Our study has several implications for HIV programs promoting condom use at primary, secondary and tertiary levels in Botswana. Ultimately, primary intervention is the main goal to ensure that there are no new cases of HIV. These interventions include developing gender responsive strategies addressing gender inequalities affecting women’s vulnerability to HIV. This can be achieved by promoting advancement of women’s education through government initiatives such as education grants for women, and delivering sexual health information on condom use using media platforms (pamphlets, billboards, radio, television) accessible to different levels of literacy. HIV programs need to be tailored for women with abusive and controlling partners. Both women and men should be educated on openly discussing sexuality and condom negotiation skills. This also includestraining targeted at men, on violence against women as a component of gender and sexuality training. Referral services such as women's groups, counseling services, peer support groups and shelters should be provided for women experiencing partner violence.
Condom socially marketing and condom use messages must targeted at cohabiting and polygamous relationships to encourage continually use of condoms within these relationships. At the secondary level, condom use campaigns should be targeted at women who are HIV positive and sero-discordant couples. Finally, there is a need to further explore the influence of gender beliefs on relationship power and intimate partner violence and their downstream effects on women’s condom use and HIV risk.
REFERENCES
1. World Health Organisation. HIV/AIDS Factsheet 2017 [8 Novemebr 2017]. Available from:
http://www.who.int/mediacentre/factsheets/fs360/en/.
2. Joint United Nations Programme on HIV/AIDS Global report. UNAIDS gap report on the global AIDS epidemic. Geneva: UNAIDS, 2014.
3. UNAIDS. UNAIDS Botswana HIV Epidemic Profile, 2014. Geneva: UNAIDS, 2014.
4. Botswana Statistics. Botswana AIDS Impact Survey IV (BAIS IV),2013. Gaborone Botswana: Botswana Statistics, 2013.
5. Pulerwitz J, Amaro H, De Jong W, Gortmaker SL, Rudd R. Relationship power, condom use and HIV risk among women in the USA. AIDS care. 2002;14(6):789-800.
6. Weller S, Davis-Beaty K. Condom effectiveness in reducing heterosexual HIV transmission (Review). The Cochrane Library. 2007;4:1-24.
7. Pinkerton SD, Abramson PR. Effectiveness of condoms in preventing HIV transmission. Social science & medicine. 1997;44(9):1303-12.
8. Amaro H, Raj A. On the margin: Power and women's HIV risk reduction strategies. Sex roles. 2000;42(7- 8):723-49.
9. Mumtaz Z, Slaymaker E, Salway S. Condom use in Uganda and Zimbabwe: exploring the influence of gendered access to resources and couple-level dynamics. A Focus on Gender. 2005:117.
10. Jewkes RK, Levin JB, Penn-Kekana LA. Gender inequalities, intimate partner violence and HIV preventive practices: findings of a South African cross-sectional study. Social science & medicine. 2003;56(1):125-34.
11. East L, Jackson D, O'Brien L, Peters K. Condom negotiation: experiences of sexually active young women. Journal of advanced nursing. 2011;67(1):77-85.
12. Shannon K, Leiter K, Phaladze N, Hlanze Z, Tsai AC, Heisler M, et al. Gender inequity norms are associated with increased male-perpetrated rape and sexual risks for HIV infection in Botswana and Swaziland. PloS one. 2012;7(1):e28739.
13. Botswana Government. Botswana National Policy on HIV and AIDS Policy 2012. Botswana: Botswana Government, 2012.
14. Agency NAC. Botswana AIDS Response Progress Report, 2014. Botswana: National AIDS Coordinating Agency, 2015.
15. Alene KA. Consistent condom use among sexually active HIV-positive women in Amhara region, Ethiopia. Open Access Journal of Contraception. 2014;5:85-90.
16. Akhlaghi L SB, Smith A,. Condom programming. National condom quantification and supply chain strengthening. Botswana: USAID, 2013.
17. Pallin SC DM, O. Lupu, K. Longfield,. A Total Market Approach.PSI/UNFPA Studies Joint Studies on the Total Market for Male Condoms in Six African Countries. Botswana: PSI/UNFPA, 2013.
