This document discusses women's disparities in access to HIV mitigation in three sub-Saharan African countries - Swaziland, Kenya, and Cameroon. It hypothesizes that women with higher levels of education will have greater access to HIV prevention and treatment services. The analysis found a strong correlation between increased educational attainment and HIV testing and access to test results for women in the three countries. However, overall testing rates remain low, likely due to social stigma rather than lack of accessibility. Women face greater HIV risk due to cultural practices like polygamy, child marriage, and lack of autonomy over sexual and reproductive health decisions.

1. The Role of Education in Women’s Disparities in Access to HIV Mitigation in Sub-Saharan Africa
Heidi Breanne Karns
Healthcare Management & Policy
Senior
Dr. Kosali Simon
Professor
School of Public and Environmental Affairs
Faculty Mentor
Abstract: Many studies have evaluated the role of gender inequalities and women’s
disproportionate risk of HIV compared to men. My thesis aims to assess women’s equity in
access to HIV mitigation in sub-Saharan Africa. I focused my research efforts on three
countries: Swaziland, Kenya, and Cameroon. I chose these countries because they have the
highest prevalence of HIV among countries in their region, and they are countries for which data
is available. Swaziland (Southern Africa) has a 26.5% HIV prevalence rate, Kenya (East Africa)
has a 6.1% prevalence rate, and Cameroon (West Africa) has a 4.5% prevalence rate (AVERTa,
2014). I hypothesize that women who receive higher levels of education will have greater access
to HIV prevention and alleviation services, and will therefore be less likely to contract HIV or
better capable of managing the disease. The analysis reveals a strong correlation between
increased educational attainment and HIV testing and access to test results in women of each
country. This pattern may also reflect the idea that educational attainment is associated with
wealth. Additionally, women of all educational backgrounds are equally likely to receive
information about HIV testing sites. Among men and women there are far more people who
know where to be tested than there are people who have actually been tested. Overall low
utilization of HIV testing resources is likely the result of stigma rather than accessibility.
Differences in resource utilization between countries may reflect differences in the
administration of these resources.

2. Introduction
The prevalence of HIV in sub-Saharan Africa is the highest in the world. In 2013 there were
25.8 million people in the region living with the virus; this number alone represents 70% of all
people in the world who have HIV although SSA is only home to 13% of the world’s population
(The Henry J. Kaiser Family Foundation [Kaiser Family Foundation], 2015).
HIV exacerbates existing poverty in SSA. It is estimated that in some sub-Saharan countries
HIV/AIDS reduces economic growth by 1% each year. HIV multiplies the cost of business
operations through employee absenteeism, lower productivity, and large turnovers. Some
companies also bear the costs of healthcare, funeral benefits, and pension funds for their
employees. Large labor costs and reduced revenues resulting from the epidemic make these
countries less desirable to industry and investment (AVERT, 2014c). High unemployment
resulting from decreased industry can also influence HIV transmission in certain populations.
For example, some women resort to trading sexual favors as a source of income (AVERT,
2014b).
The healthcare industry is especially burdened by the HIV epidemic. In 2006 more than 50% of
all hospital beds in the region were occupied by people with HIV-related illnesses. This immense
need for healthcare services is unmet due to large shortages of healthcare professionals. Many
healthcare providers are unable to work because of the role HIV plays in their personal lives;
some stay home to care for family members, while others have died or are too ill to work.
Additionally, the hazard of HIV exposure is especially relevant among healthcare professionals
because they are regularly exposed to blood and other bodily fluids. The consistent use of
universal precautions and increased awareness of the modes of HIV transmission are essential
for preserving the already small healthcare workforce. Demanding workloads and poor pay also
contribute to the shortage of healthcare professionals as some choose to seek work in developed
countries (AVERT, 2014c). Inadequate healthcare infrastructure impedes the administration and
effectiveness of HIV relief.
In addition to constraining economic growth and development, the virus has fiscal implications
on individuals and families as well. Many families become financially burdened when the
primary income earner dies or becomes too ill to work. The expensive medical costs associated
with the disease often force these families further into poverty. Soon they must rely on home-
based care, causing other income earners to forfeit earnings in order to care for their loved-ones
at home. Financial pressures become compounded when the family household is headed by a
female after the death of her spouse. Certain cultural views make it difficult for women to
maintain ownership of land and livestock, putting these women and their families in greater
threat of poverty. The role of children within the family dynamic is also changing as a result of
the epidemic. Children are often removed from school simply because uniforms and fees
become unaffordable, and the child’s potential to generate income for the family becomes a
priority (AVERT, 2014c). Children who do not attend school are limited in their ability to gain
marketable skills and break the cycle of poverty. As many HIV intervention programs are

3. administered through schools systems, those who are uneducated have not received adequate
information about HIV prevention and transmission. In addition to missing HIV education,
children are also put at greater exposure to HIV if the work in which they participate involves
commercial sex.
Women around the world (particularly between the ages of 15-24) are most vulnerable to HIV.
Each year there are 380,000 new HIV infections among women in this age group, signifying
60% of all new cases among young people. Disparate infection rates among men and women is
especially apparent in sub-Saharan Africa as 80% of all young women living with HIV globally
live in this region (AVERT, 2014d). Because sub-Saharan Africa experiences disproportionately
high rates of HIV compared to the rest of the world, and women experience higher rates than
men, women in the region are among the most at-risk of any subpopulation in the world.
Women represent 57% percent of the 25.8 million people in SSA who are living with HIV
(AVERT, 2014d). HIV in women in SSA can be linked to many patriarchal societies in the
region. Women do not have the same access as men in terms of education, employment, and
healthcare, and as a result, often do not have the autonomy to make their own medical decisions
regarding their sexual and reproductive health (AVERT, 2015b).
Background
Institutional Research
In sub-Saharan Africa HIV transmission occurs mainly through sex between men and women
(Ramjee & Daniels, 2013). Other key indicators of transmission are infrequent and irregular use
of condoms, child marriages, sex work, gender inequalities and violence against women, and
polygamy (AVERT, 2015b).
Swaziland has the highest prevalence of HIV worldwide (26.5%) with 200,000 people currently
living with the virus. Life expectancy in this country is among the lowest in the world at only
48.9 years. Because HIV is most common among the working–age population (ages 15-49),
children under the age of 14 now embody more than a third of the population, and an estimated
104,026 children are classified as orphaned or vulnerable (OVC) (AVERT, 2014b).
There are nearly 1.6 million people living with HIV in Kenya, making the epidemic the fourth-
largest in the world. In contrast to Swaziland, Kenya’s HIV epidemic equally affects people in
all stages of life including children, adults, and the elderly. Despite the generalization of HIV
infections across generations, children are still in danger of becoming OVC. In 2013 there were
1.1 million children orphaned by HIV/AIDS (AVERT, 2015a).
In Cameroon 660,000 people live with HIV. Like Kenya, the HIV epidemic in Cameroon affects
all generations equally, but children are at risk of becoming orphaned by the disease. In 2014
25% of all orphans in Cameroon were children orphaned as a result of AIDS deaths (National
AIDS Control Committee, 2010; PEPFAR, 2015). Another special consideration of the HIV
epidemic in Cameroon is the large variation in prevalence rates across different regions. The

