Gender Differences in HIV/HSV-2: Evidence from a School Support Randomized Controlled Trial Among Orphaned Adolescents in Kenya

  • Hyunsan ChoEmail author
  • Michelle E. Deming
  • Ju-Hyun Park
  • Bonita Iritani
Original Paper


Women and girls are disproportionately affected by HIV and other sexually transmitted infections (STIs) such as Herpes Simplex Virus type-2 (HSV-2) in Sub-Saharan Africa (SSA). Given this gender disparity and women’s vulnerability to HIV/STIs, prevention efforts often target women, but relatively little attention has been paid to compare whether HIV interventions produce equal program effects across gender. The purpose of this study is to examine whether the school support intervention had equal program effects on study outcomes and biomarkers by gender among orphaned adolescents in Kenya. A randomized controlled trial was conducted to test whether keeping orphaned boys and girls in school reduced risky sexual behaviors and prevented HIV/HSV-2 infection in Kenya (N = 835). We collected four annual surveys and biomarkers measures of HIV and HSV-2 at Time 1 and Time 4. Regression analysis and multi-level linear mixed models were conducted, and t test with Satterthwaites’ method for each regression coefficients was used to compare program effects by gender. There were substantial gender differences on risky sexual behaviors, HSV-2 infection, and gendered ideologies prior to intervention implementation. The school support intervention had significant gender-specific program impacts on HSV-2. The intervention females experienced a 36% increase in HSV-2 infection while intervention males experienced a 23% decrease after 3 years of program implementation. Differential program effects by gender on attitudes toward abstaining from sex were also found. More scientific research is needed to test whether HIV interventions produce equal program impacts by gender. Prevention programs should recognize gender-specific program effects and address individual, relational, and contextural factor that reinforce the gender disparity in HIV/HSV-2 risk.


Orphans School support Kenya HIV/herpes simplex-virus type-2 



We thank Isabella Mbai, Janet Itindi, Benson Milimo, Carolyn Atieno, David Okumu, Everlyn,Aloo, James Oguta, Mark Wanyama, Joan Amani for their important contributions to the project.


This study was funded by the National Institute of Mental Health, National Institutes of Health (R01MH09225, Hyunsan Cho, P.I.). The original trial was registered at (ID: NCT01501864).

Supplementary material

10461_2019_2518_MOESM1_ESM.docx (59 kb)
Supplementary material 1 (DOCX 58 kb)


