Using multilevel models to evaluate the influence of contextual factors on HIV/AIDS, sexually transmitted infections, and risky sexual behavior in sub-Saharan Africa: a systematic review

Ann Epidemiol. 2018 Feb;28(2):119-134. doi: 10.1016/j.annepidem.2017.11.006. Epub 2017 Dec 5.


Purpose: To describe the use of multilevel models (MLMs) in evaluating the influence of contextual factors on HIV/AIDS, sexually transmitted infections (STIs), and risky sexual behavior (RSB) in sub-Saharan Africa.

Methods: Ten databases were searched through May 29, 2016. Two reviewers completed screening and full-text review. Studies examining the influence of contextual factors on HIV/AIDS, STIs, and RSB and using MLMs for analysis were included. The Quality Assessment Tool for Quantitative Studies was used to evaluate study quality.

Results: A total of 118 studies met inclusion criteria. Seventy-four studies focused on HIV/AIDS-related topics; 46 focused on RSB. No studies related to STIs other than HIV/AIDS met the eligibility criteria. Of five studies examining HIV serostatus and community socioeconomic factors, three found an association between poverty and measures of inequality and increased HIV prevalence. Among studies examining RSB, associations were found with numerous contextual factors, including poverty, education, and gender norms.

Conclusions: Studies using MLMs indicate that several contextual factors, including community measures of socioeconomic status and educational attainment, are associated with a number of outcomes related to HIV/AIDS and RSB. Future studies using MLMs should focus on contextual-level interventions to strengthen the evidence base for causality.

Keywords: HIV; Multilevel analysis; Sexual behavior; Sexually transmitted diseases; Social determinants of health; Sub-Saharan Africa.

Publication types

  • Systematic Review

MeSH terms

  • Africa South of the Sahara / epidemiology
  • Female
  • HIV Infections / epidemiology*
  • Humans
  • Male
  • Multilevel Analysis
  • Poverty
  • Risk-Taking*
  • Sexual Behavior*
  • Sexually Transmitted Diseases / epidemiology*
  • Social Determinants of Health*
  • Socioeconomic Factors