4. four North-West regions experience the highest prevalence rates of HIV: North West (8.7%),
East (8.6%), Yaunde (8.3%), and South West (8%). Extreme North and North regions have the
lowest prevalence of HIV in the country at 2% and 1.7%, respectively (Denis & Lenora Foretia
Foundation, 2013; National AIDS Control Committee, 2010).
The governments of each of these countries have sponsored a variety of initiatives to reduce the
impact of HIV. Preventative efforts taken by the governments include condom promotion and
distribution, behavior change campaigns, promotion of Prevention of Mother-to-Child-
Transmission (PMTCT) and voluntary medical male circumcision (VMMC), among others.
The Swazi government has also responded to high rates of HIV by enacting legislation that
protects at-risk groups, most notably young women. In September 2012 the Swazi government
acknowledged the association between child marriage and HIV infections, and passed the Child
Protection and Welfare Act which prohibits the marriage of girls under the age of 16. In addition
to preventative services, the government has also taken steps to provide treatment to those who
already live with the disease. Since 2003 the government has worked to provide free nationwide
antiretroviral treatment. Before the World Health Organization changed their eligibility
guidelines in 2013, Swaziland was one of five sub-Saharan countries to achieve universal access
to treatment meaning more than 80% of those in need of treatment received it. Currently, all
antiretroviral drugs available in Swaziland are domestically funded. Less reliance on
international donors improves the long-term sustainability of these antiretroviral treatment
programs (AVERT, 2014b). Despite the government’s significant strides in providing
antiretroviral treatment, adherence to ART is compromised by practices of traditional medicine.
The use of witch craft as a means of healing from disease is a common practice in Swaziland,
and many people resort to traditional health practitioners for HIV treatment. Witch-doctors and
modern healthcare professionals generally have conflicting ideas as to what constitutes
appropriate treatment. To accommodate to the popular use of traditional medicine and to expand
access and adherence to modern treatments, the Ministry of Health began including these
traditional healers as a part of alleviation efforts. Other factors that impede HIV mitigation in
Swaziland involve government officials and other influential leaders undermining these
government sponsored prevention efforts. For example, King Mswati has been commended for
encouraging discussion of HIV/AIDS in Swaziland, however he contradicts himself with his
sexual practices. The King currently has 14 wives in accordance with the Swazi tradition of
polygamy (AVERT, 2014b).
The National AIDS Control Council (NACC) is the entity that governs HIV relief in Kenya. In
addition to condom distribution, PMTCT and VMMC the government has also focused on
improving and expanding the provision of HIV testing and counselling services including,
“provider initiated testing and counselling (PCT), outreach testing and counselling, home-based
testing and counselling (HBT) as well as integration of HTC in antenatal care, sexually
transmitted infections (STI) and sexual and reproductive health services”. In addition to
promoting testing and counselling, the government is also working to make available universal

5. access to antiretroviral treatment. Kenya was also one of the five sub-Saharan countries to
achieve universal access to ART before WHO amendments to eligibility requirements.
Sustaining these government sponsored resources is compromised by a heavy reliance on
external funding. Currently, 70% of the funding for HIV alleviation, including antiretroviral
treatment, comes from external donors. The remaining funding come from government
contributions (17%) and private spending (13%). Sustainability is also threatened due to the
increasing costs of the HIV response. Costs are projected to rise 114% by 2020, creating a $1.75
billion gap in funding. In preparation for these increasing costs, the Kenyan government has
established the High Level Steering Committee for Sustainable Financing. The committee plans
to create a trust fund of private resources to recoup the funding gap (AVERT, 2015a).
The Cameroon government is coordinating the efforts of internal and external agencies to expand
the national response to the HIV epidemic. The Cameroon Baptist Convention Health Services
(CBCHS) is an internal faith-based organization that exists to alleviate poverty, facilitate medical
experience and training, offer spiritual services, and provide HIV/AIDS prevention and treatment
(Cameroon Baptist Convention Health Services [CBCHS], 2014a). The CBCHS AIDS Care and
Prevention Program (ACP) incorporates a holistic approach to prevention and treatment efforts.
ACP components include: community AIDS education; PMTCT; orphan care; support groups
for people living with HIV; antiretroviral treatment; tuberculosis support; palliative care;
women’s health programs; and nutrition services (CBCHS, 2014b). The government is also
working to improve access to ART by offering free antiretroviral drugs to those who need them
(National AIDS Control Committee, 2010). Additionally, Cameroon is joining the Accelerating
Children’s HIV/AIDS Treatment (ACT) Initiative. ACT is a two year program meant to increase
antiretroviral treatment in children (PEPFAR, 2015). Despite efforts by the government to
expand access to antiretroviral drugs, only 23% of adults aged 15 or older are taking these drugs
(National AIDS Control Committee, 2010). The President’s Emergency Plan for AIDS Relief
(PEPFAR) is one of the external agencies helping to reduce the impact of the disease in
Cameroon. PEPFAR goals for the country include: “preventing mother-to-child transmission of
HIV; scaling-up access to HIV prevention, care and treatment among those most in need,
particularly key and priority populations; supporting health systems strengthening with a focus
on improving health information systems, human resources for health, laboratory and blood
safety systems, and supply chain management; and strengthening the continuum of care and
treatment and ensuring linkages in the delivery of HIV prevention, care, and treatment across all
levels of care.” (U.S. President’s Emergency Plan for AIDS Relief [PEPFAR], 2015).
Although each the countries’ governments have played a large role in promoting and sponsoring
HIV prevention and treatment, certain obstacles continue to limit the effectiveness of these
initiatives. HIV is attached to stigma, and those who reveal their positive HIV status are often
ostracized from the community and excluded from family gatherings and activities. Many
people do not want to know their HIV status and will choose not to be tested out of fear that they
will be rejected by family and friends if they are positive for HIV. Those who are aware of their
status will often keep the information secret, some not even sharing it with their sexual partners

6. (AVERT, 2015b). Technical challenges that impede HIV mitigation in each of the countries
include: cost of medical treatment and distance to facilities; limited infrastructure; lack of
capacity in treatment clinics resulting from workforce shortages and limited resources; and the
tendency of people to visit traditional healers instead of certified health professionals (AVERT,
2014b). Women in SSA are especially affected by the limitations of access to HIV testing and
treatment as is seen in the higher prevalence rates among women compared to men.
In Swaziland women account for two out of three newly reported cases of HIV. Among the
population aged 15 and older, the prevalence of HIV is 15.3% percent in women, and only 6.3%
in men (AVERT, 2014b). Polygamy and child marriage are common cultural practices in
Swaziland that influence high infection rates among women. Polygamy involves multiple sexual
partners, and a woman’s submissive role, especially in regard to sex, makes it difficult for her to
negotiate condom use. A 2011 report revealed that 15% of men between the ages of 15-49
reported having more than one sexual partner in the past 12 months compared to less than 3% of
females. Intergenerational relationships between older men and young women is related to HIV
infections in women between the ages of 15-24. Since 2007 the number of women in this age
group who have reported having unsafe sex with men who are at least 10 years older has risen
from 7% to 14%. Young women are also susceptible to the virus through acts of sexual
violence, with one in three women reporting experiences of sexual violence before the age of 18
(AVERT 2014b, AVERT 2015b).
In Kenya 6.9% of women have HIV compared to 4.2% of men. Additionally, women between
the ages of 15-24 have HIV prevalence rates nearly three times higher than those of men in the
same age group; HIV prevalence in this demographic is 3% for women and 1.1% for men. As in
Swaziland, young women in Kenya often marry early and to older men, compromising their
ability to negotiate safe sex practices even when they know the possibility of contracting HIV.
In addition to child-marriage practices influencing higher rates of HIV infections among young
women in Kenya, the 2014 Demographic Health Survey found that young women are less
knowledgeable about HIV transmission compared to men of the same age group. The survey
shows that only 54% of women ages 15-24 could correctly identify methods of HIV prevention
compared to 64% of men in the same age group (AVERT, 2015a).
HIV also disproportionately affects women in Cameroon. In Cameroon women represent three
in five (60%) people living with HIV. Moreover, 70% of all people between the ages of 15-24
who have HIV are women (National AIDS Control Committee, 2010).
Literature Review
Women and HIV
A report in AIDS Research and Therapy evaluates many studies on women’s vulnerability to
HIV in sub-Saharan Africa. The research concludes that the epidemic is dynamic, involving
many issues. The report considers the biological, cultural, socioeconomic, behavioral and
structural factors that increase women’s risk of HIV in SSA (Ramjee & Daniels, 2013).

