CHAPTER 5: PERCEPTION OF RISK OF HIV INFECTION
5.4 Perceived Personal Risk of HIV Infection
“We have a problem in Trevo neighbourhood. We have plenty of orphaned children because of AIDS. In fact, we are losing our children to this disease. In my block there are six people who are infected with HIV/AIDS and it seems that only one is taking treatment.”
(Urban married female, FGD # 04)
“I had a brother- in- law who was a truck driver. We used to tell him to be careful when you are on the road”, but unfortunately he died. He was a victim of AIDS.”
(Rural married male, IDI # 11)
This quote may serve as a clear example of the impact of HIV/AIDS on families and community.
On the other hand, however, it may reinforce the association of HIV/AIDS with particular groups of people such as truck drivers, sex workers, mine workers, etc. While these categories of people are vulnerable to HIV infection as the quotes show, the attitude that HIV/AIDS affects others may have some unintended consequences encouraging some people who are neither truck drivers nor mine workers, for example, to think that they are at low or no risk of HIV infection.
Furthermore, the widespread perception that the level of HIV/AIDS in the community is severe is also demonstrated by the comments of one HIV positive respondent who observed that there are many people in the community with similar physical symptoms as him.
“There are many cases here, but if a person does not tell you something, or does not do the test you will never know that he or she has this disease. But yes, there are many cases here.
We suspect HIV/AIDS when a person falls sick and does not get better, or when we see infections that cause death”.
(Rural married male, IDI # 13)
2007). To assess self-perceived risk of HIV infection respondents were asked: “Do you think your chances of getting HIV/AIDS are great, moderate, small, or no risk at all?” Table 5.4 shows the percentage of respondents by self-perceived risk of HIV infection.
Table 5.4 suggests that most respondents reported a low self-perceived risk of HIV infection. But men were more likely than women to report themselves at great or moderate risk of HIV infection. Almost equal proportions of men and women reported feeling little or no risk at all. On the other hand, women were more likely than men to report that they did not know if they were at risk of HIV infection. Thus, as can be noted in Table 5.4, 32 percent of interviewed men reported feeling that they were at great risk of HIV infection compared with 16 percent of women.
Seventeen of men reported feeling at moderate risk of HIV infection compared with 8 percent of women.
Table 5.4: Percentage of respondents by self-perceived risk of HIV infection
Men Women n % n % Level of perception of risk of HIV
Great 66 31.6 35 16.1 Moderate 36 17.2 18 8.3
Small 76 36.4 70 32.3 No risk at all 8 3.8 24 11.1 Living with HIV 2 1.0 0 0.0 Don’t know 21 10.0 70 32.3
Total 209 217
Of interest is the fact that quite a significant proportion of women were unable to report or specify the extent to which they perceived themselves at risk of HIV infection. Indeed, almost 32 percent of women in both study sites said that they did not know whether or not their chances of getting HIV infection were high, medium or even low compared with 10 percent of men. On the other hand, about 36 percent of men were more likely to report little risk of HIV infection compared with 32 percent of women. Furthermore, about 4 percent of men reported that they did not feel at risk of HIV infection at all compared with 11 percent of women. These findings seem
to be consistent with another study in Mozambique (Arnaldo, 2004). Two explanations can be made for these findings. First, differences in self-perceived risk of HIV infection suggests that, on one hand, the majority of women do not perceive themselves at risk of HIV infection, which may just reveal low risk perception of HIV infection among women. If this is true, these findings are very worrying in the current context of a generalized epidemic and low levels of voluntary counseling and testing. Second, self-perception of risk of HIV infection among men may reflect their own risky sexual behaviour (Maharaj, 2004; Kibombo et al., 2007). In other words, men who usually report risky sexual behavior are more likely to be aware that they are at risk of HIV infection.
To assess the association between perception of risk of HIV infection and each of the selected socio-economic and demographic characteristics, a bivariate analysis was applied. The selected background characteristics include place of residence, age, level of education, marital status, household socio-economic status, and number of sexual partners in the last 12 months.
Household socio-economic status was assessed using the Amenities Possession Index. The Amenities Possession Index comprises three values, namely low API, lower medium API and upper medium or high API. Respondents who reported that they were HIV positive (two males) were excluded from the analysis since it was felt that the question was not relevant for them.
Table 5.5 shows the percentage of respondents who reported great or moderate risk of HIV infection, by selected background characteristics.
