Background
The Dominican Republic (DR) has the second highest number (after Haiti) of adults living with HIV in the Caribbean [
1‐
3]. Over half (56 %) of these HIV cases are women, mainly young women age 15 to 24 [
1,
2,
4,
5]. Even though, prevalence rates of HIV infection are similar for men and women, men in DR are much more likely to report having sex with a non-spousal or co-habiting partner, which is considered high risk sex [
6]. In fact, DR is rated among the countries with the largest gender disparity in higher risk sex [
6]. These differences in sexual behaviors are embedded in a cultural context in which many women in unions in DR are unaware of their male partners’ encounters. As a result, they do not take the necessary steps, such as negotiating condom use, to protect themselves from STDs and HIV [
7]. These gender differences in sexual behaviors are particularly problematic in a context in which HIV transmission is primarily heterosexual and mainly attributable to unprotected sex [
1,
7,
8].
As in other Caribbean countries, social disparities in HIV rates in the DR have been associated with poverty and limited education. Women with fewer than four years of education—particularly those who live in areas of extreme poverty—are one of the groups most vulnerable to the disease [
7,
9]. Low educational level has been found to correlate with lower HIV knowledge, lower risk perception, and more risky sexual behaviors, and therefore correlates with a higher risk of acquiring HIV [
7,
10,
11].
In contrast, higher levels of education have been associated with a lower prevalence of HIV in the DR [
9]. Previous studies have shown that improving education is effective in reducing HIV risk [
12,
13]. Among women, higher education provides them with better job opportunities and financial independence, which some have suggested leads women to be less submissive when negotiating with sexual partners about the use of condoms [
14,
15]. However, a higher level of education in women has not always been found to be protective for risky sexual behaviors, such as having multiple sexual partners and inconsistent condom use [
16,
17].
Evidence from the DR and other countries indicates that women’s vulnerability to HIV is not solely due to socioeconomic factors (e.g. education, income, occupation, and availability of resources); it is also the outcome of a cumulative history of cultural influences that have shaped specific roles for men and women [
18‐
20]. Regardless of a woman’s level of education, the social normalization of gender roles may explain why she has limited power when communicating about sexuality with her partner, demanding fidelity, seeking self-protection in sexually intimate encounters, and negotiating condom use [
14,
15,
19]. In the DR, for instance, women have higher rates of enrollment in secondary and tertiary education, better HIV knowledge, and higher risk perception of acquiring HIV [
7,
21]; however, women are less likely to use condoms than men, particularly if they are married or in a committed relationship [
7]. This incongruity between what women know and what they do may be explained by culturally driven gender roles [
19].
Access to media have the potential to negatively influence gender expectations and roles, but it can also provide information towards adopting good health behaviors, therefore the role of media is complex and depends on exposure and content. For instance, it is not uncommon to find examples in the media that portrays women stereotypically—in subordinate roles, with sexualized bodies, and lacking power in male–female relationships [
22,
23], the “cultivation” theory of media effects suggests that media imagery shapes people’s views of social reality, such that those who are higher media consumers (e.g., of TV crime dramas) are more likely to believe the world looks as it does in the media version of reality [
24]. For example, previous studies indicate that media coverage about a policy issue (i.e. domestic violence) that highlights a specific target group (i.e. women) can activate stereotypes about that group in individuals’ minds, affecting the way the public (both men and women) thinks about the issue in question [
25,
26]. However, media-based interventions targeting HIV risk have been proved to be effective in modeling condom use and condom negotiation, which increases power among women about their own sexuality [
21]. This last finding suggest that the role of access to media may also have a positive impact on condom use depending on the type of message given, but limited information exists on this matter.
Several traditional health behavior theories have explained HIV risk through social-cognitive and motivational processes; however, inequalities between men and women within the labor force, in sexual relationships, and through cultural norms and social expectations can lead to women having limited power and lack of control within relationships [
11,
15,
20]. The present study uses the Sex, Gender, and Population/Health/Nutrition framework used by the Demographic and Health Survey (DHS) to evaluate the impact of gender differences on sexual behaviors in the DR [
27]. The analyses consider how socially constructed differences may determine gender inequalities in roles, responsibilities, expectations, and behaviors, and therefore in power and rights [
27]. As a result, the study includes measures related to socioeconomic determinants, media exposure, and sexual expectations, representing sexual norms associated with the culture.
Evidence suggests that in heterosexual relationships, culturally driven gender roles may work together with socioeconomic indicators to exacerbate gendered power-imbalances and lead to sexual behaviors that increase women’s risk of acquiring HIV [
15,
19]. Because the main mode of HIV transmission in the DR is heterosexual and is mainly attributable to unprotected sex [
1,
7,
8], a comprehensive analysis of gender differences in sexual behaviors needs to include both socioeconomic and cultural factors, and to consider these factors in light of gendered imbalances.
Most of the studies related to HIV risk in the DR have been descriptive [
7,
9]—we found no previous studies that examined the predictive associations between sexual behaviors and socioeconomic and cultural factors using a theory-based quantitative analysis focused on gender. Thus, the purpose of the study was to explore the differences in gendered indicators and sexual behaviors between men and women age 15 to 49 years in the DR, and to contrast the impact of gendered indicators on condom use among men and women. Based on the proposed theoretical framework the study hypothesized that (1) higher socioeconomic status increase the likelihood of condom use for both men and women; (2) higher exposure to media may increase condom use, mainly for women; (3) the role of traditional gender sexual expectations may be associated with lower condom use, mainly for women.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
All authors made substantial intellectual contributions during manuscript preparation. MJ designed the study, conducted the statistical analysis, and drafted the manuscript. FA and MR provided valuable feedback on data analysis and the methodological approach. FA assisted in revising the statistical analysis. FA, MR, and JI edited and proofread the subsequent versions of the manuscript and tables. MR edited and proofread the final version of the manuscript. All authors read and approved the final manuscript.