Examining differentials in HIV transmission risk behaviour and its associated factors among men in Southern African countries

Sub-Saharan Africa, particularly Southern and Eastern Africa, bears the brunt of the global HIV/AIDS epidemic, with the highest number of deaths and infected individuals. While considerable research has examined HIV transmission risk behaviors in various population groups within the region, there's a notable lack of studies analyzing the combined effects of associated risk factors among men, especially in Southern Africa. This study aims to address this gap by investigating variations in HIV risk behaviors among men in the region and identifying associated factors. The high prevalence of HIV among men in Southern Africa, exceeding that of other sub-regions, necessitates urgent research into factors increasing infection risk. Although global HIV prevalence in men is decreasing, it remains alarmingly high in Southern and Eastern Africa, underscoring the need for enhanced sexual and reproductive health programming. This study seeks to improve understanding of the determinants of HIV risk behavior among men at both the individual and sub-regional levels, ultimately informing policy and program development to further reduce HIV prevalence.

Early studies in sub-Saharan Africa identified formal education as a risk factor for HIV/AIDS, but later research showed a reversal of this trend, with education positively influencing HIV prevention knowledge. More recent findings suggest a curvilinear relationship, with the association shifting from positive to negative as educational attainment increases. However, this requires further validation. Governments, supported by organizations like PEPFAR and UNAIDS, have implemented numerous HIV prevention programs focusing on information dissemination, promoting abstinence or monogamy, delayed sexual debut, consistent condom use, and medical male circumcision. Research points to a negative linear relationship between education and HIV infection rates. Despite Southern Africa having the highest HIV prevalence globally, there's limited research comprehensively examining the regional role of education and other factors influencing HIV risk behaviors in men. This study aims to address this gap, focusing on individual-level and contextual factors using pooled regional data from nationally representative cross-sectional surveys.

This study utilized data from the most recent Demographic and Health Surveys (DHS) for six Southern African countries: Lesotho, Mozambique, Namibia, South Africa, Zambia, and Zimbabwe. The DHS program employs a two-stage stratified cluster sampling technique, interviewing women aged 15-49 and men aged 15-59. Data were extracted from men's recode files (MR Datasets), focusing on sexually active men. The final analytical sample included 27,019 men (weighted). Three outcome variables measuring HIV risk behavior were analyzed: condom use during sex with the most recent partner (binary: 0=no, 1=yes); multiple sexual partnerships (binary: 0=one partner, 1=two or more); and HIV testing in the past 12 months (binary: 0=no, 1=yes). Independent variables included age, marital status, residence (urban/rural), education level, literacy, household wealth index, employment status, age at first sex, and circumcision status. All analyses accounted for the complex survey design using the "svy" command in Stata SE version 17.0. Descriptive analyses (percentages, counts) and chi-square tests were conducted. Multivariate binary logistic regression models were used to examine the determinants of HIV risk behaviors, both pooled and country-specific. Odds ratios (OR) and 95% confidence intervals (95% CI) were calculated. Ethical approval was obtained through the DHS program; data were publicly available and did not contain personally identifying information.

The proportion of men engaging in HIV transmission risk behaviors was high across Southern Africa. Two-thirds reported not using condoms during their last sexual encounter, and 22% had multiple sexual partners. Condom use varied widely across countries (18% in Mozambique to 58% in Namibia). Age, residence, marital status, and household wealth significantly influenced HIV risk factors. Education's association with condom use was positive only in Zambia and Mozambique. Delayed sexual debut correlated with reduced odds of multiple partnerships. HIV prevalence rates among men aged 15-59 ranged from 8.3% (Zambia) to 19.6% (Lesotho). Pooled multivariate analysis revealed that age, residence, household wealth, and employment status significantly associated with all three HIV risk factors. Older men had lower odds of condom use. Rural men and married/formerly married men were less likely to use condoms. Men from wealthier households were more likely to use condoms and those circumcised were also more likely. Older men had lower odds of multiple partnerships. Rural men and formerly married men had higher odds. Education was not associated with multiple partnerships. Wealthier men were more likely to have multiple partners. Circumcised men were also more likely to have multiple partners. Age, residence, marital status, education, household wealth, and employment status were all linked to HIV testing. Older men (25-44) had higher odds, while rural men had lower odds. Married/formerly married men were more likely to test. Educated and wealthier men were more likely to test. Country-level analyses revealed variations in how factors influenced condom use and HIV testing. Education positively impacted condom use only in Mozambique and Zimbabwe. Older men were less likely to use condoms in most countries, except Zimbabwe. Wealthier men were more likely to use condoms in several countries. Education's association with multiple partnerships varied by country. Education was positively associated with HIV testing in most countries. Older men were more likely to test in some countries, less likely in others.

This study's findings highlight the persistent challenge of high HIV transmission risk behaviors among men in Southern Africa, despite existing prevention efforts. The lack of consistent association between education and condom use in the pooled analysis suggests that education alone isn't sufficient to promote safer sex practices. The lack of association between education and multiple sexual partnerships underscores the complexity of this behavior, driven potentially by cultural norms or personal choices rather than knowledge. However, the positive association between education and HIV testing is encouraging and supports investing in education as a long-term intervention to improve HIV prevention. The significant country-level variations in the influence of various factors on HIV risk behaviors warrant region-specific interventions. Addressing the cultural practices and societal norms promoting risky sexual behaviors is crucial for behavior change campaigns.

This study reveals the significant role of education in driving HIV testing uptake among men in Southern Africa. Country-level variations highlight the need for tailored interventions. Factors like age, residence, marital status, wealth, and circumcision status are significantly associated with HIV risk behaviors. Investing in education can improve HIV testing rates. Re-evaluation of country-level HIV prevention programs is vital. Strengthening community-based behavior change communication (SBCC) programs is necessary to discourage risky behaviors, and comprehensive sexuality education for young men is essential. Further qualitative research is needed to explore socio-cultural factors underpinning risky behaviors among educated men.

The cross-sectional nature of the DHS data limits causal inferences. The inability to trace the dynamics of HIV risk behaviors across men's lifecycles necessitates future longitudinal studies. Data unavailability for other countries within the region restricts the study's geographical scope. However, the comprehensiveness of the male DHS datasets allows a detailed investigation of men's sexual behavior.