7. Certain physiological and hormonal factors influence women’s susceptibility to HIV compared
to men. Because the mucosal lining of the female genitalia covers a larger surface area than that
of men’s, women are exposed to the virus and other sexually transmitted infections (STIs) for
longer periods of time during intercourse. The vaginal tissue is also prone to tearing and other
injury during intercourse, further increasing the possibility of the virus’ entry into the body. The
report also acknowledges the association between sexually transmitted infections (STIs) and HIV
(Ramjee & Daniels, 2013). Engaging in unprotected sexual activities not only increases the
chances of acquiring an STI, but also of contracting HIV. Having an STI increases the
likelihood of contracting HIV as openings in the skin caused by sores facilitates the virus’ entry
into the body (Centers for Disease Control and Prevention [CDC], 2015). Women who have a
sexually transmitted infection are likely to have prolonged exposure to HIV because STIs often
occur in women without symptoms; women go undiagnosed and untreated for longer periods of
time. The results of an observational study conducted by the authors coincides with this theory.
The study evaluated four clinical sites in sub-Saharan Africa to determine the prevalence of STIs
in association with HIV rates in the region. The four clinical sites included Durban and Hlabisa
(South Africa), Lusaka (Zambia) and Moshi (Tanzania). The study found that women who
lived in regions that had high rates of HIV were more likely to be diagnosed with an STI. The
study specifically found that women who sought treatment at the South African clinics were
three times more likely to have an STI than those in the Zambian and Tanzanian sites. Other
studies looking at HIV/STI rates in South Africa suggest a connection between the prevalence of
STIs and the incidence of HIV (Ramjee & Daniels, 2013).
The study proposes that certain biological hormones, including progesterone, are related to risk
of HIV infection in women. Injectable contraceptives, some of which contain progesterone, are a
common and widely used birth control method among women in sub-Saharan Africa. Some
research that has been done on the injectable contraceptive, depot medroxyprogesterone acetate
(DMPA), suggests that the contraceptive enables transmission of the virus in those women who
use it. Other studies provide contrary evidence to this claim. In response to research disputes in
regard to DMPA, the World Health Organization recommends that women who are using the
injectable birth control also use condoms to prevent infection with the virus and other STIs.
Studies in Uganda, Rwanda and Zimbabwe indicate the impact of certain hormones in the
transmission of HIV. Hormones released in the body during pregnancy, most notably oestrogen
and progesterone, may cause pregnant women to become more susceptible to the virus.
Abnormally high levels of these particular hormones can “cause changes in the structure of the
genital mucosa or cause immunological changes, such as an increase in mucosal lymphoid
aggregates or hormone-induced overexpression of co-receptors associated with HIV infection”.
Other research done on the effect of hormones in the transmission of the virus suggest women
are more likely to acquire HIV seven to ten days after ovulation (Ramgee & Daniels, 2013).
Societal norms that govern relationships between men and women make women more vulnerable
to HIV and other sexually transmitted infections. In patriarchal societies in sub-Saharan Africa

8. men are encouraged to pursue many sexual relationships and to display their dominance in
sexual activity. There is an expectation that wives submit to having sex with their husbands as a
woman is seen as the property of her husband, and sex his marital right. For example, in
Malawi, marital rape is not recognized as consensual sex is assumed within a marriage. The
cultural expectation of men to display their masculinity through sexual activity leads to
polygamous relationships and child marriages. Women often marry at a young age to much
older men, and young brides are typically not the first of their husband’s wives. Studies show
that women who marry young are less likely to receive a formal education. As many
intervention programs are administered through schools, those who do not receive an education
are not exposed to these interventions and do not hear messages about prevention and safe sex
practices. For example, many reports have documented an association between higher levels of
education and the consistent and proper use of condoms. Lack of knowledge of safe-sex
practices in conjunction with male dominance in sexual activity makes it increasingly difficult
for women to negotiate safe sex practices. Research from various sources support the theory that
expanding access to education for young girls will decrease their predisposition of HIV.
Child marriages leads to earlier sexual debut, a behavior that has been linked to precarious sexual
practices. Various studies in Africa have shown that engaging in sexual activity at an early age
is associated with susceptibility to HIV. Those who have sex at an early age are more likely to
have many partners and are less likely to use contraceptives, including condoms. A survey
conducted in South Africa found that of women between the ages of 15-24, 7.8% had sex by the
age of 14. In Uganda the government has responded to the HIV epidemic by encouraging young
people to postpone sexual activity. This behavior change is thought to have led to the decline in
HIV incidence in Uganda in recent years. Other behavior campaigns in countries across sub-
Saharan Africa work to encourage fidelity and monogamous relationships. These behavioral
campaigns are credited for the decrease in HIV infection rates in Kenya, Zimbabwe, Cote
d’Ivoire, Malawi, and Ethiopia (Ramjee & Daniels, 2013).
Studies also show that there are higher incidence rates of HIV among those with a low
socioeconomic status. Additionally, research from SSA, Asia, and Latin America suggest in
countries of high income inequality there are higher prevalence rates of HIV. Greater rates of
HIV among the impoverished is linked to apathy of disease transmission. Those who live in
poverty are more concerned with finding a means to support themselves and their families than
protecting themselves from disease. Various studies on the link between poverty and HIV rates
find that low socioeconomic status is associated with participation in unsafe sexual behaviors,
including: earlier sexual debut; lower use of contraceptives, including condoms; having sex with
many partners; first sexual experience is non-consensual; participation in transactional sex; and
greater exposure to sexual violence (Ramjee & Daniels, 2013).
Married women are also financially dependent on their husbands as men often head the
household and have sovereignty in decisions regarding the distribution of the family’s resources
and finances. Financial dependency not only puts women at risk of HIV, but also suggests

