Gender Norms and Structural Barriers to Use of HIV Prevention in Unmarried and Married Young Women in Manicaland, Zimbabwe: An HIV Prevention Cascade Analysis

Abstract

Background: Gender norms against adolescent girls and young women (AGYW)'s having pre-marital sex and using condoms in marriage are included as barriers to motivation to use condoms in HIV prevention cascades. Representative data on gender norms are needed to test this assumption.

Methods: General-population survey participants in Manicaland, Zimbabwe (ages≥15, N=9803) reported agreement/disagreement with statements on gender norms. AGYW at risk of HIV infection reported whether community views discouraged condom use. Multivariable logistic regression was used to measure associations between AGYW's perceiving negative gender norms and condom HIV prevention cascades.

Results: 57% of men and 70% of women disagreed that 'If I have a teenage daughter and she has sex before marriage, I would be ok with this'; and 41% of men and 57% of women disagreed that 'If I have a teenage daughter, I would tell her about condoms'. 32% and 69% of sexually-active HIV-negative unmarried AGYW, respectively, said negative community views were important in their decisions to use condoms and their friends were not using condoms. In each case, those who agreed had lower motivation to use condoms. Fewer unmarried AGYW with friends not using condoms used condoms themselves (39% vs. 68%; age- and site-adjusted odds ratios (aOR)=0.29, 95%CI, 0.15-0.55). 21% of men and 32.5% of women found condom use in marriage acceptable. 74% and 93% of married AGYW at risk, respectively, said negative community views influenced their decisions to use condoms and their friends did not use condoms. Fewer married AGYW reporting friends not using condoms were motivated to use condoms but no difference was found in their own condom use (4.1% vs. 6.9%; aOR=0.57, 95%CI, 0.08-2.66).

Conclusions: Negative gender norms can form a barrier to motivation to use condoms in unmarried and married AGYW at risk of HIV infection, and, for unmarried AGYW, to condom use.

Keywords: AGYW; HIV; HIV prevention cascades; Social norms; Structural barriers; Zimbabwe.

Figure 1.. HIV incidence in AGYW, Manicaland, Zimbabwe, 1998–2013.

Graph ( a): Trends over time in HIV incidence in AGYW. Graph ( b): HIV incidence in AGYW by sexual risk behaviour and marital status. AGYW: adolescent girls and young women.

Figure 2.. Numbers of survey participants providing data on social norms on AGYW’s sexual activity and use of HIV prevention methods and numbers of currently uninfected unmarried and married AGYW at risk of HIV infection.

*19 married AGYW have other partners and a regular partner who has other partners; 5 have a partner who is HIV-positive and also has other partners. AGYW: adolescent girls and young women.

Figure 3.. Condom HIV prevention cascades for unmarried and married AGYW at high risk of HIV infection, Manicaland, Zimbabwe, 2018/2019.

Horizontal dotted lines indicate 95% confidence intervals. Graph ( a): Unmarried AGYW at risk. Graph ( b): Married AGYW at risk. AGYW: adolescent girls and young women. Priority population: Priority population for using male condoms. i.e. HIV-negative AGYW who are at risk of acquiring HIV infection and therefore could benefit from using male condoms.

Figure 4.. Fully-adjusted odds ratio (aOR; diamonds) and 95% confidence interval (whiskers) for acceptance of a teenage daughter having sex before marriage by community location, relationship to an AGYW, and socio-demographic characteristics, Manicaland, Zimbabwe, 2018/2019.

Graph ( a): Male community members. Graph ( b): Female community members. AGYW: adolescent girls and young women. SES: socio-economic status. CGP: community group.

Figure 5.. Fully-adjusted odds ratio (aOR; diamonds) and 95% confidence interval (whiskers) for approval of telling a teenage daughter about condoms by community location, relationship to an AGYW, and socio-demographic characteristics, Manicaland, Zimbabwe, 2018/2019.

Graph ( a): Male community members. Graph ( b): Female community members. AGYW: adolescent girls and young women. SES: socio-economic status. CGP: community group.

Figure 6.. Fully-adjusted odds ratio (aOR; diamonds) and 95% confidence interval (whiskers) for acceptance of condom use in marriage by community location, relationship to an AGYW, and socio-demographic characteristics, Manicaland, Zimbabwe, 2018/2019.

Graph ( a): Male community members. Graph ( b): Female community members. AGYW: adolescent girls and young women. SES: socio-economic status. CGP: community group.

Figure 7.. Age- and community location-adjusted odds ratios (aOR; diamonds) and 95% confidence intervals (whiskers) for condom use at last sex and for gaps in the condom HIV prevention cascade in AGYW at high risk of HIV infection reporting structural barriers to use of condoms, Manicaland, Zimbabwe, 2018/2019.

Graph ( a): Unmarried AGYW at risk. Graph ( b): Married AGYW at risk. AGYW: adolescent girls and young women. SES: socio-economic status. CGP: community group. IPV: intimate partner violence.