Knowledge of HIV status, age-disparate sexual partnerships, and sexual risk behaviour among HIV positive men in South Africa: Evidence from two cross-sectional samples.

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Ronald Byaruhanga, Kaymarlin Govender, Ville Inkinen, Sean Beckett, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3640699/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract This study investigated the association between sexual risk behaviors, self-reported HIV status, and engagement in age-disparate relationships (defined as a 5 + year age gap) among men. Two cross-sectional household surveys were conducted in the uMgungundlovu district of KwaZulu-Natal, South Africa, spanning June 2014 to June 2016. Structured questionnaires administered by trained interviewers collected data from 3801 men aged 20 to 49 years who disclosed their HIV status. The analysis revealed that HIV-positive men had decreased odds of their three most recent relationships meeting age-disparity criteria (model ( 3 ): Adjusted Odds Ratio (AOR): 0.70; 95% Confidence Interval (CI): 0.53, 0.92; model ( 4 ): AOR: 0.73; 95% CI: 0.55, 0.96). HIV-positive respondents also showed reduced likelihood of engaging in specific sexual risk behaviors, such as multiple partnerships (AOR: 0.73; 95% CI: 0.55, 0.96), inconsistent condom use (AOR: 0.38; 95% CI: 0.28, 0.52), and casual sexual relationships (AOR: 0.66; 95% CI: 0.50, 0.87). These findings underscore the critical role of men’s HIV testing in reducing HIV incidence and transmissions. The study emphasizes the need for interventions addressing barriers to HIV testing among men, including limited access, confidentiality concerns, stigma, low risk perception, and discrimination to enhance testing uptake. Age-disparate Self-reported HIV Status Knowledge Sexual Risk Behaviour South Africa Background In spite of considerable strides in the global campaign against HIV( 1 ), certain regions and nations continue to grapple with high HIV burden. Of particular concern is the discernible burden of HIV in Sub-Saharan Africa, which disproportionately shoulders over 70% of global infections( 2 , 3 ). Foremost among these afflicted nations is South Africa, harboring an estimated 7.7 million individuals living with HIV, and the highest prevalence rate of 20.4% within the general population( 4 ). A pronounced gender dimension permeates the HIV landscape, both in South Africa and globally with women experiencing heightened susceptibility to infection attributable to a complex interplay of biological, behavioral, and structural factors( 5 ). Such factors impede women's agency in negotiating safe sex practices, often relegating control of sexual activity to men( 6 ). Consequently, HIV incidence rates are markedly higher among women as compared to men( 2 , 7 ). Despite commendable efforts in HIV prevention initiatives directed towards women( 5 ), there exists a notable neglect of men, who serve as significant transmitters of the virus to women( 8 ). Scholars have underscored the imperative of integrating men into the framework of HIV prevention interventions, with a particular focus on the context of sub-Saharan Africa. This geographic region is distinguished by a pronounced male influence on sexual activities and the consequential impact on their partners' adherence to HIV treatment and prevention initiatives. ( 8 ). While some interventions have broadened their purview to encompass men, a substantial proportion of these endeavors remain in the pilot phase, with limited scalability and efficacy( 9 ). A pivotal strategic avenue, identified by researchers, involves increasing men's awareness of their HIV status. This strategy is posited to potentially have trickledown effect on mitigating HIV incidence rates among women ( 10 ). Hence, fostering heightened engagement in HIV testing, prevention, care, and treatment services among men can yield consequential benefits( 11 ). Consequently, interventions directed at reducing risky sexual behaviors among HIV-positive men are conjectured to be efficacious in attenuating male-to-female HIV transmission dynamics( 12 ). In consideration of the foregoing, the current investigation undertook to investigate the relationship between awareness of one's HIV-positive status and the propensity to engage in age-disparate relationships among adult males living with HIV. The focal point of this study lies within the demographic landscape of South Africa, wherein HIV-positive adult men have voluntarily disclosed their serostatus. While extant literature has explored the correlation between knowledge of HIV status and sexual risk behaviors( 11 , 13 ), the unique focus of this inquiry lies in its exclusive examination of the interplay between a positive serostatus and the proclivity towards age-disparate relationships, a facet heretofore unexplored in the South African context. Notably, the dearth of specific investigations within the South African milieu underscores the significance of this study. The absence of prior research into the dynamics of age-disparate relationships among HIV-positive men in this region necessitates an in-depth analysis to address this conspicuous gap in scholarly literature. 2. Methods 2.1 Study population and setting Data for this study were collected as part of the HIV Incidence Provincial Surveillance System (HIPSS) in the rural and peri-urban areas of Vulindlela and Greater Edendale, respectively, in the uMgungundlovu district of KwaZulu-Natal, South Africa. At the time of data collection in 2014, uMgungundlovu was home to approximately 360,000 people (52% female). More details about the population and the setting have been published elsewhere( 14 , 15 ) Two cross-sectional household surveys were conducted from June 2014 to June 2015 (first survey) and from June 2015 to June 2016 (second survey). Structured interviews (in either English or Zulu) were used to collect data capturing a range of sociodemographic, economic, and behavioral characteristics. 2.2 Sample A multistage cluster sampling design was adopted to choose study participants from within enumeration areas and from individual households. Systematic random sampling was then employed to select households within each enumeration area. Further details about the sampling process can be found elsewhere( 15 ). The data through cross-sectional surveys including 7442 male respondents aged 15 to 49 years (3547 respondents in the first survey and 3895 respondents in the second survey). Since our outcome variables related to risk behavior between adult men and younger women, with a specific interest in age disparity of over five years, we restricted the sample to male respondents aged 20 or above (N = 5909). Moreover, in order to focus on the difference in outcomes arising from knowing being HIV positive in comparison to knowing being HIV negative, we only compared respondents who indicated in the survey that they have tested for HIV and who also self-reported their HIV status (N = 4364). After discarding observations with missing entries in any of the covariates included in the regression models, we retained 3801 observations in the main estimation sample. 2.3 Ethics consideration Prior to data collection, participants provided written informed consent. For participants below 18 years of age, consent was sought from their parents or guardians and the participants themselves. Compensation of 1US $ and 3US $ was given to the household leader and each participant for their participation, respectively. Regulatory approvals The study protocol, informed consent and data collection forms have been reviewed with ethics oversight and approval from the University of KwaZulu-Natal Biomedical Research Ethics Committee (BF269/13) and the Centers for Disease Control and Prevention from the United States of America and in collaboration with the Department of Health, Province of KwaZulu-Natal (HRKM 08/14). 2.4 Measures Exposure. We used self-reported HIV status (0 = self-reported HIV negative; 1 = self-reported HIV positive) was the exposure variable. Criterion variables. The primary criterion variable was age disparity to the youngest female partner among any of the three most recent sexual partners of the male respondent in the last 12 months. To measure age disparity, we constructed four different variables: ( 1 ) age difference to youngest partner (years), ( 2 ) age difference to youngest partner but censored to 0 if the female partner is older than the male respondent, ( 3 ) a binary indicator of 5 + years age gap to youngest partner with female partners up to age 25 included (0 = age gap to youngest reported partner less than 5 years; 1 = age gap to youngest reported partner at least 5 years and the partner is at most 25 years old), and ( 4 ) a similar binary indicator with female partners up to age 30 included. Additionally, we examined four risk behavior characteristics as dependent variables: having multiple sexual partners over the last 12 months (0 = 0 or 1 sexual partner in the last 12 months; 1 = two or more sexual partners in the last 12 months), condom use inconsistency in the three most recent relationships (0 = always used condoms; 1 = sometimes or never used condoms) and engaging in casual relationships among any of the three most recent sexual relationships (0 = reported no casual relationships; 1 = reported at least one casual relationship) and engaging in transactional sex in the three most recent relationships (0 = never gave or received money/gifts in order to have sex; 1 = always/sometimes gave or received money/gifts in order to have sex). Covariates. Socioeconomic characteristics included as covariates were total monthly income in the household (no income vs. R1-R500 vs. R501-R2500 vs. R2501-R6000 vs. >R6000), the respondent’s age (continuous, both linear and quadratic terms), marital status (Married, cohabiting, not married, single, has cohabited previously, single, never cohabited) and whether the respondent had completed secondary schooling (incomplete secondary schooling vs. completed secondary schooling). Sexual behavior characteristics included as covariates were the age of the respondent at first sexual intercourse (continuous), whether the respondent used condom at first intercourse (did not use condom vs. used condom) and the number of sexual partners over the respondent’s lifetime (continuous). 