9. women may not have the same access to HIV testing and prevention services as they do not have
the resource needed to pay for these services (Ramjee & Daniels, 2013).
Economic disparities in countries across the world make women vulnerable to poverty, and they
are typically forced to engage in transactional sex to as a means of sustaining their livelihoods.
Sex workers are among those most subjected to HIV. It is reported that female sex workers are
13.5 times more likely to have HIV than women who do not engage in transactional sex. Also,
15% of HIV cases in women are attributable to female sex work. Transactional sex is a
common practice in sub-Saharan Africa as women resort to offering sexual services in order to
make a living, and young girls are pressured to engage in sexual activities with older men to
receive money and other gifts that will help to support their families. HIV transmission through
female sex work is most notable in SSA with 98,000 out of 106,000 worldwide HIV deaths
related to FSW (Ramjee & Daniels, 2013).
Women of low socioeconomic status are prone to sexual violence, and violence against women
is a contributing factor in the transmission of HIV and STIs in women. Young, uneducated, and
poor women are among those most likely to experience an act of sexual violence. Intimate
partner violence is associated with drug and alcohol use, early sexual debut, multiple sexual
partners, transactional sex, and low use of contraceptives. Several studies have found that
intimate partner and gender-based violence are related to HIV infections in women in SSA. A
South African study reports that of all new cases of HIV in women, 12% are linked to sexual
violence. A Ugandan study also found that violence against women increased their risk of HIV
infection by 55% (Ramjee & Daniels, 2013).
Other cultural practices influence high HIV rates in widowed and young women. In Malawi,
Kenya, Zambia, and Botswana a widow is seen as unclean after the death of her husband. In
order to be cleansed the woman must participate in cleansing rituals led by the elders of the
community, and must engage in an unprotected sexual act. It is believed that the entrance of
semen into the woman’s body will cleans her and make her once again eligible for marriage.
The elders of the community choose a man to perform the sexual act. In most cases this man has
previously engaged in cleansing rituals and has had unprotected sex with other widows in the
community. This practice facilitates the transmission of HIV in this sub-population and makes
widowed women vulnerable to HIV infection. Sexual cleansing rituals are also thought to be a
cure for HIV; it is believed that having sex with a virgin will cure the disease (Ramjee &
Daniels, 2013).
The practice of ‘dry sex’ in which drying agents are inserted into the vagina also result in disease
transmission in women. The practice dries the mucosal lining of the vagina, increasing friction
and causing tearing. Although tears in the vaginal tissue likely expose women to HIV, there
have been no studies confirming the role of dry sex in the rapid spread of the virus in the region
(Ramjee & Daniels, 2013).

10. Stigma is a factor that prevents people from being tested, and thus receiving treatment for HIV.
Women are especially likely to experience fear of knowing their HIV status. HIV stigma
suggests a positive test result is associated with a woman’s promiscuity and infidelity. Women
who receive a positive test result are more likely to be ostracized from their families and
communities, and may lose their jobs. Studies also show that women who have HIV are more
likely to be discriminated against in the healthcare setting. Women who have HIV have reported
being denied healthcare services, having their patient confidentiality breached, receiving
judgmental treatment, and not receiving informed consent for certain medical procedures
(Ramjee & Daniels, 2013).
Although there are growing interventions and increasing availability of HIV prevention, testing
and treatment, the optimal utilization of these resources among women is questioned. For
example, although male condoms are generally the most effective and easily accessible of all
HIV prevention methods, women do not generally have to ability to negotiate condom use. To
improve women’s ability to protect themselves from getting the virus, female-initiated
prevention methods are being researched and tested. One such method is the use of
microbicides. Microbicides help to prevent the transmission of HIV through “actions such as
membrane disruption activity, prevention of virus attachment to target cells, and buffering
agents”. Although many researchers believe that microbicides can be effective at a cellular level
in preventing HIV, the benefits of the drug’s use are limited in sub-Saharan Africa. Testing of
the drug in the region has been met with limited success due to poor adherence from those
women participating in the studies. Other microbicides which incorporate the use of
antiretroviral agents have also been evaluated. The efficacy of one such microbicide containing
tenofovir was studied in South Africa. The use of the vaginal gel was associated with a 39%
decrease in the rate of HIV transmission in women. Those women who used the gel
appropriately and consistently where those most likely to benefit from its use. Again, the value
of the microbicide was found to be limited by poor adherence. Studies on microbicides suggest
that other interventions will not be successful unless more is understood of African women’s
social, cultural and traditional roles (Ramjee & Daniels, 2013).
Studies on couples with one partner having a positive HIV status and one a negative HIV status
have showed a decrease in HIV acquisition when the negative partner was given an oral pre-
exposure prophylaxis. If the negative partner took oral tenofovir as a prophylaxis they were 67%
less likely to get HIV from their partner. Negative partners who took tenofovir and emtricitibine
(Truvada) were 75% less likely to acquire the virus. However, another study in east and
southern Africa looking at the effect of Truvada in preventing HIV transmission between couples
did not support the drug’s efficacy. This study was compromised due to poor adherence in study
subjects. Other studies on the use of antiretroviral therapy in the prevention of HIV transmission
between couples have shown that when the positive partner receives ART the negative partner is
less likely to get the disease. This study reports that the use of ART for prevention in disease
transmission is 96% effective. The results of these studies suggest that the most successful
interventions target both sexual partners together (Ramjee & Daniels. 2013).

11. Educational Attainment and HIV
Another study in AIDS evaluates trends in educational attainment and its association to HIV rates
in developing countries. The original report was published in 2001 and contained data from the
pandemic before 1996. The report found that in most studies conducted in sub-Saharan Africa
during this time there was no association between level of education and HIV infection. Some
studies evaluated in the report showed that those with advanced levels of education had higher
HIV infection rates. This was suspected to be linked to greater socioeconomic status which
gives people the ability to travel, and thus expand their network of sexual interactions. The study
was updated and published again in 2008, and used data obtained between 2001 and 2006. The
updated analysis of this trend reveals that over time those who have lower levels of education
have become more prone to contracting the virus while those with higher levels of education
have become less susceptible. It is hypothesized by the authors that the trend has reversed
because those with higher socioeconomic status had better access to the growing public health
responses to the epidemic. Additionally, because HIV interventions are delivered in schools, it is
suspected that those who have greater access to education are more likely to come into contact
with these preventative efforts and adopt healthier behaviors (Hargreaves et al., 2008)
The study was conducted in the same way each time. HIV research from a variety of biomedical
databases and medical journals were analyzed and those with certain characteristics were
included in the study. Articles selected for the study were those that “reported original data
comparing individually measured educational attainment and HIV status” in populations no
smaller than 300 people and that best represent the general population (Hargreaves et al., 2008).
Research that focused only on at-risk populations were excluded from study. Articles were only
reviewed if the data had been analyzed appropriately, adjusting for locality (urban/rural), age,
and sex of study participants. Among the articles that describe the relationship between
education and HIV infection, data collected and deemed appropriately analyzed before 1996
include data from 32 different populations, and data collected after 1996 include data from 40
populations. Together the study includes 200,000 individuals from 11 countries (Hargreaves et
al., 2008).
The authors first compared rates of HIV among those with the highest levels of education to
those with the least education. The authors categorized levels of education into two to five
categories, either measured by years of school attended or the grade achieved. The authors then
identified cross-sectional data of the same populations to study trends in HIV rates between the
most and least educated over time. The data used in the report include age-stratified and time-
series analyses (Hargreaves et al., 2008).
Data before 1996 reveal that higher educational attainment was associated with greater
probability of HIV infection. This discovery was found in 15 of the 32 populations evaluated
before 1996. Contrary findings are show in those populations evaluated after 1996. Only five
out of 40 populations studied after 1996 show higher HIV rates in those with higher education

