PREDICTORS OF SELF-EFFICACY IN HIV PREVENTION AMONG

PEOPLE LIVING WITH HIV AND AIDS IN THIKA DISTRICT, KIAMBU

COUNTY, KENYA

BY
KIERU JANE NJERI (M.Sc.)

KENYATTA UNIVERSITY
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TABLE OF CONTENTS
DECLARATION.......................................................................................................... ii
DEDICATION............................................................................................................. iii
ACKNOWLEDGEMENT........................................................................................... iv
TABLE OF CONTENTS.............................................................................................. v
LIST OF TABLES........................................................................................................ix
LIST OF
FIGURES......................................................................................................xii
LIST OF ABBREVIATIONS AND ACRONYMS.................................................. xiii
ABSTRACT............................................................................................................... xiv
CHAPTER ONE: INTRODUCTION........................................................................... 1
1.1 Background to the Study......................................................................................... 1
1.2 Problem Statement.................................................................................................. 5
1.3 Purpose of the Study................................................................................................6
1.4 Objectives of the Study........................................................................................... 6
1.5 Null Hypotheses...................................................................................................... 7
1.6 Significance of the Study........................................................................................ 7
1.7 Delimitation of the Study........................................................................................ 8
1.8 Limitations...............................................................................................................8
1.9 Assumptions of the Study....................................................................................... 9
1.10 Theoretical Framework......................................................................................... 9
1.10.1 Health Belief Model......................................................................................... 10
1.10.2. General System Theory................................................................................... 12
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1.11 Conceptual Framework....................................................................................... 14

1.12 OPERATIONAL DEFINITION OF TERMS..................................................... 16
CHAPTER TWO: LITERATURE REVIEW............................................................. 18
2.1 Overview............................................................................................................... 18
2.2 Global HIV Prevalence......................................................................................... 18
2.3 The Status of the HIV and AIDS Epidemic in Kenya........................................... 18
2.4 Prevalence of HIV by Socio-demographic Characteristics................................... 20
2.5 Sexual Practices of PLWHA................................................................................. 22
2.5.1 Condom Use among PLWHA............................................................................ 24
2.5.2 HIV Disclosure by PLWHA.............................................................................. 25
2.6 Reproductive Behaviour of PLWHA.................................................................... 26
2.6.1 Desire to Have Children among PLWHA.......................................................... 26
2.7 Barriers to Safe Sexual and Reproductive Practices............................................. 28
2.8 Decision-making on Sexual and Reproductive Behaviour................................... 30
2.9 HIV Prevention with Positives...............................................................................31
2.10 Understanding Self-efficacy................................................................................ 32
2.11 Summary of Literature Review........................................................................... 33
CHAPTER THREE: METHODOLOGY................................................................... 35
3.1 Overview............................................................................................................... 35
3.2 Research Design.................................................................................................... 35
3.3. Measurement of Variables................................................................................... 35
3.4 Description of Study Area..................................................................................... 37
3.5 Study Population................................................................................................... 37
3.5.1 Inclusion Criterion............................................................................................. 38
3.5.2 Exclusion Criterion............................................................................................ 38
3.6 Sampling Technique.............................................................................................. 38
3.7 Sample Size........................................................................................................... 41
3.8 Research Instruments.............................................................................................43
3.8.1 Interview Schedules........................................................................................... 43
3.8.2 Focus Group discussions.....................................................................................43
3.9 Pre-testing the Instruments.................................................................................... 44
3.9.1 Validity............................................................................................................... 44
3.9.2 Reliability........................................................................................................... 45
3.10 Data Collection Techniques................................................................................ 45
3.11 Data Analysis...................................................................................................... 46
3.11.1 Quantitative Data Analysis................................................................................47
3.11.2 Qualitative Data Analysis..................................................................................48
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3.12 Ethical and Logistic Considerations.................................................................... 48

CHAPTER FOUR:...................................................................................................... 50
PRESENTATION AND DISCUSSION OF RESEARCH FINDINGS..................... 50
4.1 Overview............................................................................................................... 50
4.2. Socio-Demographic Characteristics of PLWHA................................................. 50
4.2.1 Age of the Respondent....................................................................................... 50
4.2.2 Gender of Respondents...................................................................................... 51
4.2.3 Residence of the Respondent............................................................................. 52
4.2.4. Marital Status of the Respondents..................................................................... 52
4.2.5 Level of Education of the Respondents.............................................................. 53
4.2.6 Employment Status of the Respondents............................................................. 54
4.2.7 Monthly Income of the Respondents................................................................. 55
4.2.8 Religion of the Respondents.............................................................................. 56
4.2.9 Number of Children ever Born........................................................................... 57
4.2.10 Duration since Testing HIV Positive of PLWHA............................................ 57
4.3 Respondents’ Attitudes......................................................................................... 58
4.3.1. Respondents’ Attitude towards HIV Epidemic................................................. 58
4.3.2 Respondents’ Attitude towards People with HIV-negative Status..................... 60
4.3.3 Respondents’ Attitude towards Sexual Behaviour............................................. 62
4.3.4 Respondents’ Attitude towards Reproductive Behaviour.................................. 64
4.4 Sexual and Reproductive Practices of PLWHA.................................................... 66
4.4.1 Number of Sexual Partners................................................................................ 66
4.4.2 Use of Condoms among PLWHA...................................................................... 69
4.4.3 Type of Sexual Relationship in the Last Six Months......................................... 71
4.4.4 Awareness of Sexual Partner’s HIV-status........................................................ 75
4.4.5. HIV Self-disclosure to Sexual Partner.............................................................. 76
4.4.6 Number of Children Born after Testing HIV Positive and Their HIV-status.... 77
4.4.7 Desire to Have More Children after Testing HIV Positive................................ 79
4.5 Barriers to Safe Sexual and Reproductive Practices............................................. 83
4.6 Decision-making on Sexual and Reproductive Behaviour................................... 88
4.7 Self-efficacy in HIV Prevention............................................................................ 91
4.8 Hypotheses Test Results.........................................................................................94
4.8.1 Relationship between Self-efficacy in HIV Prevention and Socio-Demographic
Characteristics of PLWHA.......................................................................................... 95
4.8.2 Relationship between PLWHA Attitude towards Sexual and Reproductive
Behaviour and Self efficacy in HIV Prevention.........................................................106
4.8.3 Relationship between Sexual and Reproductive Practices of PLWHA and Self-
efficacy in HIV Prevention........................................................................................111
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4.8.4 Relationship between Barriers to Safe Sexual and Reproduction Practices and
Self-efficacy in HIV Prevention.................................................................................120
4.8.5 Relationship between Decision-making on Sexual and Reproductive Behaviour
and Self-efficacy in HIV Prevention..........................................................................130
4.9 Predictors of Self-efficacy in HIV Prevention.....................................................137
4.10 Discussion of Results.........................................................................................139
CHAPTER FIVE........................................................................................................146
SUMMARY, CONCLUSIONS AND RECOMMENDATIONS..............................146
5.1 Summary of Main Findings.................................................................................146
5.1.1. Influence of Socio-demographic characteristics of PLWHA on self-efficacy in
HIV prevention...........................................................................................................146
5.1.2. Relationship between Attitude towards Sexual and Reproductive Behaviour
and Self-efficacy in HIV Prevention..........................................................................147
5.1.3 Influence of Sexual and Reproductive Practices of PLWHA on Self-efficacy
in HIV Prevention......................................................................................................148
5.1.4 Relationship between Barriers to Safe Sexual and Reproductive Behaviour
in Self-efficacy in HIV Prevention.............................................................................150
5.1.5 Relationship between Decision-making on Sexual and Reproductive
Behaviour and Self-efficacy in HIV Prevention..................................................... 151
5.1.6 Determining Predictors of Self-efficacy in HIV Prevention.............................152
5.2. CONCLUSION...................................................................................................152
5.3 Recommendations................................................................................................155
5.3.1 Implications for Theory.....................................................................................155
5.3.2 Implications for Policy......................................................................................157
5.3.3 Implications for Practice 157
5.3.4 Implications for Further Research.....................................................................158
REFERENCES...........................................................................................................160
APPENDICES............................................................................................................167
APPENDIX I: Map of Thika District.........................................................................167
APPENDIX II: Individual Consent Form..................................................................168
APPENDIX III: Interview Schedule Guide for PLWHA..........................................169
APPENDIX IV: Focus Group Discussion................................................................ 179
APPENDIX V: Key Informant Interveiw Schedule Guide....................................... 181
APPENDIX VI: Key Informant Interveiw Schedule Guide- Community Based
Organization Manager............................................................................................... 182
APPENDIX VII: Research Authorization from Kenyatta University........................183
APPENDIX VIII: Research Authorization from National Council for Science and
Technology.................................................................................................................184
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LIST OF TABLES
Table 4.1: Distribution of Respondents according to Socio-demographic Factors.....54
Table 4.15: Distribution of children born after testing HIV-positive and Their
Table 4.25: Relationship between Marital Status and Self-efficacy in HIV Prevention..
Table 4.30: PLWHA Social-demographic Predictors of Self-efficacy in HIV
Prevention...................................................................................................................105
Table 4.31: Relationship between Attitude towards HIV Epidemic by PLWHA
and Self-efficacy in HIV Prevention..........................................................................
Table 4.50: Relationship between Lack of Female Condom and Self-efficacy in HIV
Prevention........................................................................................................................
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LIST OF FIGURES

Figure 1.1: Health Belief Model……………………………………………………...10

Figure 1.2: Hypothesized Relationships between Sexual and Reproductive
Behaviour and Self-efficacy in HIV Prevention by PLWHA…………......................14
Figure 4.1: Distribution of the Respondents According to Age ……………………..51
Figure 4.2: Number of Sexual Partners………………………………………………67
Figure 5.2: A Model Depicting HIV ‘Prevention with Positives’…………………..156
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LIST OF ABBREVIATIONS AND ACRONYMS

AIDS Acquired Immune Deficiency Syndrome

ART Anti- retroviral Therapy

ARVs Anti- retrovirals

CBOs Community Based Organizations

CSIS Center for Strategic and International Studies

CCC Comprehensive Care Centre

FHI Family Health International

FGDs Focused Group Discussions

HIV Human Immunodeficiency Virus

KAIS Kenya AIDS Indicator Survey

MTCT Mother-to-Child Transmission

STIs Sexual Transmitted Infections

PLWHA People Living with HIV and AIDS

PMTCT Prevention of Mother-to-Child Transmission

PwPs Prevention with Positives

TDSP Thika District Strategic Plan

UNAIDS United Nations Joint Programme on HIV and AIDS

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UNFPA United Nations Population Fund

UNGASS United Nations General Assembly Special Session on HIV and AIDS

VCT Voluntary Counselling Testing

WHO World Health Organization

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ABSTRACT

It has been shown that PLWHA are living longer due to increasing availability and
uptake of antiretroviral therapy (ART). There has been limited research on whether
PLWHA adopt safer sexual and reproductive practices as focus has been primarily on
HIV negative persons. The purpose of this study was to determine predictors of self-
efficacy in HIV prevention among PLWHA in Thika district, Kiambu County; ‘a case
of prevention with positives’. Specific objectives included: to assess socio-
demographic characteristics of PLWHA, determine attitude towards sexual and
reproductive behaviour, establish sexual and reproductive practices, identify barriers
to safe sexual and reproductive behaviour and to analyze the decision making patterns
on sexual and reproductive behaviour and determine the predictors of self-efficacy in
HIV prevention. The study was guided by Health Belief Model and General Systems
Theory. The study employed a cross-sectional survey research design. Three divisions
of Thika district were chosen purposively namely: Ruiru, Thika Municipality and
Kamwangi. The sample size comprised 239 PLWHA. The data were collected using
interview guides, focus group discussions and key informant interviews. Both
qualitative and quantitative data analyses were used. Chi-square results yielded
significant relationship between self-efficacy in HIV prevention and gender
(p=0.000), marital status (p=0. 001), monthly income (p=0. 043), employment status
(p=0. 037), attitude towards HIV-negative people (p=0.002), attitude towards
reproductive behaviour (p=0. 049), number of sexual partners (p=0.000), type of
sexual partner (p=0.000), awareness of HIV-status of sexual partner (p=0.025), HIV
disclosure (p=0.003), number of children born after testing HIV positive (p=0.034),
partner’s condom refusal (p=0.028), alcohol and drug abuse (p=0.000), financial
constraints (p=0.000), condom fatigue (p=0.002), decision on whether to use condoms
(p=0.050), and which type of condoms used (p=0.010). Further analysis by use of
Binary Logistic Regression showed positive predictors of self-efficacy in HIV
prevention namely: gender (p=0.050), monthly income (p=0.002), attitude towards
reproductive behaviour (p=0.007), number of children born after testing sero-positive
(p=0.0.029), financial constraints and condom fatigue (p=0.046). Negative predictors
were number of sexual partners (p=0.001) and alcohol and drug abuse (p=0.021). It
was concluded that females, middle income earners, positive attitude towards
reproductive behaviour, having more than one child after testing sero-positive and
those not facing challenges condom fatigue and financial constraints predicted high
self-efficacy in HIV prevention. On the contrary, having multiple partners and
indulging in alcohol and drug abuse predicted low self-efficacy in HIV prevention. It
was recommended that there was need to promote inclusion of both men and women
in HIV and AIDS programs, ensure sustainable income generating activities, promote
sexual behaviour change programmes within the community targeting PLWHA,
ensure effective provision of alcohol and drug abuse counselling sessions among
PLWHA and strengthen consistent use of condoms. These might increase self-
efficacy in HIV prevention among PLWHA thus reducing the number of new HIV
cases.
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CHAPTER ONE: INTRODUCTION

1.1 Background to the Study

For over two decades, Human Immunodeficiency Virus (HIV) and Acquired Immune

Deficiency Syndrome (AIDS) pandemic has remained one of the most serious

challenges among communities. Indeed, it has been a global crisis with an estimated

33.2 million people infected by the end of the year 2007, out of which 22 million

people were in Sub-Saharan Africa (UNAIDS, 2007; WHO, 2008). In Kenya, control

of HIV and AIDS remains a major challenge with over 1.4 million people infected

(7.1% of adults 15-64 years) while in Central Province 3.8% of the total population is

infected (NASCOP, 2008; NACC, 2007). Although HIV prevalence seems to have

stabilized in Kenya, new HIV infections have been estimated at 166,000 annually

(NACC, 2009). The larger Thika District currently in Kiambu County has been the

worst hit district by the epidemic in Central Province with a HIV prevalence rate of

5% (Thika Health Plan, 2008/2009).

In 2006, it had registered the highest number of HIV infected people and AIDS

related deaths with a total of 17,541 HIV infected persons and 1,968 AIDS related

deaths (NACC/NASCOP, 2007). This has continued to be the most pressing

community concern within this district with emerging and re-emerging infections

(Thika Health Plan, 2008/2009). According to KDHS 2008/09, majority of these HIV

cases are in reproductive age group (15-49) which has a great implication on sexual

and reproduction aspects of an individual like sexual desire, sexual behaviour, fertility

need, family planning practices and sexually transmitted infections (STIs) (Center for

Strategic and International Studies, 2006). These implications may be influenced by

aspects such as attitude, practice and gender power relations which impacts on
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decision-making patterns all of which interact to regulate sexual and reproductive

expressions (Shapiro & Sunanda, 2007) in ways that may promote or undermine

prevention of HIV and AIDS.

Over time, since HIV made its debut on the international stage almost 30 years ago,

much has been done about its prevention. To-date, most HIV prevention campaigns

and strategies have focused their attention on people who are HIV negative where a

wide range of behaviour change strategies have been promoted. While this is crucial,

researches have largely ignored the important role of People Living with HIV and

AIDS (PLWHA) in HIV prevention where very little attention has been placed on

promoting prevention strategies (Shepherd et al., 2010; WHO 2009). Often more

emphasis has been placed on their treatment. However, research shows that

knowledge of HIV status alone does not ensure sustained safer sex practice among

PLWHA; their sexual life does not stop with an HIV positive diagnosis (Shepherd et

al., 2010). Thus some positive people may decide not to continue sexual activities

after their initial HIV diagnosis, others continue to have sex (International HIV and

AIDS Alliance, 2003).

Though risky sexual behaviour is usually the focus of HIV prevention programmes,

little attention has been given to sexual behaviour patterns among HIV positive

individuals (Thoma, Mimiga & Menon, 2009). It has been noted that the

physiological improvement due to ART drugs follows with the improvement of

sexual activities of PLWHA and majority of them continue their normal sexual

activities. It has been shown that PLWHA are living longer due to increasing

availability and uptake of antiretroviral therapy (ART). This increasing number of

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HIV discordant and concordant relationship calls for the importance of response to the

sexual and reproductive health needs and fertility choices of PLWHA. This is because

as life expectancy of PLWHA changes, their reproductive and sexual needs and

preferences are constantly changing and becoming increasingly important with the

development and use of anti- retroviral therapy (ART) (Global Network, 2009;

Debeko & Seme, 2008). Due to these improvements in quality of life, PLWHA are

regaining their normal sexual desire and hence engaging in risky sexual and

reproductive behaviours (Wamoyi, et al., 2011).

Bearing in mind that HIV does not obliterate the desire of PLWHA for sex and

procreation, this may carry with it the risk of transmission of HIV to their sexual

partners and babies (Oyebola, 2009). Hence, contrary to what people believe that

PLWHA who are aware of their status, are more likely to adopt safer sex practices

(Mugo, 2008), studies from different contexts worldwide indicate that PLWHA

manifest high-risk sexual behaviour. These behaviours are characterized by multiple

sexual partners, non-use of contraceptives, fertility intentions and non-disclosure of

HIV status to their sex partners (Kakaire, Kaye & Osinde, 2010; Oyore, 2009; Otieno,

2008). Further, studies done in USA and developing countries show that PLWHA

continue to engage in high risk sexual behaviors (Schreibman & Friedland, 2003).

Likewise, a study done in Nigeria shows that a large portion of the HIV-positive

individuals were sexually active and desired to have children (Zubairu, 2009).

Due to this indulgence in risky sexual and reproductive behaviours, PLWHA may be

re-infected with new strains of HIV, with the worst behaviour being exposing

someone else to HIV infection where the latter remains the major problem in the fight
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of HIV epidemic (NASCOP/ NACC, 2008). Therefore for PLWHA, the importance

of safer sex with a HIV negative sexual partner (discordant relationship) or one with

uncertain status (not tested) is for self-protection from STIs and to protect the partner

from becoming HIV infected which is particularly challenging. Between two people

with HIV (concordant relationship), the aim is to protect each other from STIs and re-

infection (Shapiro et al., 2007). Moore, et al., (2007) point out that although PLWHA

may be aware of the risk of infecting their sexual partners, they deliberately ignore the

risk because other considerations, such as wanting a baby, take precedence. So sexual

and reproductive behaviour of PLWHA is fundamental to their wellbeing and that of

their partners and children (WHO/UNFPA/ UNAIDS & IPPF, 2008).

Bearing in mind that all new HIV infections must involve a HIV-positive individual

(Stall, 2007; Family Health International, 2007; Carroll, 2003) and 80% of HIV

infections are sexually transmitted (Stover, Morisson & Fleischman, 2006), it is

therefore, most effective to intervene with the small minority who are HIV positive

than the majority who are HIV negative who seem to have adopted safer sexual

behaviours (Stall, 2007). This is a case of ‘prevention with positives’ (PwPs) an

intervention that is important but neglected in Kenya (Mugo, 2008; NASCOP/NACC,

2008). This ‘positive prevention’ has only recently emerged as an area of interest,

particularly in the USA with Centers for Disease Control and Prevention’s (CDC)

(Shepherd et al., 2010) and little has been done in Kenya.

Understanding the concept of susceptibility of PLWHA in Kenya in spreading the

virus though sexual and reproductive means, is important in developing HIV

preventive strategies. PLWHA will always have an essential role to play in preventing
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new infections (Boston Conference Report, 2010). This calls for a need to focus on

PLWHA in order to prevent HIV. With this backdrop, the future course of Kenya’s

AIDS epidemic may depend on having prevention programmes focusing on PLWHA

since a great proportion is their reproductive age. This would contribute to the

wellbeing of their partners, families and communities at large.

1.2 Problem Statement

With the increased access to ART, there is likelihood of many PLWHA living longer

which may play a big role in increasing the HIV incidence. PLWHA still indulge in

risky sexual and reproductive behaviours. These sexual and reproductive behaviours

are characterized by having multiple sexual partners, low condom use, fertility

intentions, non disclosure of HIV status and non-use of birth control methods. This

makes PLWHA to be highly susceptible in transmitting the virus leading to new

infections as their immune system and health status improve. Little is known about

their sexual behaviour and fertility desires to inform evidence-based intervention.

There is also almost no documented discussion on the ability of PLWHA to

successfully take a HIV preventive action especially in Kenya. This is because past

researches on HIV prevention programs have been primarily on HIV negative persons

who have embraced behavioural change. It is therefore more prudent for HIV

prevention programs to focus attention on the minority who are HIV positive than the

majority who are HIV negative.

With these advent of new treatment, there is need to focus on prevention with

positives which started in United States of America but little known in Kenya

especially in aspects of self-efficacy in HIV prevention among PLWHA where crucial

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gaps still seem to exist. These gaps are in terms of attitudes and practices of sexual

and reproductive behaviours; barriers to safe sexual and reproductive behaviours and

decision-making on sexual and reproductive behaviours and their implications on

PLWHA ability to adopt a safe HIV preventive action which was conceptualized in

this study as self-efficacy in HIV prevention. If they have high self-efficacy in HIV

prevention, this might mean reduced cases of new HIV infections and re-infections

and vice versa. With this backdrop, there was need for a comprehensive research to

assess predictors of self-efficacy in HIV prevention among PLWHA by analyzing

how PLWHA manage the disease and their sexual and reproductive behaviour.

1.3 Purpose of the Study

The aim of the study was to determine predictors of self-efficacy in HIV prevention

among PLWHA in Thika District, Kiambu County, Kenya.

1.4 Objectives of the Study

The study addressed the following specific objectives:

i. To assess the influence of socio-demographic characteristics of PLWHA on

self-efficacy in HIV prevention.

ii. To determine the relationship between attitude towards sexual and

reproductive behaviour by PLWHA and self-efficacy in HIV prevention.

iii. To establish the influence of sexual and reproductive practices of PLWHA on

self-efficacy in HIV prevention.

iv. To identify the relationship between barriers to safe sexual and reproductive

practices of PLWHA and self-efficacy in HIV prevention.

v. To analyse the relationship between decision-making patterns on sexual and

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reproductive behaviour of PLWHA and self-efficacy in HIV prevention.

vi. To determine the predictors of self-efficacy in HIV prevention among

PLWHA.

1.5 Null Hypotheses

The study tested the following hypotheses:

Ho1 There is no significant relationship between socio-demographic factors of

PLWHA and self-efficacy in HIV prevention.

Ho2 There is no significant relationship between attitude towards sexual and

reproductive behaviour by PLWHA and self-efficacy in HIV prevention.

Ho3 There is no significant relationship between sexual and reproductive practices

of PLWHA and their self-efficacy in HIV prevention.

Ho4 There is no significant relationship between barriers to safe sexual and

reproductive practices and self-efficacy in HIV prevention.

Ho5 There is no significant relationship between decision-making in sexual and

reproductive practices of PLWHA and self-efficacy in HIV prevention.

Ho6 None of the factors that had a significant relationship with self-efficacy in HIV

prevention predicted it.

1.6 Significance of the Study

The information generated from this study would be helpful to the developmental

agencies including the government and non-governmental organisations that deal with

issues of HIV and AIDS. These agencies would have a better understanding of sexual

and reproductive behaviour factors associated with self efficacy in HIV prevention

among PLWHA. They would be able to develop modalities of implementing HIV

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prevention with positives programmes. The findings would also be valuable to policy

makers and community researchers with interest in understanding the benefits of

including PLWHA in their efforts to managing prevention of HIV. This would help in

development of policies that would work to the best interests of PLWHA hence

enhance the efficacy of prevention with positives programmes. This would help in

formulating and implementing behaviour change communication (BCC) materials.

Information generated from this study would assist in bridging gaps identified in the

problem statement as shown by the HIV ‘prevention with positives’ model developed

by the study. These gaps have been due to limited research conducted on whether

PLWHA adopt safer sexual and reproductive practices as well as the little

documentation of successful models for strengthening management of HIV and

AIDS, sexual and reproductive health to meet the needs of PLWHA. Further, the

findings of this study would provide development of data base on PLWHA perception

of the disease, sexual and reproduction practices; barriers to safe sexual and

reproduction practices and decision making on sexual and reproductive behaviour.

This would provide knowledge where other community research scholars can review

literature forming a backdrop for further research on areas not covered in this study.

1.7 Delimitation of the Study

The study was confined to assessing sexual and reproductive behaviour and its

implication on self-efficacy in HIV prevention among PLWHA in Thika District,

Kiambu County, Kenya.

1.8 Limitations

There were methodological and logistic limitations since the information being sought
 9

was too sensitive and personal. The stigma associated with HIV influenced the

interview as some gave contradicting information hence underreporting their sexual

and reproductive behaviour. There were also financial and time constraints limitations

since the study was using interview schedule which consumed time in collecting the

required data. Also the respondents lived in locations that were far apart. In addition,

non-response of some respondents was a limitation as it was not possible to interview

all the sampled respondents.

1.9 Assumptions of the Study

The study assumed that PLWHA in Thika District had a negative attitude towards the

disease and sexual and reproductive behaviour. PLWHA also practised safe sexual

and reproductive behaviours in order to prevent HIV transmission. Also, the study

assumed that there were no gender power relations which could have influenced their

decision-making patterns on sexual and reproductive issues. Another assumption was

that people interviewed were truthful and honest on their behaviour.

1.10 Theoretical Framework

The study was based on Health Belief Model (Rosenstock & Stretcher, 1997 in

Turner, Hunt, DiBrezzo & Jones, 2004) and General Systems theory (Bertalanffy,

1968; Littlejohn, 1999). The Health Belief Model was used because it explains how

behaviour change process is believed to occur. The General System theory assisted in

explaining how objects interact in their environment over time which could influence

the attitude of PLWHA towards the disease and sexual and reproductive behaviour.
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1.10.1 Health Belief Model

Health Belief Model by Rosenstock and Stretcher (1997) was used to conceptualize

how individuals participate in health interventions and have a belief that being healthy

is a highly valued outcome. It captures the elements necessary for behaviour change

as it helps to understand health behaviour and possible reasons for non-compliance

with recommended health action. It aims to predict whether individuals choose to

engage in a healthy action in order to reduce or prevent the chance of the disease.

Rosenstock and Stretcher (1997) argue that it is possible to predict if an individual

would engage in positive health behaviours by determining the individual’s

perception of the disease. According to Health Belief Model as shown in Figure 1.1,

there are two main types of beliefs that influence people to take a preventive action:

Individual perception Modifying Factors Likelihood of action

Age, sex, ethnicity, Perceived

Personality, Socio- benefits minus
economic status, perceived
Knowledge barriers

Perceived
susceptibility Likelihood of
Perceived threat behaviour
Perceived (Perceived self
severity efficacy)

Cues to action

Figure 1.1: Health Belief Model

Source: Rosenstock I. M., & Stretcher V. (1997). The Health Belief Model. In
Turner L.W., Hunt S.B., DiBrezzo R. & Jones C. (2004). Design and Implementation
of Osteoporosis Prevention Program using the Health Belief Mode. American Journal
of health Studies, 19(2). Jones and Bartlett Publishers, LLC.
 11

(a) Beliefs Related to Readiness to Take Action.

This was measured by the following variables, namely:

(i) Perceived susceptibility to the illness. This is one’s subjective perception of the

risk of contracting an unhealthy condition. Personal risk or susceptibility is one of the

more powerful perceptions in promoting people to adopt healthier behaviours. The

greater the perceived risks, the greater the likelihood of engaging in behaviour to

decrease the risk. This is what prompts people to use a condom in an effort to

decrease susceptibility to HIV infection. It is only logical that when people believe

they are at risk for a disease, they will be more likely to do something to prevent it

from happening. Unfortunately, the opposite also occurs (Turner et al., 2004).

(ii) Perceived severity of the illness. This refers to feelings concerning the seriousness

of contracting an illness that includes evaluations of medical, clinical and possible

social consequences. While the perception of seriousness is often based on medical

information or knowledge, it may also come from beliefs a person has about the

difficulties a disease would create or the effects it would have on his or her life in

general. If perception of threat is to serious disease for which there is a real risk,

behaviour often changes. However, sometimes even though people perceive a threat

of illness, they still do not use safe practices all the time (Turner et al., 2004).

(b) Beliefs related to modifying factors that facilitate or inhibit action.

This was measured by the following variables:

(i) Perceived benefits which refer to perceived advantages of an action, that is, a

person’s opinion of the value of a new behaviour in decreasing the risk of developing

a disease. People tend to adopt health behaviours when they believe the new

behaviour will decrease their chances of developing a disease (Turner et al., 2004).
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(ii) Perceived barriers which are an individual’s own evaluation of the obstacles in the

way of him/her adopting a new behaviour. It is the most significant factor in

determining behaviour change. Barriers should be overcome for a new behaviour to

be adopted (Turner et al., 2004).

(iii) Modifying variables: These are individual’s characteristics that influence

personal perceptions such as religion, education, knowledge among others (Turner et

al., 2004).

(iv) Cues to action: These are events, people or things that make people to change

their behaviour. They may include illness of a family member, media reports, mass

media campaigns, advice from others, reminder postcards from a health provider or

health warning labels on a product (Turner et al., 2004).

(v) Self-efficacy which is the belief in being able to successfully execute the

behaviour required to produce the desired outcome. If one believes a new behaviour is

useful (perceived benefits) but does not believe she/he is capable of doing it

(perceived barriers), chances are that it will not be tried (Turner et al., 2004).

Each of these perceptions, individually or in combinations can be used to explain

healthy behaviour. The strength of this theory in the study lay in the identification of

key variables of the Health Belief Model that would be adopted to explore self-

efficacy in HIV prevention by PLWHA.

1.10.2. General System Theory

The General System Theory by Bertalanffy, (1968); Littlejohn, (1999) describes a

system consisting of four components, namely:

(i) Objects: Refers to elements within a system. For this study, objects referred to the
 13

individual person living with HIV and AIDS who is part of the system (community).

(ii) Attributes: Refers to qualities or properties of the system and its objects. For this

study, attributes referred to socio-demographic factors of PLWHA.

(iii) Internal Relationships: Refers to relationships among the system’s objects

either with spouses, friends/peers and/or family. These associations could be cordial

or erratic relations with partners. In the study, this was conceptualized as relations of

PLWHA and their sexual partners (regular or irregular).

(iv) Environment: They are settings within which the objects interact in. PLWHA

were studied as a subsystem within the community system in which they interact in.

The General Systems Theory also features the continual stages of input, throughput,

output and feedback mechanisms.

(i) Input: Refers to matter, information or resources that enter a system. For this

study, PLWHA and their attributes were conceptualized as the inputs.

(ii) Throughput: Refers to transformation of information or resources into an output.

PLWHA perceptions of the HIV and sexual and reproductive behaviour, sexual and

reproduction practices, barriers to safe sexual and reproductive practices and decision-

making patterns on sexual and reproductive practices formed the throughput process.

(iii) Output: Is the information or resources that is produced by a system in response

to an input and throughput processes. With the contextual factors (PLWHA factors)

being the input and modifying factors (sexual and reproductive behaviour) being

throughputs, then PLWHA are expected to be able to take a healthy HIV preventive

action. This was conceptualized as self-efficacy in HIV prevention (output).

(iv) Feedback: Is portion of output that re-enters a system as an input to affect the

succeeding output. Therefore if PLWHA perceive themselves as susceptible in

 14

transmitting HIV and AIDS through risky sexual and reproductive behaviour, then,

they have a high likelihood of taking a healthy HIV preventive action. This implies

that new cases of HIV within the community would be reduced. The reverse can also

be experienced.

1.11 Conceptual Framework

Based on these two theories, an operational model was conceptualized for this study

(Figure: 1.2) by adopting some constructs in both theories, namely: perceived

susceptibility, perceived barriers, and self-efficacy from Health Belief Model and

objects, attributes, input, throughput and output from General Systems Theory.

