According to the World Health Organization (WHO), HIV/AIDS is a pandemic with a worldwide prevalence of approximately 40 million people  Sub-Saharan Africa is the most affected region accounting for approximately 70% of people living with HIV worldwide. Ivory Coast is the most affected country in West Africa with a national HIV prevalence of 4.7% among adults,  and it is the leading cause of adult death and potential life years lost . Since the first case of HIV/AIDS in 1985, the pandemic continues to rise. Although the majority of cases are from the urban areas such as Abidjan, HIV is widespread in this country. HIV infection rates are significantly higher in women than men in Ivory Coast .
Since 2001, the Demographic and Health Surveys (DHS) Program has conducted HIV testing and collected information on social demographic, socioeconomic, knowledge, attitude and behavioral factors to estimate the prevalence of HIV in developing countries around the globe. Although it is well known that about 85% of the transmission model of HIV is through sexual intercourse with an infected person , factors that are associated with the prevalence of HIV infections are not well described in Ivory Coast. Therefore, the aim of this study is to delineate socioeconomic, sociodemographic, knowledge, attitude and behavioral factors that are associated with HIV infection among adult women in Ivory Coast. A better understanding of the drivers of HIV infection will guide effective HIV prevention strategies. To our knowledge, this is the first report of the detailed independent predictors of HIV infection among adult women in Ivory Coast using a large population-based dataset.
This study used the Demographic and Health Survey (DHS) conducted from December 2011 to May 2012 in Ivory Coast. The DHS program has earned a worldwide reputation for collecting, analyzing, and disseminating accurate data through more than 300 surveys in over 90 developing countries around the world. The DHS data is a nationally representative survey that uses a multistage and a stratified design to collect information on population health, HIV/AIDS, malaria, anemia and nutritional status within each country. The U.S. Agency for International Development (USAID) funds the MEASURE DHS project implemented by ICF international.
The survey was conducted among 4,655 women aged between 15 and 49 years in Ivory Coast who participated in the 2011-2012
DHS and for which blood was drawn for HIV testing. There were a total of 209 HIV positive cases.
HIV Testing and Procedure
Women aged 15-49 were eligible for HIV testing. Procedures and questionnaires for standard DHS surveys have been reviewed and approved by ICF Institutional Review Board (IRB) and the IRB of the host country. Blood samples were taken from all women 15-49 who voluntarily agreed to HIV testing. The protocol for HIV testing is based on the anonymous-linked protocol developed by the DHS program. According to this protocol, no name or other individual or geographical feature that identifies an individual can be bound to the sample of blood. Given that HIV testing is strictly anonymous. After reading and obtaining informed consent, the investigator levied drops of capillary blood on filter paper. A label containing a barcode was then adhered to the filter paper.
To investigate factors associated with HIV infection, we used descriptive, bivariate, and multivariable statistical methods. Due to low frequencies and missing data, some variables were collapse together to make the data more robust. In the descriptive analysis, the proportion of HIV was stratified by HIV status. In the bivariate and multivariable or adjusted logistic regression models, the binary outcome variable was regressed on the selected predictor variables. The descriptive results are presented as proportions and the multivariable logistic regression results are presented as adjusted odds ratio (aOR) with 95 percent confidence intervals (95% CI) and p-values. The OR provides an estimate of the magnitude of the association between the variables being compared. P value and 95% CI are calculated to identify the associations that are statistically significant. The statistical tests were reported as significant if the level of significance is less than alpha equal to 0.05. All statistical analyses were conducted using SAS version 9.4. Logistic regression and Chi-square tests were used to examine the bivariate relationships between HIV serostatus and socio-demographic characteristics as well as knowledge, attitudes, and sexual behavior variables. Multivariable logistic regressions were used to examine the independent association between HIV knowledge, socio-demographic factors, attitude, behavior and HIV serostatus.
Principal dependent Variable
The dependent variable was HIV status, a binary variable (1 for "positive HIV" and 0 for "negative HIV results").
The independent variables constituted of demographics and socioeconomic characteristics, HIV knowledge, attitudes, and sexual risk behaviors.