2.5 Data analysis All statistical analyses were performed using Stata v. 16.1. Descriptive analyses of participant characteristics using median and interquartile range (continuous variables) and proportions (categorical variables) was conducted. We examined the association between the explanatory variable (self-reporting as HIV positive) and the criterion variables using linear regression and logistic regression models. We reported adjusted odds ratios (AOR) with 95% confidence intervals (CIs). Regression models included sampling weights and adjusted for all covariates. Sampling weights were used, and socioeconomic and behavioral control variables were included in all regressions. 3. Results Descriptive statistics Table 1 provides descriptive statistics of male survey respondents included in the estimation sample. The estimation sample is further divided by self-reported HIV status in the second and third columns. Comparing respondents who self-reported as HIV positive (second column) to those who self-reported as HIV negative (third column), we first note that in the former group the median age was ten years higher than in the latter group. Moreover, the respondents who self-reported as HIV positive had a considerably lower rate of secondary school completion (33.7% vs. 60.4%) and on average they earned lower incomes than the respondents who self-reported as HIV negative. The median age difference to last partner was 3 years among respondents self-reporting as HIV-positive and 2 years among respondents self-reporting as HIV negative. However, the respondents who self-reported as HIV positive reported a lower rate of age disparate relationships (5 + years gap) with the previous partner (10.0% vs. 13.7%) and with any of the last three partners (14.0% vs 19.6%). Rates of intergenerational partnering (10 + years gap) were low in both groups. The respondents who self-reported as HIV positive also reported a lower rate of multiple partnering over the last 12 months (21.5% vs. 29.8%). Although reported condom use at sexual debut was low in both groups, it was lower among those who self-reported as HIV positive (5.1% vs. 20.9%). However, those who self-reported as HIV positive also reported less inconsistent condom use in the three most recent relationships (79.8% vs. 84.3%). Table 1 Descriptive statistics Full sample Self-reports as HIV+ Self-reports as HIV- (N = 3801) (N = 940) (N = 2861) Age (median, IQR) 30 (24, 38) 37 (32, 42) 27 (23, 34) Secondary school completed 53.8% 33.7% 60.4% Household monthly income: No income 8.4% 8.8% 8.2% R1-R500 6.4% 8.9% 5.6% R501-R2500 43.7% 50.2% 41.8% R2501-R6000 30.1% 26.0% 32.6% >R6000 10.3% 6.1% 11.7% Marital status: Married 8.7% 11.5% 7.8% Cohabiting, not married 4.8% 8.2% 3.7% Single, has cohabited previously 4.8% 7.1% 4.0% Single, never cohabited 81.7% 73.2% 84.5% Age at sexual debut (median, IQR) 17 (16, 19) 17 (15, 19) 17 (16, 18) Used condom at sexual debut 17.0% 5.1% 20.9% Has had more than one sexual partner 88.7% 90.5% 88.1% Has had more than one partner over last 12 months 27.8% 21.5% 29.8% Age difference to last partner, years (median, IQR) 2 (0, 5) 3 (0, 7) 2 (0, 5) Age disparate relationship (5 + yr gap) with: Last partner 12.8% 10.0% 13.7% Any of last 3 partners 18.3% 14.0% 19.6% Age disparate relationship (10 + yr gap) with: Last partner 3.7% 5.4% 3.1% Any of last 3 partners 5.4% 7.9% 4.6% Inconsistent condom use Last partner 78.1% 74.4% 79.3% Any of last 3 partners 83.1% 79.8% 84.3% Casual relationships Last partner 9.9% 6.9% 10.8% Any of last 3 partners 19.9% 14.9% 21.6% Transactional sex Last partner 11.1% 12.0% 10.8% Any of last 3 partners 12.8% 13.8% 12.5% Self-reports as HIV positive 24.7% - - HIV positive 34.1% 98.1% 13.1% Data source: HIPSS 1st and 2nd baseline cross-sectional surveys. Estimation sample: Men 20–49 years old who have tested for and self-report their HIV status. 563 observations were excluded from the analytic sample due to missing data. Regression analysis The results in Table 2 show that self-reporting as HIV positive was associated with a lower likelihood of engaging in age-disparate relationships. In model ( 1 ), the outcome variable is continuous age difference (years) to the youngest partner out of the three most recent partners. The result indicates that self-reporting as HIV positive was associated with a lower age difference when compared to respondents who self-reported as HIV negative (-0.68; 95% CI: -1.15 to -0.22). In model ( 2 ), the age difference variable is censored to zero if the female partner was older than the male respondent. The result remains qualitatively similar (-0.55; 95% CI: -0.95 to -0.16). In the third and fourth columns, the outcome variable is a binary indicator of age disparity (5 + years age difference to youngest partner). In model ( 3 ), relationships with females up to age 25 can be considered age disparate, and in model ( 4 ) the cutoff is 30 years. In both models, the results indicate that respondents who self-report as HIV positive had lower odds of any of their three most recent relationships qualifying as age disparate (model ( 3 ): AOR: 0.70; 95% CI: 0. 53 to 0. 92; model ( 4 ): AOR 0.73; 95% CI: 0.55 to 0.96).). Table 2 Association between knowledge of HIV status and age-disparate partnerships (1) (2) (3) (4) Outcome Age difference 1 Age difference 2 5 + yr gap 3 5 + yr gap 4 Independent variable Self-reports as HIV+ Self-reports as HIV+ Self-reports as HIV+ Self-reports as HIV+ Coefficient -0.68** -0.55** 0.70* 0.61*** 95% CI [-1.15, -0.22] [-0.95, -0.16] [0.53, 0.92] [0.49, 0.75] N 3801 3801 3801 3801 Data source: HIPSS 1st and 2nd baseline cross-sectional surveys. Estimation sample: Men 20–49 years old who have tested for and self-report their HIV status. 1 Continuous age difference to youngest reported partner. 2 Continuous age difference to youngest reported partner, censored to 0 if the female partner is older. 3 Binary indicator of 5 + years age gap to youngest reported partner. Female partners up to age 25. 4 Binary indicator of 5 + years age gap to youngest reported partner. Female partners up to age 30. * p < 0.05, ** p < 0.01, *** p < 0.001 Standard errors clustered at enumerator area level. Exponentiated coefficients in columns 3–4. Demographic and behavioral control variables included in all regressions (household income, age, marital status, secondary school completion, number of lifetime sex partners, age at first intercourse, use of condom at first intercourse). Sampling weights used in all regressions. Table 3 presents the Association between knowledge of HIV status and risk behavior of participants. Participants who self-reported as HIV positive had a lower odd of engaging in certain types of sexual risk behaviors, including having multiple sex partners (AOR: 0.73; 95% CI: 0.55–0.96), inconsistent condom use (AOR: 0.38; 95% CI: 0.28–0.52), and engaging in casual sexual relationships (AOR: 0.66; 95% CI: 0.50–0.87). There was little evidence to suggest that self-reported HIV positive was associated with transactional sex (AOR: 1.22; 95% CI: 0.90, 1.65). Table 3 Association between knowledge of HIV status and risk behavior (1) (2) (3) (4) Outcome Multiple partners in last 12 months 1 Inconsistent condom use 2 Casual relationships 3 Transactional sex 4 Independent variable Self-reports as HIV+ Self-reports as HIV+ Self-reports as HIV+ Self-reports as HIV+ Coefficient 0.73* 0.38*** 0.66** 1.22 95% CI [0.55, 0.96] [0.28, 0.52] [0.50, 0.87] [0.90, 1.65] N 3340 3801 3801 3801 Data source: HIPSS 1st and 2nd baseline cross-sectional surveys. Estimation sample: Men 20–49 years old who have tested for and self-report their HIV status. 1 Binary indicator of having more than one partner over last 12 months. 2 Binary indicator of reporting inconsistent condom use (0 = always used condoms; 1 = sometimes or never used condoms) with any of three most recent partners. 3 Binary indicator of reporting casual relationships among three most recent partners. 