CONTEXUAL MODIFYING FACTORS HIV PREVENTIVE

FACTORS ACTION

ATTITUDE:
 Towards sexual
and reproduction
PLWHA behaviour SELF
FACTORS EFFICACY IN
 Socio- DECISION- HIV
demographic MAKING PREVENTION
factors BY PLWHA
SEXUAL AND
REPRODUCTIVE
BEHAVIOUR:
 Practices
 Barriers

FEEDBACK

INPUT THROUGHPUT OUTPUT

Figure 1.2: Hypothesized relationship between socio-demographic factors, sexual and

reproductive behaviour and self-efficacy in HIV prevention by PLWHA.
Source: Modified from Health Belief Model by Rosenstock and Stretcher, (1997)
and General Systems Theory by Bertalanffy, (1968) and Littlejohn, (1999).
 15

Some of these constructs were modified to suit the study perspective since the

respondents were people already infected with a disease. In this study, susceptibility

reflected the vulnerability of PLWHA in transmitting HIV and AIDS through

participating in potentially unhealthy sexual and reproductive practices. Perceived

barriers referred to sexual and reproductive impediments that affect their ability in

taking a HIV preventive action (self-efficacy). Objects referred to PLWHA while

attributes referred to PLWHA socio-demographic factors. The environment was

perceived as the community in which PLWHA interact in.

As demonstrated in Figure 1.2, ability to adopt a healthy HIV preventive action (self-

efficacy in HIV prevention) could be influenced by a complex interplay of contextual

and modifying factors. The contextual factors comprised PLWHA aspects which

included socio-demographic characteristics such as gender, residence, age, marital

status, education level, occupation, average monthly income, religion, number of

children ever born, duration after testing HIV positive and HIV knowledge of

transmission and prevention. These PLWHA factors formed the inputs of the system

and might have a direct influence on their ability to adopt a healthy HIV preventive

action.

On the other hand, modifying factors comprised attitude towards sexual and

reproductive behaviour, sexual and reproductive practises and decision-making

patterns on sexual and reproductive behaviour. These factors formed the throughput

process of the system where through decision-making, an output was realised. The

conceptual framework also asserted that sexual and reproductive practices of PLWHA

could influence their ability to adopt a HIV preventive action. This was especially so
 16

if they engaged in potentially unhealthy sexual and reproductive practices such as

having concurrent multiple partners. Likewise PLWHA as they strive to have safe

sexual and reproductive practices might face barriers which could inhibit their ability

in adopting a healthy HIV preventive action.

The framework also demonstrates that PLWHA decision-making patterns on issues

pertaining sexual and reproductive behaviour could influence their ability of taking a

healthy HIV preventive action. The ability to adopt a healthy HIV preventive action

by PLWHA was conceptualized as their self-efficacy in HIV prevention. This formed

the output of the system. Therefore, analyzing socio-demographic characteristics and

sexual and reproductive behaviour of PLWHA by using Health Belief Model and

General Systems Theory could assist in better understanding of the predictors of their

ability to adopt a healthy HIV preventive action (self-efficacy in HIV prevention).

1.12 OPERATIONAL DEFINITION OF TERMS

People Living with HIV and AIDS: This referred to persons who either had been

infected by HIV which causes AIDS and/or had progressed to AIDS.

Socio-demographic factors: Referred to age, gender, residence, marital status,

education level, income, employment status, religion and duration after testing HIV

positive.

Reproductive behaviour: It referred to the practice of having children and use of

birth control methods.

Safe reproductive behaviour: This referred to actions or practices of using birth

control methods to avoid unplanned pregnancies or/and effective PMTCT practices in

order to have a HIV negative child.

 17

Sexual behaviour: This referred to practice of having an intimate relationship with

the opposite sex, number and types of sexual partners, condom use and HIV

disclosure prior to a sexual act.

Safe sexual behaviour: This reflected the practice of having an intimate relationship

with the opposite sex without putting him/her at risk of getting infected or re-infected

with HIV. These practices were measured by being faithful to a sexual partner, using

condom consistently and/ or abstaining.

Risky sexual and reproductive behaviour: Referred to those intimate actions with

the opposite sex that endangered an individual to getting infected with HIV, having

unplanned pregnancy or even being re-infected with a HIV strain resistant to ARV

drugs which hastens AIDS progression.

Regular sexual partner: This referred to a spouse or a stable sexual partner whom a

respondent had an intimate relationship lasting one year or more prior to the study.

Occasional sexual partner: Referred to a sexual partner who was not a spouse and

the period of relationship was less than one year.

Condom fatigue: Referred to condom being tiresome due to using it consistently.

A healthy HIV preventive action: Referred to strategies or efforts used to avert and

lessen the transmission of HIV which PLWHA were expected to undertake.

Self-efficacy in HIV prevention: Referred to the ability of PLWHA to successfully

take a healthy/safe HIV preventive action confidently. PLWHA were asked to judge

themselves about their capability to perform particular activities related to their sexual

and reproductive behaviour which were basically HIV preventive actions.

Prevention with positives (PwPs): This is a concept coined to describe HIV

prevention that focuses on people living with HIV to reduce the risk of HIV

transmission.
 18

CHAPTER TWO: LITERATURE REVIEW

2.1 Overview

This chapter highlights the HIV and AIDS situation in Kenya, prevalence of HIV

epidemic by socio-demographic characteristics of PLWHA, sexual and reproductive

behaviour of PLWHA. It also relates this reviewed information to the ability of

adopting a healthy HIV preventive action in order to identify gaps that justified this

study.

2.2 Global HIV Prevalence

HIV has been indeed a global crisis with an estimated 33.2 million people infected by

the end of the year 2007 and 33.4million by year 2008, out of whom 22 million

people (67%) were in Sub-Saharan Africa (UNAIDS, 2007; WHO, 2008 & UNAIDS,

2009). However, the annual number of new HIV infections has been declining

steadily and there are fewer HIV and AIDS related deaths due to the high intake of

ARVs over the past few years. Nevertheless, the overall levels of new infections are

high partly because of the increased number of PLWHA worldwide (UNGASS,

2010). Sub-Saharan Africa still seems to be the worst hit region globally with more

women than men living with the virus. Although the rate of new infections has

decreased due to the impact of HIV prevention efforts which have largely focused on

behaviour change among HIV negative people, the total number of PLWHA

continues to rise.

2.3 The Status of the HIV and AIDS Epidemic in Kenya

Over two decades since the first AIDS case was detected in Kenya in 1984, HIV and

AIDS still remains a huge challenge for the country to the extent of being declared a
 19

AIDS national disaster however it has been declining. National estimates show that in

1997- 1998 the prevalence among adults (15-49 years) was 10% declining to 6.7%

(KDHS 2003), 7.1% (KAIS 2007) and 6.3% (KDHS 2008/09, UNGASS, 2010). The

estimated number of PLWHA is 1.4 million with new infections estimated at 100,000

in 2009 for adults (15 years and older) (NACC/NASCOP, 2010) with heterosexual

sex cited as the primary form of transmission in the country. Nevertheless surveys by

KAIS (2007) and KDHS (2008/09) show that the HIV prevalence has stabilized in the

past few years. The decrease in prevalence coincided with the rapid expansion of

preventive interventions since 2000 focusing on HIV negative persons, which resulted

in a change in sexual behaviour and the increased use of condoms. The decline has

also been attributed to the large number of people dying from AIDS in Kenya, which

totalled 150,000 in 2003 alone (UNGASS, 2010).

In Kenya, more than 500,000 people are now receiving ARV therapy. This implies

that PLWHA will live longer with the disease hence putting other people at risk of

getting infected since most of them are in their reproductive years and are sexually

active. This may lead to an increase in new HIV infections hence thwarting gains so

far made in pursuits of HIV prevention which have primarily focused on HIV-

negative people. Hence the need for this research focusing on PLWHA to investigate

their likelihood of undertaking a HIV preventive action as they engage in sexual and

reproductive practices. In Central Province 3.8% of the total population is infected

(NASCOP, 2008; NACC, 2007) with Thika District having a HIV prevalence rate of

5% according to surveillance data from Thika District Hospital. This HIV prevalence

has reduced over the years as at 1999, the district was one with the highest HIV

prevalence rates of 33% (UNAIDS/WHO, 2008). However, the scourge continues to

 20

be the most pressing community concern with emerging and re-emerging infections.

Although HIV prevalence in Thika District has declined, HIV and AIDS continue to

be a great reproductive health concern. (Thika District Health Plan, 2008/2009). The

infection rate in the district has been fuelled by unsafe sexual behaviour, unsafe

motherhood leading to MTCT, ignorance of facts, presence of slow behavioural

change, family breakdowns and drug abuse especially illicit brews (Thika District

Strategic Plan, 2005-2010).

Other factors as reported by Kinyanjui (2007) are distant marriages which have led to

cohabitation of people working in the coffee and pineapple as well as low economic

status of most people residing in Thika which has led to transactional sex among

young girls and old men. All these factors can increase the spread of HIV as there are

high likelihoods of engaging in risky sexual practices. These factors such as sexual

behaviour, alcohol intake and income levels were some of the variables investigated

among the study population to shed light on their ability to use a safe sexual and

reproductive practice.

2.4 Prevalence of HIV by Socio-demographic Characteristics

HIV epidemic varies greatly across the socio-demographic groups and from one

province to another. With regard to gender, differences in prevalence persist in all

provinces, with women bearing a higher burden of HIV prevalence than men (KDHS

2008/09). This is shown by gender analysis by KAIS (2007) which indicated that

women were twice as much (8.4%) infected with HIV compared to men (5.4%) where

a similar pattern was also depicted by KDHS (2008-09) with women at 8% compared

to men (4.3%). Further, KDHS 2008/09 revealed that the HIV prevalence among
 21

adults aged 15 to 64 years in rural areas was estimated 6.7 % compared to 8.4%

among adults living in urban areas. However, given that the vast majority of people in

Kenya (75%) reside in rural areas, the absolute number of HIV infections is higher in

rural settings (1 million adults) than urban areas (0.4 million adults) (NASCOP,

2010).

According to education levels and HIV, KAIS (2007) shows that the HIV prevalence

is lower among women with secondary or higher education (6.2%) than those with

less education among women, the highest level is among those with incomplete

primary education (9%), while among men, this group has the lowest level. Further,

KAIS (2007) and KDHS (2008/09) report that HIV is more prevalent in PLWHA who

are currently employed than those who are unemployed; 11% of employed women

and 5% of employed men are HIV positive compared with 4% of women and 1% of

men who are not employed. Similar patterns were also depicted by KDHS (2008/09)

where results showed that Muslims have the lowest level of HIV infection (3%), and

those who have no religion have the highest level [7%] (KDHS 2008/09).

A key characteristic of HIV epidemic in Kenya is the risk of infections among people

in unions. This is supported by NASCOP (2010) in its latest edition on AIDS in

Kenya which indicates that nearly half of all new infections in 2008 were transmitted

during heterosexual sex within union or regular partnership. It accounted for 44.1% of

new infections, followed by casual heterosexual sex (20.3%) (UNGASS, 2010).

Studies done reveal that HIV prevalence by marital status is highest among widowed

respondents (44.4%) and the lowest among those who had never been married (2.4%)

while about 14.3% of respondents who are married or cohabitating are HIV positive
 22

(KDHS, 2008/09 & Centre for Prevention and Disease Control, 2009). Another study

in Busia District, Kenya shows that PLWHA who had never married had a higher

representation than other marital categories (Etyang, 2008). This reviewed literature

showed the need to focus on PLWHA as key vulnerable populations in transmitting

the virus. To achieve this, more research is needed on PLWHA to determine factors

that are associated with the ability to adopt a healthy HIV preventive action.

2.5 Sexual Practices of PLWHA

Research shows that a large proportion of PLWHA engage in unprotected sexual

relations with people of unknown or HIV negative status (Simbanyi, Kalichman,

Strebel, Cloete, Heda & Mgeketo, 2007). Nevertheless, Shapiro et al., (2007) in their

study in New Delhi, India note that in many settings, PLWHA are expected not to

have sexual lives, and their sexual needs may not even be considered. However it has

been noted that the physiological improvement due to ARV drugs follows with the

improvement of sexual activities of PLWHA and majority of them continue their

normal sexual activities.

It has been noted that the behaviour change interventions have had an effect on

behaviour. For instance, KAIS (2007) reports that there was an increase in condom

use, delay in sexual debut and reduction in number of sexual partners among

PLWHA. Despite the change in behaviour, PLWHA are still engaging in risky sexual

and reproductive behaviours. In the context with PLWHA, risk arises from HIV-

positive individuals engaging in risk-taking behaviour for a variety of reasons; such as

lack of awareness about possibility of re-infection, risks of other STIS, being unable

to negotiate safe sex, or may not have access to condom (Debeko et al., 2008). Also,
 23

KDHS 2008-09 points out this risky sexual behaviour by reporting that among those

who had sex in the last 12 months, 35% of men and 18% of women were likely to

engage in higher–risk sex ( sex with non-marital or non-cohabitating partners).

Other numerous studies also show that PLWHA engage in risky sexual and

reproductive health practices. For instance, Oyebola (2009) in his study carried out in

Nigeria reveals that risky sexual behaviour remains a common practice among

PLWHA. Along with this, Oyore (2009) in a study carried out in Nairobi, divulges

that PLWHA have multiple concurrent sexual partnerships with a casual or

commercial sex worker all of which are key factors in driving or escalating HIV

epidemic. Similarly, another study done in Nairobi by Otieno (2008), shows that

PLWHA after receiving a positive HIV diagnosis, continue to be sexually active and

indulge in risky sexual behaviour; a situation that may accelerate the transmission of

HIV and AIDS. Likewise, a study done in Mexico revealed that 87% continued to

have sexual activity with 13% not disclosing their HIV status to their sexual partners

but 65% of them were aware that they could transmit the HIV if they had intercourse

(Debeko et al., 2008).

In South Africa, a study conducted among PLWHA showed that they are still

susceptible to unprotected sex, despite wide spread health education. The study

revealed that at baseline 48% and 84% at follow-up of sexually active PLWHA did

not use a condom at their most recent vaginal intercourse (Olley et al., 2004). In

Uganda, a study showed that PLWHA engage in sex with multiple partners; out of

723 attending ART, 49% had sex in the preceding 6 months and 35% had other sexual

partners whom the majority (86%) had at least 3 or more partners (Bategagya &
 24

Kityo, 2006). This confirms why sexual intercourse has been rated as the major (over

80%) way of HIV transmission through unprotected sexual intercourse and having

multiple sexual partners (KAIS 2007; Stover et al., 2006; Ethiopia Public Health

Association, 2005).

2.5.1 Condom Use among PLWHA

In today’s world, condoms are a must as the threat of AIDS has reached alarming

proportions (NASCOP, 2010). However, this has not been the case as a study by

UNAIDS (2006), indicates that negative attitude towards condom use among

PLWHA remains due to ‘fatigue’ of consistency and this could hinder efforts for

prevention of HIV. Another research reported that some discordant couples do forgo

condoms as they perceive that the HIV-positive partner’s viral load is too low to

permit transmission (Allan Guttmacher Institute [AGI], 2006) leaving them at risk of

HIV and unintended pregnancy if no other contraceptive is used. A study in Kilifi

District, found that only 1% of married couples regularly used condoms (Papo, 2011).

A study done in Addis Ababa showed that 74.9% of PLWHA used condom while one

fourth did not use and were practising risk sexual behaviour. Out of those who

reported condom use, 79.8% used it regularly, while 20.2% reported irregular use.

The most common reason for non-use was partner’s dislike for condom (25.8%) while

the most common reason for condom use was advice from health professionals (63%)

(Debeko et al., 2008). Studies show that individuals tend to increase their condom use

after learning their HIV status. However, correct and consistent condom use over long

periods is difficult for most people who may experience prevention ‘fatigue’ (AGI,

2006). A study done by UNAIDS (2006) worldwide found that PLWHA do not use
 25

condoms since their partners are HIV infected while others refuse to use them.

Similarly, a study done in Togo by Moore et al., (2007) found that because sexual

behaviour involves complex dynamics, condom use is not an easy option for many

PLWHA despite years of condom distribution intervention. In fact, the complex

nature of sexuality complicates efforts to combat HIV spread and limits the

effectiveness of many prevention efforts. This may lead to spread of HIV and AIDS

especially when they engage in risky sexual behaviour.

It has been noted that levels of condom use are lower as the degree of intimacy and

stability of the relationship becomes greater. This is seen in a study done in Nairobi

that showed that the rate of condom use decline in PLWHA after some time as they

become used to each other in their intimate sexual relationships (Oyore, 2009). This

may pose a risk of transmitting HIV virus to the sexual partners or even having re-

infections. Thus, using condoms demands communication and negotiation. This is

evident in some studies which provide a more encouraging picture in terms of

women’s ability to influence men’s sense of sexual risk and condom use. Women

view the female condom as a means of enhancing their safer sex bargaining power

within the relationship as they feel more in control (Welbourn, 2006). Since HIV is

spread primarily through unprotected sex, safe sex practices such as condom use can

reduce HIV spread significantly (AGI, 2006). Use of condom was investigated among

the study population to give insight on the consistency of use and its barriers.

2.5.2 HIV Disclosure by PLWHA

HIV disclosure has remained at low levels in Kenya. This is supported by findings by

KAIS (2007) which indicate that very few respondents (35%) are aware of the HIV
 26

status of their sexual partners with 78% reporting a sexual partner of unknown HIV

status (NASCOP, 2007). Another study done in Mombasa showed that only 37% of

the respondents disclosed their HIV status to the sexual partners (Sarna et al., 2009).

This lack of information about one another’s HIV status increases the risk of HIV

infection and re-infection. It has been shown that disclosure of HIV- status to partners

promotes safer sex through increased condom use (Allen, Zulu & Fideli, 2003) which

may prevent spread of HIV and AIDS. This knowledge of a sexual partner being HIV

infected may help individuals make well-informed decisions regarding their sexual

and reproductive behaviour. Disclosing HIV HIV-positive results to sexual partner(s),

allows people to engage in preventive behaviour which ultimately decreases

transmission of HIV (Amberdir, Deribe, Haile, Woldemichal & Wondafrash, 2008).

This was assessed to establish whether PLWHA in the study area disclosed their HIV

status to their sexual partners.

2.6 Reproductive Behaviour of PLWHA

2.6.1 Desire to Have Children among PLWHA

Procreation is a basic human instinct and expectedly, HIV-affected couples also desire

to have children (Zubairu, 2009). This could be related to dominant social norms,

which continue to view reproduction as an integral part of women's lives. It has been

shown that PLWHA still desire to have children which fulfils their sexual and

reproductive rights, including the ability to decide if and when to have children. This

has been due to the availability of ART which has greatly improved the possibility of

PLWHA to have children through the PMTCT programmes as they believe that they

will leave long to take care of the children (Ayiga, 2008; CSIS, 2006). Generally,

HIV-positive individuals who desire children are younger and have fewer children or
 27

no children as compared to their counterparts who do not desire children (Debeko et

al., 2008). Literature shows that more PLWHA being in their reproductive years

continue to want children after learning their positive status; whether to start a family

or to have more children (Boston Conference report, 2010).

It has been revealed that among discordant couples, the desire for pregnancy has been

shown to outweigh concerns about horizontal transmission. This has been seen to be

influenced by significant others. A research in Brazil suggested that in some settings

due to cultural norms, HIV-positive men are more likely to want children than HIV-

positive women (Boston Conference report, 2010). Thus to meet this need, some of

HIV-positive people engage in unprotected sex while attempting to have children

(Debeko et al., 2008; Moore et al., 2007). PLWHA usually have children for varied

reasons such as desire to “leave something of themselves behind” as shown in a study

in Kenya on PLWHA CDC, 2009). Other studies in Cote d’Ivoire and South Africa

have demonstrated that some women want to become pregnant precisely to avoid the

stigma associated with childlessness. Also due to interpretation that avoiding a

pregnancy is a statement of being HIV-positive (Cooper et al., 2009).

At the same time, studies show women may not want to become pregnant for fear of

potential HIV infection in their children or the fear that these children may be

orphaned (Segurado et al. in Boston Conference Report, 2010). HIV-positive women

have also expressed concern that, once pregnant, they may be more vulnerable to

violence, backlash and abandonment by their partners, family and community

(Birungi, 2009; Cooper et al., 2009). Therefore spousal, family, community and

cultural influences greatly shape HIV-positive women’s desire for children (Boston
 28

Conference Report, 2010). The fact that many HIV-infected adults desire and expect

to have children might have important implications for the prevention of vertical and

heterosexual transmission of HIV. So the importance of children ever born after

testing HIV positive cannot be understated and this is what the study sought to

investigate.

2.7 Barriers to Safe Sexual and Reproductive Practices

Research has demonstrated that key to the household’s response when struck by HIV

is not the women’s, but their spouse’s reaction to the new crisis in the family. Studies

by WHO (2006) and Commission of HIV and AIDS and Governance in Africa

[CHGA] (2004), reveal that the struggles for equality begin in the family which is

also the primary site for stigmatization, discrimination, violence and abuse against

women like being considered vectors of HIV transmission to their children. This is

worsened by their inability to control their sexual and reproductive health which is

always hampered by the cultural norms that subject them to harmful sexual and

reproductive practices. Evidence shows that women who are HIV positive fear

seeking information on sex and buying or negotiating for condom use because they

will be labelled sexually active (General Assembly Report, 2008) reducing their

ability to successfully take a healthy sexual and reproduction action.

On the contrary, men are socially and culturally accepted to have more sexual partners

in their lifetime as opposed to women (Oyore, 2009). Bearing in mind that it has been

found that generally, there is perceived unwillingness of men to have protected sex,

women are at risk of HIV infection or re-infection. This is worsened by the lack of

female-controlled methods for preventing HIV transmission during sexual

 29

intercourse. The female condom which has been seen as a possible tool for HIV

prevention that women themselves can have control of and use, is still too expensive

and in too short supply to be widely available. Still it requires a similar kind of

negotiation as using the male condom, and may not be the solution to gender power

relations issues (CHGA 2004). The challenges for most of PLWHA are using

condoms consistently and finding a suitable sexual partner (preferably someone who

is HIV positive) who could agree to have a sexual relationship with them and provide

for their material needs (Wamoyi et. al., 2011).

Likewise, engaging in sex under the influence of alcohol can impair judgment,

compromise power relations, and increase risky sexual behaviour (KDHS 2008/09).

The use of alcohol or drugs is related to sexual behaviour that is high risk for HIV

infection. If substance use leads to unsafe sexual activity, it can be a factor

influencing the ability of taking a HIV preventive action. Hence understanding the

dynamics of this relationship can contribute to preventive efforts to contain the spread

of HIV and AIDS. The vulnerability this leads to is particularly emphasized by the

fact that marriage and other relations do not protect women against HIV. If the man

has multiple partners and does not use a condom, his female partner is vulnerable,

even if she is faithful (CHGA, 2004) or re-infection. Evidence from a study done in

Uganda by Nakawiya (2006) found that many women who have tested HIV-positive

continue to breastfeed their infants for fear of being ostracized and isolated. This puts

the children in danger of contracting HIV through MTCT. The presence of such

barriers to safe sexual and reproductive practices was investigated among the study

population to determine if they influenced their likelihood of taking a healthy sexual

and reproductive action.

 30

2.8 Decision-making on Sexual and Reproductive Behaviour

Often social norms restrict women from making decisions about their sexual relations,

hence putting them at risk of HIV. This is because whereas both partners should be

able to negotiate their own abstention, faithfulness or condom use, in reality it is men

who make these decisions. Consequently, the women particularly young women and

adolescents’ lack control of their own bodies hence lack control over their own

sexuality (CHGA 2007). On the other hand reproductive decision-making among

PLWHA seems to be made by significant others. This is supported by a study done in

Kabale, Uganda which showed that community members advise their male and

female relatives who are HIV positive to refrain from having children in the event that

they test positive and would die prematurely (Kakaire et al., 2010). Similarly Boston

Conference Report (2010) posit that a decision to become pregnant is not only a

personal choice but subject to family and community pressures, stigma and

discrimination as well as healthcare providers which may weigh heavily on a

woman’s decision on intention to have a child. Thus, reproductive decision-making

among PLWHA appears to be influenced by classical determinants that may not be

related to HIV status (Sowell, Murdaugh, Addy, Moneyham & Tavokoli, 2002).

Further, presentations in Boston Conference 2010 reveal that while some women may

make individual choices about pregnancy, many are likely to think about pregnancy in

the context of their relationship with a partner. However, men may lack the

information necessary to make informed decisions about fertility desires as

information about PMTCT is rarely targeted or made available to men. Likewise,

power imbalances in some sexual relationships may prevent women from insisting on

condom use, even though they remain the only “dual function” contraceptive method
 31

to prevent both pregnancy and HIV infection (Boston Conference Report, 2010).

Hence, women living with HIV face difficulties in making decisions regarding

childbearing. However, despite the risks and challenges, many of them are deciding to

bear children (Bunnel et al., 2005 cited in Boston Conference Report, 2010). Thus

decision making on matters of reproduction among PLWHA constituted an area of

concern to the researcher.

2.9 HIV Prevention with Positives

HIV prevention with positives is about PLWHA recognizing that they have a key role

in controlling the HIV epidemic by avoiding transmitting the virus to others. This can

be achieved by disclosing their HIV status to their sexual partners and also having

safe sex through use of condoms (International HIV/AIDS Alliance, 2003). Over the

years, HIV/STI prevention strategies have often failed to address the distinct

prevention needs of people with HIV and to acknowledge their significant efforts to

avoid infecting others as efforts have been directed to their medical needs.

Historically, HIV prevention programmes have focused on reducing HIV acquisition

risk among those not infected or those with unknown HIV status rather than on

reducing transmission risk from those already infected (CDC, 2009). This reluctance

to work on HIV prevention with people with HIV has been because of perceptions

that the concept of prevention for people already infected is inherently contradictory

(International AIDS Alliance, 2003) as it may seem to add stigma.

The advent of new treatments for HIV infection heightens this need for positive

prevention as more people are living with HIV than ever before. This increased access

to ART results to PLWHA living longer and having healthier lives, raising concerns
 32

of a potential increase in transmission risk from HIV-infected persons (Puren, Males,

Carael & Williams, 2004). So, strategies for positive prevention should aim to support

people with HIV to protect their sexual health, to delay HIV and AIDS disease

progression and to avoid passing their infection on to others (International AIDS

Alliance, 2003). This concept endorses the right of PLWHA to have a healthy sexual

life and also to acknowledge that they have a crucial role in controlling the HIV and

AIDS epidemic and avoiding transmitting HIV to others, while also preventing re-

infection among themselves (Shapiro et al., 2007).

Bearing in mind that HIV infection and disease occur after exposure and transmission

of the virus from an infected person, PLWHA will always have an essential role to

play in preventing new infections (Boston Conference Report, 2010). This calls for a

need to focus on PLWHA in order to prevent HIV. This study focused on PLWHA

and analyzed their socio-demographic characteristics and sexual and reproductive

behaviour with the implication of their ability to adopt a safe HIV preventive action.

2.10 Understanding Self-efficacy

According to Bandura (1994), self efficacy is a person’s belief in his or her ability to

succeed in a particular situation or activity. These beliefs are determinants of how

people think, behave and feel. He demonstrated that perceived self-efficacy is an

operative construct, that is, it is related to subsequent behaviour and therefore relevant

for behaviour change. He asserted that people with a high self-efficacy view

challenging situations as tasks to be mastered, develop deeper interests in activities in

which they participate and form a strong sense of commitment to this activities. On

the contrary, people with weak self-efficacy avoid challenging tasks as they believe
 33

They are beyond their capabilities. The study conceptualized this concept to refer to

ability of PLWHA to adopt a safe HIV preventive action. Therefore the study sought

to investigate self-efficacy in HIV prevention among PLWHA to assess their

capability in adopting successfully a healthy HIV preventive action.

2.11 Summary of Literature Review

HIV and AIDS in Kenya still remains a huge challenge for the country with an

estimated number of PLWHA as 1.4 million where new infections were estimated at

100,000 as in 2009 for adults (15 years and older) (NASCOP, 2008). In Central

Province 3.8% of the total population is infected with HIV while Thika District has a

HIV prevalence rate of 5% and it continues to be the most pressing community

concern with emerging and re-emerging infections (Thika Health Plan, 2008/2009).

The most affected are people in the reproductive group (15-49 years) (KDHS,

2008/09). Hence sexual and reproductive behaviour of PLWHA is fundamental to

their wellbeing and that of their partners and children. Studies reviewed showed that

PLWHA resume their ‘normal’ sexual and reproductive activities as their health

improves due to ART as they perceive they are no longer infectious (Wamoyi et al.,

2011). Some engage in risky sexual behaviours such as non-use of condoms, having

multiple partners, non-HIV disclosure and non-use of birth control methods (Kakaire

et al., 2010; Oyore, 2009 & Otieno, 2008). This puts their sexual partners at risk of

HIV infection or re-infection and unplanned pregnancy.

There is almost no documented discussion in Kenya on the ability of PLWHA to

successfully adopt a safe HIV preventive action yet they seem to be sexually and

reproductively active. Hence there are gaps in knowledge and information about
 34

sexual and reproductive behaviour of PLWHA to include their attitude, practices,

barriers and decision-making on sexual and reproductive behaviour. All these can be

considered critical in increasing the risk of HIV acquisition and transmission. This

boils down to their ability to successfully adopt a healthy HIV preventive action in the

context of their sexual and reproductive behaviour. Hence, sexual and reproductive

behaviour of HIV positive persons was an area of special interest and concern to the

researcher in the quest for preventing HIV focusing on PLWHA.

 35

CHAPTER THREE: METHODOLOGY

3.1 Overview

This section highlights methodological details used to carry out the study. It outlines

the research design, measurement of variables, description of study area, sampling

techniques, sample size, research instruments used, pre-testing techniques, data

collection techniques, data analysis and ethical and logical considerations.

3.2 Research Design

The study employed a survey research design which was cross-sectional because it

was carried out at one point in time. It was deemed appropriate because according to

Mugenda and Mugenda (2003) and Gall, Borg and Gall (1967), survey research seeks

to obtain information that describes existing phenomena by asking individuals about

their perceptions, attitudes, behaviour or values and social conditions and relations.

The survey design was also used because of its convenience in collecting extensive

data from a large sample of respondents within a short time (Miller, 1991). To this

end, it enabled the researcher to seek information from PLWHA on perceptions of the

disease and practices of their sexual and reproductive behaviour as well as studying

their socio-demographic characteristics.

3.3. Measurement of Variables

The study had both independent variables and dependent variable. The independent

variables comprised of: (a) Socio-demographic characteristics of PLWHA which was

measured by gender, residence, age, marital status, level of education, employment

status, income levels, religion, duration after testing HIV positive and knowledge of

HIV transmission and prevention. (b) PLWHA attitude towards sexual and
 36

reproductive behaviour. Attitude was measured by items related to sexual and

reproductive behaviour of PLWHA which were scored by use of a three level likert

scale, namely agree, not sure and disagree. (c) Sexual and reproductive practices

which was measured by the number of sexual partners one had in the last 12 months

prior to the study, type of sexual relationship in the last one year (whether in a regular

relationship with a spouse or stable partner or in an occasional relationship with

casual sexual partners), awareness of sexual partner’s HIV status in the last sexual

intercourse, HIV self-disclosure to the sexual partner in the last sexual encounter,

number of children born after testing HIV positive and desire to have more children

after testing HIV positive. (d) Barriers to safe sexual and reproductive behaviour

where the respondents were asked to state factors that hindered them from practicing

safe sexual and reproductive practices. (e) Decision-making patterns on sexual and

reproductive behaviour which was measured by asking the respondents to state who

made decisions on some issues related to their sexual and reproductive behaviour.

The dependent variable was self-efficacy in HIV prevention which referred to ability

to adopt a safe HIV preventive action. This was measured by asking the respondents

to judge themselves on their capability to carry out successfully six items related to

their sexual and reproductive behaviour which were basically HIV preventive actions.

Each item was measured on a five level likert scale, namely: very low, low, moderate,

high and very high. Further computation of self-efficacy in HIV prevention yielded

two outcomes, that is, low and high self-efficacy in HIV prevention (See page 97).

The relationships between the independent variables and dependent variable were

analyzed by use of Chi-square test. Further analysis was done to establish the

predictors of self-efficacy in HIV prevention using Binary Logistic Regression.