The bivariate analysis indicates that place of residence and education has a strong association with self-perceived risk of HIV infection among women. Among men, however, no association is found. Looking at each one of the variables for men, the results indicate that rural men are slightly more likely to report being at great or moderate risk of HIV infection than urban men, with 51 percent of rural men reporting so compared with 47 percent of urban men. Men aged less than 35 years were also more likely than men aged more than 35 years to report being at great or moderate risk of HIV infection. Almost 51 percent of men aged less than 35 years reported being at great or moderate risk of HIV compared with 47 percent of men aged 35 or more years.
Education seems to have some influence on perception of risk among men, but the relationship is
not significant. Thus, 52 percent of men with secondary or higher education report being at great or moderate risk of HIV infection compared with 47 percent of men with less than secondary education. Men who were neither married nor cohabiting were more likely to report a higher risk of HIV infection than married and cohabiting men. On the other hand, men with a higher socio- economic status were more likely to report a higher risk of HIV infection than men with a lower socio-economic status. Men who reported two or more partners were more likely than men with one partner to report a higher risk of HIV infection. This may suggest that respondents are aware of the risk associated with multiple sexual partnerships, but this association was not significant.
Table 5.5: Percentage of respondents who reported a moderate or high risk of HIV infection, by selected background characteristics
Men Women n % n % Background characteristics
Place of Residence
Urban 106 47.2 111 32.4*
Rural 101 50.5 106 16.0 Age
Less than 35 134 50.7 159 24.5
35 or more 73 46.6 56 25.0
Level of Education
Less than secondary 125 47.2 157 19.7*
Secondary or higher 82 52.4 60 36.7
Marital Status
Currently married/ Living together 136 48.5 120 20.0 Neither 71 50.7 97 29.9 API
Low 43 41.9 67 19.4 Lower medium 58 50.0 50 22.0 Upper medium/high 106 51.9 100 29.0
Number of sexual Partners
1 115 45.2 201 22.9 2 + 91 53.8 16 43.8
All 207 217
Note: * significant P < 0.05 percent
The bivariate results for women suggest that urban women (32 percent) were more likely to report being at great or moderate risk of HIV infection than their rural counterparts (16 percent).
Table 5.5 shows no clear difference in reporting great or moderate risk of HIV infection among women by age. Indeed, women aged 35 years or more were as likely as the women aged less than 35 years to report being at great or moderate risk of HIV infection. Level of education has a strong effect on perception of risk of HIV infection among women. Women with secondary or higher education were more likely than women with primary education and those with no education to report a great or moderate risk of HIV infection. Thirty-seven percent of women with secondary or higher education reported a great or moderate risk of HIV infection compared with 20 percent of women with less than secondary education. Thus, as with place of residence, education is statistically significant for women. Marital status, although not statistically significant, also seems to influence self-perceived risk. Women who were neither married nor cohabiting (30 percent) were more likely to report a higher risk of HIV infection than married and cohabiting women (20 percent). Of interest is that women who reported two or more partners in the past 12 months were more likely than those with one partner to report a higher risk of HIV infection. This suggests that these women are aware of the implications of engaging in multiple sexual partnerships. However, other underlying factors may impel them to engage in multiple sexual partnerships. These results conform to what other studies have found with regard to some of the factors influencing perception of risk of HIV infection among women such as place of residence and level of education (Sheppard et al., 2001).
To investigate more thoroughly the factors influencing perception of risk of HIV infection among men and women, a logistic regression analysis was applied to assess the determinants of great or moderate risk of HIV infection. Thus, risk perception of HIV infection is the dependent variable with two values. If a respondent reported a great or moderate risk of HIV infection that value was coded “1” and it was coded “0” otherwise. The independent variables are place of residence, age, level of education, marital status, household socio-economic status and number of partners in the past 12 months. Two separate models were fitted for men and women. In Model I, the logistic regression analysis assesses the effects of each independent variable without controlling for other
variables. In Model II, the odds ratios of each variable are presented after controlling for other factors. Results are presented in Table 5.6 for men and Table 5.7 for women, respectively.
The logistic regression analysis results for men show that none of the characteristics have a statistically significant unadjusted effect on perception of risk of HIV infection. Nonetheless, more educated men are more likely to report a higher perceived risk of HIV infection than less educated men. Men with secondary or higher education were more likely to report a higher risk of HIV infection (odds ratios = 1.23).
