It’s not just who you are but where you live: An exploration of community influences on individual HIV status in rural Malawi

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Abstract

Approximately 1 million people are infected with Human Immunodeficiency Virus (HIV) in Malawi. Despite efforts aimed at changing individual risk behaviors, HIV prevalence continues to rise among rural populations. Both previous research and the Political Economy of Health framework suggest that community-based socio-economic factors and accessibility may influence HIV transmission; however, these community factors have received little empirical investigation. To fill this gap, this research uses data from a nationally representative probability sample of rural Malawians combined with small area estimates of community socio-economic and accessibility data in logistic regression models to: 1) reveal relationships between community factors and individual HIV status; 2) determine whether these relationships operate through individual HIV risk behaviors; and 3) explore whether these associations vary by gender. Community socio-economic factors include relative and absolute poverty; community accessibility factors include distance to roads, cities, and public health facilities. Individual HIV risk behaviors include reported condom use, sexually transmitted infections, multiple partnerships, and paid sex. Results show that higher community income inequality, community proximity to a major road, and community proximity to a public health clinic are associated with increased odds of HIV for women. For men, community proximity to a major road and community proximity to a public health clinic are associated with increased odds of HIV infection. These direct relationships between community factors and individual HIV status are not mediated by individual HIV risk behaviors. The Political Economy of Health frames the discussion. This study provides evidence for expanding HIV prevention efforts beyond individual risk behaviors to consideration of community factors that may drive the HIV epidemic in rural Malawi.

Research highlights

► We explore relationships between community factors, risk behavior, and HIV status in rural Malawi. ► Geographic Information Systems are used to combine community data and individual behavioral data. ► Community factors significantly influence individual HIV status for men and women in rural Malawi. ► The Political Economy of Health framework provides support for interpretation and discussion. ► HIV prevention efforts should expand to consider the contextual factors that may drive the epidemic.

Introduction

Malawi, like many of its sub-Saharan African neighbors, is fighting a generalized HIV epidemic. Approximately 1 million people are infected (USAID, 2008): 10% of men aged 15–54 years and 13% of women aged 15–49 years nationwide (National Statistical Office Malawi, 2005). Known, individual risk behaviors shape the presence and patterns of HIV in Malawi (Barden-O’Fallon et al., 2004, Helleringer and Kohler, 2007, Watkins, 2004). According to the 2004 Malawi Demographic and Health Survey (MDHS), only 30% of women and 47% of men reported condom use with their last non-regular partner; over 20% of men and women who recently reported a sexually transmitted infection were HIV positive; and men who spent more than one month away from home were 4% more likely to be infected than men who did not migrate (National Statistical Office Malawi, 2005). Moreover, multiple partnerships, with or without monetary exchange, are evident for both sexes in Malawi (Kaler, 2004, Swidler and Watkins, 2007, Tawfik and Watkins, 2007). In the 2004 MDHS, 10% of all men, and 19% of men from the Northern Region, reported 2 or more sexual partners in the last 12 months; 2% of women reported similar behavior (National Statistical Office Malawi, 2005). In Malawi, men and women may use condoms only when they perceive an increased risk of HIV infection (Tavory & Swidler, 2009).

Malawi, also like many of its neighbors, still struggles to prevent new HIV infections. Despite 25 years of programming and policy efforts aimed at changing individual risk behaviors, HIV continues to spread in Malawi and in other parts of sub-Saharan Africa (Halperin et al., 2004). In Malawi, prevalence rates may be increasing in rural areas (Bello, Chipeta, & Aberle-Grasse, 2006) where over 80% of the population lives. Often overlooked is that individual health is linked to where an individual lives and that similar people behave differently in different places (Diez Roux, 2004, Duncan et al., 1998, Entwisle, 2007). Community behaviors and norms affect HIV risk (Bingenheimer, 2010, Uthman et al., 2009). Recent research suggests that patterns of HIV prevalence may also be influenced by community socio-economic factors and access to resources (Gabrysch et al., 2008, Kalichman et al., 2006, Kleinschmidt et al., 2007, Lachaud, 2007, Msisha et al., 2008, Tanser et al., 2009, Weir et al., 2003, Weir et al., 2004). However, community factors cannot directly cause HIV. Theoretical models are critical to explore the mechanisms that link community-based factors to health behaviors and to health outcomes (Macintyre, Ellaway, & Cummins, 2002). To date, few studies use a theory-driven, empirical approach to explore influences of community factors on HIV risk in sub-Saharan Africa. Examination and explication of community effects, supported by sound theoretical models, may provide new insight into the drivers of HIV and inform innovative, multi-level interventions to help assuage the epidemic.

Section snippets

Theoretical grounding

Behavior is more than a matter of personal choice. According to the Political Economy of Health (PEH) framework, individual responsibility for poor health outcomes such as HIV may be limited by community-based inequalities based on class, ethnicity, race, or gender that foster economic deprivation, social isolation, inequitable power structures, and inadequate healthcare (Altman, 1999, Doyal and Pennell, 1979, Hunter, 2007, Parker et al., 2000). These forces create a “risk environment” where

Study overview

This study examines the relationships between community factors and individual HIV status in rural Malawi using data from a nationally representative sample of rural Malawians linked with small area estimates of community socio-economic and accessibility data using Geographic Information Systems (GIS). We employ the PEH framework to guide conceptualization, interpretation, and discussion of results. To explore possible causal mechanisms, we consider whether relationships between community

Data and measures

This study was submitted to the Institutional Review Board (IRB) the University of North Carolina, Chapel Hill. The IRB declared the study exempt because it was secondary, publically available data.

Bivariate analysis

Sample demographic and behavioral characteristics, by gender, are detailed in Table 1. Bivariate logistic regression models show associations by gender between HIV status and key community and individual HIV risk behaviors (considered in the summary dichotomous mediator variable and individually) (Table 2). A linear trend is evident in the relationship between distance to an MoH clinic and individual HIV status as well as between distance to a major road and individual HIV status (not shown);

Discussion

Among rural populations in Malawi, community socio-economic and accessibility factors are significantly associated with individual HIV status above the contribution of individual demographics and HIV risk behaviors, and these relationships vary by gender. Income inequality increases the likelihood of HIV infection only for women while distances to a major road and an MoH clinic are significant predictors for both genders. The relationship between distance to a public clinic and HIV status

Conclusion

To the authors’ knowledge, this is the first study that examines whether and how community socio-economic and accessibility factors influence HIV status in rural Malawi, and if these relationships vary by gender, offering a unique opportunity to examine multiple linkages between people and place in the context of HIV in sub-Saharan Africa. The significance of community factors, especially for women, affirms the linkages between HIV and social, economic, and gender-based inequality. These

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