Descriptive analysis of the socio-demographic characteristics of the sample population Socio-demographic characteristics of the survey respondents are presented in (Table 1). Some numbers in the descriptive analysis may not add up due to missing frequencies from Chisquare test. The overall prevalence of HIV was 4.5% among women age 15 to 49 years old during the study period. There was a statistically significant difference in the prevalence of HIV among different age groups (p<0.001). Of those with HIV, the majority were 25-34 (43%) followed by 35 to 49 (38%). Women with HIV were more likely to be married and living with partners (66%), compared to those who were divorced (18%) or never married (16%). There was also a significant difference in HIV prevalence based on the geographical region (p=0.01) and place of residence area women (p=0.0005), where those with HIV were most likely to be living in the central region (38%) or an urban residences (56%). Also women infected with HIV were most likely to come from higher SES (51%) compared to those from lower SES. In addition, HIV positive women were more likely to be Muslim (36%), currently employed (76%), and exposed to the radio (51%).
Knowledge of HIV and high-risk sexual behavior stratified by HIV status
Among women who tested positive for HIV, 99% had heard about the STI and HIV/AIDS. More than half of the women had knowledge about HIV transmission during pregnancy. Of those who tested positive, most had been tested previously (54%) and knew a place they could get tested again (82%) (Table 2). Univariate logistic regression analysis of HIV associations The bivariate analysis (Table 3), shows that those 25-34 (OR=2.93 95%CI: 2.00-4.28, p=0.0006) and 35-49 years old (OR=3.13 95%CI: 2.13-4.61, p<0.0001) were 3 times more likely to have HIV compared to those aged 15-24 years. In addition, participants who were married or living with a partner (OR=1.90 95%CI: 1.30-2.78, p=0.0010) or divorced, widowed, or separated (OR=5.90 95%CI: 3.63-9.58, p<0.0001) were 2 and 6 times more likely to have HIV respectively. Those from the northern part of the country were 40% less likely to HIV compared to those from the Central region (OR=0.60 95%CI: 0.40-0.89, p= 0.00102). Likewise, those from rural areas were 40% less likely to have HIV compared to those from Urban areas (OR=0.61 95%CI: 0.46-0.81, p=0.0005). Those who were working were 1.5 times more likely to have HIV than those who were not working (OR=1.51 95%CI: 1.09-2.08, p=0.0135. Catholics were 1.56 times more likely to get HIV compared to Muslim (OR=1.56 95%CI: 1.10-2.23, P=0.0134). Those who were previously tested for HIV were twice as likely to have HIV compared to those who were never tested (OR=2.02 95%CI: 1.53-2.68, p<0.0001). Among HIV prevention knowledge, those who knew a place to get an HIV test were almost 3 times as likely of having HIV (OR=2.76 95%CI: 1.91-3.98, p<0.0001).
Likewise, those who had heard of STIs (OR=4.53 95%CI: 1.44- 14.24, p<0.0001) or HIV/AIDs (OR=5.06 95%CI: 1.61-15.9, p=0.0098) were about 5 times more likely to be infected. Also those with knowledge that HIV can be transmitted during pregnancy (OR=1.68 95%CI: 1.20=2.36, p=0.0028) or during delivery (OR=1.51 95%CI: 1.09-2.09, p=0.0119) were about 1.5 times more likely to be infected. Finally, those exposed to the radio were 1.4 times more likely to have HIV (OR=1.39 95%CI: 1.05-1.83).
Multivariable logistic regression of HIV predictors
The multivariable logistic regression results are presented in (Table 4). Independent predictors of HIV included the age groups with 25-34 years old 2.2 times more likely to have HIV (aOR=2.23 95%CI: 1.44-3.45, p=0.0003) and 35-49 years old 2.4 times more likely to have HIV (aOR=2.41 95%CI=1.51-3.85, p=0.0002) compared to those who were 15-24 years old respectively, and those who were widowed, divorced, or separated were three time more likely to have HIV compared to those never married (aOR=3.30 95%CI: 1.88-5.79, p<0.0001), those with a knowledge of place for HIV testing were two times more likely to be infected by HIV compared to those without knowledge (aOR=2.35,95%CI: 1.50-3.68,p=0.0002). In contrast, living in a rural area was protective against HIV independent of other factors. Those living in the rural area were 48% less likely to have HIV compared
to those living in the urban area (aOR= 0.52 95%CI: 0.31-0.87, p=0.0136).