Table 5.6: Odds ratios for men who reported a moderate or high risk of HIV infection by selected characteristics: logistic regression results
Odds ratios and 95% confidence intervals
Model I Model II Unadjusted Adjusted Place of Residence
Urban 1.00 1.00 Rural 1.19 (0.69 – 2.05) 1.65 (0.79 – 3.45)
Age
Less than 35 1.00 1.00
35 or more 0.85 (0.48 – 1.50) 0.87 (0.46 – 1.64)
Level of Education
Less than Secondary 1.00 1.00 Secondary or higher 1.23 (0.71 – 2.16) 1.25 (0.63 – 2.45)
Marital Status
Married/ living together 1.00 1.00 Neither 1.09 (0.61 – 1.94) 0.97 (0.48 – 1.97)
API
Low 1.00 1.00
Lower medium 1.39 (0.63 – 3.08) 1.45 (0.64 – 3.29) Upper medium/high 1.50 (0.73- 3.06) 1.93 (0.79 – 4.69)
Number of sexual Partners
1 1.00 1.00 2 + 1.41 (0.81 – 2.46) 1.39 (0.79 – 2.45)
Note: * significant P < 0.05 percent
Similar trends are observed with regard to marital status, household socio-economic status and number of partners in the past 12 months. For example, men who were neither married nor cohabiting were more likely than married and cohabiting men to report a higher risk of HIV infection. Men with a higher socio-economic status were also more likely to report a higher risk of HIV infection than men from a lower socio-economic status. Similarly, men who reported two or more partners were more likely than men with one partner in the last 12 months to report a higher risk of HIV infection (odds ratios = 1.41). After controlling for other variables, none of the independent variables have a statistically significant adjusted effect on perception of risk of HIV among men.
Table 5.7 shows the odds ratios of women who reported a great or moderate risk of HIV infection. The results of Model I show that place of residence and education have statistically significant unadjusted effects on self-perceived risk of HIV infection. Thus, women living in rural area were less likely than those living in urban area to report a higher risk of HIV infection (odds ratios = 0.40). Similarly, women with secondary or higher education were two times more likely than those with less than secondary education to report a higher risk of HIV infection (odds ratios = 2.35).
Table 5.7: Odds ratios for women who reported a great or medium risk of HIV infection by selected characteristics: logistic regression results
Odds ratios and 95% confidence intervals
Model I Model II Unadjusted Adjusted Place of Residence
Urban 1.00 1.00 Rural 0.40* (0.20 – 0.78) 0.52 (0.22 – 1.24)
Age
Less than 35 1.00 1.00
35 or more 1.03 (0.51 – 2.08) 1.52 (0. 69 – 3.35)
Level of Education
Less than Secondary 1.00 1.00 Secondary or higher 2.35* (1.22 – 4.54) 1.67 (0.76 – 3.68)
Marital Status
Married/ living together 1.00 1.00 Neither 1.71 (0.91 – 3.18) 1.51 (0.77 – 6.20) API
Low 1.00 1.00
Lowe medium 1.17 (0.46 – 2.89) 1.26 (0.49 – 3.23) Upper medium/high 1.70 (0.81- 3.57) 0.10 (0.41 – 2.42)
Number of sexual Partners
1 1.00 1.00 2 + 2.62 (0.93 – 7.42) 2.06 (0.69 – 6.20)
Note: * significant P < 0.05 percent
Other variables do not have a statistically significant unadjusted effect on perception of risk of HIV infection. Meanwhile, after controlling for all variables, place of residence and education are no longer statistically significant. This is of interest because it suggests that people’s attitudes and behaviour are influenced by a multitude of factors where a given direction caused by one factor may change or lose its strength as a result of an interaction of different factors.
During the focus group discussions and in-depth interviews the questions related to the perception of risk of HIV infection among men and women who participated in the study were asked as follows: “Do you think that both men and women in this area are aware of the risk of HIV infection?” The empirical evidence from both focus group discussions and in-depth
interviews indicate that in general men and women perceived themselves at risk of HIV infection.
Interestingly, however, neither men nor women associated their risk of HIV infection to their own sexual behaviour. They felt that they were at risk of because of their surrounding circumstances such as the harsh living conditions as well as their partner’s sexual behaviour.
Several accounts from the interviews suggest that male control of economic resources, particularly money, seems to play a critical role in exposing them and their partners to the risk of HIV infection. It was highlighted during the interviews that a man even with just a ‘little’ money may feel that he is in a position to easily meet or satisfy his sexual needs. For example, some men during focus group discussions argued that when a man has even a ‘little money’ and meets a woman in the street he feels empowered to just ‘take’ her to have sex. This can be illustrated in the quote below.