18. Botswana Government. Progress Report of the National Response to the 2011 Declaration of Commitments on HIV and AIDS Botswana. Botswana: National AIDS Coordinating Agency, 2011.
19. Botswana Statistics. Botswana AIDS Impact Survey III (BAIS III),2008. Gaborone Botswana: Botswana Statistics, 2008.
20. Reis RK, Melo ES, Gir E. Factors associated with inconsistent condom use among people living with HIV/Aids. Rev Bras Enferm. 2016;69(1):40-6.
21. Maharaj P, Cleland J. Condom use within marital and cohabiting partnerships in KwaZulu‐Natal, South Africa. Studies in family planning. 2004;35(2):116-24.
22. Ayiga N. Rates and predictors of consistent condom-use by people living with HIV/AIDS on antiretroviral treatment in Uganda. Journal of Health, Population and Nutrition. 2012:270-80.
23. Costa EC, Oliveira R, Ferreira D, Pereira MG. Predictors of consistent condom use among Portuguese women attending family planning clinics. AIDS care. 2016;28(1):119-23.
25. Prata N, Vahidnia F, Fraser A. Gender and relationship differences in condom use among 15-24-year-olds in Angola. International family planning perspectives. 2005:192-9.
26. Baiden P, Rajulton F. Factors influencing condom use among women in Ghana: an HIV/AIDS perspective. SAHARA-J: Journal Of Social Aspects Of HIV/AIDS. 2011;8(2):46-54.
27. Langen TT. Gender power imbalance on women's capacity to negotiate self-protection against HIV/AIDS in Botswana and South Africa. African health sciences. 2005;5(3):188-97.
28. Bobrova N, Sergeev O, Grechukhina T, Kapiga S. Social‐Cognitive Predictors of Consistent Condom Use Among Young People in Moscow. Perspectives on Sexual and Reproductive Health. 2005;37(4):174-8.
29. Crosby RA, DiClemente RJ, Salazar LF, Wingood GM, McDermott-Sales J, Young AM, et al. Predictors of consistent condom use among young African American women. AIDS and Behavior. 2013;17(3):865-71.
30. Blanc AK. The effect of power in sexual relationships on sexual and reproductive health: an examination of the evidence. Studies in family planning. 2001;32(3):189-213.
31. Jama Shai N, Jewkes R, Levin J, Dunkle K, Nduna M. Factors associated with consistent condom use among rural young women in South Africa. AIDS care. 2010;22(11):1379-85.
32. Verma RK, Pulerwitz J, Mahendra V, Khandekar S, Barker G, Fulpagare P, et al. Challenging and changing gender attitudes among young men in Mumbai, India. Reproductive health matters. 2006;14(28):135-43.
33. Chakrapani V, Newman PA, Shunmugam M, Dubrow R. Prevalence and contexts of inconsistent condom use among heterosexual men and women living with HIV in India: implications for prevention. AIDS patient care and STDs. 2010;24(1):49-58.
34. Seth P, Raiford JL, Robinson LS, Wingood GM, DiClemente RJ. Intimate partner violence and other partner-related factors: correlates of sexually transmissible infections and risky sexual behaviours among young adult African American women. Sexual health. 2010;7(1):25-30.
35. Ingersoll KS, Ceperich SD, Nettleman MD, Johnson BA. Risk drinking and contraception effectiveness among college women. Psychology and Health. 2008;23(8):965-81.
36. Magni S, Christofides N, Johnson S, Weiner R. Alcohol use and transactional sex among women in South Africa: results from a Nationally Representative Survey. PloS one. 2015;10(12):e0145326.
37. Dunkle KL, Wingood GM, Camp CM, DiClemente RJ. Economically motivated relationships and transactional sex among unmarried African American and white women: results from a US national telephone survey. Public Health Reports. 2010;125(4_suppl):90-100.
38. Tarkang E. Condom use and number of sexual partners among secondary school female students in an urban city of Cameroon. Rwanda Journal of Health Sciences. 2013;2(2):30-3.