4 Binary indicator of reporting engaging in transactional sex with any of three most recent partners. * p < 0.05, ** p < 0.01, *** p < 0.001 Standard errors clustered at enumerator area level. Exponentiated coefficients. Demographic and behavioral control variables included in all regressions (household income, age, marital status, secondary school completion, number of lifetime sex partners, age at first intercourse, use of condom at first intercourse). Sampling weights used in all regressions. Discussion This study undertook to examine the relationship between knowledge of HIV-positive status and the proclivity to engage in age-disparate relationships, defined by a significant age difference of 5 years or more, among adult HIV positive men who provided self-reported information about their HIV status. The overarching findings elucidated a remarkable trend, wherein men acknowledging their HIV positive status exhibited a diminished likelihood of involvement in age-disparate relationships. The statistical outcomes indicated that respondents self-identifying as HIV-positive demonstrated diminished odds of having any of their three most recent relationships classified as age disparate (model ( 3 ): Adjusted Odds Ratio [AOR]: 0.70; 95% Confidence Interval [CI]: 0.53 to 0.92; model ( 4 ): AOR 0.73; 95% CI: 0.55 to 0.96). These empirical revelations cohere with antecedent research that has firmly established a correlation between awareness of HIV serostatus and a concomitant reduction in sexual risk behavior. For instance, a seminal study conducted in Malawi scrutinized the impact of HIV testing on subjective expectations and risk behavior, revealing a discernible shift in behavior among men who received confirmation of their HIV-positive status. These individuals reported a decreased number of sexual partners and an increase in use of condoms compared to their counterparts who were untested( 10 ). Consequently, it is plausible to posit that individuals cognizant of their HIV-positive status may approach sexual relationships with heightened circumspection, rooted in concerns regarding potential transmission. Moreover, our investigation divulged that these men not only refrained from engaging in age-disparate relationships, thus mitigating potential risks to younger partners, but also exhibited a decreased likelihood of having multiple sexual partners in the 12 months prior to the survey. This observed alteration in sexual risk behavior aligns with the theoretical underpinnings expounded in extant studies, contending that awareness of one's HIV-positive status prompts individuals to embrace a more conscientious sexual lifestyle, cognizant of the potential repercussions on others( 16 ). For instance, a study among HIV-positive injecting drug users across Baltimore, Miami, New York, and San Francisco disclosed that a sense of responsibility to prevent transmission was associated with a reduced number of sexual partners (< 10 vs. ≥10, 0.57 [0.34 to 0.96]) and a diminished likelihood of engaging in unprotected sex (0.63 [0.45 to 0.89]). Furthermore, this shift in behavior could be intrinsically tied to the aspiration to restore a semblance of normalcy and social standing. Research posits that being HIV-positive often engenders social pressures, such as stigma and discrimination( 17 ). Consequently, individuals living with HIV may harbor apprehensions about jeopardizing valued relationships and, consequently, eschew behaviors that could further stigmatize them, such as engaging in precarious sexual activities that pose a risk of infection to others. Thus, it is conceivable that individuals newly diagnosed with HIV-positive status are inclined to adopt behaviors conducive to regaining social acceptance, such as avoiding risky sexual encounters that imperil the health of others within the community. Supporting this notion, a study examining risk and sexual behavior among HIV-positive individuals established that upon learning of their HIV-positive status, individuals tended to modify their sexual habits due to apprehensions about disease transmission and the challenges associated with self-protection( 18 ). Corroborating this perspective, Schiltz and Sandfort ( 19 , p. 1582) affirmed that the "fear of transmitting the virus and the fear of being shunned" may propel individuals with positive serostatus to seek partners with a similar status or transfer the onus of protective measures to their partners( 19 ). Limitations The interpretation of the outcomes of this investigation requires cautious consideration, given the inherent constraints imposed by its cross-sectional design. This design impinges upon the establishment of a definitive temporal nexus between the variables of exposure and outcome. The intricacy lies in discerning whether participants gained cognizance of their HIV-positive status antecedent to or concomitant with the preceding 12 months of their relational engagements. This temporal ambiguity introduces a noteworthy caveat, as the ascribed effects may be contingent upon the chronology of HIV status revelation, a facet that could be more judiciously explored through the utilization of longitudinal data. Furthermore, the particulars of the post-diagnostic phases individuals undergo following the revelation of their HIV-positive status introduce an additional layer of complexity to the association between knowledge of one's seropositivity and engagement in risky sexual behavior. The fluctuating dynamics of this association at different temporal junctures necessitate a sophisticated understanding. Notably, during a phase typified by denial, it is conceivable that awareness of being HIV-positive might precipitate an escalation in risky sexual behavior. Conversely, as the process of acceptance unfolds and a sense of responsibility towards the well-being of others takes root, the proclivity for engaging in such risky behavior may attenuate. This dynamic trajectory underscores the imperative to acknowledge this inherent limitation when deciphering the study's findings and underscores the need for nuanced consideration in future research endeavors. Furthermore, an exercise of circumspection is warranted in extrapolating the outcomes of this study to other contexts, as the dataset emanates from a specific geographical locus within a singular national milieu. The external validity or transferability of the findings to disparate settings ought to be approached with caution. It is imperative to underscore the necessity for additional investigations to scrutinize the generalizability of these findings across diverse contexts, thereby enriching the understanding of the broader applicability of the study's outcomes. Conclusion This investigation presents compelling empirical evidence establishing a robust correlation between heightened awareness of HIV-positive status among males and a discernible reduction in proclivities toward engaging in high-risk sexual behaviors, particularly within relationships characterized by significant age disparities. These findings accentuate the pivotal role played by HIV testing and the subsequent disclosure of results as pivotal determinants in mitigating HIV incidence rates and interrupting transmissions within the heterosexual context. To augment the implications of these revelations, there exists an imperative to broaden the implementation of targeted interventions designed to motivate and facilitate HIV testing among the male demographic. The upscaling of such initiatives necessitates a comprehensive approach aimed at undoing diverse barriers that impede men's access to testing services. These impediments encompass, but are not limited to, restricted availability of testing sites, fears pertaining to confidentiality breaches, the specter of stigmatization, socioeconomic constraints, a diminished perception of HIV risk, and instances of discriminatory practices. A proactive strategy addressing these multifaceted barriers is indispensable for interventions to carve out pathways that streamline the HIV testing process for men. By systematically dismantling these obstacles, interventions can establish facilitative avenues that simplify and destigmatize the act of undergoing HIV testing. Consequently, this recalibration in approach holds the potential to not only elevate the uptake of HIV testing services among men but also induce consequential alterations in their sexual behaviors. The ensuing impact is anticipated to reverberate across the spectrum, resulting in a diminished incidence of male-to-female HIV infections. This underscores the cascading benefits emanating from heightened testing uptake and the attendant modifications in behavioral patterns within the context of HIV prevention. Declarations Author contribution RB, VI, and KG wrote the manuscript. RC, KG, and SB were responsible for the fieldwork and quality assurance; SB and VI for statistical analysis; SB, and VI contributed to the analysis and interpretation of the data. AP, NS, ZC, and SM were responsible for laboratory measurements and quality assurance; SB, VI and KG were responsible for community and stakeholder engagement activities; all authors critically reviewed and approved the final version of the manuscript. Study sponsorship and funding statement HIPSS study is funded by the Centers for Disease Control and Prevention (CDC) under terms of the cooperative agreement 3U2GGH000372-02 W1 and the US Presidents Emergency Plan for AIDS Relief (PEPFAR). Conflict of Interest The authors declare that there no conflicts of interest regarding the research, authorship, and/or publication of this article. Availability of data and materials The datasets generated and/or analysed during the current study cannot be made public due to restrictions from the funder. However, datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. References Read SW, Kim P, Marovich M, Dieffenbach CW, Fauci AS. Forty years of investment in HIV research: progress towards ending the HIV pandemic and preparation for future pandemics. J Int AIDS Soc. 2022;25(12). Zuma K, Shisana O, Rehle TM, Simbayi LC, Jooste S, Zungu N, et al. New insights into HIV epidemic in South Africa: key findings from the National HIV Prevalence, Incidence and Behaviour Survey, 2012. Afr J AIDS Res. 2016;15(1):67–75. Kharsany AB, Karim QA. 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HIV testing barriers and intervention strategies among men, transgender women, female sex workers and incarcerated persons in the Caribbean: a systematic review. Sex Transm Infect. 2020;96(3):189–96. Latka MH, Mizuno Y, Wu Y, Tobin KE, Metsch LR, Frye V, et al. Are feelings of responsibility to limit the sexual transmission of HIV associated with safer sex among HIV-positive injection drug users? JAIDS J Acquir Immune Defic Syndr. 2007;46:88–S95. Schiltz M-A, Sandfort TG. HIV-positive people, risk and sexual behaviour. Soc Sci Med. 2000;50(11):1571–88. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3640699","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":252791350,"identity":"154c7b5b-ed56-4046-bc25-8fa87adc06b2","order_by":0,"name":"Ronald Byaruhanga","email":"data:image/png;base64,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","orcid":"","institution":"Lund University","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Ronald","middleName":"","lastName":"Byaruhanga","suffix":""},{"id":252791351,"identity":"94efb5d9-fc01-40c6-8fda-88b9c98ad1b2","order_by":1,"name":"Kaymarlin Govender","email":"","orcid":"","institution":"University of KwaZulu-Natal","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Kaymarlin","middleName":"","lastName":"Govender","suffix":""},{"id":252791353,"identity":"7d9ec79e-24fe-4d49-ac45-1fe87f0877f0","order_by":2,"name":"Ville Inkinen","email":"","orcid":"","institution":"University of Gothenburg","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ville","middleName":"","lastName":"Inkinen","suffix":""},{"id":252791355,"identity":"f7653e66-6ae4-401e-8420-5093368489d0","order_by":3,"name":"Sean Beckett","email":"","orcid":"","institution":"University of KwaZulu-Natal","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Sean","middleName":"","lastName":"Beckett","suffix":""},{"id":252791357,"identity":"091eb7c6-5cd0-4ec6-adde-e142b9238cdb","order_by":4,"name":"Richard Cowden","email":"","orcid":"","institution":"Harvard University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Richard","middleName":"","lastName":"Cowden","suffix":""}],"badges":[],"createdAt":"2023-11-20 18:29:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3640699/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3640699/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":50909397,"identity":"b0f0eb07-7cc4-4adb-acea-a72c38e4f1bd","added_by":"auto","created_at":"2024-02-09 11:46:44","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":286120,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3640699/v1/7ad0eed9-0d2d-451e-82c3-8bf42b4d5df2.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Knowledge of HIV status, age-disparate sexual partnerships, and sexual risk behaviour among HIV positive men in South Africa: Evidence from two cross-sectional samples.","fulltext":[{"header":"Background","content":"\u003cp\u003eIn spite of considerable strides in the global campaign against HIV(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e), certain regions and nations continue to grapple with high HIV burden. Of particular concern is the discernible burden of HIV in Sub-Saharan Africa, which disproportionately shoulders over 70% of global infections(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Foremost among these afflicted nations is South Africa, harboring an estimated 7.7\u0026nbsp;million individuals living with HIV, and the highest prevalence rate of 20.4% within the general population(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA pronounced gender dimension permeates the HIV landscape, both in South Africa and globally with women experiencing heightened susceptibility to infection attributable to a complex interplay of biological, behavioral, and structural factors(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Such factors impede women's agency in negotiating safe sex practices, often relegating control of sexual activity to men(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Consequently, HIV incidence rates are markedly higher among women as compared to men(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Despite commendable efforts in HIV prevention initiatives directed towards women(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), there exists a notable neglect of men, who serve as significant transmitters of the virus to women(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eScholars have underscored the imperative of integrating men into the framework of HIV prevention interventions, with a particular focus on the context of sub-Saharan Africa. This geographic region is distinguished by a pronounced male influence on sexual activities and the consequential impact on their partners' adherence to HIV treatment and prevention initiatives. (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). While some interventions have broadened their purview to encompass men, a substantial proportion of these endeavors remain in the pilot phase, with limited scalability and efficacy(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). A pivotal strategic avenue, identified by researchers, involves increasing men's awareness of their HIV status. This strategy is posited to potentially have trickledown effect on mitigating HIV incidence rates among women (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Hence, fostering heightened engagement in HIV testing, prevention, care, and treatment services among men can yield consequential benefits(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Consequently, interventions directed at reducing risky sexual behaviors among HIV-positive men are conjectured to be efficacious in attenuating male-to-female HIV transmission dynamics(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn consideration of the foregoing, the current investigation undertook to investigate the relationship between awareness of one's HIV-positive status and the propensity to engage in age-disparate relationships among adult males living with HIV. The focal point of this study lies within the demographic landscape of South Africa, wherein HIV-positive adult men have voluntarily disclosed their serostatus. While extant literature has explored the correlation between knowledge of HIV status and sexual risk behaviors(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e), the unique focus of this inquiry lies in its exclusive examination of the interplay between a positive serostatus and the proclivity towards age-disparate relationships, a facet heretofore unexplored in the South African context. Notably, the dearth of specific investigations within the South African milieu underscores the significance of this study. The absence of prior research into the dynamics of age-disparate relationships among HIV-positive men in this region necessitates an in-depth analysis to address this conspicuous gap in scholarly literature.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cp\u003e2.1 Study population and setting\u003c/p\u003e \u003cp\u003eData for this study were collected as part of the HIV Incidence Provincial Surveillance System (HIPSS) in the rural and peri-urban areas of Vulindlela and Greater Edendale, respectively, in the uMgungundlovu district of KwaZulu-Natal, South Africa. At the time of data collection in 2014, uMgungundlovu was home to approximately 360,000 people (52% female). More details about the population and the setting have been published elsewhere(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eTwo cross-sectional household surveys were conducted from June 2014 to June 2015 (first survey) and from June 2015 to June 2016 (second survey). Structured interviews (in either English or Zulu) were used to collect data capturing a range of sociodemographic, economic, and behavioral characteristics.\u003c/p\u003e \u003cp\u003e2.2 Sample\u003c/p\u003e \u003cp\u003e A multistage cluster sampling design was adopted to choose study participants from within enumeration areas and from individual households. Systematic random sampling was then employed to select households within each enumeration area. Further details about the sampling process can be found elsewhere(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe data through cross-sectional surveys including 7442 male respondents aged 15 to 49 years (3547 respondents in the first survey and 3895 respondents in the second survey). Since our outcome variables related to risk behavior between adult men and younger women, with a specific interest in age disparity of over five years, we restricted the sample to male respondents aged 20 or above (N\u0026thinsp;=\u0026thinsp;5909). Moreover, in order to focus on the difference in outcomes arising from knowing being HIV positive in comparison to knowing being HIV negative, we only compared respondents who indicated in the survey that they have tested for HIV and who also self-reported their HIV status (N\u0026thinsp;=\u0026thinsp;4364). After discarding observations with missing entries in any of the covariates included in the regression models, we retained 3801 observations in the main estimation sample.\u003c/p\u003e \u003cp\u003e2.3 Ethics consideration\u003c/p\u003e \u003cp\u003e Prior to data collection, participants provided written informed consent. For participants below 18 years of age, consent was sought from their parents or guardians and the participants themselves. Compensation of 1US\u003cspan\u003e$\u003c/span\u003e and 3US\u003cspan\u003e$\u003c/span\u003e was given to the household leader and each participant for their participation, respectively.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eRegulatory approvals\u003c/h2\u003e \u003cp\u003e The study protocol, informed consent and data collection forms have been reviewed with ethics oversight and approval from the University of KwaZulu-Natal Biomedical Research Ethics Committee (BF269/13) and the Centers for Disease Control and Prevention from the United States of America and in collaboration with the Department of Health, Province of KwaZulu-Natal (HRKM 08/14).\u003c/p\u003e \u003cp\u003e2.4 Measures\u003c/p\u003e \u003cp\u003e \u003cb\u003eExposure.\u003c/b\u003e We used \u003cem\u003eself-reported HIV status\u003c/em\u003e (0\u0026thinsp;=\u0026thinsp;self-reported HIV negative; 1\u0026thinsp;=\u0026thinsp;self-reported HIV positive) was the exposure variable.\u003c/p\u003e \u003cp\u003e \u003cb\u003eCriterion variables.