Association between Women’s Autonomy and HIV-Protective Behaviors in Nepal

Background and Purpose: Women’s autonomy in decision making has important health implications. Patriarchy, women’s exposure to violence and exploitation has been associated with women’s increased vulnerability to HIV and AIDS. Data from South Asia indicates that women’s ability to choose with whom and how they have sex and their ability to influence a partner’s action such as condom use is related to power dynamics. Understanding the association between autonomy and HIV-related risk is especially crucial for HIV surveillance given Nepal’s increasing gender disparities in new HIV infections. Using Social Dominance Theory which conceptualizes four bases of gendered power, that is, force, resource control, social obligations, and consensual ideologies (Rosenthal & Levy 2010), we analyze the relationship between women’s autonomous decision making and HIV-protective behaviors.

Methods: We sampled women from the Nepal Demographic Health Survey (NDHS) 2016 dataset who were currently in a union (N=9904). Three general structural equation models (SEM) were constructed to examine the relationship between autonomy and HIV protective behaviors. Three categorical variables operationalized HIV protective behaviors: (a) woman had sexual partner other than spouse in the last year, (b) ever received a HIV test, and (c) knows locations where HIV tests are offered. Individual and community level factors were included as control variables (attitude towards intimate partner violence, HIV knowledge, age, employment, education, religion, wealth, and region). To account for categorical variables, a polychoric correlation matrix and the means and variance-adjusted weighted least squares estimator were used. Model fit was assessed using the model χ², root mean square error of approximation (RMSEA), Comparative Fit Index (CFI), and Tucker Lewis Index (TLI).

Results: Although all model chi-square values were statistically significant (due to large sample size) other fit statistics indicated that all SEM models fit the data well. Results from model A [χ² (195) = 959, p£ 0.0001, RMSEA=0.020 (90% CI 0.019- 0.021), CFI=0.97, TLI=0.97] showed that women who recorded higher autonomy in decision making and those who were employed were less likely to have had more than one sexual partner in the last one year. Results from model B [χ² (195) = 939.6, p£ 0.0001, RMSEA=0.020 (90% CI 0.018- 0.021), CFI=0.97, TLI=0.97] indicated that women with higher autonomy and those with accurate HIV knowledge were more likely to report having had a HIV test, as were younger women, with post-secondary education, and in the highest wealth quintile. Finally, in model C [χ² (195) = 944.1, p£ 0.0001, RMSEA=0.020 (90% CI 0.018- 0.021), CFI=0.97, TLI=0.97] younger women, those with higher autonomy in decision-making, elevated HIV knowledge, and Hindu adherents were more likely to report knowing HIV testing locations.

Conclusion: These findings align with other South Asian studies that find that women’s autonomy in decision making increases HIV- protective behaviors. Besides, women’s higher education, higher wealth, religious affiliation, and youth stimulate these HIV-protective behaviors. Future HIV prevention interventions should be inclusive of strategies that support women’s social and economic empowerment and enhance women’s ability to make informed choices about their own health and risks.