HIV infection remains a priority public health problem in the West African sub-region and in Côte d’Ivoire, where prevalence has dropped from 3.7% [1] to 2.5% among adults aged 15 to 49. Several national studies have incriminated key populations of men who have sex with men [2] [3] and transgender women [4] as well as the population of male [5] and female [6] [7] [8] sex workers, migrants, and armed forces [9] [10] as being at the root of the spread of the epidemic. Individual risk behaviors that have been shown in the local literature to be responsible include anal sex [2] [3] [6], sexually transmitted infections [11] [12], unprotected sex, multiple partnerships, risky casual sex, early sex and lack of circumcision [13].

However, disparities in prevalence exist between sexes, regions, ethnic groups, living environments, etc., like in all countries of the world. Disparities between Ivorian regions range from 2.2% to 5.5% in the general population, including 1.3% to 4.1% in the male subgroup [1]. These disparities within the same country have led to a reconsideration of the fight. Therefore, the emphasis is now put on community risk behaviors research with consequent means of control. Hence, the importance of ecological studies does not use an individual as the subject of research but units grouping individuals with identical characteristics. Thus, several ecological studies have focused on HIV by looking for explanatory factors for different disparities observed in HIV prevalence between countries [14] [15], ethnic groups or regions of the same country [16] [17] [18] [19] [20]. The explanatory factors addressed in these different studies revolve around gender inequalities, sexually transmitted infections (STIs), male circumcision, condom use, high-risk sexual behaviors (casual partners, multiple lifetime partners, concurrent partners, polygamy, early sexual intercourse, premarital sex), and internal and international migration.

In Côte d’Ivoire, in spite of the means of prevention through the popularization of the use of condoms and antiretroviral treatment, the disease continues to be a threat within the general population and among men in particular, especially those who have sexual relations with other men. All studies conducted at the local level have addressed individuals’ explanatory factors that make HIV a major public health problem at the national level and place the country at the forefront of the West African region. No study has looked at regional disparities in HIV prevalence in Côte d’Ivoire to try to explain this difference in the spread of the pandemic between the country’s geographic regions. This study uses an ecological analysis to explain the extent of the differential spread of HIV between regions of Côte d’Ivoire. It aims to analyze the explanatory factors for the difference in HIV prevalence observed among men in the different regions of Côte d’Ivoire, using the 2012 Demographic and Health Surveys (DHS) database. The interest of this study is to contribute to improving HIV interventions through strategic reorientations at the regional level.

This study analyzed explanatory factors of the differential spread of HIV observed in men aged 15 - 59 years at the Ivorian geographical regions level, using the 2012 DHS database.

Spatial distribution of average male data per geographic location showed low HIV prevalence in the central-western (1.3%) and northern (1.5%) regions, but a high prevalence in the city of Abidjan (4.1%). This could be explained by socio-cultural and religious factors, since the central-western and northern regions were deeply rooted in the country’s traditional religions of Islam and Catholicism, but also in tradition. As a result, morality, respect for social norms and the weight of the elderly were paramount in decision-making. This was not the case in the big city of Abidjan, which was also a crossroads for several peoples in continuous movement. It was in the city of Abidjan that high-risk sexual practices were found, key populations in which HIV infection was concentrated, gateway populations responsible for the spread of HIV in the general population, and rising drug use [2] [3] [4] [6] [7] [8] [12] [21] [22] [23] [24] [25].

These same factors could explain the low condom use in the North-West region (17.25%), while it is high in the city of Abidjan (41.3%). Indeed, cultural and religious norms ran counter to the use of contraceptive barriers. Because condoms were seen as a contraceptive method, their use remained low in the predominantly Muslim north of the country that is in favor of large families [26].

Areas with more schooled men (the south, south-west regions and the city of Abidjan) were the most affected by HIV. These results could be explained by the fact that educated people had access to true HIV information through health professionals, mass media, internet and social networks. They would then be screened for antiretroviral treatment unlike other illiterate men, who would immure themselves in denial and prejudices of all kinds. This finding was in line with Bouba’s finding that HIV prevalence increased with educational attainment, in line with the general population in Cameroon [27].

Several previous studies have identified condom use and stable living together as factors that reduce HIV prevalence by reducing new infections at the individual level. Specifically, these factors would prevent HIV spread from key populations that are pockets of infection to the general population [28] - [33]. Therefore, it seems quite urgent to emphasize the proper use of condoms to better protect the individual against HIV infection. It is necessary to adapt awareness and information messages to the context and real needs of the people and especially to use new communication technologies (internet, all social networks, telephones) for their dissemination in the different communities [34]. Above all, it is necessary to target all the social networks used by young people and adults, the various associations to which they belong, the communities of people, etc. to communicate and meet.

In contrast, our results paradoxically indicated that mean age at first sexual intercourse was a risk factor, while frequent sexual infections reduced the risk of HIV infection.