39. Ruzagira E, Wandiembe S, Abaasa A, Bwanika AN, Bahemuka U, Amornkul P, et al. HIV incidence and risk factors for acquisition in HIV discordant couples in Masaka, Uganda: an HIV vaccine preparedness study. PloS one. 2011;6(8):e24037.
40. Messman-Moore TL, Walsh KL, DiLillo D. Emotion dysregulation and risky sexual behavior in revictimization. Child abuse & neglect. 2010;34(12):967-76.
41. Argento E, Muldoon KA, Duff P, Simo A, Deering KN, Shannon K. High prevalence and partner correlates of physical and sexual violence by intimate partners among street and off-street sex workers. PloS one. 2014;9(7):e102129.
42. Wingood GM, DiClemente RJ. Gender-related correlates and predictors of consistent condom use among young adult African-American women: A prospective analysis. International journal of STD & AIDS. 1998;9(3):139-45.
43. Decker MR, Miller E, Raj A, Saggurti N, Donta B, Silverman JG. Indian men's use of commercial sex workers: prevalence, condom use, and related gender attitudes. Journal of acquired immune deficiency syndromes (1999). 2010;53(2):240.
44. Das M, Ghosh S, Verma R, O'Connor B, Fewer S, Virata MC, et al. Gender attitudes and violence among urban adolescent boys in India. International Journal of Adolescence and Youth. 2014;19(1):99-112.
45. Senn TE, Carey MP. Child maltreatment and women’s adult sexual risk behavior: Childhood sexual abuse as a unique risk factor. Child maltreatment. 2010;15(4):324-35.
46. Brown JL, Young AM, Sales JM, DiClemente RJ, Rose ES, Wingood GM. Impact of Abuse History on Adolescent African American Women's Current HIV/STD-Associated Behaviors and Psychosocial Mediators of HIV/STD Risk. Journal of aggression, maltreatment & trauma. 2014;23(2):151-67.
47. Walsh K, Latzman NE, Latzman RD. Pathway from child sexual and physical abuse to risky sex among emerging adults: The role of trauma-related intrusions and alcohol problems. Journal of Adolescent Health. 2014;54(4):442-8.
48. Petrak J, Byrne A, Baker M. The association between abuse in childhood and STD/HIV risk behaviours in female genitourinary (GU) clinic attendees. Sexually Transmitted Infections. 2000;76(6):457-61.
49. Certain HE, Harahan BJ, Saewyc EM, Fleming MF. Condom use in heavy drinking college students: The importance of always using condoms. Journal of American College Health. 2009;58(3):187-94.
50. Munoz FA, Pollini RA, Zuniga ML, Strathdee SA, Lozada R, Martinez GA, et al. Condom access: Associations with consistent condom use among female sex workers in two northern border cities of Mexico. AIDS education and prevention : official publication of the International Society for AIDS Education. 2010;22(5):455-65.
51. Scott-Sheldon LA, Carey MP, Vanable PA, Senn TE, Coury-Doniger P, Urban MA. Alcohol consumption, drug use, and condom use among STD clinic patients. Journal of Studies on Alcohol and Drugs. 2009;70(5):762- 70.
52. Choudhry V, Ambresin A-E, Nyakato VN, Agardh A. Transactional sex and HIV risks-evidence from a cross-sectional national survey among young people in Uganda. Global health action. 2015;8.
53. Baba-Djara M, Brennan A, Corneliess C, Agyarko-Poku T, Akuoko K, Opoku KB, et al. Using what you have to get what you want”: Vulnerability to HIV and prevention needs of female post-secondary students engaged in transactional sex in Kumasi, Ghana A qualitative study. Ghana January. 2013.
54. Leigh BC. Alcohol and condom use: a meta-analysis of event-level studies. Sexually transmitted diseases. 2002;29(8):476-82.
55. Doherty IA, Shiboski S, Ellen JM, Adimora AA, Padian NS. Sexual bridging socially and over time: a simulation model exploring the relative effects of mixing and concurrency on viral sexually transmitted infection transmission. Sexually transmitted diseases. 2006;33(6):368-73.
56. Zembe YZ, Townsend L, Thorson A, Ekström AM. Predictors of inconsistent condom use among a hard to reach population of young women with multiple sexual partners in peri-urban South Africa. PloS one. 2012;7(12):e51998.