\u003c/b\u003e The primary criterion variable was age disparity to the youngest female partner among any of the three most recent sexual partners of the male respondent in the last 12 months. To measure age disparity, we constructed four different variables: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) age difference to youngest partner (years), (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) age difference to youngest partner but censored to 0 if the female partner is older than the male respondent, (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) a binary indicator of 5\u0026thinsp;+\u0026thinsp;years age gap to youngest partner with female partners up to age 25 included (0\u0026thinsp;=\u0026thinsp;age gap to youngest reported partner less than 5 years; 1\u0026thinsp;=\u0026thinsp;age gap to youngest reported partner at least 5 years and the partner is at most 25 years old), and (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) a similar binary indicator with female partners up to age 30 included. Additionally, we examined four risk behavior characteristics as dependent variables: having multiple sexual partners over the last 12 months (0\u0026thinsp;=\u0026thinsp;0 or 1 sexual partner in the last 12 months; 1\u0026thinsp;=\u0026thinsp;two or more sexual partners in the last 12 months), condom use inconsistency in the three most recent relationships (0\u0026thinsp;=\u0026thinsp;always used condoms; 1\u0026thinsp;=\u0026thinsp;sometimes or never used condoms) and engaging in casual relationships among any of the three most recent sexual relationships (0\u0026thinsp;=\u0026thinsp;reported no casual relationships; 1\u0026thinsp;=\u0026thinsp;reported at least one casual relationship) and engaging in transactional sex in the three most recent relationships (0\u0026thinsp;=\u0026thinsp;never gave or received money/gifts in order to have sex; 1\u0026thinsp;=\u0026thinsp;always/sometimes gave or received money/gifts in order to have sex).\u003c/p\u003e \u003cp\u003e \u003cb\u003eCovariates.\u003c/b\u003e Socioeconomic characteristics included as covariates were total monthly income in the household (no income vs. R1-R500 vs. R501-R2500 vs. R2501-R6000 vs. \u0026gt;R6000), the respondent\u0026rsquo;s age (continuous, both linear and quadratic terms), marital status (Married, cohabiting, not married, single, has cohabited previously, single, never cohabited) and whether the respondent had completed secondary schooling (incomplete secondary schooling vs. completed secondary schooling). Sexual behavior characteristics included as covariates were the age of the respondent at first sexual intercourse (continuous), whether the respondent used condom at first intercourse (did not use condom vs. used condom) and the number of sexual partners over the respondent\u0026rsquo;s lifetime (continuous).\u003c/p\u003e \u003cp\u003e2.5 Data analysis\u003c/p\u003e \u003cp\u003eAll statistical analyses were performed using Stata v. 16.1. Descriptive analyses of participant characteristics using median and interquartile range (continuous variables) and proportions (categorical variables) was conducted. We examined the association between the explanatory variable (self-reporting as HIV positive) and the criterion variables using linear regression and logistic regression models. We reported adjusted odds ratios (AOR) with 95% confidence intervals (CIs). Regression models included sampling weights and adjusted for all covariates. Sampling weights were used, and socioeconomic and behavioral control variables were included in all regressions.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eDescriptive statistics\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e provides descriptive statistics of male survey respondents included in the estimation sample. The estimation sample is further divided by self-reported HIV status in the second and third columns.\u003c/p\u003e \u003cp\u003eComparing respondents who self-reported as HIV positive (second column) to those who self-reported as HIV negative (third column), we first note that in the former group the median age was ten years higher than in the latter group. Moreover, the respondents who self-reported as HIV positive had a considerably lower rate of secondary school completion (33.7% vs. 60.4%) and on average they earned lower incomes than the respondents who self-reported as HIV negative. The median age difference to last partner was 3 years among respondents self-reporting as HIV-positive and 2 years among respondents self-reporting as HIV negative. However, the respondents who self-reported as HIV positive reported a lower rate of age disparate relationships (5\u0026thinsp;+\u0026thinsp;years gap) with the previous partner (10.0% vs. 13.7%) and with any of the last three partners (14.0% vs 19.6%). Rates of intergenerational partnering (10\u0026thinsp;+\u0026thinsp;years gap) were low in both groups. The respondents who self-reported as HIV positive also reported a lower rate of multiple partnering over the last 12 months (21.5% vs. 29.8%). Although reported condom use at sexual debut was low in both groups, it was lower among those who self-reported as HIV positive (5.1% vs. 20.9%). However, those who self-reported as HIV positive also reported less inconsistent condom use in the three most recent relationships (79.8% vs. 84.3%).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDescriptive statistics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFull sample\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSelf-reports as HIV+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSelf-reports as HIV-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;3801)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;940)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;2861)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (median, IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (24, 38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e37 (32, 42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e27 (23, 34)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondary school completed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53.8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e33.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e60.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHousehold monthly income:\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo income\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8.8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e8.2%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eR1-R500\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8.9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e5.6%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eR501-R2500\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e50.2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e41.8%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eR2501-R6000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30.1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e26.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e32.6%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;R6000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6.1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e11.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarital status:\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e7.8%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCohabiting, not married\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8.2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSingle, has cohabited previously\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7.1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e4.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSingle, never cohabited\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e81.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e73.2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e84.5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge at sexual debut (median, IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (16, 19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e17 (15, 19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e17 (16, 18)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUsed condom at sexual debut\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e20.9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHas had more than one sexual partner\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e88.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e90.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e88.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHas had more than one partner over last 12 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27.8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e21.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e29.8%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge difference to last partner, years (median, IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (0, 5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3 (0, 7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2 (0, 5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge disparate relationship\u003c/p\u003e \u003cp\u003e(5\u0026thinsp;+\u0026thinsp;yr gap) with:\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLast partner\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e13.