 37

3.4 Description of Study Area

The study was carried out in the greater Thika District (now in Kiambu County)

located in the southern part of Central Province with an area of 2024 square

kilometres and an approximate population of 827,767 (KNBS, 2009). It had six

administrative divisions at the time, namely: Thika Municipality, Ruiru, Gatundu

South, Kamwangi, Kakuzi and Gatanga. The district’s main economic activities are

agriculture and industries. It was divided into two zones along the Thika-Nairobi

highway with the higher agriculturally potential areas lying to the East and comprises

Gatundu South, Kamwangi, Gatanga and upper zones of Ruiru and Thika

Municipality divisions. The lower potential ones lie on the West and include Kakuzi,

Lower Ruiru and Thika Municipality divisions (Thika District Strategic Plan, 2005-

2010). Thika District was selected because it has been among the districts in Kenya

with the highest HIV prevalence rates (NACC, 2007). This has however, declined

over the years to 5% with the most affected age group being 20-49 years of whom

majority are females (Thika District Strategic Plan, 2005-2010).

3.5 Study Population

The target population comprised all persons living with HIV in Thika District, who

already knew their status and belonged to a registered support group or organisation.

These comprised 1319 persons living with HIV and AIDS. PLWHA were targeted

because they were highly susceptible in transmitting HIV through sexual contact. The

accessible population was sampled from seven randomly identified organisations

which dealt with PLWHA within the sampled divisions. This comprised 715 persons

living with HIV and AIDS. Any generalization of results to other settings should be

done with caution.

 38

3.5.1 Inclusion Criterion

The inclusion criterion was PLWHA within the reproductive age of between 18-49

years for females and 18 years and older for males. The difference in age of the

respondents was based on the fact that men are considered to be able to reproduce

even at their old age.

3.5.2 Exclusion Criterion

The exclusion criterion was PLWHA who were not members of a registered support

group or organisation.

3.6 Sampling Technique

Thika District was purposively selected for the study as it has been grouped among

the areas which have had high HIV prevalence rates in Central Province (NACC,

2005). Hence, it was deemed to have characteristics which were perceived to be

important for the study (Sproul, 1988). The sample population was drawn from

purposively selected divisions of Ruiru, Thika Municipality and Kamwangi. Ruiru

and Thika municipality were selected because they had the largest number of

registered support group of PLWHA. They are also under higher and lower

agricultural potential zones of the Thika District. Besides, Thika Municipality

represented an urban setting while Ruiru had both rural and urban setups (peri-urban).

Kamwangi represented a rural setting; it had also registered the highest incidence of

HIV within the district in 2000 (NASCOP, 2007). The three divisions presented

diverse socio-economic attributes of PLWHA.

The respondents were selected using stratified random sampling whose goal was to
 39

achieve desired representation from various subgroups in the population (Mugenda &

Mugenda, 2003). The three divisions namely, Ruiru, Thika Municipality and

Kamwangi formed the main strata and further stratification was done using the

organisations and gender. From the Thika District Office of Social Services, eleven

registered organizations or support groups whose members were PLWHA were

identified within the sampled divisions. Seven of them were purposively selected for

the study; these formed the next strata. For the organisation or group to have been

chosen, it ought to have been in existence and active for at least two years prior to the

time of the study. In Ruiru division, Ruiru Aids Awareness Group (CBO), Mugutha

Self-Help Group and Baptist Faith-Based Organization were chosen; in Thika

Municipality, Speak and Act (CBO), Life Enhancers (CBO) and KENWA (CBO)

were selected; while in Kamwangi division Integrated Aids Programme (FBO) was

chosen. One of the organisations in Thika Municipality, Partners in Prevention (PIP),

was chosen to participate in the pre-test but did not form part of the final sample.

A list of active members who were willing to talk about their personal lives from the

seven support groups/organisations was obtained from the respective support group

manager. This gave a total of 715 eligible cases that formed the sampling frame from

which the study sample was selected. A sampling frame is a list of cases or subjects

from which a sample can be selected (Mugenda & Mugenda, 2003). To get the

number of respondents for each organisation to be included in the study, proportionate

sampling was done as shown in Table 3.1. Proportionate sampling enabled the

accessible population as a whole (Robson, 2002).

 40

Table 3.1 Sampling Procedure

DIVISION ORGNISATION TYPE SAMPLIN PERCENTAGE SAMPLE

G FRAME PROPORTION SIZE
Ruiru Ruiru AIDS CBO 185 25.9 65
Awareness Group
Baptist FBO 27 3.8 10
Mugutha SHG 20 2.8 7
Thika Speak and Act CBO 107 14.9 37
Municipalit Life Enhancers CBO 46 6.4 16
y KENWA CBO 50 6.9 17
Kamwangi Integrated AIDS FBO 280 39.2 98
Programme
TOTAL 715 100 250

Source: Author

To get the actual case in the sampling frame for inclusion in the study, systematic

random sampling was used. First, with the help of the two research assistants,

community health workers (CHWs) and the organisation’s manager, a list of all the

members in the sampling frame for each organization was randomized as it was

arranged in numerical order depending on the date at which a member joined the

support group. A sampling interval was then determined by dividing the total

population in the sampling frame by the sample size. An interval of 3 was computed.

A starting point was selected blindly by closing the eyes from the table of random

numbers, 88009, (Mugenda and Mugenda, 2003) where the first digit ‘8’ was

considered. The respondent assigned number 8 in all organizations was the starting

point, every 3rd person was picked as a subject to be studied until the desired sample

size was reached.

For focus group discussion, participants were selected among those who were in the

sample size. Systematic random sampling was used using the same starting point and
 41

sampling interval as discussed for the individual intervals. However a criterion based

on gender, age which determines sessions and marital status was developed. There

were four FGDs which comprised younger male respondents (40 years or younger),

older male respondents (41 years and older), younger female respondents (35 years

and younger) and older female respondents (36 years and older). Each group had eight

respondents who were identified according to gender where X denoted females and Y

denoted males, session whether in session 1 or 2 and marital status denoted by

alphabets. Each marital status category had at least two respondents where A and B

were slots for married respondents, C and D for single, E and F for separated

/divorced and G and H for widowed. For instance, participant Y2A referred to a male

participant in session two and married. This arrangement was made possible by the

CHWs who mobilized and linked willing participants with the research team after

explaining to them the purpose of the study.

3.7 Sample Size

According to Fisher et al. (1995) in Mugenda and Mugenda (2003), the following

formula was used to determine the sample size for this study.

n = z2pq
d2
Where

n = The desired sample size (if the target population is greater than 10,000).

Z = The standard normal deviate at the required level (which is 95% level of

significance-1.96)

p= The proportion in the target population estimated to have characteristics

being measured (which is 0.50 where the figure is not known)

 42

q = 1-p (which is 0.5).

d = Level of statistical significance set (which is 95% or 0.05)

Therefore,

n = (1.96)2*(0.5)*(0.5) = 0.9604
(0.05)2 0.0025

Hence,
n = 384.16 = 384

Given that the target population of the study (715) was below 10,000, the required

sample size would be smaller. In such a case, a final sample estimate (n f) was

calculated using the Fisher et al. formula:

nf = ___n___ Where,
1+ (n/N)

nf = The desired sample size (where the target population is below 10,000).

n = The desired sample size (when the population is more than 10,000).

Thus:

nf = ___384_____ = ____384_______
1 + (384/715) 1+ 0.53706294

nf = ___ 384_______ = 249.827115 ≈ 250

(1.53706294)

A total of 239 respondents were interviewed which made up 95.6% of the original

sample size of 250 participants which was deemed high. During the data collection

exercise, some respondents were found to be too sick to be interviewed, while others

passed on before the interview. According to Timothy and Wislar (2012), a response

rate of between 80%-85% is considered to be good for a face-to-face interview.

 43

3.8 Research Instruments

The data were collected using interview schedules and focus group discussions

(FGDs). These were constructed in line with the objectives of the study.

3.8.1 Interview Schedules

Interview schedules were deemed suitable because they enabled the researcher to

obtain very sensitive and personal in-depth information from the PLWHA. They

allowed for probing, clarification, flexibility, high response and personal interaction

(Kinoti, 1989). The interview schedules were semi-structured which used an open

framework that allowed focused communication (Appendix III). The items were

designed such that they adequately solicited relevant data to address the research

objectives. They contained both open (for qualitative data) and closed-ended

questions (for quantitative data). Use of both approaches allowed for greater in-depth

understanding and insight as compared to using one approach (Roberts, 2004). It also

allowed overcoming the biases contained in each method (Mugenda & Mugenda,

2003).

3.8.2 Focus Group discussions (FGDs)

Focus group discussion was a highly efficient technique for qualitative data collection

since the amount and range of data were increased by collecting from several people

at the same time (Robson, 2002). It allowed respondents to react to and to build upon

responses of other group members and also produced data or ideas that could not have

been covered in individual interviews ((Bruce, 1998). Thus, the instrument helped to

authenticate data collected from the individual interviews. A focus group guide was

developed according to the study objectives (See Appendix IV).

 44

3.9 Pre-testing the Instruments

Pre-testing was done before the actual study. It helped to ascertain that the instrument

for collecting data was free of any pitfalls and mistakes that could have surfaced in

the main data collection process if the pre-testing of the instrument was not done

(Mugenda and Mugenda, 2003). A sample of 30 PLWHA from an organisation in

Thika Municipality (Partners in Prevention) which was not part of those which

formed the final sample participated in the pre-test. For the FGDs, two groups,

consisting of male-only and the other one female-only were also conducted. The

person in charge of Ruiru CCC was also interviewed. Adjustments were made in

order to make the research instruments more appropriate before the fieldwork began.

The vague questions which were being interpreted differently by the respondents were

rephrased to convey the same meaning to the respondents. It also helped to estimate

the length of time for the administration of the instrument.

3.9.1 Validity

Validity is the degree to which results obtained from the analysis of the data actually

represent the phenomenon under study (Mugenda and Mugenda, 2003). It was done to

ensure that the items tested what they were intended to. To enhance the validity of the

research instruments, peer review was done where the study proposal was presented

twice at the department. Expert contribution from the researcher’s supervisors and

others who were knowledgeable in this field of study was sought through consistent

consultations. The tools were also pre-tested where validity was assessed and the

responses reviewed according to the objectives of the study. The researcher also had

discussions with the experts before the final questionnaire was produced. The final

questionnaire was also translated into Swahili to enable the respondents to understand
 45

the questions. Two research assistants experienced in Social Science research and

well versed in Kiswahili and the local language, Kikuyu were employed. They were

also trained in order to understand the questions and the expectations of the study.

3.9.2 Reliability

Reliability is a measure of the degree to which a research instrument yields consistent

results after repeated trials (Mugenda and Mugenda, 2003). Reliability test was

conducted for the likert scale items using SPSS where internal consistencies were

analysed using Cronbachs Coefficient Alpha. The results of Cronbachs Coefficient

Alpha yielded a high value of 0.77 which was acceptable. This is in line with Streiner

and Norman (1989), who points out in their document on ‘From health measurement

scales; A practical guide to their development and use’ that a Cronbachs Alpha value

of 0.7 or higher is considered good enough. This internal reliability was particularly

high given that the tool was being used for the first time. Thus it indicated that the

items selected for measurement of variables were reliable measures.

3.10 Data Collection Techniques

Two research assistants who had a background on data collection assisted the

principal researcher in data collection. They were trained rigorously on data collection

before beginning of the research work. The researcher ensured that they familiarized

with the study with regard to the purpose, objectives, variables being studied,

interview conditions and instruments. They were closely supervised and guided by the

researcher throughout the study. For interview schedules, the research team was

introduced to the respondents during their weekly group meetings in all the

organisations where they were briefed on the purpose of the study, objectives, risks
 46

and benefits of participating in the study. They were also notified that the researchers

would be booking an appointment for the interview during these meetings so as to

visit them in their respective homes where informed consent would be sought and also

carry out the interview. This helped to create rapport and made it easier for the

subsequent visits to their homes.

After the respondents were selected, the community health workers helped the

research team to locate their homes. A face-to-face interview was carried out with

each respondent after seeking informed consent for participation which was followed

by an explanation of the study. At other times, interviews were done during their

weekly meetings. During the interview, notes were taken and the responses recorded

verbatim in the prepared interview schedule guide. The interviews were administered

in either Kiswahili or local language based on respondent’s preference. Each

interview took between 1½ to 2 hours.

For the FGDs, a focus group guide was used for the four focus groups involved. An

appointment was booked with them and the discussion was conducted in the language

the respondent best understood and felt most conversant with. A brief introduction

was done and they were briefed on the purpose of the study. Informed consent was

sought for them to participate and also for being voice-recorded. The discussions were

recorded through voice recorder and note taking. The researcher facilitated the FGDs

while the assistants took notes. The FGD sessions lasted for 1 to 1½ hours.

3.11 Data Analysis

The data obtained from the study were analyzed both quantitatively and qualitatively.
 47

Both techniques were used to complement each other and to enrich the discussion of

study findings.

3.11.1 Quantitative Data Analysis

The Statistical Package for Social Sciences (SPSS) version 17 was used for

quantitative data analysis. The data were cleaned then coded. Both descriptive and

inferential data analysis techniques were used. According to Sproul, (1988),

descriptive statistics are measures used to describe and summarize data while

inferential statistics uses sample data to give estimates, predictions or other

generalizations on a larger set of data (McClave and Sincich, 2000). For this study,

frequencies and percentages were used to describe and summarize the data.

Inferential statistics, precisely, Chi-square and regression were used. All the

hypotheses were analysed using Chi-square test of of significance at a probability of

error of 0.05 to determine relationship between the independent variables and

dependent variable. Chi-square test was used because both dependent and

independent variables of the study were categorical.

To determine the predictors of self-efficacy in HIV prevention among PLWHA,

Binary Logistic Regression was used. It was chosen because dependent variable data

were categorical and had two outcomes low and high self-efficacy. Low self-efficacy

was coded as 0 which signified that the respondents were not able to adopt a healthy

HIV preventive action. On the other hand, high self-efficacy was coded as 1 which

signified that there was ability to adopt a healthy HIV preventive action. Regression

model was developed based on the factors that had a significant relationship with self-

efficacy in HIV prevention. Data were presented in tables, pie charts and bar charts.
 48

3.11.2 Qualitative Data Analysis

Qualitative analysis was used to analyze the respondents’ attitude in a meaningful and

useful way. The recorded FGD data from the voice recorders and other qualitative

data from the individual interview schedules and key informants were transcribed to

allow for thematic analysis. Expanded notes were manually explored, to check for

emerging themes. They were then clustered in a patterned order so as to identify

variables that depicted similar patterns that occurred repeatedly and then differences

were noted. Inferences were made from particular data under each theme and

conclusions were then drawn from the findings.

3.12 Ethical and Logistic Considerations

Research approval was obtained from National Council of Science and Technology

and Kenyatta University which authorized the research to be conducted. Relevant

local administrators were notified before the study commenced. Permission from the

management of the support groups or organizations was also sought before actual data

collection began. Due to the sensitive and personal nature of the information being

sought, after the respondents had been identified, an informed written consent was

obtained from the respondents and only those who agreed to participate in the

research were interviewed. This was read to them in the language they preferred

which was either Kiswahili or Kikuyu. There was no name or personal identification

that was recorded on any study instrument.

The respondents were informed and alerted of potential risks of participating in the

study such as some discomfort, psychological stress and embarrassment that may
 49

arise when such issues as sexual practices are being discussed. They were assured of

confidentiality, anonymity, and privacy before starting the interview. In addition, they

were allowed to voluntarily participate and withdraw if the interview made them

uncomfortable.
 50

CHAPTER FOUR:

PRESENTATION AND DISCUSSION OF RESEARCH FINDINGS

4.1 Overview

The main purpose of the study was to determine factors associated with self-efficacy

in HIV prevention among PLWHA in three divisions of Thika District, Kenya

namely; Ruiru, Thika Municipality and Kamwangi. The findings are presented in this

chapter and are based on the five research objectives stated earlier in chapter one. The

hypotheses formulated for this study were statistically tested by use of Chi-square

test. Binary Logistic Regression analysis was also conducted to determine the

predictors of self-efficacy in HIV prevention among PLWHA. This chapter therefore

presents the socio-demographic characteristics of the respondents; PLWHA attitude

towards sexual and reproductive behaviour; sexual and reproductive practices of

PLWHA; barriers to safe sexual and reproductive behaviour and PLWHA decision-

making patterns on sexual and reproductive behaviour. The study was able to

interview 239 respondents out of the original 250 which yielded a 96.5% response

rate which was deemed to be high for a face-to-face interview.

4.2. Socio-Demographic Characteristics of PLWHA

The socio-demographic characteristics examined in the study included PLWHA

attributes which took account of age, gender, residence, marital status, level of

education, employment status, income levels, number of children ever born, religion

and duration since testing HIV positive. The results are presented in this sub-section.

4.2.1 Age of the Respondent

Age is an important demographic variable in sexual and reproductive behaviour with

great implication on prevention of HIV. The results presented in Figure 4.1 show that
 51

a large proportion (42.3%) of the respondents were aged between 31 and 40 years.

This may have great implication on their sexual and reproductive behaviour which

may influence their ability to take a HIV preventive action. This distribution was in

line with the national statistics where large proportions (18.6%) of those who are HIV

positive fall in the age category of 30-39 years (KDHS, 2008/09). Of great interest is

the age category of 50 years or older which had previously been assumed by National

surveys until when KAIS 2007 included them in their survey. They had been thought

not to be at such high risk of HIV infection. From this study, it was found that a

proportion of 9.1% of the respondents fell in this age category of 50 years or older.

This may have a far reaching implication on prevention of HIV by this age group

especially men who continue to be sexually active even after age 49 years.

n=239
100

80
PERCENTAGE

60
42.3
40 34.7

20 15.1
7.9
0
30 years or younger 31-40 years 41-50 years 51 years or older
AGE

Figure 4.1: Distribution of respondents according to age

4.2.2 Gender of Respondents

Gender is a variable that is important in sexual and reproductive behaviour and HIV

and AIDS management due to gender power relations. The results of distribution of
 52

respondents by gender are presented in Table 4.1. The results showed that 62.3% of

the respondents were females and the rest (37.7%) were males. The findings were in

line with KAIS (2007) which revealed that women had a higher prevalence rate than

men which is almost two times; 8.4% against 5.4% respectively. This gender disparity

could have been explained by the fact that females tend to engage in reproductive

activities in an earlier age than their male counterparts. The earlier entry of females

into reproduction could be explained both biologically and culturally. This is because

females reach menopause at the age of 49 years while males remain sexually active

for the rest of their lives. Hence, females seeking medical attention and psychosocial

assistance in support groups and other organisations dealing with HIV related issues

are highly likely to be more than their male counterparts.

4.2.3 Residence of the Respondent

The residence of the respondents was selected from three divisions of the greater

Thika District. They were perceived as living in urban (Thika Municipality), peri-

urban (Ruiru) and rural settings (Kamwangi). From the findings in Table 4.1, it can be

deduced that a large proportion of the respondents (41.0%) were from a rural setting

followed by peri-urban (33.5%) and urban setting (25.5%). These findings were

consistent with the national figures which showed that due to the vast majority of

people in Kenya (75%) residing in the rural areas, the absolute number of HIV

infections is higher in the rural settings (1 million adults) than urban areas (0.4 million

adults) (NASCOP, 2010).

4.2.4. Marital Status of the Respondents

Marital status was another key demographic variable that was examined among
 53

PLWHA as it influences sexual and reproductive behaviour which might have greater

implication on one’s self-efficacy in HIV prevention. Results in Table 4.1 shows that

a large proportion (45.6%) of respondents was married. The distributions across the

marital groups were supported by Ayiga (2008) whose study shows a high

representation of married persons (56.0%) among PLWHA in Uganda. On the

contrary, this contradicted results of KDHS (2008/09) on the general populace which

shows a high proportion (44.4%) of HIV infection among the widowed category with

the lowest among those who had never been married (2.4%). From the findings, it

could be deduced that a slightly more than half of the respondents (54.4%) was

dominated by individuals who were not living with their sexual partners. Since

majority of the respondents were within the reproductive age group, this could have

put unborn children and other people especially their sexual partners susceptible to

HIV infection and re-infection. This is because being HIV positive does not obliterate

them from sexual and reproductive desires. This might have had implications on self-

efficacy in HIV prevention by PLWHA.

4.2.5 Level of Education of the Respondents

Level of education of an individual is highly associated with knowledge about

management of HIV and AIDS and especially HIV transmission (KDHS, 2008/09).

This may influence decision-making on one’s sexual and reproductive practices which

may have greater implications on one’s self-efficacy in HIV prevention. Results on

level of education of the respondents are presented in Table 4.1. The findings revealed

that majority of the respondents (60.3%) had primary level of education with almost

two thirds of the respondents (65.3%) having primary level of education or no formal

education at all. This was consistent with KDHS (2008/09) results which show that a
 54

large proportion (14.5%) of the general populace infected with HIV was primary

school graduates with 5.7% having no formal education and 5.1% with secondary or

higher education. This meant that any programme targeting PLWHA in the study

needs to pay special attention to this diversity in education level with a view to

attending to their unique needs.

Table 4.1: Distribution of respondents according to socio-demographic factors

Socio-demographic Factors Frequency Percentage
Gender (n=239)
Females 149 62.3
Males 90 37.7
Residence (n=239)
Rural (Kamwangi) 98 41.0
Peri-urban (Ruiru) 80 33.5
Urban (Thika Municipality) 61 25.5
Marital status (n=239)
Married 109 45.6
Divorced/separated 52 21.8
Widow/widower 49 20.5
Single 29 12.1
Level of education (n=239)
Primary 144 60.3
Secondary and above 83 34.7
No formal education 12 5.0

4.2.6 Employment Status of the Respondents

Occupation is an important determinant of socio-economic status and livelihood of an

individual which might have an influence on an individual’s sexual and reproductive

behaviour. Table 4.2 indicates that nearly half (49.0%) of the respondents were casual

workers employed in flower farms and coffee plantations or unskilled farm workers

Slightly more than a third (36.8%) of the respondents were engaged in self-

employment. Such businesses included having green grocer kiosks, selling farm

produce like milk, selling charcoal, firewood, keeping small shops with general

merchandise and a few others were commercial sex workers (mainly self-reported
 55

females). Some of these income- generating activities such as selling charcoal, milk

or firewood were support group/organisation initiatives the respondents benefitted

from. Only 8.8% were permanently employed while 5.4% of the respondents were

unemployed. This means that over 90% of the respondents were in some kind of

employment while only 5.4% were not engaged in employment. This finding was

supported by KAIS (2007) and KDHS 2008/09 which report that HIV is more

prevalent in PLWHA who are currently employed than those who are unemployed.

4.2.7 Monthly Income of the Respondents

The study also sought to investigate the average monthly income levels of the

respondents. However, the study did not establish the household income levels as

most of the respondents could not be able to give estimates. This was because some of

the respondents did not know how much their spouses/partners or their parents (for

those who were staying with their parents) earned. The results in Table 4.2 reveal that

slightly over half of the respondents (51.3%) were earning a monthly income of below

Kshs. 5,000. A gender analysis of the results showed that a large proportion of males

(61.4%) had an average monthly income of Ksh.10,001 or more. On the contrary,

slightly more than two thirds (69.8%) had an average monthly income Ksh.5,000 or

less. This meant that there were comparatively more females than males in the lower

income groups implying higher poverty levels among female respondents. From the

study, majority earned below Kshs. 5,000; this could not have been enough to cater

for their households’ basic needs and medical expenses. This was supported by

sentiments from one participant in the FGD who said:

….sometimes I lack money to buy food and when I take these medicines in
empty stomach, I feel dizzy and vomit. With ARVS you need to take ugali 1 and
1
Ugali is a staple food in Kenya prepared from corn flour and is hard in texture; mainly taken as a
main meal
 56

uji2… Sometimes you go to the hospital thinking its side effects of medicines
only to be told its lack of eating enough food… (Participant Y2C).

This financial challenge could have made the respondents to be vulnerable to risky

sexual and reproductive behaviours. Consequently, this could have facilitated HIV

infection and re-infection.

4.2.8 Religion of the Respondents

Religion has been known to influence reproductive behaviour through use of birth

control methods. The results in Table 4.2 present the distribution of respondents by

religious affiliation. It was deduced that a higher proportion (43.9%) of the

respondents were Christians of protestant affiliation. This was consistent with national

statistics in Kenya on HIV prevalence by religious affiliation that show a high

incidence of HIV among Christians (12.5%). This could be explained by the fact that

Christians are around 90% with Muslims being 6.8% (KDHS, 2008/09).

The higher representation of those indicating non-affiliation to any religious group

could be explained by the stigma associated with HIV. This could have made some to

shy away from indicating their religion for fear of being ostracized. And the low

representation of Muslims among the respondents was considered adequate given that

Muslims were fewer in the study area. This could have been attributed by the fact that

though they were usually infected, they rarely joined support groups. This was

attested by one Muslim female respondent from Ruiru who had reported:

…some Muslim colleagues are HIV-infected and they really spread HIV but
they don’t expose themselves. (Participant X1A).

2
Uji is a semi-solid drink prepared from a mixture of cereals or from one cereal; normally taken for
breakfast or as a snack.
 57

4.2.9 Number of Children ever Born

The study sought to examine the number of children the respondents had ever had to

shed more insight on their reproductive behaviour after testing HIV positive. This is

because for people who have one or no child, they might have a desire to have more

children even after testing HIV positive. For conception to take place, unprotected sex

has to pre-cede. The study revealed that more than half of the respondents (52.3%)

had between 1 and 3 children. This pattern could have meant that most of the

respondents might not have a desire to have more children after testing HIV positive.

This could have influenced their ability to adopt a healthy HIV preventive action.

4.2.10 Duration since Testing HIV Positive of PLWHA

Duration since testing HIV positive could be a key variable in being able to take a

healthy HIV preventive action. The study investigated the duration since testing HIV

positive prior to the time of the study. The results in Table 4.2 revealed that a large

proportion (29.5%) of the respondents had tested HIV positive 6 years and over prior

to the time of study. Thus, there was a good representation of PLWHA between one

and six or more years since testing HIV-positive. This provided better relations with

selected variables under study and self-efficacy in HIV prevention by PLWHA which

was the key area of focus.

 58

Table 4.2: Distribution of respondents according to socio-demographic factors

Socio-demographic Factors Frequency Percentage

Employment status: (n=239)
Casual worker 117 49.0
Business/self employed 88 36.8
Permanent employment 21 8.8
Unemployed 13 5.4
Average monthly income: (n=226)
Below 5,000 116 51.3
5,001-10,000 66 29.2
Over 10,001 44 19.5
Religion: (n=239)
Protestant 105 43.9
Catholic 101 42.3
No religion 28 11.7
Muslims 5 2.1
Number of children: (n=239)
None 14 5.9
1-3 children 125 52.3
4 children or more 100 41.8
Duration since testing HIV positive: (n=239)
1 month – 1 year 48 20.3
2- 3 years 59 24.9
4-5 years 60 25.3
6 years and over 70 29.5

4.3 Respondents’ Attitudes

HIV infection may change one’s attitude towards sexual and reproductive behaviour.

This is due to the stigma associated with the disease which may influence one’s

ability to take a safe HIV preventive action. The study assessed respondents’ attitude

towards the virus, HIV negative people as well as attitude towards sexual and

reproductive behaviour.

4.3.1. Respondents’ Attitude towards HIV Epidemic

The respondent’s attitude towards HIV epidemic was assessed by asking them three

items which were measured on a three level likert scale. The findings are presented in

Table 4.3. The results show that a large proportion (58.8%) of respondents regretted
 59

having contracted HIV and 57.0% found living with HIV very tough. They reported

that by the virtue of being HIV positive, one was viewed as having led a promiscuous

life. This did not augur well with the female respondents especially married ones as

some claimed that they contracted the disease or infection from their husbands. This

was evidenced from the FGDs where there were common responses depicting that life

was tough for them as they lived with the virus and some regretted having contracted

it:

Taking medicine everyday is tedious (FGDs)

You are viewed as a prostitute (FGDs)

If I fall sick of any other illness (opportunistic diseases), I worry so much

(FGDs)

Table 4.3: Respondents’ attitude towards HIV epidemic

Attitude items Responses

Agree Not sure Disagree
Freq./% Freq./% Freq./%
I regret having contracted HIV (n=238) 140 6 92
(58.8%) (2.5%) (38.7%)
It is tough living with HIV (n=237) 135 19 83
(57.0%) (8.0%) (35.0%)
HIV is better than terminal illnesses 128 38 70
(n=236) (54.2%) (16.1%) (29.7%)

Slightly more than a half (54.2%) reported that HIV was manageable compared to

terminal illnesses such as cancer or diabetes. They expressed views that those who

had cancer or diabetes were usually given a specific period to live as opposed to

PLWHA who lived with the virus. They felt that as long as they adhered to the

doctors’ instructions such as being ARVs adherent, eating quality food, having sex

with a condom and consulting the doctor when one desires to conceive, respondents

could live longer just like HIV-negative people. This was supported by the following
 60

sentiments from FGDs and key informant interviews (KIIs):

…if you eat well…that is ok… (KIIs)

….take medicine at the right time… (KIIs)

…HIV is better than cancer…where you have a few months to live…(FGD)

For further analysis, the three responses were assigned scores of 1, 2 and 3 where the

negative responses were scored as 1 for ‘agree’, 2 for ‘not sure’ and 3 for ‘disagree’

and for positive responses the reverse applied. The lowest score expected was 3 and

highest 9. After computation, it was found that more than half of the respondents

(57.7%) had a negative attitude towards HIV epidemic while 42.3% had a positive

attitude. This high negative attitude could have influenced their ability of taking a

healthy HIV preventive action.

4.3.2 Respondents’ Attitude towards People with HIV-negative Status

PLWHA may isolate themselves from others within the community and especially

people with HIV-negative status as they may feel stigmatized and discriminated

against. The study assessed the respondents’ attitude towards people with HIV-

negative status by asking them six likert items measured by a three level scale;

‘agree’, ‘not sure’ and ‘disagree’. The findings are presented in Table 4.4. The results

indicate that slightly more than two thirds (69.1%) of the respondents were willing to

live among people whom they perceived as being HIV negative while 65.0% did not

have issues when in a group of HIV negative people. Also, 62.9% reported that they

were not envious about those they perceived as being HIV negative. More than half of

the respondents (58.1%) reduced their contact time with other people whom they

perceived as being HIV negative. This was due to the kind of utterances the HIV
 61

negative people made about PLWHA. Slightly less than a half of the respondents

(43.6%) felt that they were discriminated against by HIV negative people such as their

families, the church and in social gatherings. Some reported that their immediate

family members did not allow their children to mix with the children of PLWHA.

Others cited that they had been shunned from visiting their rural homes. These

findings were supported by the following common reactions during FGDs and

administered interview schedules:

… I just visit those who are like me…(FGD)

….those people (HIV-negative) do not invite us to their occasions…they think

they will be infected…we also don’t invite them… (FGD)

….go away with your HIV/AIDS…(FGD)

Table 4.4: Respondents’ attitude towards people with HIV-negative status

Attitude items Responses

Agree Not sure Disagree
Freq./% Freq./% Freq./%
Am reluctant to live with HIV negative 33 40 163
people in the same community (n=236) (14.0%) (16.9%) (69.1%)
I dislike being in a group of HIV negative 67 16 154
people (n=237) (28.3) (6.8%) (65.0%)
Feel envious towards other people who are 49 39 149
HIV negative (n=237) (20.7%) (16.5%) (62.9%)
Reduce my contact time with other people 137 12 87
who are HIV negative (n=236) (58.1%) (5.1%) (36.9%)
Feel discriminated by HIV negative people 102 39 93
(n=234) (43.6%) (16.7%) (39.7%)
PLWH are not able to mix with others in the 44 58 137
community freely (n=239) (18.4%) (24.3%) (57.3%)

Further the responses of the six items used to measure respondents’ attitude towards

HIV negative people were given scores of 1 for ‘agree’, 2 for ‘not sure’ and 3 for

‘disagree’. The items were negatively stated hence the reason why the highest score of

3 was assigned to ‘disagree’ and the lowest score of 1 assigned to ‘agree’. The
 62

minimum score expected was 6 while the maximum score expected was 18. Those

who scored between 6 and 12 were considered to have a negative attitude towards

HIV negative people while those who scored between 13 and 18 were considered to

have a positive attitude. After computation, the results showed that a large proportion

of the respondents (63.0%) had a positive attitude on HIV negative people while

37.0% held a negative attitude. This high positive attitude of HIV negative people

could have meant that the respondents were living positively and did not haboured

self (internal) stigma.

