Examining the relationship between inequitable gender norms and HIV stigma in Eswatini, Uganda, and Zimbabwe

BACKGROUND: Stigma and inequitable gender norms are social and structural drivers of the global HIV epidemic in that they can affect preventive behaviors (such as HIV testing) as well as perpetuate risk behaviors. We examined the relationships between HIV testing, stigma, and inequitable gender norms among male and female participants who were part of the Project ACCLAIM study in Eswatini, Uganda, and Zimbabwe.
METHODS: Project ACCLAIM was a three-arm, multi-country, multi-component cluster randomized trial that sampled women and men aged 18-60 years in randomly selected households. Data pertaining to participants' demographic information, HIV testing behavior, HIV stigma, and gender norms were used for this analysis. We examined differences in testing behavior, stigma, and gender normative beliefs across countries and between sexes, as well as conducted linear regression modeling to examine predictors of inequitable gender norms.
RESULTS: Our data showed several demographic variables (married status, lower educational attainment, and lack of formal employment) and several HIV stigma variables predicted stronger endorsement of inequitable gender norms but having received HIV testing was inversely related to holding inequitable gender norms. These findings were consistent across all three countries, despite the levels of inequitable gender norms being different in each country. Linear regression modeling found several significant predictors of inequitable gender norms, including sex (with men demonstrating lower inequitable gender norms scores compared to women), married or polygamous status, lower educational status, and lack of employment. Receipt of HIV testing was associated with lower inequitable gender norms scores (compared to never testing: β=-0.66, p=0.0009), and several HIV stigma items were positively and significantly associated with higher inequitable gender norms.
CONCLUSIONS: These results reinforce the importance of addressing structural factors that continue to drive HIV risk practices in both resource-rich and resource poor countries and that function as barriers to the uptake of proven effective biomedical and behavioral interventions to prevent HIV transmission.