12. levels, while seven of the 40 populations (one in 32 before 1996) saw a reduction in the rate of
HIV among the most educated. Similar results were found from a variety of studies conducted in
different countries and populations during the same time periods. 13 populations in five
countries in sub-Saharan Africa report similar findings. The populations analyzed include: one
population in Malawi, two in Tanzania, three in Uganda, six in Zambia and one in Zimbabwe.
Each of the populations saw a decrease in HIV prevalence rates among the most educated, but
the circumstances of these trends varied by population. For example, decreasing prevalence
rates were seen “in rural (but not urban) Kangera, Tanzania; females (but not males) from
Masaka, Uganda; antenatal clinic users in Fort Portal, Uganda and in Manicaland, Zimbabwe;
and among urban (but not rural) populations in Zambia” (Hargreaves et al., 2008). Additionally,
the decreased relative prevalence of HIV seen in Karonga, Malawi during the 1990s was
associated with an increase in prevalence in the least educated, not a decrease in prevalence
among the most educated. Rises or stabilization of HIV prevalence among the least educated in
Zimbabwe and Zambia contributed to the changing relative prevalence. Masaka, Uganda, was
the only population in which there was a reduction in prevalence among both the most and least
educated. In general, HIV incidence and prevalence rates reveal that after 1996 the trends began
to change to no association or decreased risk among the most educated (Hargreaves et al., 2008).
Analyses modifying for age (populations under 30 years old) were available for 35 populations
in sub-Saharan Africa after 1996. These analyses show that there was no association between
level of education and HIV among males or females between the ages of 15-24 in Kisumu,
Kenya and Ndola, Zambia. However, there was a decrease in HIV infection rates found among
the most educated women between the ages of 15-24 in Yaounde, Cameroon; there was no clear
association between HIV and level of education among men of the same age group. In contrast,
in Cotonou, Benin, there was a decrease of HIV in men with higher levels of education between
the ages of 15-24, but no association between women of the same age group. In Manicaland,
Zimbabwe it was reported that the most educated women between the ages of 15-24 were the
least likely to acquire HIV, while there was no association among men aged 17-29. Finally, in
Mwanza, Tanzania ever having attended school was associated with decreased infection in men
aged 15-19, but no association in women of the same age group (Hargreaves et al., 2008).
Time-series analyses of the most and least educated young people were also included in the
report. In Masaka, Uganda between 1989-90 and 1999-2000, there was no association between
level of education and HIV among men aged 18-29 years old. The same study showed that
among females of the same age group there was no association in 1989-90, but in 1999-2000
there was a decrease in HIV infection in young women who had higher levels of education
(Hargreaves et al., 2008).
In Fort Portal, Uganda in 1991-94 there was no association among those aged 15-24 who
attended antenatal clinics, but by 1995-1997 it was reported that there were lower rates among
the most educated of antenatal attendees aged 15-24. However, another study looking at HIV
infection rates in antenatal attendees aged 15-24 in Zambia show that there was higher rates in

13. those with higher education levels in 1994, 1998 and 2002. Differences in trends between
studies evaluating HIV in antenatal attendees may be explained by surveys only capturing
responses from those pregnant women who attended these clinics. Capturing data in this way
excludes responses from those who are sexually inactive and those who do not attend clinics
because they are unable to pay for the services (which is assumed to be those who are
uneducated). This explains why antenatal clinic data shows higher rates of infection among the
most educated (Hargreaves et al., 2008).
Time-series data that captures differences in HIV rates among the most and least educated living
in rural and urban settings were also included in the study. A study in Zambia shows that among
males aged 15-24 who lived in a rural setting, there was no association between level of
education and HIV each year of the study (1995, 1999, 2003). No association was found among
males aged 15-24 who lived in an urban setting in 1995 and 1999, however, 2003 data show
there were less HIV infections in those who had higher levels of education. The Zambian study
also revealed trends in women who lived in rural and urban settings. In Zambian women aged
15-24 who lived in a rural setting there was no association between level of education and HIV
in 1995 and 2003, but data from 1999 show that these women with the highest level of education
were more likely to have an infection. There was no association among women of the same age
group who lived in urban areas in 1995 and 1999, but 2003 data show that lower rates were
found in women who were among the most educated (Hargreaves et al., 2008).
As opposed to studies conducted before 1996, those conducted afterwards largely showed a
decrease of HIV infection among the most educated men and women. The analyses reveal that
as HIV prevalence was decreasing among the most educated, prevalence was increasing in the
least educated even when overall population prevalence was decreasing. These findings in
conjunction to one another suggest that post-1996 HIV infections in sub-Saharan Africa have
been occurring disproportionately in the least educated. It is also possible that differences in
infection rates among the most and least educated is much greater because differences in HIV
prevalence are slow to change in response to rises in incidence (Hargreaves et al., 2008).
Poverty and HIV
An article in Croatian Medical Journal evaluates the role of poverty in the transmission of HIV
across sub-Saharan Africa. The report acknowledges that the region is home to 70% of the
world’s poorest, with 60% living below the United Nation’s established poverty line of one
United States dollar a day. The article discusses sexual trade, polygamy and child marriages of
the poor as contributing factors of rapid disease transmission in the region. Each of these factors
has been acknowledge in several studies (including Ramjee & Daniels’) as behaviors that are
directly related to HIV/AIDS. The study examines illustrations in 20 poverty stricken countries
in sub-Saharan Africa as an assessment of the effect of poverty on growing HIV rates
(Dzimnenani, 2007).

14. Many studies have reported that those who live in poverty are more vulnerable to HIV infection.
Poverty is of particular threat to women because of social inequities that make women less
capable of financial stability and more reliant on men. The behaviors of the poor, rather than
reduced access to HIV education, are what proliferate the rate of transmission in this population.
It is believed that although these people hear messages about HIV prevention, protecting
themselves from the deadly virus is of low priority given the circumstances of their every-day
lives. Additionally, even if messages are understood some people lack the resources to adopt
healthier behaviors (Dzimnenani, 2007).
Those who do not possess monetary wealth typically do not have other assets or the skills needed
to achieve financial stability. As HIV/AIDS is associated with costly medical care and
treatment, even people with an abundance of resources experience diminishing of their finances
as a result of infection with the virus. Those who do not have assets to begin with are especially
ill-equipped to deal with financial pressures posed by the disease (Dzimnenani, 2007).
Worsening economic conditions in many countries in the region have made commercial sex
common place in sub-Saharan Africa. For example, in Zimbabwe, men are forced to travel long
distances to places of work and do not see their wives for long periods of time. Some men tend
to develop transactional sexual relations with women in the cities in which they work. In some
cases this leads to divorce, and wives are forced to resort to commercial sex as a means to earn
an income for themselves and their children. In many poor communities transactional sex is
accepted as a way of improving living standards (Dzimnenani, 2007).
Other cultural expectations and lack of alternative occupational opportunities for women
influence growth of the commercial sex industry. Transactional sex is a major factor in the
HIV/AIDS pandemic. Women who engage in sexual transactions, a dangerous behavior in and
of itself, are less likely to care about protecting themselves from HIV transmission by using
protective measures. It is also understood that women who are engaging in commercial sex are
not as financially well off as the men who are paying for these services, so there is an
expectation that the men provide condoms. Additionally, men are willing to pay much more for
sex that does not involve the use of a condom. Knowing that they will receive more money,
some women do not negotiate condom use during transactional sex (Dzimnenani, 2007).
Poverty also exposes children to sexual exploitation. The Integrated Regional Information
Network, a news agency that reports on humanitarian issues, reported that in Kenya female
children of poor rural families are often taken out of school and sent to larger cities to trade
sexual favors in order to support their families. Without receiving an education or marketable
skills these children often have a difficult time exiting the sex market into their adult years.
Those who do often face discrimination from their families and communities (Dzimnenani,
2007).