In contrast, our results paradoxically revealed that the average age at first sexual intercourse was a risk factor and frequent sexual infections reduced the risk of HIV infection. Indeed, late age at first sexual intercourse (after 15 years) was the most important protective factor among positive sexual behaviors of men and women in Sub-Saharan Africa [35]. Early sexual intercourse before 15 years was a risk factor for HIV infection in HIV-positive sex workers in Bangui, Central African Republic [31]. In addition, sexually transmitted infections (STIs) have always been proven to be the bed of HIV infection. At the national level, a high prevalence of HIV has been found associated with STIs in key populations of male professionals [36], in HIV-positive women [11], and in users of three sexually transmitted disease clinics [12]. STIs have been identified as high-risk factors for the high prevalence of HIV infection in Banjul, Central Africa [31], Meyomessala Health District, Cameroon [28], between ethnic groups in Uganda [16] and sex workers enrolled in behavioral intervention in Battambang, Cambodia [37]. Inadequate treatment of STIs appeared to be at the root of the higher prevalence of HIV among African populations. For example, effective large-scale STI treatment capacity was recommended for effective HIV control in Africa [14] [18].

However, our contradictory results at the individual level may well open new horizons to explain differences in HIV prevalence at the population level, between areas and regions, and between groups of individuals with identical characteristics of the same country. The persistence of HIV transmission after more than four decades of relentless struggle has not yet been sufficiently exploited. Moreover, HIV infection has not yet finished revealing its secrets, according to the results of some ecological studies. Indeed, the sub-Saharan Africa region, with more than 80% of men circumcised, recorded the highest prevalence of HIV in the world.

This paradoxical relationship between circumcision and HIV prevalence worldwide, found in black ethnic groups in South Africa, was explained by the existence of another factor whose effect would be mitigated by circumcision. Inadequate treatment of STIs has been the underlying factor in the literature with little evidence. At that time, the diverse sexual behaviors of individuals were examined more closely and revealed a differential spread of STIs through networks of sexual partnerships. The connectivity of the sexual network is determined by the number of sexual partners over life and the simultaneity of sexual partners that have been found in higher numbers in black communities with high HIV prevalence in the United States and South Africa [14] [16].

The spread of HIV is determined by a complex interaction of social, behavioral, economic and biological factors operating at multiple levels. As a result, further ecological studies were needed to explore in-depth the contradictory results of this study.

In addition to all the limitations of ecological studies known in the literature, it is known that any ecological analysis is sensitive to ecological inference error, so inferences cannot be drawn at an individual level. DHS surveys are also not optimal for determining sensitive sexual information. In addition, while response rates for participation in the HIV survey and testing were high, they varied considerably across regions [20]. As a result, the data are subject to many biases such as social desirability, recall, and non-response biases. We cannot rule out the possibility that respondents in regions where low-risk sexual behavior has been reported may be subject to a greater social desirability bias, which could invalidate our findings. However, available data suggest that only minor differences in sexual behavior exist between those who respond and those who do not respond to sexual behavior questionnaires [20]. The possibility that relationships between sexual behavior, region and HIV prevalence may be confounded by other unmeasured variables is not excluded.

Data were aggregated in eleven regions of Côte d’Ivoire and not on individuals. Data on condom use were limited to the last sexual partner, which did not inform us about condom use in pre-data sex which is regular condom use. The lack of data on individuals limits the ability to identify periods and new HIV infections (of individuals) in the regions. Finally, there were programmatic limitations to the study results. Despite these shortcomings, our study opens up prospects for operational research on the determinants of HIV prevalence and condom use between Ivorian regions, even though conclusions cannot be drawn about individuals.

The study found that factors that accounted for the difference in HIV prevalence among men in the country’s regions were union, condom use, the average age at first sexual intercourse, sexual infection, sexual activity, and multi-sexual partnership. However, only union and condom use were effective in reducing HIV prevalence through the elimination of new infections. The disparity in prevalence was mitigated by Christian religion and schooling. Mean age at first sexual intercourse was a risk factor while paradoxically frequent sexual infections reduced the risk of HIV infection.

This study confirms the critical role of sexual behavior and certain socio-demographic characteristics in the differential spread of HIV in communities. Despite good results after several years of fighting the pandemic, infection remains highly concentrated in certain groups or communities. For a long time, this struggle has been focused on the individual. It would be appropriate to go beyond the individual level to fight a much more community-based fight like Uganda, Thailand, Zambia and the gay community of the United States did with better results in the early stages of the fight against HIV/AIDS [38]. Uganda has successfully used social networks to disseminate community intervention strategies that promote behavior change among the population. These proven good practices need to be adopted by pandemic programs or adapted to the Ivorian context to enable the fight against HIV to take another turn for greater effectiveness [38] [39].

The authors declare no conflicts of interest regarding the publication of this paper.

Essis, E.M.L., Iba, B., Konan, L.L., Konan, E., Aka, J. and Ndola, P. (2022) Explanatory Factors for the Variation in HIV Prevalence between Regions of Côte d’Ivoire: An Ecological Study. Health, 14, 507-522. https://doi.org/10.4236/health.2022.145038