of the Medical University of South Carolina as not human subject research.
National Center for Biotechnology InformationU. Sexually Transmitted Diseases. Sex Transm Dis. Published online Jul Caroline J. Jeffrey E. Author information Article notes Copyright and information Disclaimer. Correspondence: Caroline J. E-mail: moc. Received Feb 28; Accepted Jun Published by Wolters Kluwer Health, Inc. This is an open access article distributed under the Creative Commons Attribution 4. This article has been cited Oral sub for women and couples other articles in PMC. Methods This analysis used data from a HIV self-testing randomized intervention trial among pregnant women attending antenatal care and their male partners.
Conclusions This study is the first of its kind to examine the association between gender equality and couples' HIV self-testing. Measurements The 2 primary exposure variables used in this study are 2 markers of gender equality—decision making power as assessed by the female, and attitudes toward IPV as reported by the male's personal attitudes.
Data Analysis SAS 9. Open in a separate window. Health Psychol ; 35 — Gender inequalities, intimate partner violence and HIV preventive practices: findings of a South African cross-sectional study. Soc Sci Med ; 56 — Intimate partner violence functions as both a risk marker and risk factor for women's HIV infection: findings from Indian husband-wife dy.
Relationship power and sexual violence among HIV-positive women in rural Uganda. AIDS Behav ; 20 — Boer H, Mashamba MT. Gender power imbalance and differential psychosocial correlates of intended condom use among male and female adolescents from Venda, South Africa.
Br J Health Psychol ; 12 — Stephenson R. Community-level gender equity and extramarital sexual risk-taking among married men in eight African countries. Int Perspect Sex Reprod Health ; 36 — Accessed February 19, AIDS ; 20 — PLoS One ; 10Oral sub for women and couples
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