15. Polygamy and child marriages are often the result of poverty and influence higher HIV
transmission in women. Polygamy is a social practice meant to display male status, and is also
used as a means to help widows and orphans to escape poverty. In some countries in sub-
Saharan Africa it is believed that the less economically advantaged women should be wed and
cared for financially by a husband. Parents of young girls will often arrange marriages between
their children and older financially established men as a strategy for attaining wealth. The
strategy is also used by orphanage caregivers who find it difficult to care for so many children,
especially in areas where there are large numbers of orphans due to the HIV epidemic. The
WHO reported that poverty increases the likelihood that a woman will be married at a young age
as female children are seen as a burden on the family’s resources. Additionally, families are
encouraged to marry their daughters at a young age because the younger the bride, the larger the
dowry paid to the family. Studies consistently show that young women who come from
impoverished families are more likely to marry at a young age. It was reported in one study that
in Cote d’Ivoire young women from the 20% poorest households were three times more likely to
marry early compared to wealthier women of the same age group. Similar data were shown in
the 20% poorest households in Senegal; there, young women were four times more likely to
marry early (Dzimnenani, 2007).
Early marriage is also practiced because it is believed that marrying at a young age decreases a
woman’s exposure to HIV and other sexually transmitted infections. However, evidence suggest
otherwise. Studies show that young brides who marry older men are more susceptible to HIV
transmission than if they were to marry men closer to their own age. On average, older husbands
are more likely to have HIV. A study conducted in Kisumu, Kenya found that of those men
married to younger women, 30% had HIV compared to 11.5% of those men who had sexual
relationships with women of the same age. Similar data was found in Ndola, Zambia. Of men
who were married to younger women, 31.6% had HIV while only 16.8% of boyfriends were
living with the virus (Dzimnenani, 2007).
Method
My hypothesis is that women who have achieve higher levels of education will be more likely to
access and utilize HIV mitigation resources. I will establish differences in access by comparing
data between countries, women and men, and women of different levels of education. Assessing
differences between Swaziland, Kenya, and Cameroon will reveal existing trends in women’s
access, and may suggest strengths and weaknesses in each countries’ administration of
alleviation efforts.
The analysis will first describe the differences in educational attainment between countries,
between men and women in each of the countries, and between women of different countries.
The second part of the analysis will evaluate differences in access to HIV/AIDS mitigation
between countries, between men and women in each country, and between women of different
educations. The variables that are used to measure access are: whether (1) a person has been

16. tested for HIV/AIDS, (2) knows where to get tested, and (3) received the results of their last
HIV/AIDS test.
The final part of the analysis will evaluate women’s access in relation to their educational
attainment. This section of the analysis will evaluate different trends in women by country and
by educational attainment. The analysis includes correlations between educational attainment
and the variables of access in each of the countries. Decisions of contraceptive use among
women who have different educations will be also assessed. This component of the analysis will
compare reported decision-makers for contraceptive use between countries and among women of
different educational backgrounds.
Data
The main variables that I will evaluate as a part of my research include: level of education,
HIV/AIDS mitigation resources, and the reported decision maker for contraceptive use. For each
dataset the case identification variable (CASEID) is used to uniquely identify survey respondents
and their responses to the survey questionnaire. The definitions of these variables are described
by the Standard Recode Manual for DHS V and VI, and are included in Appendix B of this
document.
To account for differences in research methodologies and to facilitate data comparisons across
surveys, the Demographic and Health Survey Program uses a recode file, or standardized
questionnaire format, for those countries participating in DHS phases. Each DHS phase includes
unique variables, so comparing data using different DHS phases comes with limitations. Data on
Swaziland and Kenya were retrieved using DHS V format, while data on Cameroon uses DHS
VI. In order to compare surveys it was essential to identify those variables of interest that each
survey measures. For purposes of my research I used the Individual Women’s and Men’s Data-
Individual Recode (IR) files for each dataset. These recode files have one record for every
woman or man eligible to participate in the survey. Therefore the unit of analysis is either the
woman or man (The Demographic and Health Surveys Program [DHS], n.d.).
Additionally, each survey was conducted in different years. The Swaziland survey was
administered in 2006-2007, the Kenya survey in 2008-2009, and the Cameroon survey in 2011
(USAID, 2013). The differences between years may not comprehensively account for economic
or political changes in each country, however the data is collected within a span of ten years so
these differences are assumed to be negligible.
Results and Analysis
The following data analysis refers to figures in Appendix A.
Figure 1 shows the percent of people in each country who have achieved at least a primary
education.

17. Educational attainment is comparable by country, but is highest in Swaziland followed by Kenya
and Cameroon. The finding that educational attainment is highest in Swaziland shows that better
availability of education is not necessarily associated with lower HIV prevalence as Swaziland
has the highest prevalence of HIV among the three countries (26.5%).
Figure 2 compares the percentage of men and women in each country who have attained at least
a primary education.
The data mostly reflect the trend that access to education is highest in Swaziland followed by
Kenya and Cameroon. In each of the countries, men have slightly better access to education than
women. This data provides commentary on women’s roles in sub-Saharan African culture. It
may also suggest why women in the region are more susceptible to poverty.
Figure 3 shows the difference in educational attainment of women in each country. The data
measures those women in each country who have completed at least a primary education.
Swaziland has the highest percentage of women who have some level of education (91.72%)
which reflects the trend that education is more available in Swaziland than the other two
countries.
Figure 4 shows the difference in access to HIV/AIDS mitigation by country. The data measures
the percent of men and women who have (1) ever been tested for HIV/AIDS, (2) know a place to
get tested, (3) and got the results of their last test.
Kenya has the highest percent of people who have ever been tested, know a place to get tested,
and got the results of their last test. This contradicts the theory that people with better access to
education also have better access to testing as Swaziland has the highest educational attainment
among the three countries. However, educational attainment and access in all three categories is
lowest in Cameroon; this finding supports the theory. The contrary findings may suggest
differences in the administration of these services in each of the countries. For example, Kenya
may have a more comprehensive administration of these resources compared to Swaziland and
Cameroon.
Another thing to note about the graph is that in all three countries, there are many more people
who know where to be tested than there are people actually being tested for HIV/AIDS. This
indicates that although people are hearing messages of HIV prevention and relief, many are still
choosing not to be tested. Taboo and stigma related to HIV/AIDS, and poverty in the region
may be factors deterring people from being tested. One thing to consider for future research is
differences in the availability of HIV mitigation in rural and urban locations, and the associated
burden on the impoverished.

18. Figures 5a-c show the difference in access to mitigation resources between men and women in
each country. Showing these differences may highlight the successes and weaknesses of HIV
interventions in these countries.
In general, women are more likely to be tested for HIV/AIDS than men. This might be
explained by women’s likelihood to attend a medical facility as a result of pregnancy. Women
who attend antenatal clinics are tested for HIV as a part of the services they receive from the
facility (Ramjee & Daniels, 2013). In Cameroon, women are less likely than men to be tested for
HIV/AIDS. One question to ask in future research is whether antenatal clinics are less available
to women in Cameroon than to women in Swaziland and Kenya.
In the exception of Swaziland, women and men are equally likely to hear messages of HIV
testing resources. This shows that HIV interventions in each country are successful at
disseminating information to both men and women, but there are still barriers that exist that
prevent people from being tested.
In Kenya and Cameroon men and women who have been tested for HIV/AIDS are equally likely
to receive their test results. Of those people who are tested for HIV/AIDS in Swaziland, men are
more likely to receive their results than women. A potential explanation of this finding is that
women who are diagnosed with HIV are often discriminated against in the healthcare setting.
Another reason is that healthcare providers sometimes share a woman’s health information with
her husband or closest male relative instead of her. A woman who is diagnosed with HIV may
not ever receive that information, or may first hear it through her spouse (Ramjee & Daniels,
2013).
Figure 6 shows differences in HIV testing, knowledge of testing sites, and access to test results
of women in each country.
The data show that women in Kenya are more likely to receive HIV testing and to have better
access to test results than women in Swaziland and Cameroon. HIV mitigation is more
obtainable in Kenya in general, so the fact that women in Kenya have better access to HIV
resources is not surprising.
The trend is similar among women in Cameroon. Mitigation is less attainable in Cameroon, so
women in Cameroon generally have less access than women in Swaziland and Kenya.
Figures 7a-c show differences in testing, knowledge of testing sites, and access to test results
among women of different educations in all three countries.
In each of the countries there is a trend of increased testing, knowledge of testing sites, and
reception of test results with advanced educational attainment. Women who have higher
educations are more likely to have been tested for HIV/AIDS, to know of places to get tested,

