It takes two: The dyadic and gendered context of HIV testing, risk assessment, and partner communication in Kisarawe, Tanzania
Fonner, Virginia A.
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Background: Sexual transmission of HIV takes place between two people, yet dyads are rarely the focus of HIV-related interventions. Given the increasing importance of HIV testing, understanding how dyads influence each other’s motivations for HIV testing and what drives partner communication could help create effective interventions that leverage partner testing. This dissertation seeks to understand the dyadic and gendered context of partner communication and sexual risk in influencing decisions surrounding HIV testing in Kisarawe, Tanzania. Methods: Manuscript 1 examines factors associated with prior HIV testing, stratified by gender, to better understand what drives HIV testing behavior using Social Action Theory. Manuscript 2 uses Categorization and Regression Tree analysis (CaRT) to create risk assessment tools for men and women to use during testing so that high-risk individuals can be identified and encouraged to discuss HIV testing with their sexual partners. Given the emphasis on partner communication as the referral mechanism discussed in Manuscript 2, Manuscript 3 explores factors related to partner communication about HIV using the Theory of Gender and Power. Results: Correlates of HIV testing, partner communication, and HIV-related risk differed by gender across analyses. HIV testing rates were lower for men and young people. Having had prior conversations about HIV was positively correlated with prior testing among men. At the dyadic level, knowing if a sexual partner had tested for HIV was associated with recent testing among men. As a means to foster partner referral for HIV testing, we developed a 6- and 10-item risk assessment questionnaire for men and women, respectively, to classify individuals at heightened risk of infection using simple behavioral predictors. Regarding factors related to partner communication, both men and women had higher odds of communication if they had more progressive gender norms, more favorable social norms toward HIV prevention, and were socially engaged. Conclusions: Our findings help understand the specific pathways through which gender norms and social-level factors influence dyadic behavior in relation to HIV testing and partner communication. Gender-specific, proactive interventions are needed to increase testing uptake, especially for young people and men. Interventions that encourage sexual partners to test could facilitate uptake of HIV testing services but would require increased partner communication. Drivers of partner communication are inherently socially and structurally-based. Creating change will require interventions at multiple levels—from interventions to improve individual and dyadic-level communication and negotiation skills to interventions at the social-level to increase community dialogue.