  1. 1.
    Baird SJ, Garfein RS, McIntosh CT, Özler B. Effect of a cash transfer programme for schooling on prevalence of HIV and herpes simplex type 2 in Malawi: a cluster randomised trial. The Lancet. 2012;379(9823):1320–9.CrossRefGoogle Scholar
  2. 2.
    Baker DP, Collins JM, Leon J. Risk factor or social vaccine? The historical progression of the role of education in HIV and AIDS infection in Sub-Saharan Africa. Prospects. 2008;38(4):467–86.CrossRefGoogle Scholar
  3. 3.
    Bärnighausen T, Hosegood V, Timaeus IM, Newell M-L. The socioeconomic determinants of HIV incidence: evidence from a longitudinal, population-based study in rural South Africa. AIDS (London, England). 2007;21(Suppl 7):S29.CrossRefGoogle Scholar
  4. 4.
    Cho H, Luseno W, Halpern C, Zhang L, Mbai I, Milimo B, Hallfors DD. Discordance of HIV and HSV-2 biomarkers and self-reported sexual behaviour among orphan adolescents in Western Kenya. Sex Transm Infect. 2015;91(4):260–5.CrossRefGoogle Scholar
  5. 5.
    Cho H, Mbai I, Luseno WK, Hobbs M, Halpern C, Hallfors DD. School support as structural HIV prevention for adolescent orphans in western Kenya. J Adolesc Health. 2018;62(1):44–51.CrossRefGoogle Scholar
  6. 6.
    Connell RW. Change among the gatekeepers: men, masculinities, and gender equality in the global arena. Signs. 2005;30(3):1801–25.CrossRefGoogle Scholar
  7. 7.
    Core Team R. Vienna. Austria: R Foundation for Statistical Computing; 2018.Google Scholar
  8. 8.
    Dallabetta GA, Miotti PG, Chiphangwi JD, Saah AJ, Liomba G, Odaka N, Sungani F, Hoover DR. High socioeconomic status is a risk factor for human immunodeficiency virus type 1 (HIV-1) infection but not for sexually transmitted diseases in women in Malawi: implications for HIV-1 control. J Infect Dis. 1993;167(1):36–42.CrossRefGoogle Scholar
  9. 9.
    De Neve J-W, Fink G, Subramanian S, Moyo S, Bor J. Length of secondary schooling and risk of HIV infection in Botswana: evidence from a natural experiment. Lancet Glob Health. 2015;3(8):e470–7.CrossRefGoogle Scholar
  10. 10.
    Duflo E, Dupas P, Kremer M. Education, HIV, and early fertility: experimental evidence from Kenya. Am Econom Rev. 2015;105(9):2757–97.CrossRefGoogle Scholar
  11. 11.
    Dunkle KL, Decker MR. Gender-based violence and HIV: reviewing the evidence for links and causal pathways in the general population and high-risk groups. Am J Reprod Immunol. 2013;69(s1):20–6.CrossRefGoogle Scholar
  12. 12.
    Glynn JR, Caraël M, Auvert B, Kahindo M, Chege J, Musonda R, Kaona F, Buvé A, Study Group on the Heterogeneity of HIV Epidemics in African Cities. Why do young women have a much higher prevalence of HIV than young men? A study in Kisumu, Kenya and Ndola, Zambia. AIDS. 2001;15:S51–60.CrossRefGoogle Scholar
  13. 13.
    Gregson S, Waddell H, Chandiwana S. School education and HIV control in sub-Saharan Africa: from discord to harmony? J Int Dev. 2001;13(4):467–85.CrossRefGoogle Scholar
  14. 14.
    Guo Y, Li X, Sherr L. The impact of HIV/AIDS on children’s educational outcome: a critical review of global literature. AIDS Care. 2012;24(8):993–1012.CrossRefGoogle Scholar
  15. 15.
    Gust DA, Pan Y, Otieno F, Hayes T, Omoro T, Phillips-Howard PA, Odongo F, Otieno GO. Factors associated with physical violence by a sexual partner among girls and women in rural Kenya. J Glob Health. 2017;7(2):020406.Google Scholar
  16. 16.
    Hallfors DD, Cho H, Hartman S, Mbai I, Ouma CA, Halpern CT. Process evaluation of a clinical trial to test school support as HIV prevention among orphaned adolescents in Western Kenya. Prev Sci. 2017;18(8):955–63.CrossRefGoogle Scholar
  17. 17.
    Hallfors DD, Cho H, Rusakaniko S, Mapfumo J, Iritani B, Zhang L, Luseno W, Miller T. The impact of school subsidies on HIV-related outcomes among adolescent female orphans. J Adolesc Health. 2015;56(1):79–84.CrossRefGoogle Scholar
  18. 18.
    Hargreaves JR, Bonell CP, Boler T, Boccia D, Birdthistle I, Fletcher A, Pronyk PM, Glynn JR. Systematic review exploring time trends in the association between educational attainment and risk of HIV infection in sub-Saharan Africa. AIDS. 2008;22(3):403–14.CrossRefGoogle Scholar
  19. 19.
    HIV/AIDS JUNPO. Ending AIDS: progress towards the 90-90-90 targets. Global AIDS update; 2017.Google Scholar
  20. 20.
    Hrong-Tai Fai A, Cornelius PL. Approximate F-tests of multiple degree of freedom hypotheses in generalized least squares analyses of unbalanced split-plot experiments. J Stat Comput Simul. 1996;54(4):363–78.CrossRefGoogle Scholar
  21. 21.
    Jewkes RK, Dunkle K, Nduna M, Shai N. Intimate partner violence, relationship power inequity, and incidence of HIV infection in young women in South Africa: a cohort study. The Lancet. 2010;376(9734):41–8.CrossRefGoogle Scholar
  22. 22.
    Langhaug LF, Sherr L, Cowan FM. How to improve the validity of sexual behaviour reporting: systematic review of questionnaire delivery modes in developing countries. Tropical Med Int Health. 2010;15(3):362–81.CrossRefGoogle Scholar
