Gender Dynamics, Relationship Type Shape Concordance in HIV Advocacy

Designing targeted approaches for HIV advocacy could benefit from learning about how relationship types and gender dynamics can influence the effectiveness of peer-based health advocacy in social networks, according to a study published in AIDS and Behavior.¹

Raising awareness of HIV can be conducted through HIV prevention advocacy, which can also help to reduce stigma and improving access to resources for patients with HIV.² Advocacy interventions held by peers can help in improving adherence to antiretroviral therapy (ART) and ensure sustained HIV care. Assessing the effectiveness of peer-based interventions would require learning about the agreement between advocates and recipients when it comes to advocacy.

This study aimed to use dyads in which advocacy could occur to evaluate the dyadic health influence model, which can help to evaluate why perception concordance in a dyad can affect health behaviors.The investigators wanted to assess the concordance of HIV prevention advocacy between people living with HIV (PLWH) and their alters (or advocates), identify factors that are associated with index-alter prevention advocacy concordance, and investigate if alter use of HIV protective behavior affects index-alter concordance about prevention advocacy.

This study was conducted in Uganda, with PLWH acting as the indexes and recruiting alters from their own social networks. PLWH were eligible for the study if they were 18 years or older, had been in care for at least a year, and were patients at the Infectious Disease Institute. All participants who were PLWH were recruited form the Infectious Disease Institute. If the individual who was living with HIV participated in the pilot study, they were excluded from this study.

Alters were recruited using a list of potential people from the social network of the index individual who could act in such a role. The mean (SD) number of social network members recruited was 2.8 (1.53). All alters were 18 years and older, referred by an index participant in the study, and aware of the person’s HIV status. All data were collected between January 2022 and February 2023 and all baseline surveys required completion in person. Sociodemographic characteristics were collected from all participants.

All prevention advocacy efforts that were created by the alters for the PLWH were evaluated. This included any methods where the alters were talking to the PLWH about protecting them from HIV by either getting tested or using ART. All conversations on this subject were subject to questions about whether the conversation included promoting testing or other forms of advocacy. The PLWH were asked if the alter discussed condom use, testing for HIV, use of ART, and engagement in HIV care. The PLWH were also asked if they trusted the alter and their relationship to them, as well as the frequency of contact between them.

There were 193 PLWH and 599 alters enrolled in this study, with PLWH older compared with alters (45.6 years vs 37.7 years) and more likely to be single or divorced. PLWH were also more likely to be in business professions compared with alters.

There was close to no discussion of pre-exposure prophylaxis (PrEP) among the alters and PLWH. HIV care management and ART adherence had high symmetry as well. There was concordant agreement between the alter and PLWH when it came to condom use (CP+, 0.23) and poor concordant agreement when it came to HIV testing (CP+, 0.10), with fewer PLWH that alters reporting that HIV testing prevention advocacy occurred (30.5% vs 50.5%).

Concordance was associated with the alter being a romantic partner (OR, 3.50; 95% CI, 1.22-10.06), but not if the person who had HIV was at least 10 years younger (OR, 0.23; 95% CI, 0.06-0.81). Gender composition (male to male advocacy, OR, 2.41; 95% CI, 1.11-5.23; female to male alter, OR, 2.35; 95% CI, 1.22-4.53) and when the alter was a child (OR, 0.19; 95% CI, 0.07-0.51) or a romantic partner (OR, 0.31; 95% CI, 0.10-0.94) were associated with concordance when the alter reported advocacy and the person living with HIV did not.

Alters reported increased use of condoms when both the index and alter reported that prevention advocacy occurred compared with duos where neither reported advocacy (OR, 3.90; 95% CI, 2.00-7.59) or when only the person living with HIV reported advocacy (OR, 3.71; 95% CI, 1.35-10.18). There were no factors that influenced HIV testing.

There were some limitations to this study. This was a cross-sectional study, which prevented the ability to make causal inferences, and the data were all self-reported, which could be subject to recall bias. Further, the respondents were not asked what advocacy was, which could mean that the participants held different ideas of advocacy that they presented, and this study had a small sample size that could limit the generalizability.

Advocacy interventions can be more effective when understanding the dynamics of peer interventions. Knowing what the most effective methods are can help to develop the most effective peer interventions that promote advocacy efforts.

References

1. Malika N, Green Jr HD, Bogart LM, et al. Concordance of HIV prevention advocacy reports and its associations with HIV protective behaviors. AIDS and Behavior. Published online June 20, 2024. doi:10.1007/s10461-024-04412-0
2. Anderson GZ, Reinius M, Eriksson LE, et al. Stigma reduction interventions in people living with HIV to improve health-related quality of life. Lancet HIV. 2020;7(2):e129-e140. doi:10.1016/s2352-3018(19)30343-1