UNDERSTANDING SEXUAL RISK BEHAVIORS AMONG PERSONS LIVING WITH HIV/AIDS IN ABIDJAN, COTE D’IVOIRE by FATOUMATA TRAORE Submitted in partial fulfillment of the requirements For the degree of Doctor of Philosophy Dissertation Adviser: Dr. Mendel Singer Department of Epidemiology and Biostatistics Case Western Reserve University May, 2005 CASE WESTERN RESERVE UNIVERSITY SCHOOL OF GRADUATE STUDIES We hereby approve the dissertation of ______________________________________________________ candidate for the Ph.D. degree *. (signed)_______________________________________________ (chair of the committee) ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ (date) _______________________ *We also certify that written approval has been obtained for any proprietary material contained therein. DEDICATION To my late parents, Sollo and Moussokoro TRAORE, and my family: I would not be here without their sacrifices, support and encouragement. Being where I am and having them in my life were true Blessings from God! 1 TABLES OF CONTENTS List of Tables --------------------------------------------------------------------------------- 2 List of Figures -------------------------------------------------------------------------------- 4 Acknowledgments -------------------------------------------------------------------------- 5 Abstract ---------------------------------------------------------------------------------------- 6 I. Research Question and Specific Aims ---------------------------------------------- 8 II. Background and Significance -------------------------------------------------------- 11 1 Overview of the HIV epidemic -------------------------------------------------- 11 2 Current Issues: Continued sexual risk-taking among HIV patients - 14 3 HIV prevention research among HIV infected persons ---------------------- 18 4 Shortcomings of previous research in HIV/AIDS patients -------------- 37 5 Putting everything together: Towards an integrative model ------------ 43 III. Methods ---------------------------------------------------------------------------------- 45 1 Study design, Setting, and Population --------------------------------------- 45 2 Training of the Interviewers and Pilot Study -------------------------------- 46 3 Data Collection --------------------------------------------------------------------- 48 4 Measures ---------------------------------------------------------------------------- 50 5 Data Management and Quality Control -------------------------------------- 52 6 Analytic Plans ----------------------------------------------------------------------- 52 IV. Results ------------------------------------------------------------------------------------ 60 1 Descriptive Analysis -------------------------------------------------------------- 60 2 Bivariate Analysis ----------------------------------------------------------------- 71 3 Multivariate Analysis -------------------------------------------------------------- 76 4 Post Hoc Analyses 91 V. Discussion -------------------------------------------------------------------------------- 107 VI. Appendix --------------------------------------------------------------------------------- 127 Questionnaire ----------------------------------------------------------------------------- 158 VII. Bibliography ----------------------------------------------------------------------------- 2 LIST OF TABLES Description Page Table 1. The Major Factors and their Utility in HIV Primary and Secondary 33 Prevention ------------------------------------------------------------------------------------ Table 2. Summary table for the study variables ------------------------------------- 51 Table 3. Socio-demographic information for the study sample ------------------ 61 Table 4. Health information for the study participants ----------------------------- 62 Table 5. Association between the demographic and psychological distress 64 variables and the variable ‘lifestyle changes’ ---------------------------------------- Table 6. Study participants’ sexual risk behaviors 66 Table 7. Descriptive statistics and Cronbach’s alpha for the measured 69 scales ------------------------------------------------------------------------------------------ Table 8. Classification into the high-risk group -------------------------------------- 72 Table 9. Association between demographic/health status variables and 74 sexual risk behavior ------------------------------------------------------------------------ Table 10. Association between the measured scales and sexual risk 75 behavior --------------------------------------------------------------------------------------- Table 11. Socio-demographic information for the study groups ---------------- 76 Table 12. Perceived health and sexual risk behaviors for the study groups 78 Table 13. Factor loadings and factor structure for the measured scales ---- 79 Table 14. Inter-factor correlations ------------------------------------------------------ 81 Table 15. Goodness of fit indices for the measurement model ----------------- 85 Table 16. Properties of the estimated measurement model -------------------- 87 Table 17. Goodness of fit indices for the estimated structural models ------- 89 Table 18. Factor loadings and factor structure for the women ----------------- 91 3 Table 19. Factor loadings and factor structure for the men --------------------- 92 Table 20. Goodness of fit indices for the estimated measurement models - 94 Table 21. Properties of the revised measurement models ---------------------- 96 Table 22. Goodness of fit indices for the women’s structural models -------- 98 Table 23. Goodness of fit indices for the men’s structural models ------------ 100 Table 24. Goodness of fit indices for the measurement models --------------- 103 Table 25. Goodness of fit indices for the structural model ----------------------- 105 4 LIST OF FIGURES Description Page Figure 1. The Health Belief Model (HBM) -------------------------------------------- 21 Figure 2. Overview of the AIDS Risk-Reduction Model Stages ---------------- 28 Figure 3. Proposed Conceptual Model ---------------------------------------------- 44 Figure 4. Hypothesized Conceptual Model ------------------------------------------ 55 Figure 5. The initial measurement model ------------------------------------------- 84 Figure 6. The initial structural model -------------------------------------------------- 88 Figure 7. Final structural model and standardized estimates ------------------ 89 Figure 8. The initial measurement model for the women ------------------------ 93 Figure 9. The initial measurement model for the men ---------------------------- 85 Figure 10.The initial structural model for the women ----------------------------- 97 Figure 11.Final structural model and standardized estimates for women ---- 98 Figure 12.The initial structural model for the men ---------------------------------- 99 Figure 13.Final structural model and standardized estimates for men -------- 101 Figure 14.Initial overall measurement model ---------------------------------------- 102 Figure 15. Final overall structural model and standardized estimates -------- 106 5 ACKNOWLEDGMENTS I would like to express my sincere thanks to my advisor, Dr. Mendel Singer for his motivation, his support at critical times, and his guidance throughout this work. It was a real pleasure and honor working with him and I will forever be indebted to him. I would like to thank my committee members, Dr. Phil Allen, Dr. Kathy Smyth and Dr. Sana Loue for their dedicated assistance. Their insightful comments made this work better than it otherwise would have been. Next, I would like to thank my family for their support, most importantly my husband Serge whose tireless encouragement and unconditional love helped me keep going, and my sister-in-law Gisele Toure, who helped me get the approval to conduct my study at the USAC clinic. Finally, I am grateful to a number of individuals for their help: my friends Lamine, Tina and Fatou for their encouragement at critical times; my friend Achilles who contributed by reviewing the final work and encouraging me at all times; Drs. Constance Kanga and Alex Ani from the USAC clinic for all their help during the data collection; all the interviewers (Olga, Edith, Sekongo and Zehi) whose effort had made this work possible; and last but not least to all the patients at USAC (specifically Yolande), who spontaneous agreed to participate. Thanks also to everyone who contributed in any way towards completion of this work. 6 Understanding Sexual Risk Behaviors among Persons Living with HIV/AIDS in Abidjan, Cote d’Ivoire Abstract by FATOUMATA TRAORE Background: Recent studies have found that as many as one in three HIV infected persons may continue to engage in unprotected sex, sexual contact often occurring with seronegative or unknown status partners. While the issue of prevention has received greater attention in developed countries, little is known about the extent to which persons living with HIV/AIDS (PLWHA) might continue to engage in high-risk sexual behaviors in sub-Saharan Africa. Objectives: Propose and test a conceptual model explaining sexual-risk behaviors among PLWHA in terms of cognitive and situational factors. Methods: Cross-sectional study conducted in Abidjan, Cote d’Ivoire (West Africa). The study sample consisted