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAny of last 3 partners\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e19.6%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge disparate relationship\u003c/p\u003e \u003cp\u003e(10\u0026thinsp;+\u0026thinsp;yr gap) with:\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLast partner\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAny of last 3 partners\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7.9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e4.6%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInconsistent condom use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLast partner\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e78.1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e74.4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e79.3%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAny of last 3 partners\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e83.1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e79.8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e84.3%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCasual relationships\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLast partner\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6.9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e10.8%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAny of last 3 partners\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19.9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14.9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e21.6%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTransactional sex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLast partner\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e10.8%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAny of last 3 partners\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13.8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e12.5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSelf-reports as HIV positive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHIV positive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34.1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e98.1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e13.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003eData source: HIPSS 1st and 2nd baseline cross-sectional surveys.\u003c/p\u003e \u003cp\u003eEstimation sample: Men 20\u0026ndash;49 years old who have tested for and self-report their HIV status. 563\u0026nbsp;observations were excluded from the analytic sample due to missing data.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eRegression analysis\u003c/h2\u003e \u003cp\u003eThe results in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e show that self-reporting as HIV positive was associated with a lower likelihood of engaging in age-disparate relationships.\u003c/p\u003e \u003cp\u003eIn model (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e), the outcome variable is continuous age difference (years) to the youngest partner out of the three most recent partners. The result indicates that self-reporting as HIV positive was associated with a lower age difference when compared to respondents who self-reported as HIV negative (-0.68; 95% CI: -1.15 to -0.22). In model (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e), the age difference variable is censored to zero if the female partner was older than the male respondent. The result remains qualitatively similar (-0.55; 95% CI: -0.95 to -0.16).\u003c/p\u003e \u003cp\u003eIn the third and fourth columns, the outcome variable is a binary indicator of age disparity (5\u0026thinsp;+\u0026thinsp;years age difference to youngest partner). In model (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e), relationships with females up to age 25 can be considered age disparate, and in model (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) the cutoff is 30 years. In both models, the results indicate that respondents who self-report as HIV positive had lower odds of any of their three most recent relationships qualifying as age disparate (model (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e): AOR: 0.70; 95% CI: 0. 53 to 0. 92; model (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e): AOR 0.73; 95% CI: 0.55 to 0.96).).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAssociation between knowledge of HIV status and age-disparate partnerships\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(1)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(2)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(3)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(4)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOutcome\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAge difference\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAge difference\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5\u0026thinsp;+\u0026thinsp;yr gap\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5\u0026thinsp;+\u0026thinsp;yr gap\u003csup\u003e4\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIndependent variable\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSelf-reports as HIV+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSelf-reports as HIV+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSelf-reports as HIV+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSelf-reports as HIV+\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCoefficient\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.68**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.55**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.70*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.61***\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e[-1.15, -0.22]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e[-0.95, -0.16]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e[0.53, 0.92]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e[0.49, 0.75]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3801\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3801\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3801\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3801\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eData source: HIPSS 1st and 2nd baseline cross-sectional surveys.\u003c/p\u003e \u003cp\u003eEstimation sample: Men 20\u0026ndash;49 years old who have tested for and self-report their HIV status.\u003c/p\u003e \u003cp\u003e\u003csup\u003e1\u003c/sup\u003e Continuous age difference to youngest reported partner.\u003c/p\u003e \u003cp\u003e\u003csup\u003e2\u003c/sup\u003e Continuous age difference to youngest reported partner, censored to 0 if the female partner is older.\u003c/p\u003e \u003cp\u003e\u003csup\u003e3\u003c/sup\u003e Binary indicator of 5\u0026thinsp;+\u0026thinsp;years age gap to youngest reported partner. Female partners up to age 25.\u003c/p\u003e \u003cp\u003e\u003csup\u003e4\u003c/sup\u003e Binary indicator of 5\u0026thinsp;+\u0026thinsp;years age gap to youngest reported partner. Female partners up to age 30.\u003c/p\u003e \u003cp\u003e* p\u0026thinsp;\u0026lt;\u0026thinsp;0.05, ** p\u0026thinsp;\u0026lt;\u0026thinsp;0.01, *** p\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003cp\u003eStandard errors clustered at enumerator area level. Exponentiated coefficients in columns 3\u0026ndash;4.\u003c/p\u003e \u003cp\u003eDemographic and behavioral control variables included in all regressions (household income, age, marital status, secondary school completion, number of lifetime sex partners, age at first intercourse, use of condom at first intercourse). Sampling weights used in all regressions.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e presents the Association between knowledge of HIV status and risk behavior of participants. Participants who self-reported as HIV positive had a lower odd of engaging in certain types of sexual risk behaviors, including having multiple sex partners (AOR: 0.73; 95% CI: 0.55\u0026ndash;0.96), inconsistent condom use (AOR: 0.38; 95% CI: 0.28\u0026ndash;0.52), and engaging in casual sexual relationships (AOR: 0.66; 95% CI: 0.50\u0026ndash;0.87). There was little evidence to suggest that self-reported HIV positive was associated with transactional sex (AOR: 1.22; 95% CI: 0.90, 1.65).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAssociation between knowledge of HIV status and risk behavior\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(1)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(2)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(3)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(4)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOutcome\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMultiple partners in last 12 months\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInconsistent condom use\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCasual relationships\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTransactional sex\u003csup\u003e4\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIndependent variable\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSelf-reports as HIV+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSelf-reports as HIV+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSelf-reports as HIV+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSelf-reports as HIV+\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCoefficient\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.73*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.38***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.66**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.22\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e[0.55, 0.96]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e[0.28, 0.52]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e[0.50, 0.87]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e[0.90, 1.65]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3340\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3801\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3801\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3801\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eData source: HIPSS 1st and 2nd baseline cross-sectional surveys.