  23. 23.
    Leclerc-Madlala S. Transactional sex and the pursuit of modernity. Soc Dyn. 2003;29(2):213–33.CrossRefGoogle Scholar
  24. 24.
    Luke N. Age and economic asymmetries in the sexual relationships of adolescent girls in sub-Saharan Africa. Stud Fam Plann. 2003;34(2):67–86.CrossRefGoogle Scholar
  25. 25.
    Luke N. Confronting the’sugar daddy’stereotype: age and economic asymmetries and risky sexual behavior in urban Kenya. Int Fam Plan Perspect. 2005;31:6–14.CrossRefGoogle Scholar
  26. 26.
    Luke N, Kurz K. Cross-generational and transactional sexual relations in sub-Saharan Africa. Washington, DC: International Center for Research on Women (ICRW); 2002.Google Scholar
  27. 27.
    Maughan-Brown B, George G, Beckett S, Evans M, Lewis L, Cawood C, Khanyile D, Kharsany AB. Age-disparate partnerships and HSV-2 among adolescent girls and young women in South Africa: implications for HIV infection risk. Sex Transm Infect. 2019. Scholar
  28. 28.
    Mee P, Fearon E, Hassan S, Hensen B, Acharya X, Rice BD, Hargreaves JR. The association between being currently in school and HIV prevalence among young women in nine eastern and southern African countries. PLoS ONE. 2018;13(6):e0198898.CrossRefGoogle Scholar
  29. 29.
    Mojola SA. Love, money, and HIV: Becoming a modern African woman in the age of AIDS. Oakland: Univ of California Press; 2014.CrossRefGoogle Scholar
  30. 30.
    Operario D, Underhill K, Chuong C, Cluver L. HIV infection and sexual risk behaviour among youth who have experienced orphanhood: systematic review and meta-analysis. J Int AIDS Soc. 2011;14(1):25.CrossRefGoogle Scholar
  31. 31.
    Ott MQ, Bärnighausen T, Tanser F, Lurie MN, Newell M-L. Age-gaps in sexual partnerships: seeing beyond ‘sugar daddies’. AIDS. 2011;25(6):861.CrossRefGoogle Scholar
  32. 32.
    Perry B, Oluoch L, Agot K, Taylor J, Onyango J, Ouma L, Otieno C, Wong C, Corneli A. Widow cleansing and inheritance among the Luo in Kenya: the need for additional women-centred HIV prevention options. J Int AIDS Soc. 2014;17(1):19010.CrossRefGoogle Scholar
  33. 33.
    Pettifor A, MacPhail C, Hughes JP, Selin A, Wang J, Gómez-Olivé FX, Eshleman SH, Wagner RG, Mabuza W, Khoza N. The effect of a conditional cash transfer on HIV incidence in young women in rural South Africa (HPTN 068): a phase 3, randomised controlled trial. Lancet Glob Health. 2016;4(12):e978–88.CrossRefGoogle Scholar
  34. 34.
    Pettifor AE, Measham DM, Rees HV, Padian NS. Sexual power and HIV risk, South Africa. Emerg Infect Dis. 2004;10(11):1996.CrossRefGoogle Scholar
  35. 35.
    Pratto F, Walker A. The Bases of Gendered Power. New York: Gulford Press; 2004.Google Scholar
  36. 36.
    Rajagopal S, Magaret A, Mugo N, Wald A. Incidence of herpes simplex virus type 2 infections in Africa: a systematic review. In: Paper presented at the Open forum infectious diseases; 2014.Google Scholar
  37. 37.
    Rosenthal L, Levy SR. Understanding women’s risk for HIV infection using social dominance theory and the four bases of gendered power. Psychol Women Q. 2010;34(1):21–35.CrossRefGoogle Scholar
  38. 38.
    Sia D, Onadja Y, Hajizadeh M, Heymann SJ, Brewer TF, Nandi A. What explains gender inequalities in HIV/AIDS prevalence in sub-Saharan Africa? Evidence from the demographic and health surveys. BMC Public Health. 2016;16:1–18. Scholar
  39. 39.
    Sidze EM, Stillman M, Keogh S, Mulupi S, Egesa CP, Leong E, Mutua M, Muga W, Bankole A, Izugbara CO. From paper to practice: sexuality education policies and their implementation in Kenya. New York: Guttmacher Institute; 2017.Google Scholar
  40. 40.
    Stoebenau K, Heise L, Wamoyi J, Bobrova N. Revisiting the understanding of “transactional sex” in sub-Saharan Africa: a review and synthesis of the literature. Soc Sci Med. 2016;168:186–97.CrossRefGoogle Scholar
  41. 41.
    Stoner MC, Pettifor A, Edwards JK, Aiello AE, Halpern CT, Julien A, Selin A, Twine R, Hughes JP, Wang J, Agyei Y. The effect of school attendance and school dropout on incident HIV and HSV-2 among young women in rural South Africa enrolled in HPTN 068. AIDS. 2017;31(15):2127–34.CrossRefGoogle Scholar
  42. 42.
    UNAIDS & The African Union. Empower young women and adolescent girls. Fast-Traking the end of the AIDS epidemic in Africa. Geneva: UNAIDS; 2015.Google Scholar
  43. 43.
    UNICEF. Africa’s orphaned and vulnerable generations: children affected by AIDS. New York: UNICEF; 2006.Google Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Hyunsan Cho
    • 1
    Email author
  • Michelle E. Deming
    • 1
  • Ju-Hyun Park
    • 2
  • Bonita Iritani
    • 3
  1. 1.Department of Health Promotion, Education, and Behavior, Arnold School of Public HealthUniversity of South CarolinaColumbiaUSA
  2. 2.Department of StatisticsDongGuk UniversitySeoulKorea
  3. 3.Pacific Institute for Research and EvaluationChapel HillUSA

Personalised recommendations