Unequal Access to HIV Prevention Services by Gender in Benin

HIV infection remains a serious issue of community intervention. In this context, many actions are developed and implemented by both public au-thorities and non-governmental organizations. These are interventions to prevent HIV transmission, overall care, etc. There is a problem of differential propensity according to gender and belonging to social categories access to prevent HIV services. This study aims to identify the explanatory factors for unequal access to HIV prevention services in Benin. Thus, data from the survey on gender-based violence related to HIV collected in 2017 by Plan International Benin were used. The sample size is 929; composed of vulnerable and key populations. Access to prevention services is a composite indicator based on four variables (screening, condom promotion, management of STIs, information, education and communication (IEC) and Communication for Behavioral Change (CBC)). The analysis is done using SPSS.21 software. The bi-varied association was performed using Pearson’s Chi2 and Fisher’s F tests and prediction of explanatory factors by logistic regression. In both 929 populations, 64.5% (599) are key populations and 35.5% (330) are vulnerable. In total, 22.5% (209) population did not have access to prevention services including have the highest odds ratio of poor access to HIV prevention services. From the above, it is necessary for the establishment of a mechanism to facilitate vulnerable people, especially women, access to HIV prevention services. In addition, there is a need to ensure global coverage of the availability and geographical accessibility of prevention services with particular attention in the department of Mono-Couffo.


Introduction
In West and Central Africa (WCA), 6.1 million people are living with HIV, 370,000 are newly infected and more than 280,000 are dying from the disease mainly due to lack of access to prevention services, treatment and care for HIV infection [1]. Despite the progress made in the response to the disease in recent years through the implementation of the various strategies (combined prevention, screening and differentiated care, community screening, self-testing, test and treat, option B+ etc.), the HIV pandemic remains one of the most serious threats to public health in many countries in sub-Saharan Africa. Beyond the consequences of the disease on individuals, it is families, communities and national economies that are paying the heaviest tribute to this pandemic. Recognizing the scale of this public health problem and the need to put in place urgent and adequate strategies, in September 2005, 191 United Nations member States adopted the goal of universal access: "to create an environment in which HIV prevention, treatment, care and support interventions are available, accessible and affordable for all who need them". This action strategy takes into account a wide range of interventions for individuals, families, communities and countries.
In this context, preventive interventions include information and education, awareness raising, screening and management of sexually transmitted infections (STIs), HIV counseling and testing, promotion and distribution condoms [2] [3] [4]. There is also pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) in key populations that have been initiated recently but are in the pilot phase in several West African countries including Benin. According to UNAIDS, key populations include all those who are at higher risk of HIV transmission or who may be infected. Their mobilization and involvement are essential to the success of a response to the virus, in that they are essential for both the dynamics of the epidemic and the response.
Whatever the typology of the HIV epidemic, it is recommended by the World Health Organization (WHO) as part of the implementation of the universal access strategy, to give priority to accelerated prevention service through 1) the selection of prevention interventions that better match the modes of HIV transmission, 2) the identification and concentration of actions in geographical areas  [8].
In accordance with WHO guidelines, Benin set up prevention and treatment interventions with progressive extension throughout the country following the discovery of the AIDS disease in 1985. These interventions include services such as: 1) Information, Education and Communication (IEC), 2) Communication for a Change of Behaviours (CBC), 3) Sexually Transmitted Infections (STI) management, 4) promotion and awareness of the correct and consistent use of condoms, 5) HIV testing, 6) HIV care and treatment, 7) screening and pre-and post-exposure prophylaxis among key population groups. However, Gender-Based Violence (GBV), stigma and discrimination represent major obstacles to universal access to HIV prevention and treatment programs.
Gender is culturally defined as a set of roles, responsibilities, economic, social and political rights and obligations associated with being a woman or a man. It refers to power relations between and among women and men, boys and girls. Thus, the status of the individual according to gender varies from one culture to another, from one geographical area to another, from one era to another and according to the sub-categories that make up the general population (vulnerable people, key populations, etc.). In such a context, anyone whose gender identity does not conform to the norms and expectations traditionally associated with their genital sex assigned at birth are otherwise perceived in their community. Such a climate makes them victims of many ills (violence, discrimination, stigmatization, harassment, social exclusion, etc.). For example, among the groups of key populations trans-sexual is distinguished; these are people who, while physically belonging to one sex, have the feeling of belonging to another; they often try to access a more coherent and less equivocal identity by submitting to medical care and surgical interventions in order to adapt their physical characteristics to their psychic character. These key populations by their gender identity are particularly overexposed to contaminations, especially through HIV and face specific health problems. For example, HIV prevalence is 7.7% among MSM while it is below 2% in the general population [7].
The gender-based violence (GBV) is a violence that finds these roots in gender inequalities and refers to the abuse of power of a person because of his gender identity and expectations of his role in a society or in a culture. In African societies, GBV is one of the determinants of the spread of HIV, particularly in the subpopulations of girls/women and key populations. As an illustration, in Benin, the results of the study on the extent and types of violence suffered during childhood in trans-sexual persons, shows that verbal abuse is the most frequent (90.0%). They are followed by physical violence (56.9%) and sexual violence: 5.9% [9].  [10].
From above, this paper raises the issue of the explanatory factors of unequal access to HIV prevention services in the Beninese context.