19. and to have access to their test results. This supports the hypothesis that advanced educational
attainment is associated with improved access to and utilization of resources.
Figures 8a-d describe differences in HIV testing rates among women of different education
levels, and compares trends across countries.
In each of the countries there is a strong positive correlation between higher levels of education
and HIV testing in women. This data indicates that women who have higher education levels are
more likely to be tested for HIV. Education is associated with greater wealth which may explain
why women of higher educations are more likely to be tested. Women of lower socioeconomic
status may not have monetary resources to access medical care and are therefore not tested, even
if they know where to be tested. Additionally, women of lower socioeconomic status may rely
on their spouse or another male relative to be tested. In many cases women must ask their
husbands for money needed to pay the medical provider, and also must ask permission to go to a
testing facility (Ramjee & Daniels, 2013).
Figures 9a-d show the difference is women’s knowledge of HIV/AIDS testing sites, and
compares trends in Swaziland, Kenya and Cameroon.
There is a positive correlation between increased educational attainment and better knowledge of
existing testing sites, but it is a weak correlation. This might indicate that, overall, women of all
levels of education have similar knowledge of locations to be tested. This trend is seen in all
countries.
Figures 10a-d show differences in access to test results among women of different educational
backgrounds in each of the countries.
There is a strong positive correlation between higher educational attainment and access to test
results in all three countries. This could be because women with higher levels of education are
likely to have greater wealth and have improved access to testing in general. It may be more
difficult for women of lower socioeconomic status to attend a testing center more than once in
order to receive the results of her test, especially if she must ask her husband for money and
permission.
Figure 11 shows the difference in contraceptive decision makers in each country. The data is
reported by women.
In each of the countries the decision to use contraceptives is a joint decision between a woman
and her sexual partner.
Figures 12a-c show differences in contraceptive use among women of different education levels
in each country.

20. The data show that in all countries women of all levels of education are more likely to make
contraceptive decisions with their partners. This reflects the trends that, in general, women in
each of the countries are more likely to make this decision jointly. It also provides commentary
on the success of HIV prevention initiatives to target men and women as sexual partners.
Overall, the findings show that access to basic education is not necessarily related to better
access to and utilization of HIV resources, but increased educational attainment is. Additionally,
although many people know of these resources there are still barriers that prevent optimal
utilization. Differences in the strategies of government initiatives and the views of women in
each of the countries should be further assessed to explain variations in utilization of these
resources.

21. Bibliography
AVERT (2015a, May 01). HIV & AIDS in Kenya. Retrieved from
http://www.avert.org/professionals/hiv-around-world/sub-saharan-africa/kenya
AVERT. (2014a, June 06). HIV and AIDS in sub-Saharan Africa. Retrieved from
http://www.avert.org/hiv-aids-sub-saharan-africa.htm
AVERT. (2014b, June 06). HIV & AIDS in Swaziland. Retrieved from
http://www.avert.org/hiv-aids-swaziland.htm
AVERT. (2015b, May 01). HIV & AIDS in Swaziland. Retrieved from
http://www.avert.org/professionals/hiv-around-world/sub-saharan-africa/swaziland
AVERT. (2014c, June 06). Impact of HIV and AIDS in sub-Saharan Africa. Retrieved from
http://www.avert.org/impact-hiv-and-aids-sub-saharan-africa.htm
AVERT. (2014d, June 06). Women and HIV/AIDS. Retrieved from
http://www.avert.org/women-and-hiv-aids.htm
Cameroon Baptist Convention Health Services. (2014a). About Us. Retrieved from
http://www.cbchealthservices.org/html/about_us.html
Cameroon Baptist Convention Health Services. (2014b). AIDS Care and Prevention Program.
Retrieved from http://www.cbchealthservices.org/html/a_c_p.html
Centers for Disease Control and Prevention. (2015, Oct. 14). STDs and HIV- CDC Fact Sheet.
Retrieved from http://www.cdc.gov/std/hiv/stdfact-std-hiv.htm
The Demographic and Health Surveys Program. (n.d). Dataset Types. Retrieved from
http://dhsprogram.com/data/Dataset-Types.cfm
Denis &Lenora Foretia Foundation. (2013, Dec. 01). HIV AIDS in Cameroon- An Update.
Retrieved from http://www.foretiafoundation.org/hiv-aids-in-cameroon-an-update/
Dzimnenani Mbirimtengerenji, N. (2007). Is HIV/AIDS Epidemic Outcome of Poverty in Sub-
Saharan Africa? Croatian Medical Journal, 48(5), 605–617.
Hargreaves, J. R., Bonell, C. P., Boler, T., Boccia, D., Birdthistle, I., Fletcher. A.,… Glynn, J. R.
(2008). Systematic review exploring time trends in the association between educational
attainment and risk of HIV infection in sub-Saharan Africa. AIDS, 22(3), 403-414. doi:
10.1097/QAD.0b013e3282f2aac3

22. The Henry J. Kaiser Family Foundation. (2015, July 31). The Global HIV/AIDS Epidemic.
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National AIDS Control Committee. (2010, Sept.). The Impact of HIV and AIDS in Cameroon
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http://www.healthpolicyinitiative.com/Publications/Documents/1250_1_Cameroon_EN_
Singles_Reduced_acc.pdf
Ramjee, G. & Daniels, B. (2013). Women and HIV in Sub-Saharan Africa. AIDS Research and
Therapy, 10, 30. doi: 10.1186/1742-6405-10-30
United States Agency for International Development. (2013, March 22). Standard Recode
Manual for DHS 6. Retrieved from
https://dhsprogram.com/pubs/pdf/DHSG4/Recode6_DHS_22March2013_DHSG4.pdf
U.S. President’s Emergency Plan for AIDS Relief. (2015, Aug.). Partnering to Achieve Epidemic
Control in Cameroon. Retrieved from
http://www.pepfar.gov/documents/organization/203142.pdf

23. Appendix A: Analysis Graphs
Figure 1
Figure 2
91.85%
87.82% 84.87%
0
10
20
30
40
50
60
70
80
90
100
Swaziland Kenya Cameroon
Percentofpeoplewhohavecompletedatleasta
primaryeducation
Countries in SSA
Differences in Educational Attainment by Country
0 10 20 30 40 50 60 70 80 90 100
Swaziland
Kenya
Cameroon
Percentage of men and women who have at least a primary education
CountriesinSSA
Differences in Educational Attainment Between Men and
Women in Each Country
Men Women

24. Figure 3
Figure 4
91.72%
85.29%
81.87%
0 10 20 30 40 50 60 70 80 90 100
Swaziland
Kenya
Cameroon
Percentage of women who have completed at least a primary education
CountreisinSSA
Women's Educational Attainment by Country
At least primary No Education
0
10
20
30
40
50
60
70
80
90
100
Ever been tested Know a place to get tested Did get results of test
Percentofpeople
Measures of Access
Access to HIV Mitigation by Country
Swaziland Kenya Cameroon