4.3.3 Respondents’ Attitude towards Sexual Behaviour

Attitude towards sexual behaviour among PLWHA is an important aspect which may

have far reaching implications on HIV prevention. This was assessed by asking the

respondents their attitude towards a set of items related to sexual behaviour on aspects

of abstinence, faithfulness and condom use. These items were measured by a three

level likert scale which comprised ‘agree’, ‘not sure’ and ‘disagree’. The findings are

discussed next. The results in Table 4.5 revealed that a large proportion of the

respondents (90.8%) felt that they should be faithful to their sexual partners. This was

supported by the large proportion of the respondents (87.0%) who felt that PLWHA

should not have multiple sexual partners. Likewise, a large proportion of the

respondents (86.6%) felt that condoms were necessary for PLWHA when engaging in

sexual intercourse. However, slightly more than three quarters of the respondents

(76.6%) acknowledged that condoms reduced sexual satisfaction. This negative

attitude towards condoms was in line with results by UNAIDS (2006) which indicated

that negative attitude towards condom use among PLWHA remained due to ‘fatigue’

of consistency. The findings also showed that majority of the respondents (71.8%) felt
 63

that PLWHA should not abstain from sex. This was supported by the following

common response that was observed during the FGDs:

Sex is like food…you cannot live without it… (FGD)

Further, slightly more than two thirds of the respondents (68.2%) felt that they should

not disclose their HIV status to every sexual partner they had sex with. This could be

a hindrance in the pursuit of HIV prevention. In addition to this, more than half of the

respondents (59.8%) felt that buying of condoms was not embarrassing. This was a

good motivator of taking a healthy HIV preventive action as they did not view buying

of condoms as being associated with promiscuity.

Table 4.5: Attitude towards sexual behavior by the respondents

Attitude items Responses

Agree Not sure Disagree
Freq./% Freq./% Freq./%
PLWHA should abstain from sex. (n=238) 62 5 171
(26.1%) (2.1%) (71.8%)
PLWHA should be faithful to their sexual 217 4 18
partner (n=217) (90.8%) (1.7%) (7.5%)
Using condoms is necessary for PLWHA 207 4 28
(n=239) (86.6%) (1.7%) (11.7%)
PLWHA should disclose their HIV status to 63 12 161
every sexual partner they have (n=236) (26.7%) (5.1%) (68.2%)
PLWHA should not have sex with many 208 18 13
partners (n=239) (87.0%) (7.5%) (5.4%)
Buying of condoms is embarrassing for 71 25 143
PLWHA (n=239). (29.7%) (10.5%) (59.8%)
Condoms diminish sexual pleasure 183 17 39
(n=239) (76.6%) (7.1%) (16.3%)

Further, the seven items used to measure respondents’ attitude towards sexual

behaviour, were assigned scores of 1, 2 and 3 for ‘agree’, ‘not sure’ and ‘disagree’

respectively for negatively stated items while the reverse was done for the positively

stated items. The minimum score expected was 7 while the maximum score expected
 64

was 21. Those who scored 7-14 were considered to have a negative attitude towards

sexual behaviour while those who scored 15-21 were considered to have a positive

attitude. After computation, the results showed that a larger proportion of the

respondents (86.6%) had a positive attitude towards sexual behaviour while 13.4%

held a negative attitude. This high positive attitude on sexual behaviour could have

explained why PLWHA were still sexually active even after testing HIV positive.

4.3.4 Respondents’ Attitude towards Reproductive Behaviour

Attitude towards getting children is an important aspect among PLWHA which may

have great implications on HIV prevention. This was assessed by asking the

respondents their attitude towards a set of items related to reproductive behaviour on

aspects of children and birth control methods. These items were measured by a three

level likert scale which were ‘agree’, ‘not sure’ and ‘disagree’.

Table 4.6: Attitude towards reproductive behaviour by the respondents

Attitude items Responses

Agree Not sure Disagree
Freq./% Freq./% Freq./%
PLWHA should have more children if they 154 17 68
desire (n=239) (64.4%) (7.1%) (28.5%)
PLWHA should use birth control methods to 215 14 8
avoid a pregnancy (n=237) (90.7%) (5.9%) (3.4%)
Use of birth control methods to avoid 26 113 99
pregnancy is ungodly (n=238) (10.9%) (47.5%) (41.6%)
Birth control methods reduces sexual urge 126 57 56
(n=239) (52.7%) (23.8%) (23.4%)

The results in Table 4.6 revealed that a large proportion of the respondents (90.7%)

felt that they should use birth control methods to avoid a pregnancy. This could be

explained by the common sentiments against becoming pregnant given during FGDs:
 65

Pregnancy weakens one’s body and may lead to death (FGDs).

You may conceive and then you get a HIV positive child which increases your
problems (Female participant FGDs).

Despite the fact that the respondents felt PLWHA should use birth control methods,

almost two thirds of the respondents (64.4%) had the opinion that they should have

children if one desired. Nonetheless, slightly more than a half of the respondents

(52.7%) felt that birth control methods reduced sexual satisfaction. Interestingly,

10.9% of the respondents held a misconception that birth control methods are

ungodly. This could have influenced the respondent’s use of birth control methods

leading to unplanned pregnancies which might predispose the child to vertical

transmission of HIV.

Further, the responses of each of the four items used to measure attitude towards

reproductive behaviour were assigned scores of 1, 2 and 3 for ‘agree’, ‘not sure’ and

‘disagree’ respectively for negatively stated items while the reverse was done for the

positively stated items. The minimum score expected was 4 while the maximum score

expected was 12. Those who scored between 4-8 were considered to have a negative

attitude towards reproductive behaviour while those who scored between 9-12 were

considered to have a positive attitude. After computation, the results showed that two

thirds of the respondents (66.5%) had a positive attitude towards reproductive

behaviour while 33.5% held a negative attitude.

For the purpose of further analysis of relationships and predictions, the overall

perception of the respondents on the four aspects, that is, HIV and AIDS, HIV

negative people, reproductive behaviour and sexual behaviour was calculated based

on the overall perception of each aspect. A score of 1 and 2 were assigned to the

negative and positive perceptions respectively of every aspect assessed and for every
 66

respondent. The minimum score a respondent could attain was 4 and the maximum 8.

The overall perception was categorized as 4-6 as negative overall perception and 7-8

as positive overall perception as presented next. After computation, the study

established that more than half of the respondents (54.8%) had an overall positive

attitude towards HIV epidemic, HIV negative people, sexual and reproductive

behaviour while 45.2% held a negative attitude. This high overall positive attitude

towards the four aspects could have influenced the respondent’s sexual and

reproductive practices with an implication on their ability to take a healthy HIV

preventive action. On the contrary, those harbouring an overall negative attitude

towards the four aspects could have prevented them from taking a healthy HIV

preventive action, hence facilitating transmission of new cases of HIV infections and

re-infections.

4.4 Sexual and Reproductive Practices of PLWHA

This study sought to investigate the sexual and reproductive practices of PLWHA

after testing HIV positive to establish whether they engage in risky sexual practices

with great implication on their self-efficacy in HIV prevention.

4.4.1 Number of Sexual Partners

Number of sexual partners is a major risk factor in transmission of HIV. In the study,

number of sexual partners was assessed by asking respondents to indicate the number

of sexual partners they had in the last 12 months prior to the study. The results

presented in Figure 4.2 indicate that 48.1% had not been faithful to their sexual

partners for the previous 12 months prior to the study while 44.8% had been faithful.

Only 7.1% of the respondents were abstaining. This implied that nearly half of the

respondents had had extramarital sexual relationships. This finding was supported by
 67

a study in South Africa on PLWHA which found that 29% of the study population

had multiple sexual partners (Simbayi et al., 2007).

(n=239)

None
7%

One
45%

Many
48%

Figure 4.2: Number of sexual partners

For those who had additional sexual partners, 67.0% (n=115) indicated they had an

affair with a casual sex partner while the remaining 33.0% had had sex with a stable

sexual partner. The findings were consistent with Oyore (2009) in a study carried out

in Nairobi where he reported that PLWHA have multiple concurrent sexual

partnerships with a casual or commercial sex worker.

Reasons for Having Multiple Sexual Partners among the Respondents

The study sought to explore the reasons for having multiple partners among the

respondents. The respondents were asked to rate selected factors that could explain

the practice of multiple sexual partners. The results were presented in Table 4.7. The

results show that the key explanations for having multiple sexual partners included

relationship issues and desire for revenge.

 68

Table 4.7: Reasons for having multiple partners among the respondents

Reasons Responses
Disagree Not Sure Agree
Sexually Dissatisfied (n=237) 7.2% 1.3% 91.5%
Lack of money (n=234 ) 20.5% 8.5% 71.0%
Peer Pressure (n=232) 51.3% 11.6% 37.1%
Bitterness of being HIV positive (n=231) 20.8% 15.2 64.0%
Infect others (n=235) 8.1% 11.9% 80.0%
Strained relationships (n=231) 1.7% 1.3% 97.0%
HIV negative partner refusing sex (n=233) 1.8% 3.0% 95.3%
Death of a spouse (n=235) 30.6% 19.6% 49.8%

As shown, 97.0% of the respondents agreed that strained relationship with a spouse or

a stable partner could force the respondents to have multiple partners. Other family

related factors included HIV negative partner refusing sex (95.3%) and lack of sexual

satisfaction (91.5%). It was also clear that the respondents were motivated by the

desire to revenge their HIV status. The results showed that 80.0% of the respondents

agreed that some respondents were involved with multiple sexual partners in order to

infect others while others did so as a result of being bitter of their condition (64.0%).

Economic and social considerations were also highly ranked with 71.0% of the

respondents reporting lack of money forced a considerable proportion of the

respondents into having multiple sexual partners and peer pressure cited by 37%.

The findings also showed that the psychological loneliness emanating from the loss of

a loved one was considered by nearly half of the respondents (49.8%) as a factor in

multiple sexual relationships. Therefore, the problem of multiple sexual partners

among the respondents was a multifaceted phenomenon driven by strained social

family relationships, economic disempowerment, lack of self-acceptance, and

emotional instability at the loss of a loved one.

 69

4.4.2 Use of Condoms among PLWHA

Use of condoms among PLWHA is strongly recommended since it reduces re-

infections and new infections for discordant sexual partners. The study sought to

establish the use of condoms during the last sexual intercourse prior to the study and

the reasons for use and non-use of condoms.

Use of Condom during the Last Sexual Intercourse

The study explored the use of condom during the last sexual intercourse.

Table 4.8: Condom use during the last sexual intercourse

Status Frequency Percentage

Used 146 65.8
Did Not Use 73 32.9
Can’t remember 3 1.3
Total 222 100

The results presented in Table 4.8 indicated that almost two thirds (65.8%) had used

a condom during their last sexual intercourse at the time of the study while 32.9% did

not use. This proportion of those who did not use a condom was lower than those of a

study conducted in South Africa among PLWHA which revealed that at baseline 48%

and 84% at follow-up of sexually active PLWHA did not use a condom at their most

recent vaginal intercourse (Olley et al., 2004). However, the finding was consistent

with a study done in Addis Ababa that showed that 74.9% of PLWHA used a condom

while 25.1% did not use (Debeko et al., 2008).

Reasons for Use or Non-Use of Condoms

As shown in Table 4.9, the main reasons for the use of condoms were cited as

preventing re-infection (48.6%), preventing new infections (31.5%), and to protect the

respondent from contracting STIs (15.0%). Other reasons given included lack of
 70

knowledge of partner’s HIV status (5.4%), prevent conception (4.7%), and lack of

trust of the sexual partner (0.7%). Thus, the use of condom was largely attributed to

health considerations and birth control.

Table 4.9: Reasons for using or not using condoms

Reasons Frequency Percentage

Reasons for using a condom during the last sexual intercourse (n=146)
Avoid re-infection 71 48.6
Prevent infecting partner 46 31.5
Avoid contracting STIs 22 15.0
Did not know partner’s HIV status 8 5.4
Avoid a pregnancy 7 4.7
Did not trust partner 1 0.7
Reasons for not using a condom during the last sexual intercourse (n=73)
Partner’s refusal 36 49.3
To enjoy sex 22 30.1
Did not disclose HIV status 3 4.1
To conceive 3 4.1
Both HIV infected 2 2.7
Condom not available 2 2.7
To get more money 1 1.3

A proportion of 49.3% indicated that they did not use condom because the other

partner refused while 30.1% showed they wanted to enjoy sex and 4.1% took

advantage of their sexual partner’s not knowing their HIV status. The other reason for

non-use of condoms were cited as to conceive (4.1%), both HIV- infected (2.7%),

condom not available (2.7%) and to get more money in the case of commercial sex

workers (1.3%). Thus, the reasons provided for not using condom were mainly as a

result of sexual power relation, quest for sexual satisfaction, fear of stigma, desire to

have a child, mutual agreement, lack of condom and financial considerations. The use

of condom among the respondents was a multidimensional phenomenon explained by

a number of factors including gender, psychological factors, economic factors, social

considerations, personal preferences and availability of condoms. This was evidenced

 71

by the qualitative data where there were such sentiments as some attested to:

…..that is like eating a sweet with a wrapper (referring to condom use)

(Participant Y2C)

Others wanted to enjoy sex without a condom and disregarded one’s HIV status as

one reported:

…..even if you tell some men you are HIV positive, they do not believe
because health-wise you are ok… they observe with the eyes…. Participant
X2D

For other respondents, religion prohibited use of condoms as indicated by a Muslim

female respondent:

…..Muslims are not supposed to use those things (referring to condoms)

…..Participant X1A

These findings of use and non-use of condoms among PLWHA were closely

consistent with a study in Addis Ababa where the most common reason for non-use

was partner’s dislike for condom (25.8%) while the most common reason for condom

use was due to health as advised by health professionals (63%) (Debeko et al., 2008).

However the results contradicted the study by AGI (2006) which reported that some

discordant couples do forgo condoms when they perceive that the HIV-positive

partner’s viral load is too low to permit transmission.

4.4.3 Type of Sexual Relationship in the last six months

The study sought to investigate the type of sexual partner the respondents had within

six months prior to the time of the study. From the findings in Table 4.10, it was

deduced that a large proportion of the respondents (61.7%) had regular sexual

relationship while 38.3% had occasional sexual relationship. These results were in
 72

line with findings by Oyore 2008 in his study in Nairobi who found that PLWHA had

multiple concurrent sexual partnerships with a casual or commercial sex worker.

Table 4.10: Type of sexual relationship

Type of sexual relationship Frequency Percentage

Regular sexual relationship 137 61.7
Occasional sexual relationship 85 38.3
Total 222* 100.0
*17 did not have sex in the preceding six months prior to the study

Condom Use and Type of Sexual relationship

When compared to the type of sexual relationship, the results in Table 4.11 revealed

that majority of the respondents (61.6%) had used condoms with their regular sexual

relationship as compared to those who had sex with their occasional sexual

relationship (38.4%).

Table 4.11: Condom use in last sexual encounter and type of sexual relationship

Condom use Type of sexual relationship

Regular sexual relationship Occasional sexual
relationship
Freq. % Freq. %
User 90 61.6 56 38.4
Non- users 46 63.0 27 37.0
Can’t remember 1 33.3 2 66.7
Total 136 100 85 100

The most striking finding was that among those who did not use a condom in their last

sexual encounter, a larger proportion of the respondents (63.0%) were those who had

sex with a regular sexual partner. This showed that some respondents were engaging

in unprotected sex putting their sexual partners at risk of HIV infection or re-infection

even after knowing their HIV status. These results were supported by Debeko et al.,

(2008) in a study in Addis Ababa where HIV-positive individuals engaged in sexual

 73

risk-taking behaviour due to lack of awareness of re-infection. The results pointed to

greater concern since 35.2% of the respondents did not know the HIV status of the

last sexual partner. When the use of condom in the last sexual encounter was

compared with knowledge of HIV status of the sexual partner, the results showed that

29.6% of those who did not know the partners’ status did not use condom while

10.5% who knew their partners were HIV-negative did not use a condom. Likewise,

36.4% of those who knew their sexual partners were HIV-positive also did not use a

condom. Hence, the respondents engaged in unprotected sexual relations with people

of unknown and known HIV status putting their sexual partners at risk of infection or

re-infection. These findings concurred with a study done in Mombasa which showed

that 62% of the respondents reported having unprotected sex with regular partners of

HIV-negative or unknown HIV status (Sarna et al., 2009).

The non-use of condom by the respondents left wide avenues for re-infections and

possible new infections. This was clearly shown with near equal proportion in the use

of condom regardless of the type of sexual partner. As discussed above, the use was

slightly high for regular sexual partners as compared to occasional sexual partners.

This meant that the respondents sought sexual satisfaction outside regular unions.

Consistency of Condom Use

The study sought to investigate the consistency of condom use by type of partner

within the past six months prior to the study. The results in Table 4.12 revealed that of

those respondents using condoms always, a higher proportion was reported among the

regular sexual partners (56.6%) as compared to those who had occasional sexual

partners (32.7%). Those indicating using condoms, ‘sometimes’ had a higher

 74

representation among occasional sexual partners as opposed to regular sexual partners

(28.6%). Rare use of condom was high among occasional sexual partner (7.3%) as

compared to regular sexual partner (6.6%). Non-use of condom was reported to be

highest among the regular sexual partners (8.2%) as compared to occasional sexual

partners (1.8%).

Table 4.12: Consistency of condom use for the last six months

Consistency of Type of sexual partner

condom use Regular sexual partner Occasional sexual partner
Freq. % Freq. %
Always 111 56.6 36 32.7
Sometimes 56 28.6 64 58.2
Rarely 13 6.6 8 7.3
Never 16 8.2 2 1.8
Total 196 100 110 100

Consistency in the use of condom was high in sexual relations involving regular

sexual partners. This meant that some respondents sought sexual satisfaction away

from their closely-knit sexual relationship with spouse for the married and a stable

partner for the singles. Consequently, this perhaps indicated that the use of condoms

was to a lesser extent driven by health considerations. The results presented a strong

case for sexual satisfaction and economic considerations as the underlying factors

explaining the non-use of condoms. This boiled down to engaging in risky sexual

practices. The figure for consistency of condom use among regular sexual partners

was much higher than for a study in Kilifi District, Kenya on PLWHA which found

that only 1.0% of married couples regularly used condoms (Papo, 2011). However,

the findings were consistent with results from a study in Addis Ababa where a larger

proportion (79.8%) among stable partners used condoms regularly while 20.2%

reported irregular use (Debeko et al., 2008). This could be explained by the fact that
 75

correct and consistent condom use over long periods is difficult for most people who

may experience prevention ‘fatigue’ (AGI, 2006).

4.4.4 Awareness of Sexual Partner’s HIV-status

Awareness of sexual partner’s HIV status may be critical when having sex in order to

prevent new infection or re-infections. This variable was investigated to give insight

on whether the respondents discussed about safer sexual practices which could

enhance their likelihood of taking a HIV preventive action. The respondents were

asked whether they knew the HIV-status of the sexual partner during the last sexual

intercourse and if so what the status was.

Table 4.13 Awareness of sexual partner’s HIV-status

Awareness (n=231) HIV status (n=150)

Aware Not aware Positive Negative
Frequency 150 81 131 19
Percentage 64.9 35.1 87.3 12.7

From Table 4.13, it can be shown that a large proportion of the respondents (64.9%)

were aware of their sexual partner’s HIV status in their last sexual encounter while

35.1% were not aware. This contradicted findings by KAIS (2007) which indicated

that very few respondents (35.0%) were aware of the HIV status of their sexual

partners. Further probing of those who were aware of their sexual partner’s HIV status

showed that a large proportion (87.3%) indicated that they were HIV positive while

12.7% indicated that they were HIV negative. This showed that there were some

discordant couples among the sampled respondents who could be at risk of HIV

infection if safe sexual practices were not considered. For those who knew their

sexual partner’s HIV status, they reported that they had either tested jointly or/and had

met in the support groups, seminars or at the CCC. Among those who did not know
 76

about their sexual partner’s HIV status, some accounted that they did not discuss HIV

issues while others had refused to be tested. This could put their sexual partners at risk

of getting infected or re-infected. Therefore, knowledge of a sexual partner being HIV

infected could help individuals make well-informed decisions regarding their sexual

behaviour.

4.4.5. HIV Self-disclosure to Sexual Partner

HIV self-disclosure is an important aspect in the lives of PLWHA as it may have far

reaching implications on whether they use a healthy HIV preventive action. The study

sought to investigate whether the respondents disclosed their HIV status in their last

sexual encounter. This was discussed as shown in Table 4.14.

Table 4.14: HIV self-disclosure

Disclosure Frequency Percentage

Disclosed 157 67.4
Did not disclose 76 32.6
Total 233 100

The results showed that two thirds of the respondents (67.4%) disclosed their HIV

status in their last sexual intercourse at the time of the study while 32.6% did not

disclose. That revealed that some respondents engaged in sexual relations without

necessarily disclosing their HIV status. This concurred with a study done in Mombasa

that showed that only 37% of the respondents disclosed their HIV status to the sexual

partners (Sarna et al., 2009). Further analysis between condom use and HIV

disclosure showed that majority of those who disclosed (63.3%) used a condom. This

was in line with a study by CDC (2009) where it was reported that disclosure of HIV

status to sexual partners has been known to promote safer sex through increased

condom use (Allen et al., 2003 cited in CDC, 2009) which may prevent the spread of
 77

HIV and AIDS. Interestingly, 35.0% of those who did not use a condom had disclosed

their HIV status to their sexual partner. A 25.3% who did not use a condom also did

not disclose their HIV status. The findings also showed that a large proportion of the

respondents (89.5%) who did not disclose their HIV status had no prior knowledge of

HIV status of the sexual partner while majority of those who disclosed (80.8%) knew

their sexual partner’s HIV status as positive.

Further probing showed that majority of the respondents refused to disclose for fear of

being rejected (98.8%), conflicts in the relationship (96.2%), loss of intimate

relationship (96.2%), wanting to infect others (73.0%) and fearing loss of job

(61.8%). This was supported by Supra et al., (2007) who found that fear of

consequences of disclosure of HIV to a sexual partner hampered communication

around sexual issues. Therefore, disclosing HIV-positive results to sexual partner(s),

could allow people to engage in preventive behaviour and motivate partners to seek

testing or change behaviour which could ultimately decrease transmission of HIV.

4.4.6 Number of Children Born after Testing HIV Positive and Their HIV-status

The importance of children ever borne after testing HIV positive cannot be

understated among PLWHA. In this regard, the number of children born after testing

HIV positive and their HIV status was investigated to provide information on their

reproductive practices. The findings as presented in Table 4.15 show that 40.2% of

the respondents had children after testing HIV positive. Out of those who had children

19.8% had two children while the remaining 80.2% had one child. These findings

contradicted a report by Boston Conference Report, (2010) which indicated that due
 78

to social and cultural attitudes, PLWHA upon learning their positive status, would no

longer want to bear children. When asked about the HIV status of the children born

after testing HIV positive, 43.8% indicated that their children were HIV negative

while 35.7% reported that their children were HIV positive. A large proportion of

those whose children were HIV negative (88.0%) reported that they followed the

recommendations for PMTCT closely while 12.0% claimed that it was just by “God’s

grace”.

Table 4.15: Distribution of children born after testing HIV-positive and children
HIV status

Had Children? Number of children HIV status of children

(n=239) born (n=96) born (n=115)
Did not Had One Two Negative Positiv Don’t
have e know
Freq 143 96 77 19 50 41 24
% 59.8 40.2 80.2 19.8 43.4 35.7 20.9

On the other hand, a proportion of those whose children were HIV positive (68.3%)

indicated that it was difficult for them to practise PMTCT while 24.4% reported that

they did not know how to prevent MTCT. A 7.3% did not have a reason.

Unfortunately, 20.9% did not know the HIV status of their children giving varied

reasons; such as they had not yet taken the child for testing (29.2%) since they had

given birth at home and also feared the outcome. This was attested by this common

reaction from the respondents:

Not having enough courage to pick the results for the fear of the outcome
especially if it turns out to be positive (Female FGDs).

This was followed by 20.8% who said that their children died before they picked the

HIV status results while 16.7% were expectant at the time of the study. Another

12.5%
 79

were waiting for the results though some held some fears and were stressed in case

the results would be positive as one remarked:

If my baby turns out to be positive, I will die of psychological stress but not
HIV and AID. Participant X1D.
A small proportion of 8.3% reported having had a miscarriage. For those who

reported that practising PMTCT was difficult, they cited that option of not

breastfeeding was stressful due to people’s inquisitiveness. Such female respondents

were liable to give a lie as one casual worker in a coffee plantation around Ruiru

attested to:

…if somebody asks me why I am not breastfeeding, I usually tell them that the
baby cannot breastfeed during the day because of the kind of job I am doing
so I prefer breastfeeding at night. Participant X2A.

On the contrary, for those who opted to breastfeed exclusively, the fear was that the

child might be fed in her absence so she had to carry the baby everywhere she went

for the six months which was so demanding for her.

4.4.7 Desire to Have More Children after Testing HIV Positive

Desire to have children after testing HIV positive can be a predisposing factor in HIV

transmission by PLWHA. This is because in order to conceive, unprotected sex

precedes which may put the sexual partner at risk of getting infected (for discordant

couples) or re-infection (concordant couples) and also infection of the baby through

mother-to-child transmission. The study investigated desire for more children among

PLWHA after testing HIV positive and also probed for reasons for the response given.

Results in Table 4.16 shows that, a large proportion (71.5%) of the respondents did

not desire to have more children with only 28.5% indicating they had a desire to have

more children. This concurred with Ayiga (2008) who had a similar observation from

a study in Uganda where 30% of PLWHA who participated in his study reported that
 80

they intended to have children with 70% on the contrary. This showed that being HIV

positive modified but did not remove reproductive desires and that diversity existed in

reproductive desires. Similarly, studies show that more PLWHA being in their

reproductive years continue to want children after learning their positive status;

whether to start a family or to have more children (Boston Conference Report, 2010).

Table 4.16: Desire to have more children

Desire Frequency Percentage

Desired 68 28.5
Did not desire 171 71.5
Total 239 100.0

Further probing showed that the respondents had varied reasons of either wanting or

not wanting to have more children as shown in Table 4.17 and Table 4.18.

Reasons for Desiring More Children

As shown in Table 4.17, the major reasons given for desiring more children were:

children were good and would care for them when they were sick and also in their old

age (39.5%). This could be explained by the fact that the respondents were found to

have a positive attitude towards reproductive behaviour. Also, due to ARV intake and

PMTCT programmes they could raise their children who would take care of them in

their old age. This was consistent with various studies which attributed that

availability of ART greatly improved the possibility of PLWHA to have children

through the PMTCT programmes as they believed that they would leave long to take

care of their children (Ayiga, 2008; CSIS, 2006). Strong desires to experience

parenthood and keep the family lineage was another reason given by 28.4%. This

could have emanated from social and cultural norms in African settings that

encourage childbearing. This finding was in consonance with many studies done
 81

worldwide which showed that PLWHA still desired to have children to fulfil their

sexual and reproductive rights (Boston Conference Report, 2010; CDC, 2009; Cooper

et al., 2009).

Thus, the results showed that the respondents would have desired to have children so

as to have heirs, give purpose to life and to regain their sense of womanhood and

sexuality so as to avoid stigma associated with childlessness. This is very critical in

the African settings where children are perceived as social security and continuation

of family lineage.

Table 4.17: Distribution showing reasons for desiring more children

Reasons Frequency Percentage

Help me in old age and when sick 32 39.5
Parenthood and keeping family lineage 23 28.4
One child is lonely 10 12.3
To inherit my property 8 9.9
Husband demands 4 4.9
Parents demands 2 2.5
Total 81 100
*multiple responses allowed

Other reasons given were that one child would feel lonely (12.3%) and if the only

child died, one would be left childless; to inherit one’s property (9.9%) which is

another paramount issue in African culture; husband’s demand (4.9%) and parents

demand for additional children (2.5%). Therefore, spousal, family, community,

cultural and social factors influenced the respondent’s desire for children.

Reasons for Not Desiring More Children

Table 4.18 showed that among those who did not desire more children, majority of

them (38.5%) felt that financial constraints restricted them to have more children

since more than half of them (52.6%) were earning less that Ksh.5000 which was not
 82

enough to cater for the family basic needs and their own medical expenses. This

finding concurred with a research in by Boston Conference Report 2010 which

reported that lack of adequate financial resources complicated their desire to have

more children. Another reason cited by 22.6% of the respondents indicated that they

did not want HIV-positive children as this would add their expenses yet their financial

situation was already precarious. They felt that it was difficult to practise PMTCT.

Table 4.18: Distribution showing reasons for not desiring more children

Reasons Frequency Percentage

Financial constraints 75 38.5
Don’t want HIV positive children 44 22.6
Single parenthood 27 13.8
Low immunity/my body is weak 25 12.8
Are enough 16 8.2
Due to old age 6 3.1
Step parents mistreat children 1 0.5
Spouse is HIV negative 1 0.5
Total 195 100
*multiple responses allowed

A 13.8% felt that being single parents deterred them from having more children.

These respondents felt that it would be strenuous caring for the children single

handedly as they claimed their sexual partners were not supporting them financially as

one female respondent attested:

I have a stable sexual partner and five children and one of them is HIV
positive. My partner does not help me financially; I am thinking of parting
ways. I want to stay alone because it’s just stressful. (Participant X1B)

Another 12.8% of the respondents felt that they had low immunity where additional

pregnancies could complicate their already weak bodies and poor health leading to

faster death. Other reasons given were: have enough children (8.2%), due to old age

(3.1%), step-parents mistreat children (0.5%) and spouse was HIV-negative (0.5%).
 83

These findings of reasons for not desiring children among PLWHA are supported by

Birungi, (2009) and Cooper et al., (2009) who purport that HIV-positive women once

pregnant, may be more vulnerable to poor health and ridicule from other people.

4.5 Barriers to Safe Sexual and Reproductive Practices

The challenges PLWHA face as they try to have safe sexual and reproductive

practices may have far reaching implications on their ability to take a HIV preventive

action. The study, therefore, sought to identify whether the respondents were facing

any barriers in their quest to having safe sexual and reproductive practices. The study

established that the respondents were experiencing various barriers to safe sexual and

reproductive practices as shown in Table 4.19. The findings are presented next. The

findings depicted that majority of the respondents indicated that partner’s refusal to

use a condom (40.3%) was a paramount barrier in their quest to having safe sexual

and reproductive practices.

Table 4.19: Barriers to safe sexual and reproductive practices

Barriers Frequency (n=238) Percentage

Partners refusal to use condoms 96 40.3
Alcohol intake 91 38.2
Stigma, isolation and discrimination 85 35.7
Lack of money 67 28.1
Condom being tiresome 56 23.5
Lack of female condoms 42 17.6
Ignorance of non-acceptance 36 15.1
People’s curiosity 12 5.0
Peer influence 7 2.9
Desire to have more children 6 2.5
Multiple partners 5 2.1
Lack of protective material e.g gloves 4 1.7

*Multiple responses allowed

This observation was found to apply across both categories of sexual partners, that is,
 84

regular and occasional sexual partners. This led to re-infections or new HIV

infections. This was more critical among the regular sexual partners where the

husband/male sexual partner felt that as long as they were a concordant couple, they

could have sex without a condom. This was attested by the following sentiments

which were very common during FGDs:

If both of us are infected, why use a condom (FGDs)

Sometimes men refuse to use condoms since both of us are HIV positive
(Female FGDs)
Mzee (husband) sometimes refuses to use a condom…. he says its boring,
tiring and inconveniencing…. sex is not enjoyable….. (Participant X1A).

These findings were consistent with a study done by CHGA (2004) which found that

PLWHA did not use condoms as there was perceived unwillingness of men to have

protected sex, putting women at risk of HIV infection or re-infection. Alcohol intake

was also reported as a major barrier to having safe sexual and reproductive practices

by a large proportion (38.2%). From further probing, it was established that those

sexual partners who took alcohol reported getting into risky sexual behaviour.

Consequently, they forgot to take medicine which with time lowered their body’s

immunity and weakened them as sometimes they did not eat well. This was evidenced

by some qualitative data:

….changa’a3 leads to having unprotected sex with strangers and makes one
to forget to take medicine worsening the condition. (Male participant FGDs).

These findings coincided with KDHS 2008/09 report that suggested the use of alcohol

or drugs is related to sexual behaviour that is high risk for HIV infection. The survey

reported that engaging in sex under the influence of alcohol can impair judgment,

compromise power relations, and increase risky sexual behaviour. However, other

3
changa’a is a cheap local brew that is intoxicating and taken by people who are low income earners
 85

respondents indicated that alcohol helped them to dissolve stress and also gave them

the zeal to have sex.