\u003c/p\u003e \u003cp\u003eEstimation sample: Men 20\u0026ndash;49 years old who have tested for and self-report their HIV status.\u003c/p\u003e \u003cp\u003e\u003csup\u003e1\u003c/sup\u003e Binary indicator of having more than one partner over last 12 months.\u003c/p\u003e \u003cp\u003e\u003csup\u003e2\u003c/sup\u003e Binary indicator of reporting inconsistent condom use (0\u0026thinsp;=\u0026thinsp;always used condoms; 1\u0026thinsp;=\u0026thinsp;sometimes or never used condoms) with any of three most recent partners.\u003c/p\u003e \u003cp\u003e\u003csup\u003e3\u003c/sup\u003e Binary indicator of reporting casual relationships among three most recent partners.\u003c/p\u003e \u003cp\u003e\u003csup\u003e4\u003c/sup\u003e Binary indicator of reporting engaging in transactional sex with any of three most recent partners.\u003c/p\u003e \u003cp\u003e* p\u0026thinsp;\u0026lt;\u0026thinsp;0.05, ** p\u0026thinsp;\u0026lt;\u0026thinsp;0.01, *** p\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003cp\u003eStandard errors clustered at enumerator area level. Exponentiated coefficients. Demographic and behavioral control variables included in all regressions (household income, age, marital status, secondary school completion, number of lifetime sex partners, age at first intercourse, use of condom at first intercourse). Sampling weights used in all regressions.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study undertook to examine the relationship between knowledge of HIV-positive status and the proclivity to engage in age-disparate relationships, defined by a significant age difference of 5 years or more, among adult HIV positive men who provided self-reported information about their HIV status. The overarching findings elucidated a remarkable trend, wherein men acknowledging their HIV positive status exhibited a diminished likelihood of involvement in age-disparate relationships. The statistical outcomes indicated that respondents self-identifying as HIV-positive demonstrated diminished odds of having any of their three most recent relationships classified as age disparate (model (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e): Adjusted Odds Ratio [AOR]: 0.70; 95% Confidence Interval [CI]: 0.53 to 0.92; model (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e): AOR 0.73; 95% CI: 0.55 to 0.96). These empirical revelations cohere with antecedent research that has firmly established a correlation between awareness of HIV serostatus and a concomitant reduction in sexual risk behavior.\u003c/p\u003e \u003cp\u003eFor instance, a seminal study conducted in Malawi scrutinized the impact of HIV testing on subjective expectations and risk behavior, revealing a discernible shift in behavior among men who received confirmation of their HIV-positive status. These individuals reported a decreased number of sexual partners and an increase in use of condoms compared to their counterparts who were untested(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Consequently, it is plausible to posit that individuals cognizant of their HIV-positive status may approach sexual relationships with heightened circumspection, rooted in concerns regarding potential transmission.\u003c/p\u003e \u003cp\u003eMoreover, our investigation divulged that these men not only refrained from engaging in age-disparate relationships, thus mitigating potential risks to younger partners, but also exhibited a decreased likelihood of having multiple sexual partners in the 12 months prior to the survey. This observed alteration in sexual risk behavior aligns with the theoretical underpinnings expounded in extant studies, contending that awareness of one's HIV-positive status prompts individuals to embrace a more conscientious sexual lifestyle, cognizant of the potential repercussions on others(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). For instance, a study among HIV-positive injecting drug users across Baltimore, Miami, New York, and San Francisco disclosed that a sense of responsibility to prevent transmission was associated with a reduced number of sexual partners (\u0026lt;\u0026thinsp;10 vs. \u0026ge;10, 0.57 [0.34 to 0.96]) and a diminished likelihood of engaging in unprotected sex (0.63 [0.45 to 0.89]).\u003c/p\u003e \u003cp\u003eFurthermore, this shift in behavior could be intrinsically tied to the aspiration to restore a semblance of normalcy and social standing. Research posits that being HIV-positive often engenders social pressures, such as stigma and discrimination(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Consequently, individuals living with HIV may harbor apprehensions about jeopardizing valued relationships and, consequently, eschew behaviors that could further stigmatize them, such as engaging in precarious sexual activities that pose a risk of infection to others. Thus, it is conceivable that individuals newly diagnosed with HIV-positive status are inclined to adopt behaviors conducive to regaining social acceptance, such as avoiding risky sexual encounters that imperil the health of others within the community. Supporting this notion, a study examining risk and sexual behavior among HIV-positive individuals established that upon learning of their HIV-positive status, individuals tended to modify their sexual habits due to apprehensions about disease transmission and the challenges associated with self-protection(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Corroborating this perspective, Schiltz and Sandfort (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, p. 1582) affirmed that the \"fear of transmitting the virus and the fear of being shunned\" may propel individuals with positive serostatus to seek partners with a similar status or transfer the onus of protective measures to their partners(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThe interpretation of the outcomes of this investigation requires cautious consideration, given the inherent constraints imposed by its cross-sectional design. This design impinges upon the establishment of a definitive temporal nexus between the variables of exposure and outcome. The intricacy lies in discerning whether participants gained cognizance of their HIV-positive status antecedent to or concomitant with the preceding 12 months of their relational engagements. This temporal ambiguity introduces a noteworthy caveat, as the ascribed effects may be contingent upon the chronology of HIV status revelation, a facet that could be more judiciously explored through the utilization of longitudinal data.\u003c/p\u003e \u003cp\u003eFurthermore, the particulars of the post-diagnostic phases individuals undergo following the revelation of their HIV-positive status introduce an additional layer of complexity to the association between knowledge of one's seropositivity and engagement in risky sexual behavior. The fluctuating dynamics of this association at different temporal junctures necessitate a sophisticated understanding. Notably, during a phase typified by denial, it is conceivable that awareness of being HIV-positive might precipitate an escalation in risky sexual behavior. Conversely, as the process of acceptance unfolds and a sense of responsibility towards the well-being of others takes root, the proclivity for engaging in such risky behavior may attenuate. This dynamic trajectory underscores the imperative to acknowledge this inherent limitation when deciphering the study's findings and underscores the need for nuanced consideration in future research endeavors.\u003c/p\u003e \u003cp\u003eFurthermore, an exercise of circumspection is warranted in extrapolating the outcomes of this study to other contexts, as the dataset emanates from a specific geographical locus within a singular national milieu. The external validity or transferability of the findings to disparate settings ought to be approached with caution. It is imperative to underscore the necessity for additional investigations to scrutinize the generalizability of these findings across diverse contexts, thereby enriching the understanding of the broader applicability of the study's outcomes.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis investigation presents compelling empirical evidence establishing a robust correlation between heightened awareness of HIV-positive status among males and a discernible reduction in proclivities toward engaging in high-risk sexual behaviors, particularly within relationships characterized by significant age disparities. These findings accentuate the pivotal role played by HIV testing and the subsequent disclosure of results as pivotal determinants in mitigating HIV incidence rates and interrupting transmissions within the heterosexual context.\u003c/p\u003e \u003cp\u003eTo augment the implications of these revelations, there exists an imperative to broaden the implementation of targeted interventions designed to motivate and facilitate HIV testing among the male demographic. The upscaling of such initiatives necessitates a comprehensive approach aimed at undoing diverse barriers that impede men's access to testing services. These impediments encompass, but are not limited to, restricted availability of testing sites, fears pertaining to confidentiality breaches, the specter of stigmatization, socioeconomic constraints, a diminished perception of HIV risk, and instances of discriminatory practices.