57. Gorman BK, Bohon SA. HIV testing, perceptions of AIDS risk, and condom use motivation among US women. Population Research and Policy Review. 2001;20(4):321-43.
58. Allen S, Tice J, Van de Perre P, Serufilira A, Hudes E, Nsengumuremyi F, et al. Effect of serotesting with counselling on condom use and seroconversion among HIV discordant couples in Africa. Bmj. 1992;304(6842):1605-9.
59. Earl A, Albarracín D. Nature, decay, and spiraling of the effects of fear-inducing arguments and HIV counseling and testing: a meta-analysis of the short-and long-term outcomes of HIV-prevention interventions. American Psychological Association; 2007.
60. Fladseth K, Gafos M, Newell ML, McGrath N. The impact of gender norms on condom use among HIV- positive adults in Kwazulu-Natal, South Africa. PLoS One. 2015;10(4):e0122671.
61. Thompson NJ, Potter JS, Sanderson CA, Maibach EW. The relationship of sexual abuse and HIV risk behaviors among heterosexual adult female STD patients. Child Abuse & Neglect. 1997;21(2):149-56.
62. Harrison A, O'Sullivan LF, Hoffman S, Dolezal C, Morrell R. Gender role and relationship norms among young adults in South Africa: measuring the context of masculinity and HIV risk. Journal of Urban Health. 2006;83(4):709-22.
63. Dunkle KL, Jewkes RK, Brown HC, Gray GE, McIntryre JA, Harlow SD. Gender-based violence, relationship power, and risk of HIV infection in women attending antenatal clinics in South Africa. The lancet. 2004;363(9419):1415-21.
64. Muldoon KA, Deering KN, Feng CX, Shoveller JA, Shannon K. Sexual relationship power and intimate partner violence among sex workers with non-commercial intimate partners in a Canadian setting. AIDS care.
65. Pulerwitz J, Gortmaker SL, DeJong W. Measuring sexual relationship power in HIV/STD research. Sex Roles. 2000;42(7-8):637-60.
66. Thomas J. Women's lack of control in relationships may lead to inconsistent condom use. International Perspectives on Sexual and Reproductive Health. 2005;31(1):45.
67. Soler H, Quadagno D, Sly DF, Riehman KS, Eberstein IW, Harrison DF. Relationship dynamics, ethnicity and condom use among low-income women. Family planning perspectives. 2000:82-101.
68. Cabral RJ, Pulley L, Artz LM, Brill I, Macaluso M. Women at risk of HIV/STD: the importance of male partners as barriers to condom use. AIDS and Behavior. 1998;2(1):75-85.
69. Teitelman AM, Ratcliffe SJ, Morales-Aleman MM, Sullivan CM. Sexual relationship power, intimate partner violence, and condom use among minority urban girls. Journal of interpersonal violence. 2008;23(12):1694-712.
70. Macharia AG, Kombe Y, Mwaniki P. Consistent condom use among HIV positive women attending comprehensive care centre of Thika level 5 hospital, Kenya. World Journal of AIDS. 2015;5(3):141-50.
71. Gender Links. The Gender Based Violence Indicators Study: Botswana, 2011. Gaborone Bostwana: Gender Violence nad Women Affairs Department, 2012.
72. Statistics B. Population and Housing Census 2011 Analytical Report. Gaborone Botswana: Botswana Statistics, 2014.
73. García-Moreno C, Jansen H, Ellsberg M, Heise L, Watts C. WHO Multicountry Study on Women’s Health and Domestic Violence against Women: summary report of initial results on prevalence, health outcomes and women’s responses. 2005.
74. Bernstein DP, Fink L. Childhood trauma questionnaire: A retrospective self-report: Manual: Harcourt Brace & Company; 1998.
75. Machisa MT, Christofides N, Jewkes R. Structural pathways between child abuse, poor mental health outcomes and male-perpetrated intimate partner violence (IPV). PLoS one. 2016;11(3):e0150986.
76. Saunders JB, Aasland OG, Babor TF, De la Fuente JR, Grant M. Development of the alcohol use disorders identification test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption‐II. Addiction. 1993;88(6):791-804.