Stigma was also cited as a barrier to safe sexual and reproductive behaviour by

slightly more than a third of the respondents (35.7%). They asserted that HIV

disclosure was not easy and if a sexual partner insisted on not using a condom, so be

it. One female respondent from Thika Municipality (who reported that she was a

commercial sexual worker) said:

I usually tell them to use a condom but they refuse, so we just have sex…I
don’t disclose my status…(Participant X2C).

Another young female respondent (21 years) who was also a commercial sexual

worker operating in Nairobi but attending a support group in Ruiru (informed by her

close friend and also deduced from the interaction) accounted that:

…I don’t tell them (sexual partners) my condition….if they want to use a

condom or not, it is up to them… (Participant X1C.)

Lack of money was also another barrier to safe sexual and reproductive practices the

respondents encountered (28.1%). They reported that most of their finances were used

in medication and having quality food in order to manage the virus. As such they

found themselves compromising on having unsafe sex in exchange for more money

(transactional sex) which could put them into risks of unplanned pregnancies. This

was evidenced by a female respondent who said:

…there is more money in having sex without a condom….with a condom is

around Kshs. 100-200 and without is Kshs.1,000 and more if operating in
Nairobi…(Participant X1C).
 86

This was in line with Heard et. al., (2007) as cited Boston Conference report (2010)

who noted that lack of adequate financial resources complicated decision-making

about pregnancy for PLWHA. Use of a condom was also found to be tiresome and

reduced sexual satisfaction (23.5%). Some respondents did not use condoms through

mutual understanding with their sexual partners especially where both were positive).

Others who consistently used condoms with their regular partners reported having

sexual relations with occasional sexual partner where a condom was not used. This

was supported by qualitative data from one male respondent from Ruiru:

I sometimes go out there (engaging in extra- marital sex) to have sex without a
condom… at least to remind myself how it used to feel before I became HIV
positive…(Respondent Y2E).

The results were supported by Wamoyi et al., (2011) who reported that the challenges

for most of PLWHA were using condoms consistently and finding a suitable sexual

partner (preferably someone who is HIV positive) who could agree to have a sexual

relationship with them and provide for their material needs. This could hinder efforts

for prevention of HIV. Hence, if the man has multiple partners and does not use a

condom, his female partner is vulnerable, even if she is faithful.

The female respondents also experienced the challenge of lacking female condoms

(17.6%). They reported that femidoms (female condoms) were expensive and not

commonly available. This made them to compromise on safe sexual practices when

their sexual partners refused to use condoms. They emphasized that if femidoms were

easily available and accessible, they could be in a better position to negotiate for safe

sex as remarked by one female respondent from Thika municipality:

…problem comes in because our (female) condoms are not available and are
very expensive….so you can’t do anything… (Participant X1C).
 87

Similar findings were reported by CHGA 2004 which reported that there is general

unwillingness of men to have protected sex. This is worsened by female condom

being still too expensive and in too short supply to be widely available. Still it

requires a similar kind of negotiation as using the male condom, and may therefore,

not be the solution to gender power relations issues. Other barriers included

ignorance and non-acceptance where sexual partners did not believe that one was HIV

infected (15.1%) as the respondents appeared normal and looked healthy due to ARV

therapy. People’s curiosity about their life issues such as not breastfeeding if one had

an infant or why one had only one child was observed to be another barrier that

hindered safe sexual and reproductive practices (5.0%). Therefore for fear of others

knowing their HIV status, the respondents compromised in situations that jeopardized

their children, sexual partners or themselves of HIV infection or re-infection. This

was evidenced by these sentiments made by the respondents:

…I used to become irritated by people questioning me why I was not

breastfeeding so sometimes I could breastfeed … and finally he became HIV
infected… (Middle aged, married female respondent)

Why do you have only one child? This has stressed me so much that we are
not using a condom…but the doctor tells me my CD4 count is low. I am
confused… (Young, re-married female respondent)

This finding was consistent to an observation made by a study done in Uganda by

Nakawiya (2006) who found that many women who had tested HIV-positive

continued to breastfeed their infants for fear of being ostracized and isolated. This put

the children in danger of contracting HIV through MTCT. Others included peer

pressure (2.9%), desire to have more children (2.5%), multiple partners (2.1%) and

lack of protective material like gloves (1.7%), to use when giving first aid or helping

another woman to deliver at home.

 88

4.6 Decision-making on Sexual and Reproductive Behaviour

The study sought to explore the decision-making of the respondents’ sexual and

reproductive behaviour to determine the gender power relations which could have

some implications on the ability to take a HIV preventive action. The results were

disscussed next.

Table 4.20: Decision-making on sexual and reproductive behaviour

Decision issue Responses

Woman Man Jointly Others None
Freq. / % Freq. / % Freq. / % Freq. / Freq. /
% %
Whether to have sexual 37 141 45 0 0
intercourse (n=223) (16.6) (63.2) (20.2) (0.0%) (0.0%)
Whether to use condoms 7 163 41 0 0
(n=211) (3.3) (77.3) (19.4) (0.0%) (0.0%)
Which type of condom 19 65 117 0 0
to use (n=201) (9.5) (32.3) (58.2) (0.0%) (0.0%)
Whether to have a child 38 41 32 105 12
(n=228) (16.7%) (17.9%) (14.0%) (46.1%) (5.3%)
Use of other birth 197 8 9 2 0
control methods (91.2%) (3.7%) (4.2%) (0.9%) (0.0%)
(n=216)
Who to buy or obtain 42 73 88 0 2
condoms (n=205) (20.5%) (35.6%) (42.9%) (0.0%) (1.0%)

The results presented in Table 4.20 showed that nearly two thirds of the respondents

(63.2%) considered decisions with regard to when to have sexual intercourse as a

male issue as compared to 16.6% who attributed such decisions to females. Only

20.2% considered such decisions as meriting joint efforts between males and females

even though the actual act involved both parties. Slightly above three quarters

(77.3%) considered decision with regard to use of condom as a male issue. On the

contrary, 58.2% of the respondents considered decision with regard to type of condom

to use as an issue meriting joint decisions. In relation to use of condom, 19.4% of the

respondents identified such decisions as a joint venture with 3.3% attributing such
 89

roles to females. Decisions on the type of condom to use were associated with males

by 32.3% as compared to 9.5% for females. Therefore, the use of condom had tilted

the gender power relation towards males while still retaining some powers to joint

decisions leaving females with little say about condom use.

From the results, it was shown that pressures from the significant others (in-laws,

friends, workmates, health workers and support group members) had a greater

influence on the number of children the respondents had. The significant others had a

46.1% probability on influencing decisions on whether to have a child as compared to

17.9% probability of influence from the male, 16.7% from the females, 14.0% both

partners and 5.3% on dependence on supernatural power. These results were

supported by various studies for instance a study done in Kabale, Uganda showed that

community members advised their male and female relatives who were HIV positive

to refrain from having children in the event that they tested positive and would die

prematurely (Kakaire et al., 2010). Also in Birungi, (2009) decision to have a child

even among PLWHA was not only a personal choice but subjected to family and

community pressures as well as healthcare providers which weighed heavily on a

woman’s decision on intention to have a child.

Likewise, presentations in Boston Conference Report 2010 revealed that while some

women may make individual choices about pregnancy, many are likely to think about

pregnancy in the context of their relationship with a partner. However, men may lack

the necessary information to make informed decisions about fertility desires as

information about PMTCT is rarely targeted or made available to men (Boston

Conference Report 2010). Thus, reproductive decision-making among PLWHA

 90

appears to be significantly influenced by classical determinants that may not be

related to HIV status (Sowell et al., 2002). Conversely, decisions regarding birth

control methods except for condom use was considered to be a female’s affair

(91.2%). Only 3.7% identified the task as that of the male while 4.2% considered it as

a joint venture. Only 0.9% reported decision being made by significant others such as

friends. From the results, it was clear that the effort to incorporate men in decision-

making in regard to birth control methods was negligible.

Acquisition of condoms was perceived to be a joint (42.9%) or a male (35.6%) and

female (20.5%) affair. Surprisingly 1.0% of the respondents had a belief that the

acquisition of condom could still be controlled by invisible supernatural forces. These

results portrayed improved gender power relations with regard to decision-making on

condom acquisition. However, power imbalances in some sexual relationships may

prevent women from insisting on condom use which may inhibit a woman’s ability to

decide if and when to have children. This concurs with results of General Assembly

Report, (2008) which show that women who are HIV positive fear seeking

information on sex and buying or negotiating for condom for fear of being labelled

sexually active. The continued perception of the dominance of men with regard to

condom acquisition could have negative implications on the decision on condom use.

The results showed that on matters of sexuality, the gender power relations still

remained tilted in favour of males at the expense of females. This could be associated

with social and cultural norms which deter women from making decisions about their

sexual relations. These findings were consistent with Stuart, 2009a who cite that

power imbalances in some sexual relationships may prevent women from insisting on
 91

condom; even though they remain the only “dual function” contraceptive method to

prevent both pregnancy and HIV infection. The findings were also supported by

CHGA (2007) which report that whereas both partners should be able to negotiate on

condom use, in reality it is men that make these decisions. Hence women lack control

of their own bodies and sexuality.

4.7 Self-efficacy in HIV Prevention

The focus of the study was to assess predictors of self-efficacy in HIV prevention

among PLWHA. This is an important aspect in the quest for preventing HIV in the

case of ‘prevention with positives’. It was measured by six items which were basically

ways of preventing HIV transmission. The respondents were asked to assess

themselves concerning their ability to successfully and confidently adopt a healthy

HIV preventive action against the six items. Each item was measured on a five level

likert scale, namely: very low, low, moderate, high and very high for every

respondent as shown in Table 4.21.

Table 4.21: Self-efficacy in HIV prevention by PLWHA

Statements Responses
Very Low Moderate High Very
low high
Abstaining from sex for life 145 34 7 10 43
(n=239) 60.7% 14.2% 2.9% 4.2% 18.0%
Being faithful to your partner 48 34 19 55 82
(n=228) 20.2% 14.3% 8.0% 23.1% 34.5%
Ability to use a male condom 38 29 14 62 96
correctly and consistently 15.9% 12.1% 5.9% 25.9% 40.2%
(n=239)
Ability to use a female condom 103 63 39 18 16
correctly and consistently(n=239) 43.1% 26.4% 16.3% 7.5% 6.7%
Disclosing my HIV status to 144 56 14 13 11
every sexual partner I meet 60.5% 23.5% 5.9% 5.5% 4.6%
(n=238)
Reducing the number of sexual 27 31 37 44 100
partners I have(n=239) 11.3% 13.0% 15.5% 18.4% 41.8%
 92

The results show that two thirds of the respondents (66.1%) were able to use the male

condom correctly and consistently. This could have been attributed by the fact that

male condoms were easily accessible to the respondents as they were given free from

the CCC. This finding contradicted a study done in Togo by Moore et al., (2007) who

found that condom use is not an easy option for many PLWHA despite years of

condom distribution intervention. A proportion of 60.2% of the respondents, indicated

being able to reduce the number of sexual partners after testing HIV positive. This

result concurred with KAIS 2007 which show an increase in condom use and

reduction in number of sexual partners.

The results also showed that more than half of the respondents were able to remain

faithful to their sexual partners (57.6%) after testing HIV positive. This could have

been due to the information the respondents got from the support groups, CCC and

seminars they attended. This was supported by the key informant interviews with

Thika DASCO and organisation’s managers who indicated that the respondents were

educated on ways of preventing HIV transmission to other people and also how to

avoid re-infection. However, these findings contradicted various studies done in

Nairobi which showed that PLWHA engage in risky sexual behaviour with multiple

sexual partners even after learning their HIV positive status (Oyore, 2009; Otieno,

2008). These HIV preventive actions which the respondents were able to execute fully

could enhance pursuits of HIV prevention.

On the contrary, a great proportion of the respondents (84.0%) indicated that they

were not able to disclose their HIV status to every sexual partner they met. This could

have been as a result of the stigma, discrimination and rejection reported as being one

of the main effects of living with the virus. Surprisingly almost three quarters of the
 93

respondents indicated they were not able to abstain from sex for life (74.9%) putting

their sexual partners at risk of infection. This could be explained by the fact that sex

is a physiological need. This was supported by qualitative data from FGDs where

there were common sentiments and others from individual participants:

….sex is like food…you cannot do without it” (Male participant FGDs)

….we are usually taught in the seminars we attend that sex is like a therapy
which soothes the mind… (Both male and female FGDs)

…when I realised that I was HIV positive, I managed to stay for two years
without having sex….life was hard…but I decided life had to continue
normally…. (Middle aged male respondent)

More than two thirds (69.5%) reported that they were not able to use female condom

always. This could have been attributed to the fact that female condoms were not

easily available at the time of the study in the CCCs and were also expensive hence

majority of the women could not afford them. These HIV preventive actions which

the respondents were not able to execute fully could jeopardize pursuit of prevention

of HIV creating new HIV infections and also affecting their health.

The responses given on successfully and confidently carrying out a healthy HIV

preventive action were then scored as 1 for very low, 2 for low 3 for moderate, 4 for

high and 5 for very high. This was done on the basis that those who had a high ability

to adopt a HIV preventive action were given a high score of 5 and vice versa. The

minimum score expected was 6 while the maximum score was 30. From the raw

scores of self-efficacy in HIV prevention, a mean was computed which was 17. The

mean was used because it is more stable and uses every score in the data set unlike

median and mode which ignores most of the scores. Self-efficacy categories were

determined as low self efficacy (6-16) and high self-efficacy (17-30). A composite
 94

score was computed as shown in Figure 4.3. The outcome showed that slightly more

than half of the respondents (52.7%) had a high self-efficacy in HIV prevention while

47.3% had a low self efficacy in HIV prevention. This results demonstrated that more

than half of the respondents were able to adopt a HIV preventive action consistently

thus preventing the spread of HIV and AIDS. On the other hand, 47.3% were not able

to consistently adopt a HIV preventive action thus could be jeopardizing pursuits of

HIV prevention. Those two categories of self-efficacy were used for further analysis.

SELF-EFFICACY IN HIV PREVENTION

45%
55%

Figure 4.3: Self-efficacy in HIV prevention

4.8 Hypotheses Test Results

The study focused on assessing factors associated with self-efficacy in HIV

prevention by PLWHA; the case of ‘prevention with positives’. This section presents

the relationship between the respondent’s self-efficacy in HIV prevention and their

socio-demographic characteristics; their attitude towards sexual and reproductive

behaviour; sexual and reproductive practices; barriers to safe sexual and reproductive

practices and decision-making on sexual and reproductive issues.

 95

4.8.1 Relationship between Self-efficacy in HIV Prevention and Socio-

Demographic Characteristics of PLWHA

Hypothesis 1: There is no significant relationship between socio-demographic

characteristics of PLWHA and their self-efficacy in HIV prevention.

The selected socio-demographic characteristics comprised of gender, residence, age,

marital status, level of education, employment status, monthly income, religion,

number of children ever born and duration since testing HIV positive, The results of

these relationships are elaborated in the section that follow.

Gender and Self-efficacy in HIV Prevention

Gender is an important variable in HIV prevention in terms of condom negotiation

and child-bearing among others. The results of the relationship between gender and

self- efficacy in HIV prevention are presented in Table 4.22. It indicates that slightly

more than half of the female respondents (61.7%) had a high self-efficacy in HIV

prevention as compared to their male counterparts (37.8%). On the contrary, 62.2%

the male respondents had a low self efficacy in HIV prevention. The results of the

Chi-square test of relationships (χ2=12.930; df=1; p=0.000) showed that the observed

variations in taking a healthy HIV preventive action among the respondents was

significant at 0.05 probability of error. The contingency coefficient measure of

association (C=0.227) indicated that gender explained 22.7% of the total variations in

self-efficacy in HIV prevention. Therefore, observed variation for self-efficacy in

HIV prevention varied significantly by gender. Thus, the hypothesis that there is no
 96

significant relationship between social demographic characteristics of PLWHA by

gender and self-efficacy in HIV prevention is rejected.

Table 4.22: Relationship between gender and self efficacy in HIV prevention

Gender Low self-efficacy High self -efficacy Total

Male 56 34 90
(62.2%) (37.8%) (100.0%)
Female 57 92 149
(38.3%) (61.7) (100.0%)
Total 113 126 239
(47.3%) (52.7%) (100.0%)
2
C=0.227; χ =12.930; df=1; p=0.000

Residence and Self-efficacy in HIV Prevention

Urban and rural settings may have an influence on an individual’s ability to take a

healthy HIV preventive action. The findings in Table 4.23 show that a higher

proportion (60.2%) of respondents in the rural setting had a high self-efficacy in HIV

prevention as compared to those from peri-urban (48.8%) and urban areas (45.9%) in

that order. The results of the Chi-square test of relationships (χ2 = 3.846; df = 2; p =

0.146) showed that the observed variations in taking a healthy HIV preventive action

among the respondents was not significant at 0.05 probability of error. The

contingency coefficient measure of association (C=0.126) indicated that residence

explained 12.6% of the total variations in self-efficacy in HIV prevention. Therefore,

observed variation for self-efficacy in HIV prevention did not vary significantly by

residence. Thus, the hypothesis that there is no significant relationship between socio-

demographic characteristics of PLWHA by residence and self-efficacy in HIV

prevention is retained.
 97

Respondents from the rural settings were able to take a healthy HIV preventive action

successfully than those from peri-urban and urban settings. This phenomenon could

be attributed to the fact that more respondents living in the rural areas were found to

have a higher use of condom (66.3%) than their counterparts in the peri-urban

(65.8%) and urban areas (57.0%) respectively. This showed behaviour change after

testing HIV positive in the rural setting is greatly embraced as opposed to peri-urban

and urban settings.

Table 4.23: Relationship between residence and self-efficacy in HIV prevention

Residence Low self-efficacy High self-efficacy Total
Urban (Thika 33 28 61
municipality) (54.1%) (45.9%) (100.0%)
Peri-urban (Ruiru) 41 39 80
(51.3%) (48.8%) (100.0%)
Rural (Kamwangi) 39 59 98
(39.8%) (60.2%) (100.0%)
Total 113 126 239
(47.3%) 52.7% (100.0%)
2
C=0.126; χ = 3.846; df = 2; p = 0.146

Age and Self-efficacy in HIV Prevention

Age of an individual is an important factor that has far reaching inferences in the

ability to take a safe HIV prevention action by an individual. Table 4.24 show the

relationship between age and self-efficacy in HIV prevention. The findings indicate

that a large proportion (57.9%) of those aged 51 years and older had a high self-

efficacy in HIV prevention followed by those aged between 31-40 years (54.9%), 41-

50 (53.7%) and 30 years or younger (41.7%) in that order. Chi-square results (χ 2 =

2.192; df = 3; p=0.533) showed that the observed variations for self-efficacy in HIV

prevention was not significant at 0.05 probability of error. Further analysis using

contingency coefficient measure of association (C=0.095) indicated that age

accounted for 9.5% of the total variations in self-efficacy in HIV prevention.

 98

Therefore, observed variation for self-efficacy in HIV prevention did not vary

significantly by age. Thus, the hypothesis that there is no significant relationship

between socio-demographic characteristics of the respondents by age and self-

efficacy in HIV prevention was retained.

This pattern showed that the ability to adopt a HIV preventive action was high among

respondents aged 51 years and older while those who were younger (30 years or

younger) were not able to take a HIV preventive action. This could have been

attributed to by the fact that majority of the younger respondents were still in their

reproductive age hence desire for more children could still be eminent. Also, the

younger respondents could still have been sexually active and perhaps were not

economically stable hence engaging in transactional sex. For the older category (51

years and older), this group comprised of male respondents who could have been

resilient in living with the virus and thus able to adopt a HIV preventive action.

Table 4.24: Relationship between age and self-efficacy in HIV prevention

Age Low self-efficacy High self-efficacy Total

30 years or younger 21 15 36
(58.3%) (41.7%) (100.0%)
31-40 years 46 56 102
(45.1%) (54.9%) (100.0%)
41-50 years 38 44 82
(46.3%) (53.7%) (100.0%)
51 years or older 8 11 19
(42.1%) (57.9%) (100.0%)
Total 113 126 239
(47.3%) (52.7%) (100.0%)
C=0.095; χ2 = 2.192; df = 3; p = 0.533

Marital Status and Self-efficacy in HIV Prevention

Marital status of the respondents was also examined to assess its influence on self-

efficacy in HIV prevention. This relationship is presented in Table 4.25. The findings

reveal that a large proportion of the respondents who were widowed (73.5%) had a
 99

high self-efficacy in HIV prevention followed by married (54.1%), divorced/separated

(44.2%) and singles (27.6%) in that order. Conversely, almost three quarters of those

who were single (72.4%) had a low self-efficacy in HIV prevention followed by

divorced/separated (55.8%), married (45.9%) and widowed (26.5%) respectively. The

Chi-square results (χ2 = 17.403; df = 3; p = 0.001) showed that the observed variations

for self-efficacy in HIV prevention by marital status was significant at 0.05

probability of error. Further analysis using contingency coefficient measure of

association (C=0.261) indicated that marital status accounted for 26.1% of total

variations in self-efficacy in HIV prevention. Therefore, observed variation for self-

efficacy in HIV prevention varied significantly in marital status. Thus, the hypothesis

that there is no significant relationship between socio-demographic characteristics of

the respondents by marital status and self-efficacy in HIV prevention is rejected.

Table 4.25: Relationship between marital status and self-efficacy in HIV

prevention

Marital Status Low self-efficacy High self-efficacy Total

Married 50 59 109
(45.9%) (54.1%) (100.0%)
Single 21 8 29
(72.4%) (27.6%) (100.0%)
Widow/Widower 13 36 49
(26.5%) (73.5%) (100.0%)
Divorced/Separated 29 23 52
(55.8%) (44.2%) (100.0%)
Total 113 126 239
(47.3%) (52.7%) (100.0%)
C=0.261; χ2 = 17.403; df = 3; p = 0.001

These findings contradicted a survey by KDHS 2008/09 which had revealed that HIV

prevalence by marital status was highest among widowed respondents (44.4%). This

could have been attributed perhaps by the fact that the widowed respondents could
 100

have changed their attitude towards the epidemic and were more likely to embrace

behavioural change after losing a spouse to HIV and AIDS.

Monthly Income and Self-efficacy in HIV Prevention

Average monthly income may have a far reaching implication in an individual’s self-

efficacy in HIV prevention. This relationship is presented in Table 4.26. From the

findings it was construed that more than half of the respondents (63.9%) who earned

between Kshs. 5,001-10,000 had a high self-efficacy in HIV prevention followed by

those who earned below Kshs. 5,000 (46.8%) and those who earned over Kshs.

10,001 (44.2%) respectively. The Chi-square results (χ 2 = 6.303; df = 2; p = 0.043)

showed that the observed variations for self-efficacy in HIV prevention by average

monthly income was significant at 0.05 probability of error.

Table 4.26: Relationship between monthly income and self-efficacy in HIV

prevention

Income levels Low self-efficacy High self-efficacy Total

Below 5,000 59 52 111
(53.2%) (46.8%) (100.0%)
5,001-10,000 26 46 72
(36.1%) (63.9%) (100.0%)
Over 10001 24 19 43
(55.8%) (44.2%) (100.0%)
Total 109 117 226
(48.2%) (51.8%) (100.0%)
C= 0.165; χ2 = 6.303; df = 2; p = 0.043

Further analysis using contingency coefficient measure of association (C= 0.165)

indicated that average monthly income accounted for 16.5% of the total variations for

self-efficacy in HIV prevention. Thus, observed variation for self-efficacy in HIV

prevention varied significantly by average monthly income. Thus, the hypothesis that
 101

there is no significant relationship between background characteristics of PLWHA by

monthly income and self-efficacy in HIV prevention is rejected.

Employment Status and Self-efficacy in HIV Prevention

The results presented in Table 4.27 show the relationship between employment status

and self-efficacy in HIV prevention. The findings indicate that a large proportion

(59.1%) of those respondents who were in business or were self employed had a high

self-efficacy in HIV prevention followed by those who were unemployed (53.8%),

casual workers (53.0%), and permanent employed (23.8%) in that order. Conversely,

three quarters of those who were permanently employed (76.2%) had a low self-

efficacy in HIV prevention followed by casual workers (47.0%) unemployed (46.2%),

and those in business or self-employed (40.9%). The Chi-square results (χ 2 = 8.455; df

= 3; p = 0.037) showed that the observed variations for self-efficacy in HIV

prevention by employment status was significant at 0.05 probability of error. Further

analysis using contingency coefficient measure of association (0.185) indicated that

employment status accounted for 18.5% of the total variations for self-efficacy in HIV

prevention. This revealed that observed variation for self-efficacy in HIV prevention

varied significantly by employment status. Thus, the hypothesis that there is no

significant relationship between socio-demographic characteristics of PLWHA by

employment status and self-efficacy in HIV prevention is rejected.

Table 4.27: Relationship between employment status and self-efficacy in HIV

prevention

Employment status Low self-efficacy High self-efficacy Total

Permanent 16 5 21
(76.2%) (23.8%) (100.0%)
Casual worker 55 62 117
 102

(47.0%) (53.0%) (100.0%)

Business/Self 36 52 88
(40.9%) (59.1%) (100.0%)
Unemployed 6 7 13
(46.2%) (53.8%) (100.0%)
Total 113 126 239
(47.3%) (52.7%) (100.0%)
C=0.185; χ2 = 8.455; df = 3; p = 0.037

Religion and Self-efficacy in HIV Prevention

Religion is an important factor that shapes human perceptions, desires, behaviour and

practices which is not an exemption among PLWHA. The results presented in Table

4.28 show that a larger proportion (53.8%) of those who reported being Protestants

had a high self-efficacy in HIV prevention as compared to those who were Catholics

(53.0%) and those who indicated no allegiance to any religion (46.4%) in that order.

On the other hand, a large proportion of those who indicated had no allegiance to any

religion (53.6%) had a low self-efficacy in HIV prevention followed by those who

were Catholics (47.0%) and Protestants (46.2%) in that order.

Table 4.28: Relationship between religion and self-efficacy in HIV prevention

Religion Low self-efficacy High self-efficacy Total

Catholic 47 53 100
(47.0%) (53.0%) (100.0%)
Protestant 49 57 106
(46.2%) (53.8%) (100.0%)
No Religion 15 13 28
(53.6%) (46.4%) (100.0%)
Total 111 123 234
(47.4%) (52.6%) (100.0%)
C= 0.046; χ2 = 0.493; df = 2; p = 0.782

The results of Chi-square test of relationship (χ 2 = 0.493; df = 2; p = 0.782) indicated

that the observed variation for self-efficacy in HIV prevention by religion was not

significant at 0.05 % probability of error. Further analysis using contingency

coefficient measure of association (0.046) revealed that religion attributed to 4.6% in

 103

self-efficacy in HIV prevention. The results implied that religion did not play a major

role in self efficacy in HIV prevention among the respondents. Hence, the hypothesis

that there is no significant relationship between socio-demographic characteristic of

PLWHA by religion and self-efficacy in HIV prevention was retained. The results

revealed that the Catholics were embracing use of a HIV preventive action. This

contrasted findings by KDHS 2008/09, where the Catholics were found not to have

embraced the use of condom.

Duration since testing HIV Positive and Self-efficacy in HIV Prevention

The results presented in Table 4.29 show the relationship between duration since

testing HIV positive and self-efficacy in HIV prevention. The findings show that a

large proportion (61.7%) of those who tested HIV positive 4-5 years prior to the time

of the study had a high self-efficacy in HIV prevention followed by 6 years and over

(52.9%), 2 to 3 years (49.2%) and 1 month to 1 year (47.9%) in that order. The Chi-

square results (χ2 = 2.651; df = 3; p = 0.448) showed that the observed variations in

self-efficacy in HIV prevention by duration since testing HIV positive was not

significant at 0.05 probability of error.

Table 4.29: Relationship between duration since testing HIV positive and self-

efficacy in HIV prevention

Duration since testing Low self-efficacy High-self efficacy Total

HIV positive
1 month-1 year 25 23 48
(52.1%) (47.9%) (100.0%)
2-3 years 30 29 59
(50.8%) (49.2%) (100.0%)
4-5 years 23 37 60
(38.3%) (61.7%) (100.0%)
6 years and over 33 37 70
(47.1%) (52.9%) (100.0%)
Total 111 126 237
 104

(46.8%) (53.2%) (100.0%)

C=0.105; χ2 = 2.651; df = 3; p = 0.448

Further analysis using contingency coefficient measure of association (C=0.105)

indicated that duration since testing HIV positive accounted for 10.5% of the total

variations for self-efficacy in HIV prevention. Therefore, observed variation in self-

efficacy in HIV prevention did not vary significantly by duration after testing HIV

positive. Thus, the hypothesis that there is no significant relationship between socio-

demographic characteristics of PLWHA by duration after testing HIV positive and

self-efficacy in HIV prevention was retained. This showed that the respondents who

had lived with HIV for a longer duration (more than 4 years and over) had a higher

ability of taking a HIV preventive action as compared to those who had lived with

HIV within a shorter duration (3 years or less). This could be explained by the fact

that those with longer durations after testing HIV positive were able to overcome

many barriers such as stigma or people’s curiosity. Hence they had become resilient

in living with the virus and so were able to take a HIV preventive action.

The socio-demographic characteristics of the respondents that were established to

have a significant relationship with self-efficacy in HIV prevention were further

analyzed using binary logistic regression to determine if they predicted self-efficacy

in HIV prevention.

Regression model fit

A regression model relates Y to a function of X and β.

Y i =βo+ X1, + X2+ X3+ X4.......................................................................Ԑi

 105

Where, Y i is the dependent variable (self-efficacy in HIV prevention)

βo is the point of interception

X1 – X4 are the independent variables that have a significant relationship with

self-efficacy in HIV prevention.

Ԑi is the error of the difference between scores

Therefore, X1 is gender, X2 is marital status, X3 is monthly income and X4 is

employment status

Table 4.30: PLWHA socio-demographic predictors of self-efficacy in HIV

prevention

Background characteristics AOR Sig. 95% of Confidence

Interval
Gender 3.186 0.001* 1.766-7.113
Marital status 1.033 0.000* 1.290-1.395
Monthly income 1.137 0.029* 1.430-2.739
Employment status 1.217 0.131 1.061-9.875
*significant predictors at p≤ .05

The results in Table 4.30 indicate that gender, marital status and average monthly

income were positive predictors of self-efficacy in HIV prevention with Adjusted Odd

Ratio (AOR) more than one (AOR≥1.000). Among these predictors gender was found

to be a strong predictor with AOR of 3.186 unlike monthly income (AOR=1.137) and

marital status (AOR=1.137). With regard to gender, female respondents had a high

self-efficacy in HIV prevention and were three times (AOR=3.186) able to take a HIV

preventive action as compared to male respondents. As for the marital status, the

widowed respondents were found to have a high self-efficacy and were one time able

to take a HIV preventive action as opposed to all other marital categories. These

findings could be attributed perhaps by the fact that the majority of the widowed

respondents were abstaining at the time of the study. They also had an overall positive
 106

attitude towards the epidemic and perhaps were more likely to embrace behaviour

change after losing a spouse to HIV and AIDS. This contradicted finding by KDHS

2008/09 which reported that HIV preference by marital status was highest among

widowed respondents (44.4%) for the general populace. As for monthly incomes, it

was shown that those respondents who had middle monthly incomes (Kshs.5,001-

10,000) had a high self-efficacy.

4.8.2 Relationship between PLWHA Attitude towards HIV and Sexual and

Reproductive Behaviour and Self-efficacy in HIV Prevention

Hypothesis 2: There is no significant relationship between attitude towards HIV and

sexual and reproductive behaviour of PLWHA and self-efficacy in HIV prevention.

Attitude towards HIV Epidemic

There was no significant relationship between PLWHA attitude towards HIV

epidemic and self-efficacy in HIV prevention. The results of the relationship were

presented in Table 4.31. The findings show that a large proportion of those who had a

negative attitude towards HIV epidemic (52.9%) had a high self-efficacy in HIV

prevention while majority of those who had a positive attitude (47.5%) had a low self-

efficacy. Chi-square test of relationships (χ2 = 0.004; df = 1; p = 0.948) showed that

there was no significant relationship between attitude towards HIV epidemic by the

respondents and self-efficacy in HIV prevention at 0.05 probability error. The

contingency coefficient measure of association (C=0.004) indicated that attitude

towards HIV epidemic by PLWHA explained 0.4% of the total variations in self-

efficacy in HIV prevention.