Data
This study is based on data collected in 2017 by Plan International Benin. They were collected as part of the investigation into gender-based violence related to HIV. The sampling takes into account the urban, the rural erea and also the twelve departments of the country. The data collected relate to: 1) the risks of gender-based violence and its consequences, 2) the institutional and legal framework, the constraints related to equitable access to HIV prevention, care and treatment services; 3) the potential social, behavioral, environmental, organizational and other factors of stigmatization and discrimination associated with gender-based violence specific to women, girls, and key populations [7]. The data collected made it possible to assess the accessibility of the various prevention services except PrEP and PEP, which are in the experimental phase.
The dependent variable is a composite variable calculated from four variables (information, education and communication: IEC/Communication for Behavioral Change: CBC, HIV testing, STI management, and condom promotion). A person who claims to have benefited from at least one of the four services has been considered to have accessed HIV prevention services. The variable to be explained is a binary variable with two (02) modalities: "benefited" and "did not benefit".
The explanatory variables were recorded in two categories: socio-demographic characteristics (age, sex, education level, marital status, place of residence, department of residence and nationality) and economic characteristics (occupation). The choice of these explanatory variables is essentially based on the literature review and the possibilities offered by the database.

Methods
The data analysis is descriptive, bi-varied and multivariate from a logistic regression for the explanatory factors search. The search for associations between the studied phenomenon and the explanatory variables was carried out on the basis of the Pearson Chi2 and F Fischer association measurement tests. Moreover, in addition to the association tests, the collinearity conditions were verified by measuring the gross effects before the actual logistic regression into three models: a model on all two categories of population studies and two other models on each type of population. A threshold of significance of 5% is retained.
The multivariate logistic regression model is as follows: logit(p) = probability of unequal access to prevention services; X i = Set of explanatory variables (with i ranging from 1 to n); β i = coefficients β respectively attached to each explanatory factor; ε = error term.

Description of the Sample
The socio-demographic and economic characteristics of the sample are presented in (

Classification According to the Degree of Inequality in Access to Prevention Services
Among the subjects who benefited from prevention services during the reference period, a classification according to the degree of accessibility allows a hierarchy at four levels: 1) weak access: when a person has benefited from a single service; 2) average access: when a person has benefited from two services; 3) high access: when one person has received three services and 4) very high access: when a person has benefited from the four prevention services during the reference period.

Unequal Access to HIV Prevention Services and Associated Factors
Overall, 22.5% (209) of the study population report that they did not have access to at least one of the four HIV prevention services considered in the twelve months preceding the survey. Of these, six in ten (66.5%, n = 139) are vulnerable, compared to only three out of ten among key populations (33.5%, n = 70) (p < 0.001).
Following the order of importance among the subgroups of populations who did not have access to prevention services over the observation period, women (51.7%), followed by men (14.8%) and Sex workers (10.5%) are mainly those with limited access to HIV prevention services ( Figure 2).
Not access to HIV prevention services is associated with age, sex, marital status, education level, occupation, and areas of residence ( As for the category of key populations, it appears that the same variables as those mentioned above, except gender and education level, are associated with the low accessibility to HIV prevention services ( Table 2). Teenagers under 20

Explanatory Factors of Unequal Access to HIV Prevention Services
Model 1 ( for the residents of the departments of Mono-Couffo and Zou-Collines. As for model 3, four variables are associated with the low accessibility of prevention services in key populations. In fact, compared to adults aged 25 and over, young people aged 20 -24 are 0.37 times less likely (p < 0.05) not to access prevention services. Relative to those in a union, single people were 0.37 times less likely (p < 0.05) to miss out on HIV prevention services. Unemployed persons and traders were 0.49 times (p < 0.05) and 0.16 times (p < 0.001) less likely to have access to prevention services compared to public servants. In addition, residents of the departments of Borgou-Alibori and Ouémé-Plateau were 0.37 times (p < 0.05) and 0.16 times (p < 0.001) less risky than those in the departments of Atlantique-Littoral not to benefit from services to prevent HIV infection.

Discussion
The results of this study show that key populations are more likely to benefit from HIV prevention services compared to vulnerable people. This finding is not consistent with literature data that highlights the hidden nature of key populations  [15].
The influence of occupation on accessibility cannot be surprising. Indeed, some studies have shown that the type of occupation according to the exercise environment conditions access to prevention services. Economic activity allows the individual to have the resources to cover his or her health needs. Even if prevention services are normally free, there are and still indirect costs or costs related to geographical accessibility that limit access to the poorest. As a result, farmers in rural areas as well as housewives with low purchasing power, will be limited to access because of these constraints. By way of illustration, [19] shows in Cameroon that compared to farmers, persons with a profession in the craft sector and civil officials were respectively 1.47 times and 2.32 times (p < 0.05) more access to prevention services, in particular screening services.

Conclusions
The purpose of this study is twofold in the way to show that there is inequality in access to HIV prevention services by gender and social status, and to investigate the factors behind this situation.
The results show that there is indeed inequality in access to HIV prevention interventions according to the degree of vulnerability and risk.
Teenagers and women who are particularly vulnerable to HIV have very little access to prevention services. The main factors explaining these differences for the entire population under study are occupations and the areas of residence. To these two factors are added age and marital status in the group of key populations.
These results suggest the establishment of a system that can enable vulnerable people in general and women in particular who are most at risk of HIV to access prevention services. Also, it is essential to take steps to ensure geographical accessibility and permanent availability of HIV prevention services in all departments of Benin, particularly those of Ouémé-Plateau and Mono-Couffo.