77. Machisa MT, Christofides N, Jewkes R. Mental ill health in structural pathways to women’s experiences of intimate partner violence. PLoS one. 2017;12(4):e0175240.
78. Pulerwitz J, Barker G. Measuring attitudes toward gender norms among young men in Brazil development and psychometric evaluation of the GEM scale. Men and Masculinities. 2008;10(3):322-38.
79. Peng C-YJ, Harwell M, Liou S-M, Ehman LH. Advances in missing data methods and implications for educational research. Real data analysis. 2006:31-78.
80. Carey KB, Senn TE, Walsh JL, Scott-Sheldon LA, Carey MP. Alcohol use predicts number of sexual partners for female but not male STI clinic patients. AIDS and Behavior. 2016;20(1):52-9.
81. Exavery A, Kanté AM, Jackson E, Noronha J, Sikustahili G, Tani K, et al. Role of condom negotiation on condom use among women of reproductive age in three districts in Tanzania. BMC public health. 2012;12(1):1097.
82. Vittinghoff E, McCulloch CE. Relaxing the rule of ten events per variable in logistic and Cox regression. American journal of epidemiology. 2007;165(6):710-8.
APPENDICES
APPENDIX I- PLAGIARISM DECLARATION
PLAGIARISM DECLARATION TO BE SIGNED BY ALL HIGHER DEGREE STUDENTS SENATE PLAGIARISM POLICY: APPENDIX ONE
I ___Chenai Mlandu____ (Student number: __1155482____) am a student
registered for the degree of __MSC Infectious Disease Epidemiology_in the academic year ___2017___. I hereby declare the following:
I am aware that plagiarism (the use of someone else’s work without their permission and/or without acknowledging the original source) is wrong.
I confirm that the work submitted for assessment for the above degree is my own unaided work except where I have explicitly indicated otherwise.
I have followed the required conventions in referencing the thoughts and ideas of others. I understand that the University of the Witwatersrand may take disciplinary action against
me if there is a belief that this is not my own unaided work or that I have failed to acknowledge the source of the ideas or words in my writing.
APPENDIX 111- EDITED QUESTIONNAIRE SHOWING SELECTED VARIABLES Relationship Survey Women (English)
RELATIONSHIPS HOUSEHOLD SURVEY - Botswana WOMENS QUESTIONNAIRE
Q1. Self administered Interview 1 Yes
0 No
Q2. Study ID number: __ __ __ __ __
Q3. Visit Number __ __
Q4. Date of Interview __ __ / __ __ / __ __ __ __ mm / dd / yyyy
Q5. Interviewer Number __ __ __ __
Q6. Interview Site __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
Q7. Cluster Number __ __
Q8. Start time of interview: __ __ : __ __ : __ __ hh : mm : ss
READ: Thank you very much for agreeing to participate in this survey. We would like to remind you that this questionnaire is anonymous and that there will be no way to link you to your answers. We aim to protect your privacy because we want you to feel free in answering our questions. We know some questions are more difficult to answer than others. Please take your time and relax. All the questions are about your life and your ideas. There are no right or wrong answers. The first questions we will ask you are about yourself, your home and your childhood. If there is a question you do not want to answer please tell me and I will skip to the next question.
WomenSurvey_v1.9 SECTION 1: BACKGROUND SECTION 1: BACKGROUND
READ: Let us begin. Please remember that everything you tell me will be kept secret.
Q9. How old are you? (Choose one) 01 18-20
02 21-24 03 25-29 04 30-34 05 35-39 06 40-44 07 45 -49 08 50 - 54 09 55 or older 97 Don't Know 98 Refuse to Answer 99 Not Applicable Q10. What is the highest standard or grade you have completed at school? (Choose one)