 107

Table 4.31: Relationship between attitude towards HIV epidemic by PLWHA

and self-efficacy in HIV prevention

Attitude Low self-efficacy High self-efficacy Total

Negative attitude 65 73 138
(47.1%) (52.9%) (100.0%)
Positive attitude 48 53 101
(47.5%) (52.5%) (100.0%)
Total 113 126 239
(47.3%) (52.7%) (100.0%)
C=0.004; χ2 = 0.004; df = 1; p = 0.948
These results showed that those respondents who had a negative attitude of the

disease were able to take a healthy HIV preventive action as compared to those who

had a positive attitude. Thus, the hypothesis that there was no significant relationship

between attitude towards HIV epidemic by PLWHA and self-efficacy in HIV

prevention was retained.

Attitude towards HIV-negative People

There was no significant relationship between PLWHA attitude towards HIV negative

people and self-efficacy in HIV prevention. The results of the relationship are

presented in Table 4.32. The findings indicate that a large proportion (60.7%) of those

who had a positive attitude towards HIV-negative people had a high self-efficacy in

HIV prevention. On the other hand, 60.2% those who had a negative attitude towards

HIV-negative people had a low self-efficacy in HIV prevention.

Table 4.32: Relationship between PLWHA attitude towards HIV-negative people

and self-efficacy in HIV prevention

Attitude Low self-efficacy High self-efficacy Total

Negative Attitude 53 35 88
(60.2%) (39.8%) (100.0%)
Positive Attitude 59 91 150
(39.3%) (60.7%) (100.0%)
Total 112 126 238
(47.1%) (52.9%) (100.0%)
 108

C= 0.198; χ2 = 9.719; df = 1; p = 0.002

Chi-square test of relationships (χ2 = 9.719; df = 1; p = 0.002) showed that there was a

significant relationship between PLWHA attitude towards HIV-negative people and

self-efficacy in HIV prevention at 0.05 probability error. The contingency coefficient

measure of association (C=0.198) indicated that PLWHA attitude towards HIV-

negative people explained 19.8% of the total variations in self-efficacy in HIV

prevention. This showed that PLWHA attitude towards HIV-negative people had an

influence on their self-efficacy in HIV prevention. Hence this positive attitude by the

respondents towards HIV-negative people could have made the respondents to be

resilient about living with the virus. This could have enhanced their ability to take a

healthy HIV preventive action as compared to those who harboured a negative

perception about HIV-negative people. Thus the hypothesis that there was no

significant relationship between perceptions of PLWHA about HIV-negative people

and self-efficacy in HIV prevention is rejected.

Attitude towards Sexual Behaviour

There was no significant relationship between attitude towards sexual behaviour by

PLWHA and self-efficacy in HIV prevention. The results of the relationship are

presented in Table 4.33.

Table 4.33: Relationship between attitude towards sexual behaviour of PLWHA

and self-efficacy in HIV prevention

Attitude Low self-efficacy High-self efficacy Total

Negative attitude 19 13 32
(59.4%) (40.6%) (100.0%)
Positive attitude 94 113 207
(45.4%) (54.6%) (100.0%)
Total 113 126 239
 109

(47.3%) (52.7%) (100.0%)

C=0.095; χ2 = 2.168; df = 1; p = 0.141

The findings show that a more than half the respondents who had a positive attitude

towards sexual behaviour (54.6%) had a high self-efficacy in HIV prevention while

59.4% of those who had a negative attitude had a low self-efficacy in HIV prevention.

The Chi-square test of relationships (χ2 = 2.168; df = 1; p = 0.141) showed that there

was no significant relationship between attitude towards sexual behaviour by PLWHA

and self-efficacy in HIV prevention at 0.05 probability error. The contingency

coefficient measure of association (C=0.095) indicated that attitude towards sexual

behaviour explained 9.5% of the total variations in self-efficacy in HIV prevention.

Therefore, attitude towards sexual behaviour of PLWHA had no influence on their

self-efficacy in HIV prevention. However from the findings, it could be deduced that

those who had a positive attitude towards sexual behaviour were able to take a safe

HIV preventive action. The hypothesis that there was no significant relationship

between attitude towards sexual behaviour by PLWHA and self-efficacy in HIV

prevention is retained.

Attitude towards Reproductive Behaviour

There was no significant relationship between attitude towards reproductive

behaviour by PLWHA and self-efficacy in HIV prevention. The results of the

relationship are presented in Table 4.34. The findings show that a large proportion

(57.2%) of those who had a positive attitude towards reproductive behaviour had a

high self-efficacy in HIV prevention while 56.3% of those who had a negative attitude

towards reproductive behaviour had a low self-efficacy in HIV prevention.

 110

Table 4.34: Relationship between attitude towards reproductive behaviour of

PLWHA and self-efficacy in HIV prevention

Attitude Low self-efficacy High self-efficacy Total

Negative attitude 45 35 80
(56.3%) (43.8%) (100.0%)
Positive attitude 68 91 159
(42.8%) (57.2%) (100.0%)
Total 113 126 239
(47.3%) (52.7%) (100.0%)
C=0.126; χ2 = 3.881; df = 1; p = 0.049

Chi-square test of relationships (χ2 = 3.881; df = 1; p = 0.049) showed that there was a

significant relationship between attitude towards reproductive behaviour by PLWHA

and self-efficacy in HIV prevention at 0.05 probability error. The contingency

coefficient measure of association (C=0.126) indicated that attitude towards

reproductive behaviour explained 12.6% of the total variations in self-efficacy in HIV

prevention. Thus, the hypothesis that there was no significant relationship between

attitude towards reproductive behaviour by PLWHA and self-efficacy in HIV

prevention is rejected.

Attitude aspects by PLWHA that registered a significant relationship with self-

efficacy in HIV prevention were further analyzed using binary logistic regression to

establish whether they predicted self-efficacy in HIV prevention. The results are

presented in Table 4.35.

Regression model fit

Y i =βo+ X1, + X2............................................................................ Ԑi

Where, Y i is the dependent variable (self-efficacy in HIV prevention)

βo is the point of interception

X1 – X2 are the independent variables of attitude aspect of PLWHA that

 111

had a significant relationship with self-efficacy in HIV prevention.

Ԑi is the error of the difference between scores

Therefore, X1 is attitude towards HIV negative people and X2 is the attitude towards

reproductive behaviour.

From the results in Table 4.35, it was ascertained that the both attitude factors were

positive predictors of self-efficacy in HIV prevention with Adjusted Odd Ratio more

than one (AOR≥1.000). Attitude towards reproductive behavior was a strong predictor

with AOR of 2.336 as compared to attitude towards HIV negative people

(AOR=1.747). Those who had a positive attitude towards reproductive behavior had a

high self-efficacy in HIV prevention and were twice as much able to adopt a healthy

HIV preventive action as compared to those who had a positive attitude towards HIV-

negative people.

Table 4.35: Attitude predictors of self-efficacy in HIV prevention

Attitude factors AOR Sig. 95% of Confidence

Interval
Attitude towards HIV 1.747 0.049* 1.004-3.040
negative people
Attitude towards 2.336 0.002* 1.358-4.020
reproductive behaviour
*significant predictors at p≤ .05

4.8.3 Relationship between Sexual and Reproductive Practices of PLWHA and

Self-efficacy in HIV Prevention

Hypothesis 3: There is no significant relationship between sexual and reproductive

practices of PLWHA and self-efficacy in HIV prevention.

These practices comprised number of sexual partners a respondent had in the last 12

months prior to the study, types of sexual partners in the last six months prior to the
 112

study, knowledge of HIV status of sexual partner, HIV disclosure to sexual partner,

children born after testing HIV positive and desire to have children after testing HIV

positive. The results of the relationships are discussed next.

Number of Sexual Partners and Self-efficacy in HIV Prevention

This relationship was analyzed as shown in Table 4.36. The results show that a large

proportion of the respondents (76.9%) who had one sexual partner for the last 12

months, had a high self-efficacy in HIV prevention as opposed to those who had no

sexual partner (73.7%) and those who had many (25.9%). Conversely, almost three

quarters of those who had multiple partners (74.1%) had a low self-efficacy.

Table 4.36: Relationship between number of sexual partners and self-efficacy in

HIV prevention

Number of sexual Low self- High self-efficacy Total

partners efficacy
One 25 83 108
(23.1%) (76.9%) (100.0%)
Many 83 29 112
(74.1%) (25.9%) (100.0%)
None 5 14 19
(26.3%) (73.7%) (100.0%)
Total 131 95 226
(58.0%) (42.0%) (100.0%)
C=0.451; χ2 = 60.920; df = 2; p = 0.000

The results of Chi-square test of relationships (χ2 = 60.920; df = 2; p = 0.000) showed

that there was a significant relationship between number of sexual partners and self-

efficacy in HIV prevention at 0.05 probability error. The contingency coefficient

measure of association (C=0.451) indicated that number of sexual partners explained

45.1% of the total variations in self-efficacy in HIV prevention.

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Type of Sexual Relationship and Self-efficacy in HIV Prevention

The result of the relationship is shown in Table 4.37. From the results, two thirds of

the respondents (66.4%) who had regular sexual relationship in the last three months

prior to the study had a high self efficacy in HIV prevention as opposed to those who

had occasional sexual relationship (23.5%). Conversely, slightly more than three

quarters of the respondents (76.5%) who had occasional sexual relationship in the last

three months prior to the study had a low self-efficacy in HIV prevention as compared

to those who had regular sexual relationship (33.6%).

Table 4.37: Relationship between type of sexual relationship and self-efficacy in

HIV prevention

Type of sexual relationship Low self- High self- Total

efficacy efficacy
Regular sexual relationship 46 91 137
(33.6%) (66.4%) (100.0%)
Occasional sexual relationship 65 20 85
(76.5%) (23.5%) (100.0%)
Total 111 111 222
(50.0%) (50.0%) (100.0%)
C=0.385; χ2 = 38.605; df = 1; p = 0.000

The results of Chi-square test of relationships (χ2 = 38.605; df = 1; p = 0.000) showed

that there was a significant relationship between type of sexual relationship and self-

efficacy in HIV prevention at 0.05 probability error. The contingency coefficient

measure of association (C=0.385) indicated that type of sexual relationship explained

38.5% of the total variations in self-efficacy in HIV prevention. Thus, the hypothesis

that there is no significant relationship between sexual practices in regard to type of

sexual relationship and self-efficacy in HIV prevention is rejected.

The respondents who had regular sexual relationship were able to use a healthy HIV

preventive action as compared to those who had occasional sexual relationship. This
 114

could be explained by the fact that almost two thirds (62.9%) of the respondents were

found to consistently use a condom were in regular sexual relationship as opposed

those who were in occasional sexual relationship. Sex with a condom was reported to

be dissatisfying, therefore, the respondents engaged in unprotected sex outside their

regular unions. This concurred with studies carried out in Nairobi which indicated that

PLWHA continued to be sexually active and indulged in risky sexual behaviour with

a casual or commercial sex worker (Oyore, 2009 & Otieno 2008).

Awareness of Sexual Partner’s HIV status in the Last Sexual Encounter

This relationship was analyzed as shown in Table 4.38. The results indicate that, a

larger proportion of the respondents (57.6%) of those who were aware of their sexual

partner’s HIV status had a high self-efficacy in HIV prevention as compared to those

partner’s who were not aware (42.7%). On the contrary, 57.3% of those respondents

who were not aware of the HIV status of their sexual partners had a low self-efficacy

in HIV prevention as opposed to those who were aware (42.4%). The results of Chi-

square test of relationships (χ2 4.751; df = 1; p = 0.029) showed that there was

significant relationship between awareness of sexual partners HIV status and self-

efficacy in HIV prevention at 0.05 probability error. The contingency coefficient

measure of association (C=0.141) indicated that awareness of HIV status of sexual

partner explained 14.1% of the total variations in self-efficacy in HIV prevention.

Thus, the hypothesis that there is no significant relationship between sexual practices

with regard to awareness of sexual partner’s HIV status and self-efficacy in HIV

prevention is rejected.

Table 4.38: Relationship between awareness of sexual partner’s HIV-status in

the last sexual encounter and self-efficacy in HIV prevention
 115

Awareness Low-self efficacy High-self efficacy Total

Aware 64 87 151
(42.4%) (57.6%) (100.0%)
Not aware 47 35 82
(57.3%) (42.7%) (100.0%)
Total 111 122 233
(47.6%) (52.4%) (100.0%)
C=0.141; χ2 4.751; df = 1; p = 0.029

However, the respondents who were aware of their sexual partner’s HIV status were

able to use a HIV preventive action as compared to those who were not aware. Hence,

awareness of HIV status of a sexual partner influenced the ability of taking a safe HIV

preventive action. This awareness of a sexual partner being HIV infected could have

helped individuals make well-informed decisions regarding their sexual behaviour.

HIV Disclosure in the Last Sexual Encounter and Self-efficacy in HIV Prevention

This relationship was analyzed as shown in Table 4.39.

Table 4.39: HIV self-disclosure in the last sexual encounter and self-efficacy in
HIV prevention
HIV disclosure Low self-efficacy High self-efficacy Total
Disclosed 64 93 157
(40.8%) (59.2%) (100.0%)
Did not disclose 47 29 76
(61.8%) (38.8%) (100.0%)
Total 111 122 233
(47.6%) (52.4%) (100.0%)
C= 0.194; χ2 = 9.121; df = 1; p = 0.003

The results indicate that a large proportion of the respondents (59.2%) who disclosed

their HIV status in their last sexual intercourse had a high self-efficacy in HIV

prevention as compared to those who did not disclose (38.8%). On the other hand,

61.8% of those who did not disclose their HIV status had a low self-efficacy in HIV
 116

prevention as opposed to those who disclosed their HIV status (40.8%). The results of

Chi-square test of relationships (χ2 = 9.121; df = 1; p = 0.003) showed that there was a

significant relationship between HIV disclosure and self-efficacy in HIV prevention at

0.05 probability error. The contingency coefficient measure of association (C=0.194)

indicated that HIV self- disclosure explained 19.4% of the total variations in self-

efficacy in HIV prevention. Thus, the hypothesis that there is no significant

relationship between sexual practices in regard to HIV disclosure and self-efficacy in

HIV prevention is rejected.

The respondents who disclosed their HIV status were able to use a HIV preventive

action as compared to those who did not disclose. Hence, HIV disclosure influenced

their ability to take a safe HIV preventive action. This meant that raising or discussing

the issue of HIV and AIDS during sexual encounters enhanced the ability of using

HIV preventive actions. As shown from the study, some respondents reported that the

issue of HIV and AIDS did not feature in their sexual encounters. However, self-

disclosure of HIV status to sexual partner(s), has been shown to prevent risky sexual

behaviour as it helps people to engage in preventive behaviour and motivate partners

to seek testing or change behaviour which ultimately decreases transmission of HIV.

This was in line with Marks et al. (2001), who in their study on self-disclosure and

sexual practices by men living with HIV in Los Angeles revealed that 40% of them

withheld disclosure to their sexual partners and engaged in safe sex, 35% did not

disclose and engaged in safe sex, 12% disclosed and engaged in unsafe sex while 13%

did not disclose and engaged in unsafe sex. Likewise, disclosure of HIV status to

sexual partners has been known to promote safer sex through increased condom use

(Allen, 2003) which might prevent spread of HIV and AIDS.

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Number of Children born After Testing HIV Positive and Self-efficacy in HIV

Prevention

This relationship was analyzed as shown in Table 4.40. From the results, it was shown

that three quarters of the respondents who had two children (75.0%) had a high self-

efficacy in HIV prevention followed by those who had one child (57.9%) and those

who had no child after testing HIV positive (46.9%) in that order. Conversely, slightly

more than a half of those who had no child after testing HIV positive (53.1%) had a

low self-efficacy in HIV prevention followed by those who had one child (42.1%) and

those who had two children (25.0%) respectively.

Table 4.40: Relationship between number of children after testing HIV positive
and self-efficacy in HIV prevention

Number of children Low self-efficacy High self-efficacy Total

No child 76 67 143
(53.1%) (46.9%) (100.0%)
One child 32 44 76
(42.1%) (57.9%) (100.0%)
Two children 5 15 20
(25.0%) (75.0%) (100.0%)
Total 113 126 239
(47.3%) (52.7%) (100.0%)
C=0.166; χ2 = 6.774; df = 2; p = 0.034

The results of Chi-square test (χ2 = 6.774; df = 2; p = 0.034) showed that there was a

significant relationship between number of children born after testing HIV positive

and self-efficacy in HIV prevention at 0.05 probability error. Further analysis using

contingency coefficient measure of association (C=0.166) indicated that number of

children born after testing HIV positive accounted for 16.6% of the total variations for

self-efficacy in HIV prevention. Thus, the hypothesis that there is no significant

 118

relationship between reproductive practices by number of children born after testing

HIV positive and self-efficacy in HIV prevention is rejected.

Desire to Have More Children and Self-efficacy in HIV Prevention

This relationship was analyzed as shown in Table 4.41. From the results, more than

half of those respondents who desired to have children (57.4%) had a high self

efficacy in HIV prevention while 49.1% of those who did not desire to have children

had a low self-efficacy in HIV prevention. The results of Chi-square test (χ2 = 0.819;

df = 1; p = 0.366) showed that there was no significant relationship between desire to

have more children and self-efficacy in HIV prevention.

Table 4.41: Relationship between desire to have more children and self-efficacy
in HIV prevention

Desire Low self-efficacy High self-efficacy Total

Desired 29 39 68
(42.6%) (57.4%) (100.0%)
Did not desire 84 87 171
(49.1%) (50.9%) (100.0%)
Total 113 126 239
(47.3%) (52.7%) (100.0%)
C= 0.058; χ2 = 0.819; df = 1; p = 0.366

The contingency coefficient measure of association (C=0.058) indicated that desire to

have more children explained 5.8% of the total variations in self-efficacy in HIV

prevention. Thus, the hypothesis that there is no significant relationship between

reproductive practices by desire to have children and self-efficacy in HIV prevention

is retained.

Sexual and reproductive practices that were observed to have a significant

relationship with self-efficacy in HIV prevention were further analyzed using binary
 119

logistic regression to establish whether they predicted self-efficacy in HIV prevention.

The results are presented next.

Regression model fit

Y i =βo+ X1, + X2+ X3+ X4 + X5....................................................................... Ԑi

Where, Y i is the dependent variable (self-efficacy in HIV prevention)

βo is the point of interception

X1 – X5 are the independent variables of sexual and reproductive practices that

had a significant relationship with self-efficacy in HIV prevention.

Ԑi is the error of the difference between scores

Therefore, X1 is number of sexual partners, X2 is type of sexual relationship, X3 is

awareness of sexual partner’s HIV status, X4 is HIV self-disclosure and X5 is number

of children born after testing HIV positive.

Table 4.42: Sexual and reproductive practices of PLWHA predictors of self-

efficacy in HIV prevention

Sexual and reproductive AOR Sig. 95% of Confidence

practices Interval
Number of sexual partners 0.220 0.000* 0.105-0.460
Type of sexual relationship 0.395 0.030* 0.171-0.915
Awareness of sexual partner’s 1.743 0.305 0.603-5.040
HIV status
HIV self-disclosure 1.715 0.338 0.569-5.167
Number of children born after 8.503 0.003* 1.279-13.582
testing HIV positive
*significant predictors at p≤ .05

The results presented in Table 4.42 indicate that having two children after testing HIV

positive was a strong positive predictor of high self-efficacy in HIV prevention with

Adjusted Odd Ratio of 8.503 which was more than one (AOR≥1.000). On the

contrary, having multiple sexual partners (AOR=0.220) with occasional sexual

 120

relationships (AOR=0.395) were negative predictors of self-efficacy in HIV

prevention with Adjusted Odd Ratio less than one (AOR≤1.000). These factors

predicted low self-efficacy in HIV prevention.

With regard to number of children born after testing HIV positive, it was found that

respondents who had two children had a high self-efficacy in HIV prevention and

were eight times (AOR =8.503) able to adopt a HIV preventive action as compared to

those who had one or no child at all. Respondents with multiple sexual partners who

had occasional sexual relationship were not able to adopt a safe HIV preventive action

as opposed to those who had one sexual partner in a regular sexual relationship.

4.8.4 Relationship between Barriers to Safe Sexual and Reproduction Practices

and Self-efficacy in HIV Prevention

Hypothesis 4: There is no significant relationship between barriers to safe sexual and

reproductive practices and self-efficacy in HIV prevention.

Relationship between specific barriers to safe sexual and reproductive behaviour and

self-efficacy are discussed next.

Partner’s Condom Refusal and Self-efficacy in HIV Prevention

Condom use is one of the ways of preventing HIV transmission. Use or non-use of it

has far reaching implications on management of HIV and AIDS. This relationship is

analyzed as shown in Table 4.43. The findings reveal that, a large proportion of the

respondents who did not face the barrier of partner’s refusal and disapproval of

condoms (58.2%) had a high self-efficacy in HIV prevention unlike their counterparts

who faced that barrier (43.3%).

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Table 4.43: Relationship between partner’s condom refusal and self-efficacy in

HIV prevention

Barrier Low self-efficacy High self-efficacy Total

Facing partners condom 55 42 97
refusal and disapproval (56.7%) (43.3%) (100.0%)
Not facing partners condom 51 71 122
refusal and disapproval (41.8%) (58.2%) (100.0%)
Total 106 113 219
(48.4%) (51.6%) (100.0%)
C=0.146; χ2 = 4.802; df = 1; p = 0.028

Conversely, 56.7% of those who faced barrier of partner’s condom refusal had a low

self-efficacy as compared to those who did not (41.8%). The results of Chi-square test

of relationships (χ2 = 4.802; df = 1; p = 0.028) showed that there was a significant

relationship between partner’s refusal and disapproval of condoms and self-efficacy in

HIV prevention at 0.05 probability error. The contingency coefficient measure of

association (C=0.146) indicated that partner’s condom refusal explained 14.6% of the

total variations in self-efficacy in HIV prevention. Those respondents who faced the

barrier of partner’s refusal and disapproval of condom were not able to take a healthy

HIV preventive action. This might have led to non-use of condoms. This caused

frustrations to the female respondents who reported that sometimes they refused sex

for fear of re-infection or new HIV infections where there was no HIV self-disclosure.

This complicated the sexual relationship as those sexual partners deprived and

aggrieved sought sexual relations outside their unions.

These findings were consistent with a study by CHGA (2004) which shows that there

is perceived general unwillingness of men to have protected sex and women lack

control of their own sexuality and are vulnerable to HIV infection (or re-infection)

due to lack of female-controlled methods for preventing HIV transmission during

 122

sexual intercourse. Thus, the hypothesis that there is no significant relationship

between barriers to safe sexual and reproductive practices by partner’s disapproval of

condoms and self-efficacy in HIV prevention is rejected.

Alcohol and Drug Abuse and Self-efficacy in HIV Prevention

Taking of alcohol and other drugs may have far reaching implications on self-efficacy

in HIV prevention in that it impairs judgement leading to risky sexual practices. This

relationship is presented in Table 4.44. The findings show that slightly more than two

thirds of the respondents (68.5%) who were not experiencing the barrier of alcohol

and drug abuse had a high self-efficacy in HIV prevention as compared to those who

were experiencing (28.6%). Conversely, nearly three quarters (71.4%) of the

respondents who were experiencing that barrier had a low self-efficacy in HIV

prevention as compared to 31.5% who were not experiencing.

Table 4.44: Relationship between alcohol and drug abuse and self-efficacy in
HIV prevention
Barrier of alcohol Low self-efficacy High self-efficacy Total
and drug abuse
Not experiencing 46 100 146
(31.5%) (68.5%) (100.0%)
Experiencing 65 26 91
(71.4%) (28.6%) (100.0%)
Total 111 126 237
(46.8%) (53.2%) (100.0%)
C=0.363; χ2 = 35.881; df = 1; p = 0.000

The Chi-square results (χ2 = 35.881; df = 1; p = 0.000) showed that the observed

variations in self-efficacy in HIV prevention by alcohol and drug abuse was

significant at 0.05 probability of error. The contingency coefficient measure of

association (C=0.363) indicated that alcohol and drug abuse explained 36.3% of the

total variations in self-efficacy in HIV prevention. Thus, the hypothesis that there is
 123

no significant relationship between barriers to safe sexual and reproductive behaviour

by alcohol abuse and self-efficacy in HIV prevention is rejected.

Stigma and Self-efficacy in HIV Prevention

Stigma, isolation and discrimination are aspects that may have a great role in the

management of HIV and AIDS with an implication on its prevention. This

relationship is analyzed as shown in Table 4.45. The results reveal that a larger

proportion of the respondents who faced the barrier of being stigmatized (59.1%) had

a high self-efficacy in HIV prevention while majority of those who did not face

(51.9%) had a low self-efficacy in HIV prevention. The results of Chi-square test (χ2

= 2.554; df = 1; p=0.110) showed that there was no significant relationship between

stigma and self-efficacy in HIV prevention at 0.05 probability error. The contingency

coefficient measure of association (C=0.107) indicated that stigma explained 10.7%

of the total variations in self-efficacy in HIV prevention.

Table 4.45: Relationship between stigma and self-efficacy in HIV prevention

Barriers Low self-efficacy High self-efficacy Total

Facing stigma 36 52 88
(40.9%) (59.1%) (100.0%)
Not facing stigma 68 63 131
(51.9%) (48.1%) (100.0%)
Total 104 115 219
(47.5%) (52.5%) (100.0%)
C=0.107; χ2 = 2.554; df = 1; p = 0.110

Therefore, respondents who were stigmatized were able to take a healthy HIV

preventive action unlike their counterparts who were not facing barrier of being

stigmatized. Being stigmatized might have influenced their HIV self-disclosure or

even suggesting use of a condom during sexual encounters. This finding was not as
 124

per the expectations as one would expect those who were stigmatised not to be able to

take a HIV preventive action. This contradicted a study by CHGA (2004) which

report that women face more AIDS-related stigma, discrimination and marginalization

which lower HIV prevention. Also the findings were not consistent with a study by

WHO (2006), which found that most women living with HIV and AIDS suffered from

stigmatization and discrimination like being considered vectors of HIV transmission

to their children; which might hamper HIV self-disclosure. The findings was also not

in line with an observation made by Nakawiya (2006) in a study done in Uganda who

found that many HIV positive women continued to breastfeed their infants for fear of

being ostracized and isolated. Thus, the hypothesis that there is no significant

relationship between barrier to safe sexual and reproductive practice by stigmatization

and self-efficacy in HIV prevention is retained.

Financial Constraints and Self-efficacy in HIV Prevention

Money is a crucial resource for PLWHA due to management of the disease. Hence

lack of it may have far reaching implications in their quest for preventing HIV. This

relationship is analyzed as shown in Table 4.46. The results showed that a larger

proportion of the respondents who did not experience financial constraints (61.1%)

had a high self-efficacy in HIV prevention unlike their counterparts who experienced

that barrier (30.0%). Conversely, 70.0% of those experiencing financial constraints

had a low self-efficacy. The results of Chi-square test (χ2 = 18.404; df =1; p = 0.000)

showed that there was a significant relationship between financial constraints and

self-efficacy in HIV prevention at 0.05 probability error.

Table 4.46: Relationship between financial constraints and self-efficacy in HIV

prevention
 125

Barriers Low self-efficacy High self-efficacy Total

Experiencing 49 21 70
financial constraints (70.0%) (30.0%) (100.0%)
Not experiencing 58 91 149
financial constraints (38.9%) (61.1%) (100.0%)
Total 107 112 219
(48.9%) (51.1%) (100.0%)
C=0.278; χ2 = 18.404; df =1; p = 0.000

Further analysis showed that contingency coefficient measure of association

(C=0.278) indicated that financial constraints explained 27.8% of the total variations

in self-efficacy in HIV prevention. The hypothesis that there is no significant

relationship between barriers to safe sexual and reproductive practices by lack of

money and self-efficacy in HIV prevention is rejected.

People’s Curiosity and Self-efficacy in HIV Prevention

The respondents cited people’s curiosity as a barrier of not being able to practice safe

sexual and reproductive practices. This relationship is analyzed as in Table 4.47.

Table 4.47: Relationship between people’s curiosity and self-efficacy in HIV

prevention
Barriers Low self-efficacy High self-efficacy Total
Experience people’s 3 9 12
curiosity (25.0%) (75.0%) (100.0%)
Not experiencing 106 112 218
people’s curiosity (48.6%) (51.4%) (100.0%)
Total 109 121 230
(47.4%) (52.6%) (100.0%)
2
C=0.105; χ = 2.546; df =1; p = 0.111

The results reveal that three quarters of the respondents who experienced the barrier

of people’s curiosity (75.0%) had a high self-efficacy in HIV prevention while 48.6%

of those who did not experience that barrier had a low self-efficacy. The results of

Chi-square test (χ2 = 2.546; df =1; p = 0.111) showed that there was no significant
 126

relationship between barrier of people’s curiosity and self-efficacy in HIV prevention

at 0.05 probability error. Further analysis showed that contingency coefficient

measure of association (C=0.105) indicated that people’s curiosity explained 10.5% of

the total variations in self-efficacy in HIV prevention. Therefore, respondents who

faced the barrier of people’s curiosity were able to take a healthy HIV preventive

action than those not facing this barrier. This finding was not as anticipated as

respondents facing the barrier of people’s curiosity were expected to have a low self-

efficacy in HIV prevention. However, this curiosity could have been a motivator for

the respondents to take a healthy HIV preventive action. Thus, the hypothesis that

there is no significant relationship between barrier of people’s curiosity and self-

efficacy in HIV prevention is retained.

Ignorance and Non-acceptance of HIV Status and Self-efficacy in HIV Prevention

Due to intake of ARVs, majority of the PLWHA have enhanced physical appearance

hence the probability of other people believing and accepting that they are HIV

positive is low. This relationship is analyzed as shown in Table 4.48. From the

findings, a large proportion of the respondents who were not facing the barrier of

ignorance and non-acceptance that they were HIV positive (53.0%) had a high self-

efficacy in HIV prevention while majority of those who were facing this barrier

(51.4%) had a low self-efficacy. The results of Chi-square test (χ2 = 0.237; df = 1; p =

0.626) showed that there was no significant relationship between ignorance and non-

acceptance of HIV infection and self-efficacy in HIV prevention at 0.05 probability

error.

Table 4.48: Relationship between ignorance and non-acceptance of HIV infection

and self-efficacy in HIV prevention

Barriers Low self-efficacy High self-efficacy Total

 127

Facing ignorance and 19 18 37

non-acceptance (51.4%) (48.6%) (100.0%)
Not facing ignorance 85 96 181
and non-acceptance (47.0%) (53.0%) (100.0%)
Total 104 114 218
(47.7%) (52.3%) (100.0%)
C=0.033; χ2 = 0.237; df = 1; p = 0.626

Results of contingency coefficient measure of association (C=0.033) indicated that

ignorance and non-acceptance of being HIV positive explained 3.3% of the total

variations in self-efficacy in HIV prevention. Thus, the hypothesis that there is no

significant relationship between barrier of ignorance and non-acceptance of HIV

infection and self-efficacy in HIV prevention is retained. The respondents who did not

face the barrier of non-acceptance of HIV infection were able to take a healthy HIV

preventive action as compared to those who were not believed to be HIV positive.

Condom Fatigue and Self-efficacy in HIV Prevention

Use of condom consistently is an important aspect in the pursuit of HIV prevention

among PLWHA. The results of this relationship as analyzed in Table 4.49 show that a

large proportion of the respondents who did not experience condom fatigue (57.9%)

had a high self-efficacy in HIV prevention as compared to their counterparts who

experienced this barrier (33.9%). On the contrary, two thirds of the respondents who

experienced condom fatigue (66.1%) had a low self-efficacy in HIV prevention unlike

those who did not experience (42.1%). The results of Chi-square test (χ2 = 9.892; df =

1; p = 0.002) showed that there was a significant relationship between barrier of

condom fatigue and self efficacy in HIV prevention at 0.05 probability error.

Table 4.49: Relationship between condom fatigue and self-efficacy in HIV

prevention
Barrier Low self-efficacy High self-efficacy Total
Experience condom 39 20 59
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fatigue (66.1%) (33.9%) (100.0%)

Do not experience 67 92 159
condom fatigue (42.1%) (57.9%) (100.0%)
Total 106 112 218
(48.6%) (51.4%) (100.0%)
C=0.208; χ2 = 9.892; df = 1; p = 0.002

Further analysis using contingency coefficient measure of association (C=208)

indicated that condom fatigue accounted for 20.8% of the total variations for self-

efficacy in HIV prevention. Thus, the hypothesis that there is no significant

relationship between barriers to HIV prevention by condom fatigue and self-efficacy

in HIV prevention is rejected.