The results of this national study demonstrate the high burden of HIV infection among adult women in Ivory Coast. The overall prevalence of HIV among women aged 15-49 using 2012 DHS data was 4.5%, twice the overall prevalence in adults aged 15-49 in sub-Saharan Africa .
The study found that the prevalence of HIV infection was the highest among young adults 25.
years and older, which is congruous with previous studies in the same sub-Saharan African region [6-9]. This finding could be partly explained by the high-risk sexual behaviors in this age group such as having multiple sexual partners and the inconsistent use of condoms during sexual intercourse. In addition, a second hypothesis for higher prevalence rates of HIV in older age group is the temporal association where older women could have been infected at a younger age but over time, the cumulative number of people living with HIV/AIDS (PLWHA) increased. The introduction of highly active antiviral (HAART) in the late 1980 substantially improved the survival probabilities of PLWHA [10,11]. Third, older women who have entered menopause may not consistently use condoms to protect themselves against pregnancy hence putting themselves at higher risk of acquiring HIV than younger women. In many African countries, women are likely to engage in high-risk sexual behaviors including transactional sex with increase age .
Being widowed or divorced or separated was significantly associated with higher risk of HIV. In African countries, men with HIV usually die earlier compared to their infected spouses . As a results, the high rates of HIV seen in the widowed group could be explained death of an HIV spouse who passed away from AIDS. Furthermore, others may have divorced or separated as a result of HIV infection. In the circumstance of couple infected with HIV, more often than not, the blame is put on the women as the source of infection [14,15]. Additionally, high-risk traditional practices such as wife inheritance and widow cleansing, where a widow is expected to either marry or have sex with relatives and non-relative of the deceased husband respectively, female genital mutilation, can increase older women's exposure to the virus [16-18]. Knowledge of place for HIV testing was also associated with higher risk of HIV. One hypothesis, participants who were HIV seropositive, already knew their HIV status prior to the study. As thus, they could have visited HIV testing centers and therefore already knew about the place of HIV testing.
Lastly, living in the rural area was negatively associated with lower risk of HIV during the study period. Several studies have found
significant association between HIV and those living in the urban area . Many women living in the urban are more likely to engage in high-risk sexual behaviors such as transactional sex, multiple sexual partners and use of injectable drugs. In addition, the urban areas are also characterized by the reduction or disappearance of sexual values and norms compared to rural areas .
Study strengths and limitations
The study involved a nationally representative and large data set with high response rate of testing for HIV. However, the study has drawbacks. First, this is a retrospective cross-sectional study. The cross-sectional nature of the survey does not allow for the determination of a temporal or causal relationship between the explored variables and HIV infection. From different studies, there is evidence that women tend to underreport and men tend to exaggerate their premarital and extramarital sexual activity . In addition, because most of the items in the questionnaire elicit self- reported information on sensitive issues such as condom use and HIV/AIDS, the respondent might have been bias in responding some of the items. Many answers to a sensitive questionnaire may introduce bias because of the fact that sexuality is still a taboo in many African societies. Notwithstanding these limitations, this study provides a current prevalence and the associated risk factors of HIV among adult women in Ivory Coast. The findings are useful in identifying intra/inter-personal, knowledge and behavioral factors influencing the prevalence of HIV among women. These findings should help tailor regional and individualized HIV prevention strategies.
Older age, being widowed or divorced or separated, living in the urban region, and knowledge of place for HIV testing were independent high-risk factors associated with HIV among adult women in Ivory Coast. HIV preventative programs tailored at regional and group specific needs highly needed to improve prevention of HIV transmission.
The authors received no financial support (external or internal) for this study
The data may be found on https://dhsprogram.com/whatwe-do/survey/survey-display-437.cfm
The authors thank the DHS program for their support and for free access to the original data.
We would like to acknowledge Guodong Liu, Douglas Leslie, and Kani Dembele for helpful suggestions.
MT, AS, PS and DB participated in the conception and design of the study, data cleaning and analysis, results interpretation, and drafting and revision of the manuscript. All authors participated in review of statistical methods, results interpretation, and revision of the manuscript. All authors read and approved the final manuscript.
The authors declare that they have no competing interests.
Consent for Publication
No consent to publish was needed for this study as we did not use any details, images or videos related to individual participants. In addition, data used is available in the public domain.