\u003c/p\u003e \u003cp\u003eA proactive strategy addressing these multifaceted barriers is indispensable for interventions to carve out pathways that streamline the HIV testing process for men. By systematically dismantling these obstacles, interventions can establish facilitative avenues that simplify and destigmatize the act of undergoing HIV testing. Consequently, this recalibration in approach holds the potential to not only elevate the uptake of HIV testing services among men but also induce consequential alterations in their sexual behaviors. The ensuing impact is anticipated to reverberate across the spectrum, resulting in a diminished incidence of male-to-female HIV infections. This underscores the cascading benefits emanating from heightened testing uptake and the attendant modifications in behavioral patterns within the context of HIV prevention.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthor contribution\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRB, VI, and KG wrote the manuscript. RC, KG, and SB were responsible for the fieldwork and quality assurance; SB and VI for statistical analysis; SB, and VI contributed to the analysis and interpretation of the data. AP, NS, ZC, and SM were responsible for laboratory measurements and quality assurance; SB, VI and KG were responsible for community and stakeholder engagement activities; all authors critically reviewed and approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStudy sponsorship and funding statement\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHIPSS study is funded by the Centers for Disease Control and Prevention (CDC) under terms of the cooperative agreement 3U2GGH000372-02 W1 and the US Presidents Emergency Plan for AIDS Relief (PEPFAR).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConflict of Interest\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that there no conflicts of interest regarding the research, authorship, and/or publication of this article.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAvailability of data and materials\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analysed during the current study cannot be made public due to restrictions from the funder. However, datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eRead SW, Kim P, Marovich M, Dieffenbach CW, Fauci AS. Forty years of investment in HIV research: progress towards ending the HIV pandemic and preparation for future pandemics. J Int AIDS Soc. 2022;25(12).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZuma K, Shisana O, Rehle TM, Simbayi LC, Jooste S, Zungu N, et al. New insights into HIV epidemic in South Africa: key findings from the National HIV Prevalence, Incidence and Behaviour Survey, 2012. Afr J AIDS Res. 2016;15(1):67\u0026ndash;75.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKharsany AB, Karim QA. HIV infection and AIDS in sub-Saharan Africa: current status, challenges and opportunities. The open AIDS journal. 2016;10:34.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMahy MI, Sabin KM, Feizzadeh A, Wanyeki I. Progress towards 2020 global HIV impact and treatment targets. J Int AIDS Soc. 2021;24:e25779.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKarim QA, Sibeko S, Baxter C. Preventing HIV infection in women: a global health imperative. Clin Infect Dis. 2010;50(Supplement3):122\u0026ndash;S9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBraitstein P, Boulle A, Nash D, Brinkhof MW, Dabis F, Laurent C, et al. Gender and the use of antiretroviral treatment in resource-constrained settings: findings from a multicenter collaboration. J women's health. 2008;17(1):47\u0026ndash;55.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMarinda E, Simbayi L, Zuma K, Zungu N, Moyo S, Kondlo L, et al. Towards achieving the 90-90-90 HIV targets: results from the south African 2017 national HIV survey. BMC Public Health. 2020;20:1\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBarker G, Ricardo C. Young men and the construction of masculinity in sub-Saharan Africa: Implications for HIV/AIDS. conflict, and violence: Citeseer; 2005.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAluisio A, Richardson BA, Bosire R, John-Stewart G, Mbori-Ngacha D, Farquhar C. Male antenatal attendance and HIV testing are associated with decreased infant HIV infection and increased HIV free survival. Journal of acquired immune deficiency syndromes (1999). 2011;56(1):76.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGigu\u0026egrave;re K, Eaton JW, Marsh K, Johnson LF, Johnson CC, Ehui E, et al. Trends in knowledge of HIV status and efficiency of HIV testing services in sub-Saharan Africa, 2000\u0026ndash;20: a modelling study using survey and HIV testing programme data. The Lancet HIV. 2021;8(5):e284\u0026ndash;e93.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAnand A, Shiraishi RW, Bunnell RE, Jacobs K, Solehdin N, Abdul-Quader AS, et al. Knowledge of HIV status, sexual risk behaviors and contraceptive need among people living with HIV in Kenya and Malawi. Aids. 2009;23(12):1565\u0026ndash;73.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMontgomery E, van der Straten A, Torjesen K. Male involvement in women and children's HIV prevention: challenges in definition and interpretation. JAIDS J Acquir Immune Defic Syndr. 2011;57(5):e114\u0026ndash;e6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eScott-Sheldon LA, Carey MP, Carey KB, Cain D, Simbayi LC, Mehlomakhulu V, et al. HIV testing is associated with increased knowledge and reductions in sexual risk behaviours among men in Cape Town, South Africa. Afr J AIDS Res. 2013;12(4):195\u0026ndash;201.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKharsany AB, Cawood C, Khanyile D, Lewis L, Grobler A, Puren A, et al. Community-based HIV prevalence in KwaZulu-Natal, South Africa: results of a cross-sectional household survey. The Lancet HIV. 2018;5(8):e427\u0026ndash;e37.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGovender K, Beckett SE, George G, Lewis L, Cawood C, Khanyile D, et al. Factors associated with HIV in younger and older adult men in South Africa: findings from a cross-sectional survey. BMJ open. 2019;9(12):e031667.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHalli SS, Khan CH, Moses S, Blanchard J, Washington R, Shah I, et al. Family and community level stigma and discrimination among women living with HIV/AIDS in a high HIV prevalence district of India. J HIV/AIDS Social Serv. 2017;16(1):4\u0026ndash;19.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHamilton A, Shin S, Taggart T, Whembolua G-L, Martin I, Budhwani H, et al. HIV testing barriers and intervention strategies among men, transgender women, female sex workers and incarcerated persons in the Caribbean: a systematic review. Sex Transm Infect. 2020;96(3):189\u0026ndash;96.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLatka MH, Mizuno Y, Wu Y, Tobin KE, Metsch LR, Frye V, et al. Are feelings of responsibility to limit the sexual transmission of HIV associated with safer sex among HIV-positive injection drug users? JAIDS J Acquir Immune Defic Syndr. 2007;46:88\u0026ndash;S95.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchiltz M-A, Sandfort TG. HIV-positive people, risk and sexual behaviour. Soc Sci Med. 2000;50(11):1571\u0026ndash;88.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Age-disparate, Self-reported, HIV Status, Knowledge, Sexual Risk Behaviour, South Africa","lastPublishedDoi":"10.21203/rs.3.rs-3640699/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3640699/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThis study investigated the association between sexual risk behaviors, self-reported HIV status, and engagement in age-disparate relationships (defined as a 5\u0026thinsp;+\u0026thinsp;year age gap) among men. Two cross-sectional household surveys were conducted in the uMgungundlovu district of KwaZulu-Natal, South Africa, spanning June 2014 to June 2016. Structured questionnaires administered by trained interviewers collected data from 3801 men aged 20 to 49 years who disclosed their HIV status. The analysis revealed that HIV-positive men had decreased odds of their three most recent relationships meeting age-disparity criteria (model (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e): Adjusted Odds Ratio (AOR): 0.70; 95% Confidence Interval (CI): 0.53, 0.92; model (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e): AOR: 0.73; 95% CI: 0.55, 0.96). HIV-positive respondents also showed reduced likelihood of engaging in specific sexual risk behaviors, such as multiple partnerships (AOR: 0.73; 95% CI: 0.55, 0.96), inconsistent condom use (AOR: 0.38; 95% CI: 0.28, 0.52), and casual sexual relationships (AOR: 0.66; 95% CI: 0.50, 0.87). These findings underscore the critical role of men\u0026rsquo;s HIV testing in reducing HIV incidence and transmissions. The study emphasizes the need for interventions addressing barriers to HIV testing among men, including limited access, confidentiality concerns, stigma, low risk perception, and discrimination to enhance testing uptake.\u003c/p\u003e","manuscriptTitle":"Knowledge of HIV status, age-disparate sexual partnerships, and sexual risk behaviour among HIV positive men in South Africa: Evidence from two cross-sectional samples.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-11-29 17:03:30","doi":"10.21203/rs.3.rs-3640699/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"952cc141-b410-4065-a3bd-472ad109f043","owner":[],"postedDate":"November 29th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-02-09T11:38:37+00:00","versionOfRecord":[],"versionCreatedAt":"2023-11-29 17:03:30","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3640699","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3640699","identity":"rs-3640699","version":["v1"]},"buildId":"-HB7Z8yhvgn0wM9Nzuekk","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}