Lack of Female Condoms and Self-efficacy in HIV Prevention

This relationship is analyzed as in Table 4.50. From the results, a large proportion

of the respondents who experienced lack of female condoms (55.8%) had a high self-

efficacy in HIV prevention while majority of those who did not experience that

barrier (48.6%) had a low self-efficacy in HIV prevention. The results of Chi-square

test (χ2 = 0.266; df = 1; p = 0.606) showed that there is no significant relationship

between lack of female condoms and self-efficacy in HIV prevention at 0.05

probability error. Further analysis using contingency coefficient measure of

association (C=0.035) indicated that lack of female condom accounted for 3.5% of the

total variations for self-efficacy in HIV prevention. Thus, the hypothesis that there is

no significant relationship between barriers to HIV prevention by lack of female

condoms and self-efficacy in HIV prevention is retained.

Table 4.50: Relationship between lack of female condom and self-efficacy in HIV
prevention

Barriers Low self-efficacy High self-efficacy Total

 129

Experience lack of 19 24 43
female condom (44.2%) (55.8%) (100.0%)
Do not experience lack 85 90 175
of female condom (48.6%) (51.4%) (100.0%)
Total 104 114 218
(47.7%) (52.3%) (100.0%)
C= 0.035; χ2 = 0.266; df = 1; p = 0.606

Those respondents who faced the barrier of lack of female condom were able to take a

healthy HIV preventive action. This could have meant that since female condoms

were reported to be expensive and not commonly available, these respondents could

have been using the male condoms. Similar findings were reported by CHGA 2004

that female condoms are still too expensive and in too short supply to be widely

available.

Barriers to safe sexual and reproductive behaviour that had a significant relationship

with self-efficacy in HIV prevention were further analyzed using binary logistic

regression to establish whether they predicted self-efficacy in HIV prevention.

Regression model fit

Y i =βo+ X1, + X2+ X3+ X4............................................................................ Ԑi

Where, Y i is the dependent variable (self-efficacy in HIV prevention)

βo is the point of interception

X1 – X5 are the independent variables of barriers to safe sexual and

reproductive behaviour that had a significant relationship with self-efficacy in

HIV prevention.

Ԑi is the error of the difference between scores

Therefore, X1 is partner’s condom refusal, X2 is financial constraints, X3 is condom

fatigue and X4 is alcohol and drug abuse.

Table 4.51: Barrier predictors and self-efficacy in HIV prevention

Barriers AOR Sig. 95% of Confidence

 130

Interval
Partner’s condom refusal 1.362 0.353 0.710-2.614
Financial constraints 1.362 0.001* 0.710-2.614
Condoms fatigue 2.506 0.012* 1.223-5.133
Alcohol and drug abuse 0.191 0.000* 0.099-1.367
*significant predictors at p≤ .05

The results as presented in Table 4.51 indicate that not experiencing barriers of

financial constraints and condom fatigue were positive predictors of high self-efficacy

in HIV prevention with Adjusted Odd Ratio of more than one (AOR≥1.000). On the

contrary indulging in alcohol and drug abuse was a predictor of low self-efficacy in

HIV prevention (AOR=0.191) with Adjusted Odd Ratio of more than one

(AOR≤1.000). Not experiencing condom fatigue was found to be a strong predictor

(AOR=2.506) of high self-efficacy in HIV prevention as opposed not experiencing

barrier of financial constraint (AOR=1.362). This meant that those who were not

experiencing condom fatigue were two times able to adopt a HIV preventive action as

compared to those who were not experiencing financial constraints.

4.8.5 Relationship between Decision-making on Sexual and Reproductive

Behaviour and Self-efficacy in HIV Prevention

Hypothesis 5: There is no significant relationship between decision-making on

sexual and reproductive practices by PLWHA and self-efficacy in HIV prevention.

Decision-making on Whether to Have Sex and Self-efficacy in HIV Prevention

This decision was found to be largely made by males (63.2%) and the relationship is

analyzed as shown in Table 4.52.Table 4.52: Relationship between decision-

making on whether to have sex and self-efficacy in HIV prevention

Decision made Low self-efficacy High self-efficacy Total

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by…
Female 22 15 37
(59.5%) (40.5%) (100.0%)
Male 68 73 141
(48.2%) (51.8%) (100.0%)
Jointly 18 27 45
(40.0%) (60.0%) (100.0%)
Total 108 115 223
(48.4%) (51.6%) (100.0%)
C= 0.117; χ2 = 3.085; df = 2; p = 0.214

The results indicate that more than half of the respondents (60.0%) who reported that

the decision on whether to have sex was a joint venture had a high self-efficacy in

HIV prevention followed by males (51.8%) and females (40.5%) respectively.

Conversely, a large proportion of the respondents (59.5%) who indicated that this

decision was made by females had a low self-efficacy in HIV prevention followed by

males (48.2%) and jointly (40.0%) in that order. The results of Chi-square test of

relationships (χ2 = 3.085; df = 2; p = 0.214) showed that there was no significant

relationship between decision on whether to have sex and self efficacy in HIV

prevention at 0.05 probability error. Further analysis using contingency coefficient

measure of association (C=0.117) indicated that decision on when to have sex

accounted for 11.7% of the total variations for self-efficacy in HIV prevention.

Therefore, in cases where the decision on whether to have sex was a joint venture, the
sexual partners were able to take a healthy HIV preventive action unlike in cases
where the males or females made the decision. The hypothesis that there is no
significant relationship between decision on whether to have sex and self-efficacy in
HIV prevention is retained.
Decision-making on Whether to Use Condoms and Self-efficacy in HIV Prevention
This decision was found to be primarily made by males (77.3%). The relationship is
analyzed as shown in Table 4.53.

Table 4.53: Relationship between decision-making on whether to use condoms

and self-efficacy in HIV prevention
Decision made by… Low self-efficacy High self-efficacy Total
Female 4 4 8
(50.0%) (50.0%) (100.0%)
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Male 88 77 165
(53.3%) (46.7%) (100.0%)
Jointly 12 26 38
(31.6%) (68.4%) (100.0%)
Total 121 80 201
(60.2%) (39.8%) (100.0%)
2
C=0.164; χ = 5.850; df = 2; p = 0.050

The findings show that more than two thirds of the respondents who indicated that the

decision on whether to use condoms was jointly made (68.4%) had a high self-

efficacy in HIV prevention followed by females (50.0%) and by males (46.7%) in that

order. On the other hand, 53.3% of the respondents who reported that this decision

was made by males had a low self-efficacy followed by females (50.0%) and jointly

(31.6%) respectively. The results of Chi-square test (χ2 = 5.850; df = 2; p = 0.050)

showed that there was a significant relationship between decision-making on whether

to use condoms and self-efficacy in HIV prevention at 0.05 probability error. Further

analysis using contingency coefficient measure of association (C=0.164) indicated

that decision on whether to use condoms accounted for 16.4% of the total variations

for self-efficacy in HIV prevention. Therefore, decision pertaining to whether to use a

condom when made jointly resulted to high self-efficacy. This implied that decisions

on safe sexual and reproduction practices require contribution of both partners which

would translate to HIV prevention. Thus, the hypothesis that there is no significant

relationship between decision-making on whether to use a condom and self-efficacy

in HIV prevention is rejected.

Decision-making on Whether to Have a Child and Self-efficacy in HIV Prevention

This decision was found mostly to be made by significant others (46.1%). This

relationship is analyzed as shown in Table 4.54. The findings revealed that slightly

more than two thirds of the respondents who reported that the decision on whether to
 133

have a child was made by the significant others (68.6%) had a high self-efficacy in

HIV prevention followed by those who indicated that it was by chance (53.3%), by

females (46.7%), jointly (45.7%) and males (43.2%) in that order. Conversely, a large

proportion of the respondents (56.8%) who indicated it was made by males, had a low

self-efficacy in HIV prevention. The results of Chi-square test of relationships (χ 2 =

6.309; df = 4; p = 0.177) showed that there was no significant relationship between

decision-making on whether to have a child and self-efficacy in HIV prevention at

0.05 probability error.

Table 4.54: Relationship between decision-making on whether to have a child

and self-efficacy in HIV prevention

Decision made by… Low self-efficacy High self-efficacy Total

Woman 24 21 45
(53.3%) (46.7%) (100.0%)
Man 25 19 44
(56.8%) (43.2%) (100.0%)
Jointly 25 21 46
(54.3%) (45.7%) (100.0%)
Others 11 24 35
(31.4%) (68.6%) (100.0%)
None/by chance 14 16 30
(46.7%) (53.3%) (100.0%)
Total 99 101 200
(49.5%) (50.5%) (100.0%)
2
C= 0.175; χ = 6.309; df = 4; p = 0.177

Further analysis using the contingency coefficient measure of association (0.175)

indicated that decision on whether to have a child accounted for 17.5% of the

observed variations in the self-efficacy in HIV prevention. Those respondents who

indicated that decision on whether to have a child was by significant others were able

to take a healthy HIV preventive action. This was in line with Kakaire et al., (2010)

who reported that community members advise their HIV positive relatives to refrain

from having children in the event that they test positive and would die prematurely.
 134

Thus, the hypothesis that there is no significant relationship between decision-making

on whether to have a child and self-efficacy in HIV prevention is retained.

Decision-making on Who to Obtain Condoms and Self-efficacy in HIV Prevention

This decision was found to be a joint venture (42.9%) and the relationship is analyzed

as shown in Table 4.55. The results reveal that more than half of the respondents who

reported that decision on who to buy or obtain condoms was a woman issue (57.1%)

were found to have a high self-efficacy in HIV prevention followed by those who

indicated it was a joint venture (54.5%) and those who indicated it was a man issue

(38.4%) in that order. On the contrary, 61.6% of the respondents who indicated that

this decision was a male issue had a low self-efficacy in HIV prevention. The results

of Chi-square test (χ2 = 5.500; df = 2; p = 0.064) showed that there was no significant

relationship between decision-making on who to acquire condoms and self-efficacy in

HIV prevention at 0.05 probability error.

Table 4.55: Relationship between decision making on who to obtain condoms

and self efficacy in HIV prevention

Decision made by… Low self-efficacy High self- Total

efficacy
Woman 18 24 42
(42.9%) (57.1%) (100.0%)
Man 45 28 73
(61.6%) (38.4%) (100.0%)
Jointly 40 48 88
(45.5%) (54.5%) (100.0%)
Total 103 100 203
(50.7%) (49.3%) (100.0%)
C=0.162; χ2 = 5.500; df = 2; p = 0.064

Further analysis using the contingency coefficient measure of association (0.162)

indicated that decision on who to acquire condoms accounted for 16.2% of the
 135

observed variations in the self-efficacy in HIV prevention. Those respondents where

decision to buy or obtain condoms was made by the females, were able to use them.

This could have facilitated prevention of new HIV infection, re-infection and also

avoiding unplanned pregnancies as condoms play a dual role. However this could

have been hampered by the fact that men were reported to make decision on whether

to use condoms which resulted to low self-efficacy. The hypothesis that there is no

significant relationship between decision-making on who to buy or obtain condoms

and self-efficacy in HIV prevention is retained.

Decision-making on Which Type of Condom to use and Self-efficacy in HIV

Prevention

This decision was found to be a joint venture (58.2%) and the relationship is analyzed

as shown in Table 4.56.

Table 4.56: Relationship between decision making on which type of condom to

use and self efficacy in HIV prevention

Decision made by… Low self-efficacy High self-efficacy Total

Woman 10 9 19
(52.6%) (47.4%) (100.0%)
Man 43 22 65
(66.2%) (33.8%) (100.0%)
Jointly 50 67 117
(42.7%) (57.3%) (100.0%)
Total 103 98 201
(51.2%) (48.8%) (100.0%)
C=0.209; χ2 = 9.189; df = 2; p = 0.010

The results in Table 4.56 reveal that more than a half of the respondents who reported

that decision on which type of condom to use was a woman issue (47.4%) were found

to have a high self-efficacy in HIV prevention followed by those who indicated it was

a woman issue (47.4%) and being a joint venture (57.3%) in that order. On the

contrary, two thirds (66.2%) of the respondents who indicated that this decision was a
 136

male issue had a low self-efficacy in HIV prevention. The results of Chi-square test

(χ2 = 9.189; df = 2; p = 0.010) showed that there was a significant relationship

between decision-making on which type of condom to use and self-efficacy in HIV

prevention at 0.05 probability error. Further analysis using the contingency

coefficient measure of association (0.209 indicated that decision on which type of

condom to use accounted for 20.9% of the observed variations in the self-efficacy in

HIV prevention. Those sexual relations where decision on which type of condom to

use was a joint venture, was found to adopt the HIV preventive action, that is, use of

condom. This could have facilitated prevention of new HIV infection, re-infection and

also avoiding unplanned pregnancies as condoms play a dual role. However this could

have been hampered by lack of female condoms. But, still the female condoms could

have required a similar kind of negotiation as using the male condom as a study by

CHGA (2004) reported. Therefore use of female condoms may not be the solution to

gender power relations issues. The hypothesis that there is no significant relationship

between decision-making on which type of condom to use and self-efficacy in HIV

prevention is rejected.

Decision-making on issues of sexual and reproduction that were found to have a

significant relationship with self-efficacy in HIV prevention were further analyzed

using binary logistic regression to establish whether they predicted self-efficacy in

HIV prevention.

Regression model fit

Y i =βo+ X1, + X2.......................................................................................... Ԑi

Where, Y i is the dependent variable (self-efficacy in HIV prevention)

 137

βo is the point of interception

X1 – X5 are the independent variables of decision-making on sexual and

reproductive behaviour that had a significant relationship with self-efficacy in

HIV prevention.

Ԑi is the error of the difference between scores

Therefore, X1 is decision on whether to use condoms and X2 is decision on which type

of condom to use.

Table 4.57: Decision-making predictors of self-efficacy in HIV prevention

Decision-making patterns AOR Sig. 95% of Confidence

Interval
Whether to use condoms 1.765 0.101 0.895-3.479
Which type of condom to use 0.105 0.087 0.945-2.336
*significant predictors at p≤ .05

The results as presented in Table 4.57 show that none of the decisions making aspects

on sexual and reproductive behaviour were a predictor of self-efficacy in HIV

prevention.

4.9 Predictors of self-efficacy in HIV prevention

Hypothesis 6: None of the variables that had a significant relationship with self-

efficacy in HIV prevention predicted it.

All those variables that predicted self-efficacy in HIV prevention in each objective

were further analyzed using binary logistic regression to eliminate the confounders so

as to establish the unique factors that predicted self efficacy in HIV prevention among

respondents. The results are presented in Table 4.58.

Regression model fit

 138

Y i =βo+ X1, + X2+ X3+ X4+ X5 + X6 + X7+ X8+ X9+ X10+ X11......................... Ԑi

Where, Y i is the dependent variable (self-efficacy in HIV prevention)

βo is the point of interception

X1 – X11 are the independent variables that predicted self-efficacy in HIV

prevention in each of the factors.

Ԑi is the error of the difference between scores

Therefore, X1 is gender, X2 is marital status, X3 is income, X4 is positive attitude toward

HIV negative people, X5 is attitude towards reproductive behaviour, X6 is number of

sexual partners, X7 is type of sexual partner, X8 is number of children born after testing

HIV positive, X9 is alcohol and drug abuse, X10 is financial constraints and X11 is

condom fatigue.

From the results, it was revealed that gender, monthly income, positive attitude

towards reproductive behaviour, number of children born after testing HIV positive,

financial constraints and condom fatigue were positive predictors of self efficacy in

HIV prevention among the respondents with Adjusted Odd Ratio of more than one

(AOR≥1.000).

Table 4.58: Predictors of self-efficacy in HIV prevention

Predictors AOR Sig. 95% of Confidence Interval

Gender 2.560 0.050* 1.981-6.680
Marital status 1.259 0.176 0.902-1.756
Monthly income 3.328 0.002* 1.401-4.349
Positive attitude towards
HIV negative people 1.419 0.422 0.603-3.338
Positive attitude towards
reproductive behaviour 3.328 0.007* 1.385-7.996
Number of sexual partners 0.225 0.001* 0.091-0.554
Type of sexual relationship 0.029 0.126 0.169-1.246
Number of children born
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after testing HIV positive 2.016 0.029* 1.073-3.788

Alcohol and drug abuse 0.363 0.021* 0.153-0.859
Financial constraints 8.039 0.000* 3.020-21.395
Condom fatigue 2.703 0.046* 1.017-7.188
*significant predictors at p≤ .05

On the contrary, number of sexual partners and alcohol and drug abuse were negative

predictors of self-efficacy in HIV prevention Adjusted Odd Ratio of less than one

(AOR≤ 1.000). Not experiencing financial constraints was found to be a strong

predictor of high self-efficacy in HIV prevention (AOR=8.039) followed by middle

income (AOR=3.328), positive attitude towards reproductive behaviour

(AOR=3.328), not experiencing condom fatigue (AOR=2.703), female respondents

(AOR=2.560) and having two children after testing HIV positive (AOR=2.016) in that

order. Conversely, having multiple sexual partners was found to be a strong predictor

of low self-efficacy in HIV prevention (AOR=0.225) followed by those indulging in

alcohol and drug abuse (AOR=0.363).

4.10 Discussion of Results

The study established that 52.8% of the respondents had a high self-efficacy in HIV

prevention while 47.3% had a low self-efficacy. This demonstrated that more than

half of the respondents were able to adopt a safe HIV preventive action thus

preventing HIV transmission. On the contrary, 47.2% of the respondents were not

able to consistently adopt a safe HIV preventive action thus jeopardizing pursuits of

HIV prevention. This could have meant that this proportion of the respondents was

contributing to spread of HIV epidemic. The findings revealed that self-efficacy in

HIV prevention among respondents in the study area was an interplay of many factors

which predicted it.

 140

As regards to gender, the results showed that the female respondents had a high self-

efficacy in HIV prevention as opposed to their male counterparts. These female

respondents were two times able to adopt a HIV preventive action (AOR=2.560) as

opposed to other predictors. This observation could have been attributed to the fact

that more than half of the female respondents (59.1%) had an overall positive attitude

towards HIV and sexual and reproductive behaviour as opposed to 47.8% of their

male counterparts. Also, majority of the female respondents (49.0%) were faithful to

their sexual partners as opposed to their male counterparts (37.8%). Similarly, twice

as much of the females (8.7%) were abstaining from sex compared to the male

respondents (4.4%). This could probably also have been attributed by the fact that

more females (81.8%) than males did not have desire to have more children after

testing HIV positive for the fear of transmitting the virus to the children. They were

found to cautious in having safe sexual and reproductive practices through use of

condoms.

In addition, the study established that slightly more than two thirds (67.6%) of the

females had used condoms in their last sexual intercourse prior to the study as

opposed to their male counterparts. Moreover, it could also be explained by the fact

that nearly three quarters of the female respondents (72.8%) did not indulge in alcohol

and drug abuse as opposed to more than half of the males (51.1%) who indulged in it.

Alcohol and drug abuse was found to lead to risky sexual behaviour. These findings

concurred with studies reported in Boston conference (2010) who found that more

women than men did not desire more children after testing HIV positive hence would

more likely use condoms to avoid an unplanned pregnancy. These necessitated

prevention of HIV infections and re-infections and also unplanned pregnancies.

 141

With regard to monthly income, those who earned middle incomes (Kshs.5,001-

10,000) had a high self-efficacy in HIV prevention as compared to those who earned

high income (over Kshs. 10,001) and low income (below Kshs.5,000). Those who

earned middle incomes were three times (AOR=3.328) able to adopt a HIV preventive

action as compared to other predictors. This could be explained by the fact that the

middle income earners were found not to experience that barrier of financial

constraints. Hence they might not have indulged in transactional sex where condom

use was compromised. In addition majority of this income category was found to be

faithful to their sexual partners. On the other hand poverty could have driven the

respondents who earned low incomes (below Kshs.5000) to have transactional sex

where use of condom was compromised. This was evidenced by qualitative data

where respondents reported that there was more money in having unprotected sex.

From this study, it could be deduced that monthly income predictor was closely linked

with financial constraints which was found to be a very strong predictor (AOR=8.039)

as compared to other predictors. Those who were not experiencing it were found to

have a high self-efficacy in HIV prevention as opposed to those who were

experiencing it and were eight times able to adopt a safe HIV preventive action. This

could be explained by the fact that those who were not financially constrained might

not have engaged in transactional sex where consistent condom use was

compromised. The results were consistent with CHGA (2004) which reported that the

households affected by HIV and AIDS experience financial constraints as they deal

with increasing expenses contributing to fuelling of HIV epidemic as they try to uplift

their economic status. This may mean that with high levels of poverty in the country,
 142

HIV epidemic may be deemed to escalate if prevention with positive programmes are

not put in place.

On the other hand, majority of those who had high incomes (over Kshs. 10,000) were

found to lead affluent lifestyles with indulgence in alcohol and drug abuse. This made

them vulnerable to risky sexual behaviour. This ascertained why alcohol and drug

abuse was found to be a predictor of low self-efficacy in HIV prevention. Studies

show that alcohol is known to impair judgment, compromise power relations and

increase risky sexual behaviour that is high risk for HIV infection (KDHS, 2008/09).

An aspect of concern to be addressed by HIV prevention programmes is to target

persons living with HIV and AIDS leading affluent lifestyles and those who live in

poverty as they seemed to engage in risky sexual behaviour.

The results also revealed that positive attitude towards reproductive behaviour

predicted high self-efficacy in HIV prevention as opposed to negative attitude. It was

shown that respondents who had a positive attitude towards reproductive behaviour

were three times able to take a healthy HIV preventive action (AOR=3.328) as

compared to other predictors. This positive attitude towards reproductive behaviour

could have been as a result of children being viewed as social security by the

respondents. Majority of them reported that they had children after testing HIV

positive to keep the family lineage and also to provide care when the respondents

were incapacitated.

From this study it could be argued that attitude and practice influence one another.

This is because number of children born after testing HIV positive was found to be a
 143

predictor of self-efficacy in HIV prevention. Respondent who had two children were

found to have a high self-efficacy in HIV prevention and were two times able to adopt

a healthy HIV preventive action (AOR=2.016). Hence it could be deduced that

successive number of children born after confirmation of HIV-positive status yielded

high self-efficacy in HIV prevention. This enhanced effective adherence to PMTCT

practices which could have translated to high survival rates of children born after

testing HIV positive. These respondents with two children after testing HIV positive

could have been able to have overcome people’s curiosity.

These findings was supported by Asunta Wagura, director KENWA-Kenya who

reported in a Kenyan Daily Newspaper that she is never bothered by people’s attitude

towards her (Daily Nation, August 8th Wednesday, 2012) and especially after giving

birth to two children who are HIV negative after living with the virus for more than

20 years. This positive attitude towards her reproductive behaviour could have

enhanced her ability to take a healthy HIV preventive action such as effective

PMTCT practices leading to having HIV-negative children. Therefore, positive

attitude enhanced ability to take a HIV preventive action which translated to safe

reproductive practices. It can be argued that every individual has desires to have

sexual relations. Additionally, children are considered an invaluable asset in the

family and a symbol of status in many societies in the world and in Africa. PLWHA

are not an exception as they may also desire to have children of their own. This may

put unborn children and other children at risk of getting infected as they strive to

satisfy their sexual and reproductive desires. This may have implications for new

infections and re-infections.

 144

With regard to barrier of condom fatigue, those who did not experience it were found

to have a high self-efficacy in HIV prevention as compared to those who experienced

it. Those respondents who did not experience condom fatigue were found to be two

times able to adopt a healthy HIV preventive action (AOR=2.703) as compared to

other predictors. This could have been due to consistent use of condom among the

respondents in regular sexual relationships. The study demonstrated that the

respondents who knew their HIV status, still had unprotected sex with their

occasional sexual partners putting them at risk of HIV infection and re-infection.

These results concurred with studies carried out in Nairobi which indicated that

PLWHA continued to be sexually active and indulged in risky sexual behaviour of

having multiple concurrent sexual partnerships with a casual or commercial sex

worker (Oyore, 2009 & Otieno 2008). Similarly, the results were supported by

Wamoyi et al., (2011) who indicated that the challenges for most PLWHA are using

condoms consistently and finding a suitable sexual partner (preferably someone who

is HIV positive). Likewise, a study by UNAIDS (2006) indicated that negative

attitude towards condom use among PLWHA remained due to ‘fatigue’ of

consistency and this could hinder efforts for prevention of HIV.

From the study, it was also revealed that number of sexual partners predicted low self-

efficacy in HIV prevention. Respondents with multiple sexual partners were found to

have low self-efficacy in HIV prevention as opposed to those who had one or none.

This could have been attributed by some respondent’s reports who attested that they

were not able to use condoms consistently even in occasional sexual relationships.

Cases abound where there were reports that sex with a condom was reported to be

dissatisfying and led to condom fatigue leading to having unprotected sex. Those who
 145

were in regular sexual relationships reported using condoms consistently with their

spouses or stable sexual partners. It was shown that the respondents who had one

sexual partner and those who had none had a high self efficacy in HIV prevention.

This boiled down to abstinence and being faithful to one’s sexual partner.

As for the barrier of alcohol and drug abuse, it was found to predict low self-efficacy

in HIV prevention (AOR=0.363). The study established that, those who faced this

barrier of alcohol and drug abuse were not able to take a HIV preventive action. This

could have been attributed by the fact that alcohol and drug abuse could have led to

risky sexual behaviour. This finding was supported by qualitative data that taking

alcohol led to non-use of condoms and/or non-disclosure of HIV status to sexual

partner(s). The finding was also consistent with a report by KDHS 2008/09 that

suggests that the use of alcohol or drugs is related to sexual behaviour that is high risk

for HIV infection. Engaging in sex under the influence of alcohol can impair

judgment, compromise power relations, and increase risky sexual behaviour.

These findings elicit some concern in that the respondents were found to indulge in

risky sexual and reproductive behaviour. These results are of significance in the

pursuit of preventing the spread of HIV and AIDS. The study was able to contribute

to new information on self-efficacy in HIV prevention among PLWHA; a case of

prevention with positives. This is an area that has not been documented on especially

in Africa including Kenya. PLWHA should be the focus in programmes promoting

HIV prevention. This is because the study established nearly five in ten respondents

were facilitating in the spread of the virus as opposed to those who were able to
 146

prevent it. These issues need to be addressed by adopting a multi-sectoral approach

comprising the government, non-state players, private sector and general public.

CHAPTER FIVE

SUMMARY, CONCLUSIONS AND RECOMMENDATIONS

5.1 Summary of Main Findings

This section contains a summary of the main study findings based on the objectives

earlier stated in Chapter 1. The study’s primary focus was to determine factors that

predicted self-efficacy in HIV prevention by PLWHA with a view to developing

intervention strategies that would be put in place to prevent HIV and AIDS by

focusing on PLWHA; a case ‘prevention with positives’. Slightly more than half of

the respondents (52.7%) were found to have a high self-efficacy in HIV prevention

with 47.3%) having a low self-efficacy in HIV prevention.

5.1.1. Objective 1: To assess the influence of socio-demographic characteristics of

PLWHA on self-efficacy in HIV prevention.

More than half of the respondents (62.3%) were females and a larger proportion

(41.0%) was residing in the rural areas. Majority of the respondents (42.3%) were in

the age category of 31-40 years while nearly five in every ten respondents (45.6%)

were married. Almost two thirds of the respondents (65.3%) had attained primary

school education or no education. Nearly half of the respondents (49.0%) were casual

workers while slightly more than a half of the respondents (51.3%) earned below

Kshs. 5,000. Five in every ten respondents (52.3%) had between 1-3 children and a

larger proportion of the respondents had tested HIV-positive six years and over from

the time of the study.

 147

The study established that some socio-demographic characteristics namely: gender

(χ2=12.930; df=1; p=0.000), marital status (χ2 = 17.403; df = 3; p = 0.001), monthly

income (χ2 = 6.303; df = 2; p = 0.043) and employment status (χ 2 = 8.455; df = 3; p =

0.037) had a significant relationship with self-efficacy in HIV prevention. The female

respondents, widowed, middle income earners and the respondents who were in

business were found to have a high self-efficacy in HIV prevention. Conversely,

residence (χ2 = 3.846; df = 2; p = 0.146), age (χ 2 = 2.192; df = 3; p = 0.533), religion

(χ2 = 0.493; df = 2; p = 0.782) and duration after testing HIV positive (χ 2 = 2.651; df =

3; p = 0.448) had no significant relationship with self-efficacy in HIV prevention.

Further analysis using Binary Logistic Regression showed that socio-demographic

factors of PLWHA that were predictors of self-efficacy in HIV prevention were

gender (p=0.001), marital status (p=0. 000) and monthly income (p=0. 029). Thus,

these socio-demographic factors predicted the ability to take a healthy HIV preventive

action. Gender emerged as a strong predictor (AOR=3.186) of self-efficacy in HIV

prevention as compared to marital status and monthly income. This meant that female

respondents were three times able to adopt a healthy HIV preventive action. Social

demographic factor of PLWHA that did not predict self-efficacy in HIV prevention

was employment status (p=0.252).

5.1.2. Objective 2: To determine the relationship between attitude towards sexual

and reproductive behaviour by PLWHA and self-efficacy in HIV prevention.

More than half of the respondents (57.7%) had a negative attitude towards HIV

epidemic while a large proportion of the respondents (63.0%) had a positive attitude
 148

HIV-negative people. Nearly nine in every ten respondents (86.6%) had a positive

attitude towards sexual behaviour while almost seven in every ten respondents

(66.5%) had a positive attitude towards reproductive behaviour. The findings

established that the selected aspects of attitude towards HIV-negative people (χ 2 =

9.719; df = 1; p = 0.002) and attitude towards reproductive behaviour (χ 2 = 3.881; df =

1; p = 0.049) had a significant relationship with self-efficacy in HIV prevention at

0.05 probability of error. Those who had a positive attitude towards HIV-negative

people and/or reproductive behaviour had a high self-efficacy in HIV prevention On

the other hand, attitude of PLWHA towards HIV epidemic (χ 2 = 0.004; df = 1; p =

0.948) and attitude towards sexual behaviour (χ2 = 2.168; df = 1; p = 0.141) had no

significant relationship with self-efficacy in HIV prevention.

Further analysis using Binary Logistic Regression showed that both attitude aspects of

PLWHA that had significant relationship with self-efficacy in HIV prevention were

also predictors of the same; attitude towards HIV-negative people (p=0.049) and

attitude towards reproductive behaviour (p=0.002). The respondents who had a

positive attitude towards HIV negative people and /or positive attitude towards

reproductive behaviour were able to take a healthy HIV preventive action. However

those who had a positive attitude towards reproductive behaviour were twice as much

(AOR=2.336) to adopt a HIV preventive action than those who had a positive attitude

towards HIV negative people.

5.1.3. Objective 3: To establish the influence of sexual and reproductive practices of

PLWHA on self-efficacy in HIV prevention.

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The study established that a large proportion of the respondents (48.1%) had multiple

sexual partners. Almost two thirds (65.8%) had used a condom during their last sexual

intercourse within six months from the time of the study. A large proportion of the

respondents (61.7%) were in regular sexual relationships within the last one year from

the time of the study. A large proportion of the respondents (64.9%) were aware of

their sexual partner’s HIV-status in their last sexual encounter with 87.3% being HIV-

positive. Two thirds of the respondents (67.4%) disclosed their HIV status in their last

sexual intercourse at the time of the study. Six in every ten respondents had a child

after confirmation of the HIV-positive status with majority (80.2%) having one child;

majority (43.4%) of those children had HIV-negative status. Nearly three quarters

(71.5%) of the respondents did not desire to have more children.

The results demonstrated that number of sexual partners a respondent had in the last

12 months prior to the study (χ2 = 60.920; df = 2; p = 0.000), type of sexual partner in

the last six months prior to the study (χ 2 = 38.605; df = 1; p = 0.000), awareness of

HIV status of sexual partner (χ2 4.751; df = 1; p = 0.029), HIV disclosure (χ2 = 9.121;

df = 1; p = 0.003) and number of children born after testing HIV positive (χ 2 = 6.774;

df = 2; p = 0.034) had a significant relationship with self-efficacy in HIV prevention.