01 No schooling
02 Primary school incomplete
03 Primary school complete (grade7/std5) 04 High school incomplete
05 High school complete
06 Further degree/Qualification incomplete 07 Further degree/Qualification complete 08 DON'T KNOW
98 Refuse to Answer 99 Not Applicable Q15. Have you worked to earn money in the last 12 months?
1 Yes
0 No Skip to Q18
8 Refuse to Answer Skip to Q18
Q16. How much do you earn per month, before tax, and including benefits? (Choose one)
01 P1 - P500 02 P501 - P1000 03 P1 001 - P2000 04 P2001 - P5000 05 P5001 - P10 000 06 P10 001 - P20 000 07 P20 000 or more 97 Don't Know 98 Refuse to Answer 99 Not Applicable
WomenSurvey_v1.9 SECTION 2: CHILDHOOD (FROM BIRTH TO 18 YEARS)
SECTION 2: CHILDHOOD (FROM BIRTH TO 18 YEARS)
READ: I want to ask you some questions about your childhood and teenage years. Can you tell me how often the following things happened to you? I will read out some statements and I want to know if each one was never true, sometimes true, often true or very often true.
Q24. Before I reached 18 I did not have enough to eat. (Choose one) (Choose one)
1 Never true
2 Sometimes true
3 Often true
4 Very often true
7 Don't Know 8 Refuse to Answer 9 Not Applicable Q25. Before I reached 18 I lived in different households at different times. (Choose one)
1 Never true
2 Sometimes true
3 Often true
4 Very often true
7 Don't Know 8 Refuse to Answer 9 Not Applicable Q26. Before I reached 18 I saw or heard my mother being beaten by her husband or boyfriend. (Choose one)
1 Never true
2 Sometimes true
3 Often true
4 Very often true
5 No mother 7 Don't Know 8 Refuse to Answer 9 Not Applicable Q27. Before I reached 18 I was told I was lazy or stupid or weak by someone in my family. (Choose one)
1 Never true
2 Sometimes true
3 Often true
4 Very often true
7 Don't Know 8 Refuse to Answer 9 Not Applicable
WomenSurvey_v1.9 SECTION 2: CHILDHOOD (FROM BIRTH TO 18 YEARS)
Q28. Before I reached 18 someone touched my buttocks or genitals or made me touch them when I did not want to. (Choose one)
1 Never true
2 Sometimes true
3 Often true
4 Very often true
7 Don't Know 8 Refuse to Answer 9 Not Applicable Q29. Before I reached 18 I was insulted or humiliated by someone in my family in front of other people.
(Choose one)
1 Never true
2 Sometimes true
3 Often true
4 Very often true
7 Don't Know 8 Refuse to Answer 9 Not Applicable Q30. Before I reached 18 I was beaten at home with a belt or stick or whip or something else which was hard.
(Choose one)
1 Never true
2 Sometimes true
3 Often true
4 Very often true
7 Don't Know 8 Refuse to Answer 9 Not Applicable Q31. Before I reached 18 I had sex with a man who was more than 5 years older than me. (Choose one)
1 Never true
2 Sometimes true
3 Often true
4 Very often true
7 Don't Know 8 Refuse to Answer 9 Not Applicable
WomenSurvey_v1.9 SECTION 2: CHILDHOOD (FROM BIRTH TO 18 YEARS)
Q32. Before I reached 18 one or both of my parents were too drunk to take care of me. (Choose one) 1 Never true
2 Sometimes true
3 Often true
4 Very often true
5 No parents 7 Don't Know 8 Refuse to Answer 9 Not Applicable Q33. Before I reached 18 I was beaten so hard at home that it left a mark or bruise. (Choose one)
1 Never true
2 Sometimes true
3 Often true
4 Very often true
7 Don't Know 8 Refuse to Answer 9 Not Applicable Q34. Before I reached 18 I spent time outside the home and none of the adults at home knew where I was.
(Choose one)
1 Never true
2 Sometimes true
3 Often true
4 Very often true
5 No adults 7 Don't Know 8 Refuse to Answer 9 Not Applicable Q35. Before I reached 18 I had sex with someone because I was threatened or frightened or forced. (Choose
one)
1 Never true
2 Sometimes true
3 Often true
4 Very often true
7 Don't Know 8 Refuse to Answer 9 Not Applicable
WomenSurvey_v1.9 SECTION 2: CHILDHOOD (FROM BIRTH TO 18 YEARS)
Q36. Before I reached 18 I was beaten or physically punished at school by a teacher . (Choose one)