Academic journal article Demographic Research

Overestimating HIV Infection: The Construction and Accuracy of Subjective Probabilities of HIV Infection in Rural Malawi

Academic journal article Demographic Research

Overestimating HIV Infection: The Construction and Accuracy of Subjective Probabilities of HIV Infection in Rural Malawi

Article excerpt

Abstract

In the absence of HIV testing, how do rural Malawians assess their HIV status? In this paper, we use a unique dataset that includes respondents' HIV status as well as their subjective likelihood of HIV infection. These data show that many rural Malawians overestimate their likelihood of current HIV infection. The discrepancy between actual and perceived status raises an important question: Why are so many wrong? We begin by identifying determinants of self-assessed HIV status, and then compare these assessments with HIV biomarker results. Finally, we ask what characteristics of individuals are associated with errors in self-assessments.

1. Introduction

The rise of HIV infection during the early years of the AIDS epidemic resulted in a rapid increase in mortality - particularly during adulthood - in eastern and southern Africa, with further increases in AIDS-related mortality projected for the next decade (Timaeus and Jasseh 2004). For individuals, such changes in mortality levels often result in considerable uncertainty about the magnitude of risk (Montgomery 2000). This uncertainty is heightened due to information constraints in sub-Saharan Africa (SSA), as accurate up-to-date information about changing mortality conditions is often not available for many, particularly those residing in rural areas. Moreover, this uncertainty is likely to be particularly severe in the context of HIV, where the long latency period between infection and death makes it difficult to connect the source of infection with deaths a decade or so later.

In the low- and middle-income countries of sub-Saharan Africa, people facing the tide of the AIDS epidemic have little alternative but to rely on subjective assessments of their HIV status. Virtually all living in highly AIDS-affected areas of SSA know that HIV is sexually transmitted, and some have engaged in what they believe is risky sex or believe their sexual partner has engaged in risky sex. It would not be surprising, then, that many think that they have already been infected. However, UNAIDS and WHO estimate that in low- or middle-income countries only 10% of people at risk of HIV infection have access to voluntary counseling and testing (VCT) (UNAIDS 2004) that provides the possibility for individuals to confirm their HIV status. The few existing VCT centers are concentrated in urban areas, making certainty particularly difficult for rural residents.3 Those who are promoting the expansion of VCT as a weapon in the battle against AIDS believe that it is critical for people to know their status accurately. The assumption is that knowledge of one's status will affect behavior: those who learn they are negative will be motivated to adopt stronger prevention methods, whereas those who learn they are positive will change their behavior so as not to infect others (Holbrooke 2004). There is little evidence to support these predictions of behavioral change. It is, however, reasonable to maintain that in the absence of testing facilities, subjective assessments are likely to drive behavior. As has been said, "If [people] define situations as real, they are real in their consequences." (Thomas and Thomas 1928: 572).

In this paper, we use a unique dataset from rural Malawi that includes respondents' HIV status as well as their subjective assessment of currently being infected with HIV. These data show that 12% of rural Malawian men and women estimate a medium or high likelihood of current infection. At 7%, actual prevalence was significantly lower. (Obare et al, 2008). The difference between the measures of self-assessed and objective HIV status raises important questions: How accurate are rural Malawians in assessing their HIV status, and why are these self-assessments incorrect?4 Addressing this question is related to the important issue of subjective HIV risk assessment construction. In this paper, we therefore begin by identifying characteristics or beliefs that lead individuals to believe they are, or are not, already infected. …

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