“When a man has got his ‘little of money’ and meets a woman in the street he just takes her to have sex. Sometimes, he does not carry a condom to protect himself. The same thing might happen tomorrow and after tomorrow. This may increase their risk of HIV infection”.
(Urban non-married males, FGD # 17)
Denialism seems to be another obstacle to personal perception of risk of HIV infection. It seems that the majority of respondents had heard of AIDS and was aware of the dangers of unprotected sexual intercourse and some also knew people living with HIV/AIDS but they did not feel personally at risk of HIV infection.
“Nowadays the slogan is ‘be faithful to one another’. But it seems that both men and women are competing in having sexual partners. But if they do this, they must use condoms. They must like their bodies, and avoid diseases. I think there is a kind of ‘ignorance’ among people.
My brother-in-low usually says: ‘AIDS does not exist’. So it is not because people do not have information. It is not because he does not hear or he does not see. I have relatives who have already died of AIDS. When he is told that this might be HIV/AIDS, he just refuses. He says: ‘no, it is not’. When he goes to the hospital, I ask him what the doctor said, he answer: ‘the doctor
said nothing’. The big challenge is that people blame witchcraft or they feel that they will never get infected. They tend to think that it happens to others”.
(Urban non-married females, FGD #02)
There is a tendency for some people to pretend that HIV/AIDS is not their problem, but ‘a problem of others’. In other words, they will ‘deny’ the problem and rather evoke supernatural forces such as witchcraft as the cause of their illness. However, denialism is directly related to fear of stigma and discrimination. In a society in which beliefs about witchcraft are still strong, if one can manage to sell the idea that they are the victim of witchcraft, the society will take pity on them, but if they are perceived to be suffering from HIV/AIDS, the society will blame them and they will experience feelings of embarrassment and shame.
Furthermore, fatalistic ideas may exacerbate low perceived risk of HIV/AIDS. In addition, personally knowing someone who was either living or had died of AIDS may lead some people to think that death is inevitable, it is better to die having had sex instead of dying without having had sex. In this regard, sex is viewed as the ultimate reward before death arrives.
“We know that AIDS exists. But when you have a chance to have sex, you just forget it. I had gonorrhoea twice. The first time I had it, I started feeling the symptoms two days after having had sexual intercourse. I went to the health care centre and they told me that I had gonorrhoea and they gave me a prescription. I followed the prescription and I told my girlfriend to go there and she also followed the prescription. After some time, I had sex with her again and I was again infected. I do not know whether I was careless or the medicine they gave me was not helping but the truth is that I had another treatment, it was then that I learned that I had to use condoms”.
(Urban non-married men, FGD # 18)
“Sometimes we have unprotected sex because we have in mind that we will die anyway whether we will use condoms or not. So why should we use them? When I talk with my friends
and we discuss AIDS, some ask why we should use condoms. If we are going to die, we rather die with a full stomach”
(Urban non-married men, FGD # 18)
These two quotes encapsulate graphically the many contexts of sexual risk that men, particularly young men experience in the study sites. For example, the respondent told his personal sexual stories in a focus group discussion with a little bit of pride. He talked about the two times he got a sexually transmitted infection which shows that he is a man and he has had sexual intercourse regularly, even if in a dangerous way. He shows no remorse for his risky sexual behaviour. In addition, he speaks about some of the conversations he has had with peers about the real need for using condoms. In order to minimize the importance of condoms, he and his peers evoke the inevitability of death. If condoms are available they can be used, but if not, they will prefer to have sex without a condom instead of postponing having sex.
Sometimes women do not think about their personal risk of HIV infection. They are more concerned about surviving in the face of difficult socio-economic conditions. This is particularly true for some women for whom securing a relationship is more vital than trying to impose some conditions in their relationships. The quotes below may illustrate this.
“Look, I have a sexual relationship with a married man. I cannot prohibit him to have other partners, because when we started this relationship, he already had others. We do not use condoms”
(Rural non-married female, IDI # 04)
“I think sometimes, a married woman is afraid to demand her husband to use a condom because she may end up being beaten. For the husband, her request may be understood as lack of trust. In addition, if they had children, they have to explain to one another why condoms are now necessary in the relationship”
(Urban married female, IDI # 08)