25. Figures 5a-c
a)
b)
0
20
40
60
80
100
Ever been tested for HIV/AIDS Know a place to get HIV/AIDS test Did get results of test
Percentofpeople
Measures of Access
Differences in Access Between Men and Women in
Swaziland
Women Men
0
10
20
30
40
50
60
70
80
90
100
Ever been tested for HIV/AIDS Know a place to get HIV/AIDS test Did get results of test
Percentofpeople
Measures of Access
Differences in Access Between Men and Women in Kenya
Women Men

26. c)
Figure 6
0
20
40
60
80
100
Ever been tested for HIV/AIDS Know a place to get HIV/AIDS test Did get results of test
PercentofPeople
Measures of Access
Differences in Access Between Men and Women in
Cameroon
Women Men
0
10
20
30
40
50
60
70
80
90
100
Ever been tested for HIV/AIDS Know a place to get HIV/AIDS test Did get results of test
Percentofpeople
Measures of Access
Women's Access to HIV Mitigation by Country
Swaziland Kenya Cameroon

27. Figures 7a-c
a)
b)
0 10 20 30 40 50 60 70 80 90 100
Ever been tested
know place to get tested
got results of last test
Percent of women
MeasuresofAccess
Swaziland Women's Acces to HIV/AIDS Mitigation by Lvl
Education
higher secondary primary no education
0 10 20 30 40 50 60 70 80 90 100
Ever been tested
know place to get tested
got results of last test
Percent of women
MeasuresofAccess
Kenya Women's Access to HIV Mitigation by Lvl Education
higher secondary primary no education

28. c)
Figures 8a-d
a)
0 10 20 30 40 50 60 70 80 90 100
Ever been tested
know place to get tested
got results of last test
Percent of women
MeasuresofAccess
Cameroon Women's Access to Mitigation by Lvl Education
higher secondary primary no education
0
10
20
30
40
50
60
70
80
90
100
Swaziland Kenya Cameroon
Percentofwomenwhohavebeentested
Countries in SSA
Education and HIV Testing of Women in SSA
no education primary secondary higher

29. b)
c)
R² = 0.805
0
10
20
30
40
50
60
70
80
90
100
no education primary secondary higher
Percentofwomenwhohavebeentested
Levels of Education
HIV Testing of Swazi Women
R² = 0.9402
0
10
20
30
40
50
60
70
80
90
100
no education primary secondary higher
Percentofwomenwhohavebeentested
Levels of Education
HIV Testing of Kenyan Women

30. d)
Figures 9a-d
a)
R² = 0.9545
0
10
20
30
40
50
60
70
80
90
100
no education primary secondary higher
Percentofwomenwhohavebeentested
Levels of education
HIV Testing of Cameroonian Women
0
10
20
30
40
50
60
70
80
90
100
Swaziland Kenya Cameroon
Percentofwomen
Countries in SSA
Education and Knowledge of Testing Sites of Women in SSA
no education primary secondary higher

31. b)
c)
R² = 0.7021
0
10
20
30
40
50
60
70
80
90
100
no education primary secondary higher
Percentofwomenwhoknowwheretogettested
Level of Education
Education and Knowledge of Testing Sites in Swazi Women
R² = 0.7426
0
10
20
30
40
50
60
70
80
90
100
no education primary secondary higher
Percentofwomenwhoknowwheretogettested
Level of Education
Education and Knowledge of Testing Sites in Kenyan
Women

32. d)
Figures 10a-d
a)
R² = 0.8523
0
10
20
30
40
50
60
70
80
90
100
no education primary secondary higher
Percentofwomenwhoknowwheretogettested
Level of Education
Education and Knowledge of Testing Sites in Cameroonian
Women
70
75
80
85
90
95
100
Swaziland Kenya Cameroon
Percentofwomenwhogottestresults
Countries in SSA
Education and Women's Access to Test Results in SSA
no education primary secondary higher

33. b)
c)
R² = 0.9209
0
10
20
30
40
50
60
70
80
90
100
no education primary secondary higher
Percnetofwomenwhogottestresults
Level of Education
Education and Swazi Women's Access to Test Results
R² = 0.8642
0
10
20
30
40
50
60
70
80
90
100
no education primary secondary higher
Percnetofwomenwhohaverecievedtestresults
Level of Education
Education and Kenyan Women's Access to Test Results

34. d)
Figure 11
R² = 0.9748
0
10
20
30
40
50
60
70
80
90
100
no education primary secondary higher
Percentofwomenwhohaverecievedtestresults
Level of Education
Education and Cameroonian Women's Access to Test
Results
0 10 20 30 40 50 60 70 80 90 100
mainly respondent
mainly husband, partner
joint decision
other
missing
Percent of reported contraceptive decision-makers
Reportedcontraceptivedecision-makers
Women Report Contraceptive Decision-Makers in SSA
Cameroon Kenya Swaziland

35. Figures 12a-c
a)
b)
0 10 20 30 40 50 60 70 80 90 100
mainly respondent
mainly husband, partner
joint decision
other
Percent of reported contraceptive decision-makers
Reporteddecision-makers
Swazi Women Report Contraceptive Decision- Maker
higher secondary primary no edu
0 10 20 30 40 50 60 70 80 90 100
mainly respondent
mainly husband, partner
joint decision
other
missing
Percent of reported contraceptive decision-makers
Reporteddecision-makers
Kenyan Women Report Contraceptive Decision-Maker
higher secondary primary no edu

36. c)
0 10 20 30 40 50 60 70 80 90 100
mainly respondent
mainly husband, partner
joint decision
other
missing
Percent of reported contraceptive decision-makers
Reporteddecision-makers
Cameroonian Women Report Contraceptive Decision-
Maker
higher secondar primary no edu

37. Appendix B: DHS Variables and Definitions
CASEID In most surveys this is constructed by concatenating the cluster or sample point number,
the household number and the respondent’s line number, but in some surveys this may be
the questionnaire number taken from the front page of the questionnaire
V106 Highest education level attended. This is a standardized variable providing level of
education in the following categories: No education, Primary, Secondary, and Higher.
V376 Reason the respondent does not intend to use a method of contraception in the future.
BASE: All women not currently using a contraceptive method and not intending to use a
method in the future (V362=5). This question is no longer part of the DHS VI core
questionnaire, but the variable is kept in the DHS VI recode.
V379 Source of any method of contraception is formed from a combination of responses. For
current users of modern methods, it is the source of that method. For women who are not
currently using a methods, it is a source from which they know they can obtain family
planning methods, if they know any source. This is not in general part of the standard
questionnaire since it is replaced with a multiple-choice question. However, it is left as a
standard variable in case the question asked has only one answer.
V467 Getting medical care for herself. In case where the respondent is sick, this set of
questions give an answer to the major problems preventing her from getting medical
advice or treatment. The questions pertaining to V467A, V467E, V467G, V467H and
V467I are no longer part of the DHS VI core questionnaire, but the variables are kept in
the DHS VI recode.
V467A Knowing where to go
V467B Getting permission to go
V467C Getting money needed for treatment
V467D Distance to the health facility
V467E Having to take transport
V467F Not wanting to go alone
V467G Concern that there may not be a female health provider
V467H Concern that there may not be a provider
V467I Concern that there may not be drugs available
V632 Women using contraception are asked who decided on the use of contraception
V744 When wife’s beating or hitting is justified
V744A Goes out without telling him
V744B Neglects the children
V744C Argues with him
V744D Refuses to have sex with him
V744E Burns food
V781 Ever been tested for AIDS
V783 Know a place to get AIDS test
V828 Did get results for last test
(USAID, 2013)