Those respondents with either no or one sexual partner who was regular, knew the

HIV-status of their sexual partner, had self-disclosed HIV-status and/or had two

children after testing HIV-positive had a high self-efficacy in HIV prevention as

compared to those who reported otherwise. Number of children born after testing HIV

positive was a strong positive predictor of high self-efficacy in HIV prevention

(AOR=8.503). On the contrary, desire to have more children (χ 2 = 0.819; df = 1; p =

0.366) did not have a significant relationship with self efficacy in HIV prevention.
 150

Further analysis using Binary Logistic Regression showed that sexual and

reproductive practices that was a positive predictor of self-efficacy in HIV prevention

was number of children born after testing HIV positive (p=0. 003; AOR=8.505)

which predicted high self efficacy while the number of sexual partners (p=0. 000;

AOR=0.220) and type of sexual partner (p=030; AOR=0.395) were negative

predictors which predicted low self-efficacy in HIV prevention. Factors that did not

predict self-efficacy in HIV prevention were awareness of HIV-status of sexual

partner (p=0.305) and HIV self-disclosure (p=0.338).

5.1.4. Objective 4: To identify the relationship between barriers to safe sexual and

reproductive practices of PLWHA and self-efficacy in HIV prevention.

A large proportion of the respondents (94.5%) were experiencing barriers which

impeded safe sexual and reproductive practices. Such barriers included partner’s

refusal to use condoms, alcohol and drug abuse, stigma, financial constraints, condom

fatigue, lack of female condoms, ignorance of non-acceptance and people’s curiosity.

The findings showed that barriers of partner’s condom refusal and disapproval (χ2 =

4.802; df = 1; p = 0.028), alcohol and drug abuse (χ 2 = 35.881; df = 1; p = 0.000),

financial constraints (χ2 = 18.404; df =1; p = 0.000) and condom fatigue (χ 2 = 9.892;

df = 1; p = 0.002) had a significant relationship with self-efficacy in HIV prevention.

Those respondents who experienced the barriers of partner’s condom refusal and

disapproval, alcohol and drug abuse, financial constraints and/or condom fatigue had

a low self-efficacy in HIV prevention as opposed to those who reported otherwise.

Conversely, stigma (χ2 = 2.554; df = 1; p = 0.110), people’s curiosity (χ 2 = 2.546; df

=1; p = 0.111), ignorance and non-acceptance of someone being HIV infected (χ 2 =

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0.237; df = 1; p = 0.626) and lack of female condoms (χ 2 = 0.266; df = 1; p = 0.606)

did not demonstrate a significant relationship with self-efficacy in HIV prevention.

Further analysis using Binary Logistic Regression showed that the barriers to safe

sexual and reproductive practices that were positive predictors of self-efficacy in HIV

prevention were financial constraints (p=0. 001; AOR=1.362) and condom fatigue

(p=0. 012; AOR=2.506) which predicted high self efficacy while alcohol and drug

abuse (p=0. 000; AOR=0.191) was a negative predictor which predicted low self

efficacy in HIV prevention. Partner’s condom refusal and disapproval (p=0. 353) did

not predict self-efficacy in HIV prevention.

5.1.5. Objective 5: To analyse the relationship between decision-making on sexual

and reproductive practices of PLWHA and self-efficacy in HIV prevention.

Majority of the male respondents made decision on whether to have sexual

intercourse and whether to use condoms. Decision on which type of condom to use

and who to obtain condoms were found to be made jointly by the sexual partners.

Decision on whether to have a child was established to be made by significant others

such as in-laws, friends and relatives while the females made decision on whether to

use other birth control methods. The findings revealed that decision on whether to use

condoms (χ2 = 5.850; df = 2; p = 0.050) and which type of condom to use (χ 2 = 9.189;

df = 2; p = 0.010) had a significant relationship with self-efficacy in HIV prevention.

High self-efficacy in HIV prevention was yielded when decision on whether to use

condoms was made jointly and which type of condoms was made by females. On the

contrary, decisions on whether to have sex (χ2 = 3.085; df = 2; p = 0.214), who should

obtain condoms (χ2 = 5.500; df = 2; p = 0.064) and whether to have a child (χ 2 =

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6.309; df = 4; p = 0.177) had no significant relationship with self efficacy in HIV

prevention.

Further analysis using Binary Logistic Regression showed that none of the decision

making aspects on sexual and reproductive issues predicted self-efficacy in HIV

prevention, that is, whether to use condoms (p=0.101) and which type of condoms to

use (p=0.087).

5.1.6. Objective 6: To determine the predictors of self-efficacy in HIV prevention

among PLWHA.

Further analysis using binary logistic regression of all those factors that predicted self-

efficacy in HIV prevention in each variable yielded the predictors. The positive

predictors that predicted high self-efficacy in HIV prevention were gender (p=0.050;

AOR=2.560), monthly income (p=0.002; AOR=3.328), attitude towards reproductive

behaviour (p=0.007; AOR=3,328), number of children born after testing HIV positive

(p=0.029; AOR=2.016), financial constraints (p=0.000; AOR=8.039) and condom

fatigue (p=0.046; AOR=2.703). On the contrary, number of sexual partner (p=0.001;

AOR=0.225) and alcohol and drug abuse (p=0.021; AOR=0.0363) were negative

predictors which predicted low self-efficacy in HIV prevention.

5.2. CONCLUSION

From the findings, it was concluded that self-efficacy in HIV prevention among

PLWHA was predicted by a number of factors:

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(a) Socio-demographic characteristics of PLWHA that were predictors of self efficacy

in HIV prevention were gender and average monthly income. With regard to gender,

female respondents were found to have a high self-efficacy in HIV prevention as

compared to their male counterparts who had a low self efficacy. Hence female were

able to take a safe HIV preventive action as compared to males. As for the average

monthly income, the study established that middle income earners (Kshs.5,001-

10,000) had a high self-efficacy in HIV prevention. Those who earned high (over

Kshs.10,001) had a low self efficacy followed by those who earned low income

(below Kshs.5,000). This could be construed to imply that low income earners could

have been having transactional sex with high income earners where use of condom

was highly compromised.

(b) Attitude aspect of PLWHA that predicted self-efficacy in HIV prevention was

having a positive attitude towards reproductive behaviour. Those respondents who

had a positive attitude towards reproductive behaviour were able to take a healthy

HIV preventive action as opposed to their counterparts who perceived them

negatively. This positive attitude towards reproductive behaviour could have

enhanced their ability to take a healthy HIV preventive action such as using a condom

to prevent unplanned pregnancies or adhering to PMTCT practises.

(c) The respondents’ sexual and reproductive practices that were a predictor of self-

efficacy in HIV prevention comprised of number of sexual partners a respondent had

and number of children born after testing HIV-positive. It was shown that the

respondents who had one or no sexual partner (being faithful or abstaining) for the

last 12 months prior to the study were able to take a healthy HIV preventive action as

compared to those who had multiple sexual partners. Moreover, those respondents
 154

who had two children after testing HIV-positive had a high self-efficacy as opposed to

those who had no child.

(d) The barriers to safe sexual and reproductive practices that were predictors of self-

efficacy in HIV prevention by PLWHA were alcohol and drug abuse, financial

constraints and condom fatigue. The study established that these barriers reduced the

ability to adopt a healthy HIV preventive action. Alcohol could have led to risky

sexual behaviour as it is known to impair judgment and compromise gender power

relations. For the financial constraints, it could have led the respondents to

transactional sex where use of condom was highly compromised. Condom fatigue led

to inconsistent use of the condom among the respondents.

(e) The study was able to determine predictors of self-efficacy in HIV prevention

among the respondents. The positive predictors were gender, monthly income attitude

towards reproductive behaviour, number of children born after testing HIV positive,

condom fatigue and financial constraints. The negative predictors were number of

sexual partners and indulging in alcohol and drug abuse. It was concluded that female

respondents, middle income earners, positive attitude towards reproductive behaviour,

having more than one child after testing HIV-positive and those not facing challenges

of condom fatigue and financial constraints predicted high self-efficacy in HIV

prevention. On the contrary, having multiple partners and indulging in alcohol and

drug abuse predicted low self-efficacy in HIV prevention.

The predictors of self-efficacy in HIV prevention by PLWHA were summarized as

depicted in the conceptual model in Figures 5.1.

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CONTEXUAL FACTORS
PREVENTIVE ACTION

PLWHA PREDICTOR VARIABLES

 Gender (p=0.050)
 Income (p=0.002) SELF-
 Attitude towards reproductive EFFICACY IN
behaviour (p = 0.007) HIV
PREVENTION
 Number of sexual partners (p = 0.001)
 Number of children born after testing
HIV positive (p = 0.029)
 Financial constraints (p=0.000)
 Condom fatigue (p=0.021)
 Alcohol abuse (p=0.046)

FEEDBACK

INPUT OUTPUT

Factors significant at p ≤ 0.05 level

Figure 5.1: A model depicting predictors of self-efficacy in HIV prevention by
PLWHA.

5.3 Recommendations

Implications for theory, practice, policy and research were elaborated in this section.

5.3.1 Implication for theory

The study established that self-efficacy in HIV prevention by PLWHA is an output of

several individual inputs namely: gender, income, attitude towards reproductive

 156

behaviour, number of sexual partners, number of children born after testing HIV-

positive, alcohol and drug abuse, financial constraints and condom fatigue. These

inputs could be transformed by the throughputs of HIV intervention strategies which

could be put in place to enhance the ability of adopting a safe HIV preventive action

by PLWHA as the output. This may raise self-efficacy in HIV prevention of PLWHA

thereby reducing cases of new HIV infection and re-infection. The study

accomplished that purpose and added to the body of existing literature, thus providing

further direction in this regard of ‘prevention with positives’.

A model for HIV ‘prevention with positives’ was developed as shown in Figure 5.2.

CONTEXUAL MODIFYING PREVENTIVE

FACTORS FACTORS ACTION

PLWHA FACTORS  Promote inclusion of both

 Females men and women in HIV and
AIDS programs.
 Middle income
 Ensure sustainable income
 Positive attitude generating activities through
towards reproductive training and education.
behaviour  Promote PMTCT programs
 One sexual to enhance child survival HIGH SELF-
rates for PLWHA EFFICACY IN
partner HIV
 Promote behaviour change
 Having more than PREVENTION
programmes within the
one child after testing community to target PLWHA.
HIV positive  Enhance and ensure
 Condom fatigue effective provision of alcohol
 Financial constraints and drug abuse counselling
sessions among PLWHA
Alcohol and drug
 Promote correct and
Abuse
consistent use of condoms

Reduced cases of
new HIV infection
and re-infection

INPUTS THROUGH-PUTS OUTPUTS

 157

Figure 5.2: A model depicting HIV ‘prevention with positives’

Source: Author

The factors that were associated with self-efficacy in HIV prevention formed the input

or contextual components of the model. They included: gender, income, attitude

towards reproductive behaviour, number of sexual partners and alcohol and drug

abuse. The throughput components were the HIV intervention strategies which could

be put in place in order to prevent HIV by focusing on PLWHA; a case of ‘prevention

with positives.’ To this end, PLWHA would be expected to have a high ability of

adopting a HIV preventive action (High self-efficacy in HIV prevention) which is the

output. This could lead to reduced cases of new HIV infection and re-infection within

the community.

5.3.2 Implications for Policy

The study findings accentuated a number of factors that predicted self-efficacy in HIV

prevention among PLWHA. Therefore in relation to HIV intervention programmes,

the focus should be on addressing those factors by putting in place HIV intervention

strategies that would raise self-efficacy in HIV prevention among PLWHA. There is

need for the government and other relevant stakeholders to review and implement

existing policies on HIV and AIDS to determine their applicability to self-efficacy in

HIV prevention by focusing on PLWHA.

5.3.3 Implications for Practice

(a) There is need to promote inclusion of both men and women in HIV and AIDS

programs to enhance decision making in all aspects of socio-economic development.

These might promote behaviour change among PLWHA within the community.
 158

PLWHA should be encouraged to be faithful to their sexual partners. Both men and

women should be sensitized to join support groups for PLWHA. This will enhance

acquisition of sexual and reproduction information which would assist in bridging the

significant differences that were found to exist across gender lines.

(b) The government in collaboration with organisations dealing with HIV and AIDS

should enhance programs for economic empowerment for PLWHA. They should

focus on having sustainable income generating activities by putting in place

mechanisms to enhance management of these activities. This could be achieved

through training and educating PLWHA on aspects of entrepreneurship and business

management in order to improve their economic well-being.

(c) There is need to integrate sexual and reproductive health programs and HIV

management. In line with this also, there is need to enhance the implementation of

maternal and child health programs in HIV and AIDS programs. This would assist in

promoting PMTCT programs to enhance child survival rates for PLWHA. These

issues need to be addressed by adopting a multi-sectoral approach comprising the

government, non-state players, private sector and general public.

(d) Organizations dealing with HIV prevention programmes and the government

need to enhance and ensure effective provision of alcohol and drug abuse counselling

sessions among PLWHA. In addition effective follow-up mechanisms need to be

ensured as this is an integral component of care for people who have just tested HIV

positive. The support groups need to be assisted to widen the scope and enhance

capacity to handle additional concerns of PLWHA.

 159

(e) The government and other stakeholder dealing with HIV prevention need to

strengthen mechanisms that would promote correct and consistent use of condoms

among PLWHA. This would assist in behaviour change in sexual risky practices.

5.3.5 Implications for Further Research

This study has shown that some PLWHA factors are associated with self-efficacy in

HIV prevention while others fail to do so. Further research can be done on:

 A study of PLWHA who are not registered in a support group to establish

whether there are any variations in self efficacy in HIV prevention between

members and non-members.

 A study should be done with different populations to compare self-efficacy in

HIV prevention between HIV-negative people and PLWHA.

 160

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APPENDICES

APPENDIX I: Map of Thika district

 168

APPENDIX II: INDIVIDUAL CONSENT FORM

Good morning/afternoon, my name is Jane, PhD student from Kenyatta University

and I am currently undertaking a PhD study. I am conducting a study in Thika district
from PLWHA aged between 18-49 years to learn about their reproductive health
 169

behavior in order to develop a community based intervention model to be used by

PLWHA in their quest to prevent and mitigate HIV and AIDS. Your opinions and
experiences are important in developing the model. You have been chosen by virtue
of being in this support organization to participate in the study.

I want to assure you that whatever information you give will be treated as
confidential. I will not take record of your name or address. You have the right to stop
the interview at any time, or to skip any questions that you don’t want to answer.
These issues may seem difficult to discuss, but many PLWHA have found it useful to
have the opportunity to talk about their experiences. Your participation is completely
voluntary and will be highly appreciated so please try to be honest and truthful in the
discussions and in answering the questions. Your experiences could be very helpful to
other PLWHA in Kenya. Do you have any questions? The interview takes
approximately one hour to complete. Do you agree to voluntarily participate in this
study?

Note whether respondent agrees to participate or not.

[ ] Does not agree to be participate - thank participant for her time and end.
[ ] Agrees to participate.

TO BE COMPLETED BY INTERVIEWER
I certify that I have read the above consent procedure to the participant.
Signed: --------------------------------------- Date: ---------------------------------

TO BE COMPLETED BY RESPONDENT
Signature of respondent: ------------------------------------ Date: ----------------------
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APPENDIX III: INTERVIEW SCHEDULE GUIDE FOR PLWHA

Topic: Predictors of Self-efficacy in HIV Prevention among People Living with HIV
and AIDS in Thika District, Kiambu County, Kenya.

Division _____________________ Name of Organisation _____________________

Type of Organisation _________________________ Date _____________________

SECTION I: RESPONDENTS SOCIO -DEMOGRAPHIC INFORMATION

1. Sex/ Gender of Respondent. 1) Male [ ] 2) Female [ ]

2. What is your age in years? _________________________________________

3. Where do you stay? ______________________________________________

4a). What is your current marital status?

1) Married/cohabiting [ ] 2) Single (never married) [ ]
3) Widow/widower [ ] 4) Divorced/Separated [ ]

b) If married, what type of marriage are you in?

1) Monogamous [ ] 2) Polygamous [ ]

c) What is your family type?

1) Nuclear [ ] 2) Extended [ ]

5. What is your highest level of education?

1) No formal education [ ] 2) Primary []

3) Secondary [ ] 4) College/Tertiary [ ]

6. What has been your occupation for the last six months?
1) Permanently/contract employed [ ] 2) Casual worker [ ]
3) Business/ self employed [ ] 4 Unemployed [ ]
5) Others ________________________

7a) If on permanent or contract employment, what is your average monthly

income in Kenya Shilling?
1 Below 1,000 [ ] 2) 1,001-5,000 [ ]
3) 5,001-10,000 [ ] 4) Over 10,000 [ ]

b) If on casual or self employment, how much do you earn per day in Kenya
Shilling? __________________________________

c) How many days do you work per week on average? _____________________

(Compute average monthly income)______________________

8. What religion are you affiliated to?

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1) Catholic [ ] 2) Protestant [ ]
3) Muslim [ ] 4 No religion [ ]
5) Others (specify) _________________________________

SECTION II: ATTITUDES OF PLWHA ON HIV AND SEXUAL AND

REPRODUCTIVE HEALTH

Part A: Attitude towards HIV Epidemic by PLWHA

The following aspects concern attitude towards HIV/AIDS by PLWHA. Tell
me whether you agree (A), not sure (NS) or disagree (D) with each statement.
I ……. A NS D
a) Regret having contacted HIV/AIDS
b) Its tough living with HIV/AIDS
c) HIV is better than terminal illnesses

Part B: Attitude of PLWHA towards sero-negative people

The following aspects concern your attitude towards HIV sero negative people. Tell
me whether you agree (A), not sure (NS) or disagree (D) with each statement.

I……… A NS D
a) Am reluctant to live with HIV negative people in the same
community
b) Dislike being in a group of HIV negative people
c) Feel envious towards other people who are HIV negative
d) Reduce my contact time with other people who are HIV
negative
e) Feel discriminated by HIV negative people
f) PLWHA are not able to mix with others in the community
freely

Part C: Attitude towards Sexual Behaviour by PLWHA

The following aspects concern attitude towards sexual behaviour of PLWHA. Tell me
whether you agree (A), not sure (NS) or disagree (D) with each statement.

POSITIVE STATEMENTS A NS D
a) PLWHA should abstain from sex.
b) PLWHA should be faithful to their sexual partner
c) Using condoms is necessary for PLWHA.
d) PLWHA should disclose their HIV status to every sexual partner
they have
e) PLWHA should not have sex with many partners
f) Buying of condoms is embarrassing for PLWHA.
g) Condoms diminish sexual pleasure
Part D: Attitude towards Reproductive Behaviour by PLWHA
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The following aspects concern attitude towards reproductive behaviour of PLWHA.

Tell me whether you agree (A), not sure (NS) or disagree (D) with each statement.
POSITIVE STATEMENTS A NS D
a) PLWHA should have more children if they desire
b) PLWHA should use birth control methods to avoid a pregnancy.
c) Use of birth control methods to avoid pregnancy is ungodly
d) Birth control methods reduces sexual urge.
e) HIV-positive women have a right to advocate for safe sex

SECTION III: SEXUAL PRACTICES OF PLWHA

Part A: Type of Sexual partner and sexual activity

1. How old were you the first time you had sexual intercourse with someone of
the opposite sex ___________________________________________

2.a) If married, do you have other sexual intimate partner(s) apart from your
husband? (Refer to sec.1 Q4)

0) No [ ] 1) Yes [ ]

b) If yes, describe your sexual relationship with these partner(s)?

1) Stable [ ] 2) Casual [ ] 3) Both [ ]

3.a) If single, widowed or separated, do you have a sexual intimate partner? (Refer
to sec.1 Q4)

0) No [ ] 1) Yes [ ]

b) If yes, describe your sexual relationship with these partner(s)?

1) Stable [ ] 2) Casual [ ] 3) Both [ ]

Probe for the type of sexual partner e.g is same sex, commercial sex worker
______________________________________________________________

4. How often do you have sex with the following sexual partners?
Once a week
Daily

Once a month

Twice a month

How often do you have sexual

2-3 times a

intercourse with:

a) Your wife/husband
b) Stable sexual partner
week

c) Casual acquaintance

5. The following statements are concerned with aspects of sexual satisfaction

with your partner(s). Tell me how satisfied you are.
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Neutral

Very satisfied
How satisfied are you when having

dissatisfiedVery

Dissatisfied

Satisfied
sex…..

a) With:
i) Your wife/husband
ii) Stable sexual partner
iii) Casual sex partner
iv) Commercial sex worker
b) Using a female condom
c) Using a male condom
d) Without a condom

PART B: Condom use

1. For the last 12 months, have you ever had sexual intercourse with somebody
else apart from your spouse/stable partner?
0) No [ ] 1) Yes [ ]

2. If yes what is the relationship with this partner(s) for the last six months?
1) Casual acquaintance [ ] 2) Stable partner [ ]

3. I want to know more about your consistency of condom use. Please tell me
how consistently you use a condom with the following sexual partners.
Never

Nearly Always
Rarely
How often do you use a condom with:

Always
Sometimes

a) Your wife/ husband

b) Stable sexual partner
c) Casual sex partner
d) Commercial sex worker
e) Stranger

4. The last time you had sexual intercourse with another person apart from your
spouse/stable partner was a condom used?

0) No [ ] 1) Yes [ ]

Probe for reasons for the response.__________________________________

______________________________________________________________
______________________________________________________________

5 What was the HIV status of that person?

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1) Positive [ ] 2) Negative [ ] 3) I don’t know [ ]

Probe for reasons of not knowing ___________________________________
_______________________________________________________________

6. Did you disclose your HIV status?

0) No [ ] 1) Yes [ ]

Probe for reasons for the response __________________________________

_______________________________________________________________
_______________________________________________________________

5. The following are some of the reasons why PLWHA may use or may not use a
condom when having sexual intercourse. Please tell me whether you strongly
agree (SA), agree (A), not sure (NS), disagree (D) or strongly disagree (SD)
with each statement.

Reasons why PLWHA use a condom….. SD D NS A SA

a) For fear of HIV re-infection and STIs
b) To avoid a pregnancy
c) To Both prevent HIV re-infection and STIs
d) For lack of trust of sex partner
e) Because the partner wants to use
f) Not knowing partner’s HIV status
Reasons why PLWHA do not use a
condom……
a) Partners refusal and disapproval of condom
use
b) Wanting to infect others
c) It is tiring to use it
d) Avoiding raising suspicion about their status

Part C: Number of sexual partners (Multiple partners)

1. For the last 12 months, how many sexual partners have you had?
1) One [ ] 2) Many [ ] 3) None [ ]

Probe for reasons of the response given ______________________________

______________________________________________________________

2. Here are some statements that may explain the reasons why PLWHA have
multiple partners. Tell me whether you strongly agree (SA), agree (A), not
sure (NS), disagree (D) or strongly disagree (SD) with each statement.

Reasons of having multiple partners SD D NS A SA

a) Being sexually dissatisfied
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b) Lack of money
c) Due to friend/peer pressure
d) Bitterness of being HIV positive
e) To spread to others
f) Spousal strained relationships
g) HIV negative partner refusing sex
h) Death of a spouse

PART D: Disclosure of HIV status

1. What year did you get infected with HIV/AIDS? _______________________

2. When did you first test HIV positive? ________________________________

3. Did you do the testing jointly with your regular sexual partner or alone?
______________________________________________________________

4. What is your current partner’s HIV status?

1) Positive [ ] 2) Negative [ ] 3) I don’t know [ ]

Probe for reasons if status is not known ______________________________

_______________________________________________________________

5. Does your current partner know you are HIV positive?

0) No [ ] 1) Yes [ ] 3) I don’t know [ ]

Probe for reasons of the response given ______________________________

_______________________________________________________________
_______________________________________________________________

6. Here are some reasons that make PLWHA not to disclose their HIV status.
Tell me whether you strongly agree (SA), agree (A), not sure (NS), disagree
(D) or strongly disagree (SD).

Reasons why PLWHA do not disclose their HIV SD D NS A SA

status
a) Raise suspicion about unfaithfulness
b) Cause conflict in the relationship
c) Fear of being rejected and stigmatized
d) Leads to job loss
e) Leads to loss of intimate relationship
f) Wanting to infect more people
g) To avoid raising suspicion about one’s status

7. I would like to know how often you disclose your HIV status to the following
persons since you learnt of your HIV positive status.
Never

Sometim

How often do you disclose your HIV

Nearly

Always
Rarely

status to:
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salway
es
a) Your spouse
b) Stable sexual partner
c) Casual sex partner
d) Commercial sex worker
e) Stranger

SECTION IV: REPRODUCTIVE PRACTICES OF PLWHA

Part A: Desire to have children

1. How old were you when you first married/got married? _________________

2. What age were you when you first got your first child? __________________

3. How many children do you have? ___________________________________

(Probe if there are any children to whom she is not the biological
mother/father ___________________________________________________

4. After testing HIV positive, have you been pregnant or impregnated someone?

0) No [ ] 1) Yes [ ]

5. Did you attend ante-natal clinic?

0) No [ ] 1) Yes [ ] 2) N/A [ ]

6. What information is given at ante-natal clinics? ________________________

7. What is the child/children’s HIV status?

1) Positive [ ] 2) Negative - [ ] 3) I don’t know [ ]

Probe further for response given ____________________________________

______________________________________________________________
_______________________________________________________________

8. Do you desire to have more children?

0) No [ ] 1) Yes [ ]

Probe for reasons for the response. __________________________________

_______________________________________________________________

Part B: Use of birth control methods

1 Do you know of any birth control methods a couple can use to delay or avoid a
pregnancy?
0) No [ ] 1) Yes [ ]
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If yes, which ones? _______________________________________________

_______________________________________________________________

2. Have you ever used birth control methods after testing positive to delay or
avoid a pregnancy with your husband/stable partner?
0) No [ ] 1) Yes [ ]

If yes, which ones? _______________________________________________

_______________________________________________________________

If no, why haven’t you used ________________________________________

_______________________________________________________________
3. Have you ever dropped any birth control method(s) with your partner?

0) No [ ] 1) Yes [ ]

If yes, which ones and why ________________________________________

_______________________________________________________________
_______________________________________________________________
_______________________________________________________________

If no, why have you kept on using it _________________________________

_______________________________________________________________
_______________________________________________________________
_______________________________________________________________

4. Which one(s) are you currently using with your partner to avoid or delay a
pregnancy? _____________________________________________________

SECTION V: BARRIERS TO SAFE SEXUAL AND REPRODUCTIVE

BEHAVIOUR
1) In your opinion, are there any barriers that prevent you from practicing safe
sexual and reproductive behaviour?

0) No [ ] 1) Yes [ ]
b) If yes which ones? _______________________________________________
_______________________________________________________________
_______________________________________________________________

SECTION VI: DECISION-MAKING PATTERNS

1. The following are aspects of sexual and reproductive behaviour that may
influence self efficacy in HIV prevention. Tell me who makes the decisions
concerning these aspects in your relationship(s).

Aspects of sexual behaviour Decision maker

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Others
Self

Jointly
Man
a) How to have sexual intercourse
b) Whether to use condoms
c) Which type of condom to use
Aspects of reproductive behaviour
a) Whether to have a child
b) Whether to use other birth control methods
c) When to have a child
d) Who to buy or obtain condoms

SECTION VII: MANAGEMENT OF HIV/AIDS

Part A: Knowledge of HIV and AIDS
1. The following are ways of transmitting HIV/AIDS. Please tell me whether you
strongly agree (SA), agree (A), not sure (NS), disagree (D) or strongly
disagree (SD) with each statement.

HIV can be transmitted through…. SD D NS A SA

a)Unprotected sexual intercourse
b) Receiving unscreened blood
c) Sharing of unsterilized sharp objects e.g.
needles
d) Mother to child transmission
e) Physical contact e.g shaking hands
f) Mosquito bites

2. I would like to learn more about ways PLWHA can prevent transmission of
HIV and AIDS. Please respond to the following statements by telling me how
much you strongly agree (SA), agree (A), not sure (NS), disagree (D) or
strongly disagree (SD).

HIV/AIDS can be prevented by …... SD D NS A SA

a) Abstaining from sex for life
b) Being faithful to your partner
c) Condom use
d) Not sharing sharp objects
e) Avoiding mosquito bite
f) Not sharing food or combs with PLWHA
g) Avoiding physical contact e.g. shaking hands

4. The following aspects concerns transmission of HIV that causes AIDS from a
mother to her baby (MTCT). Please tell me whether you strongly agree (SA),
agree (A), not sure (NS), disagree (D) or strongly disagree (SD) with each
statement.

HIV can be transmitted from mother to child… SD D NS A SA

a) During pregnancy
b) During delivery
c) By breastfeeding
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5. The following aspects concerns prevention of HIV from a mother to her baby
(PMTCT). Please tell me whether you strongly agree (SA), agree (A), not sure
(NS), disagree (D) or strongly disagree (SD) with each statement.

HIV can be prevented from mother to child by… SD D NS A SA

a) Exclusive breastfeeding
b) Delivering through caesarean section
d) Treatment of mother with certain drugs
f) Treatment of the baby with certain drugs
SECTION VIII: SELF-EFFICACY IN HIV PREVENTION
1. Here are some statements that may help to assess your ability to successfully
carry out a healthy HIV preventive action. Please tell me how you rate
yourself under the following statements.

Very high
Very low
Statements on how best you rate yourself in…..

High
Low
Moderate
a) Abstaining from sex for life
b) Being faithful to your partner
c) Ability to use a male condom correctly and
consistently
d)Ability to use a female condom correctly and
consistently
e) Disclosing HIV status to every sexual partner
f) Reducing the number of sexual partners

APPENDIX IV: FOCUS GROUP DISCUSSION

Sexual and Reproductive Behaviour
1. Should people after testing HIV positive engage in sexual relations? (Probe
for reasons behind their responses
 180

2. Should people after testing HIV positive have children? (Probe for reasons
behind their responses)

3. How can a pregnant HIV positive woman pass the virus to the unborn child.

4. How can this be prevented?

5. Whom would you publicly disclose your HIV status to? (Probe for reasons of
disclosing and not disclosing)

Perceptions of HIV/AIDS
1. What do you think are the effects of the virus on people living with it? (Probe
for social, emotional economic & physical).

2. How are PLWHA susceptible in transmitting the virus to others?

3. What makes PLWHA not to practice safe sexual and reproductive practices?
(Probe for barriers to safe sexual and reproductive practices)

4. How possible is it for PLWHA to practice the ABC rule? (Probe for how they
rate themselves in abstaining, being faithful and consistency of condom use;
reasons for using and not using condoms by some PLWHA; why PLWHA may
have multiple sexual partners )

5. What messages help PLWHA to protect themselves from re-infection and

infecting others.

APPENDIX V: KEY INFORMANT INTERVEIW SCHEDULE GUIDE

1a) What can you say about the prevalence of HIV/AIDS in this area? Probe for
statistics for PLWHA in this community –men, women and children and most
vulnerable age-group. Is it a serious problem?
 181

b). What is the rate of new HIV infections by looking at the persons coming for HIV
testing?

c) Do they come for testing alone or jointly? Specify the people accompanying them.

2. How do people perceive the i) the disease; ii) HIV sero-negative people; iii) sexual
behaviour; iv) reproductive behaviour

3a). What can you say about the fertility status of PLWHA in this area/support group?
Probe for desire to have children.

b) Do the women who attend anti-natal clinic always follow instructions given to
prevent the child contracting the virus? Probe for the probability of having HIV
positive children.

4a) What is the rate of contraceptive use among PLWHA in this community? Probe
for mostly used contraceptives.

b) Are there issues of the contraceptives not interacting well with the drugs taken by
PLWHA? Probe for which do or do not interact well with the HIV treatment drugs.

c) What can you say about the demand for condoms by PLWHS among this
community? Probe for availability and usage of female condoms.

5. What is your opinion on compliance/adherence of HIV/AIDS drugs among

PLWHA in this community? Probe for who are more compliant-men or women.

6. What comments can you give on the sexual behaviour among PLWHA?

8. What prevention methods do PLWHA use to curb the spread of HIV and AIDS?

9. In your opinion, what do you think can be done to help PLWHA to practise safe
sexual and reproductive behaviour?

10.What challenges do you experience in your work as you advice PLWHA to

practise safe sexual and reproductive ?

APPENDIX VI: KEY INFORMANT INTERVEIW SCHEDULE GUIDE-

COMMUNITY BASED ORGANIZATION MANAGER

Name of organisation __________________________________________________

Organisation’s funders _________________________________________________
Period of existence ____________________________________________________
 182

1. What kind of assistance do you give to PLWHA?

2. In your opinion, what can you say about their sexual and reproductive behaviour?

3. What challenges do PLWHA face as they try to practice safe sexual and
reproductive behaviour?

4. What do think can be done to PLWHA to promote safe sexual and reproductive
behaviour?

5. What are the major effects of HIV epidemic on PLWHA?