The intersection of financial agency, sexual decision-making power, and HIV risk among adolescent girls and young women in Zambia

HIV incidence rates have been on the decline globally, yet certain sub-populations have seen their incidence rates increase, bearing an extraordinary share of the HIV disease burden. In Eastern and Southern Africa, the rate of new HIV infections disproportionately affects adolescent girls and young women (AGYW) with up to three times as many young women ages 15-24 living with HIV as compared to their male peers. These statistics make AGYW a key demographic for action in order to realize an AIDS-free generation. To most effectively intervene, researchers must examine the rationale for higher infection rates among young females. Recent studies have found positive correlation between economic strengthening interventions (such as cash transfers, savings accounts, or financial literacy) and HIV sexual risk among AGYW, however, the majority of the literature to date understands these economic strengthening interventions at the household level, as a mechanism for providing insurance against economic shocks and as an incentive for keeping girls in school, a key predictor of reduced HIV. Fewer studies have sought to understand how increased resources, and power over those resources, affects the thoughts and behaviors of AGYW at the individual level. Does this enhanced agency translate into greater power in intimate relationships? Does she feel more entitled to make decisions over her own body once she has the power to meet her own basic needs? And does agency over her body inevitably translate to fewer HIV risk behaviors? This three-paper dissertation examines data collected with AGYW living in two urban areas, characterized by HIV prevalence. These areas are the sites of a multi-sectoral DREAMS program, a public-private partnership to reduce HIV incidence in ten countries within sub-Saharan Africa. Paper 1 examined the construct of financial agency through the development of a scale, finding variations in experience of financial autonomy between age cohorts with younger adolescents’ autonomy correlated to a higher likelihood of being sexually active and exposure to partner violence. Financial agency was not strongly associated with HIV risk reduction variables at any age. Paper 2 sought to understand the correlational relationships between personal financial agency, sexual relationship power (SRP), and reduced sexual HIV risk for AGYW in Zambia in order to determine if SRP may be a potential mediator between financial agency and sexual HIV risk reduction. Paper 2 found that SRP within sexual relationships did convert to HIV protective behaviors and that while financial agency did correlate with SRP for the oldest cohort, financial agency on its own was not sufficient to reduce sexual HIV risk. Paper 3 explored how AGYW in Zambia understand financial agency as a construct and how it does or does not affect their power in intimate relationships. This study demonstrated that financial independence is an aspiration of AGYW, however, that autonomy is tied up with negative community-based perceptions about what it means to be a woman earning and with control over her own income. Financial independence has promise as a mechanism for sexual HIV risk reduction, specifically the reduction of transactional sex; however, the realities of male sexual privilege may remain an obstacle to risk reduction irrespective of financial decision-making power. Women’s sexual agency was viewed as far greater in non-martial relationships as opposed to within marriage, where religious mores on headship created a power imbalance. Overall, findings from this dissertation contribute empirically to the literature on economic strengthening and HIV prevention for AGYW, providing new insights on the influence of individual financial agency. Findings suggest a nuanced relationship between financial agency and sexual HIV risk reduction, one that is not necessarily linear or positively correlated. HIV prevention programs that wish to incorporate economic strengthening into their multi-sectoral models should consider the influence of gender norms and sexual relationship power which could continue to keep AGYW in positions of vulnerability regardless of their financial autonomy.