Between a Rock and a Hard Place: How poverty and lack of agency affect HIV risk behaviors among married women in 25 African countries: A cross-sectional study

Background Gender inequality and poverty exacerbate the burden of HIV/AIDS among women in Africa. AIDS awareness and educational campaigns have been inadequate in many countries and rates of HIV testing and adherence to condom use remains considerably low, especially among married women. We investigate whether higher HIV knowledge is equally effective in lowering risky behaviors among groups of women with different levels of wealth and agency. Methods Pooled data on 113 151 adult married women from Demographic and Health Surveys (DHS) in 25 African countries was used (2010 to 2016). Agency was defined as women's ability to refuse sex and ask her partner to use a condom, plus have a role in decision making in household spending and health-related issues. The lowest tertile of DHS wealth index defined poverty. Questions about HIV prevention and mother-to-child transmission were used to create a scale for knowledge (0-5). Use of condom, HIV testing, absence of sexually transmitted disease (STD), and having one partner were dependent variables. Regression models investigated the effect of agency and knowledge as predictors of behaviors. Separate additional models were run to measure associations of each behavior with knowledge scores on groups of women divided by agency and poverty. Analyses were adjusted for demographic factors, history of pregnancy, wife-beating attitude, and country dummies. Results Significantly higher risk and lower level of protective factors exist for poor women who lack agency. Knowledge had positive associations with a better score in behavior, higher rate of condom use and testing for HIV both among poor and not poor women. When examining compound effects of agency and poverty, absence of agency reduces the positive effect of knowledge on lowering STD rate and overall behavior score among poor women. It also nullifies the effect of knowledge on condom use in both wealth groups. Conclusion Knowledge of HIV does not exert its potential protective effect when women live in poverty compounded with lack of agency. Success of anti-HIV programs should be tailored to dynamics of risk and sociocultural and economic context of target populations.