HIV This Week

Bongaarts J. Late marriage and the HIV epidemic in sub-Saharan Africa. Popul Stud (Camb) 2007;61:73-83.

The causes of large variation in the sizes of HIV epidemics among countries in sub-Saharan Africa are not well understood. Here Bongaart assesses the potential roles of late age at marriage and a long period of premarital sexual activity as population risk factors, using ecological data from 33 sub-Saharan African countries and with individual-level data from Demographic and Health Surveys (DHS) in Kenya and Ghana in 2003. The ecological analysis finds a significant positive correlation between HIV prevalence and median age at first marriage, and between HIV prevalence and interval between first sexual intercourse and first marriage. The individual-level analysis shows that HIV infection per year of exposure is higher before than after first marriage. These findings support the hypothesis of a link between a high average age at marriage and a long period of premarital intercourse during which partner changes are relatively common and facilitate the spread of HIV.

Editors’ note: This ecological association makes common sense overall, particularly for young men and increasingly for young women. However, in societies in which adolescent marriage – a human rights concern - is common, HIV prevalence can be higher among married adolescent girls than among unmarried sexually active girls of the same age. This can be the result of the broader age gap between spouses versus between girlfriend-boyfriends, with implications for pre-marital HIV risk in the husband, and difficulties in negotiating condom use within marriage. Marriage cannot automatically be assumed to be either risky or protective – it is the behaviours that make the difference when HIV is looking for opportunities.

Porto MP. Fighting AIDS among adolescent women: effects of a public communication campaign in Brazil. J Health Commun 2007;12:121-32.

In 2003, Brazil’s Ministry of Health launched a national campaign aimed at promoting the use of condoms by adolescent women. The Carnival Campaign was broadcast on television and radio between February 16 and March 3 and targeted young women, between 13 and 19 years of age, a social group that previously had registered a growth in the number of cases of AIDS and other sexually transmitted diseases (STDs). The Ministry hired Kelly Key, a Brazilian pop singer, to deliver the campaign messages. One of the objectives was to empower the girls and encourage them not to be ashamed to buy condoms and to demand that their partners use them. The article presents the results of a national survey conducted with 1,006 adolescent women, which was sponsored by the Ministry of Health. The results show that campaign materials reached the main target public and that they were very positively received. Moreover, the survey data show that the Carnival Campaign had important effects, generating discussions in the adolescents’ social environments and reinforcing a social norm that favours the participation of women in the purchase and use of condoms.

Editors’ note: Social change communication to create and reinforce new social norms for HIV prevention can use strategies like this one which open up space for discussion, negotiation and safer behaviour. Although a well known woman artist influenced and empowered adolescent girls, the fact that the campaign messages were carried on television and radio meant that it was likely that considerable numbers of men and boys would also have seen and heard the messages, enhancing the probability that they will react favourably. The next step is to change social norms about what it means to be a real man so that men and boys will act favourably from the start.

Boer H, Mashamba MT. Gender power imbalance and differential psychosocial correlates of intended condom use among male and female adolescents from Venda, South Africa. Br J Health Psychol 2007;12:51-63.

In South Africa, a gender power imbalance exists which may prevent women from negotiating safe sexual encounters. In this study Boer and colleagues tested which constructs from Protection Motivation Theory (PMT) and the Theory of Planned Behaviour (TPB) and their circumstances were most related to condom use intention. The authors hypothesized that in a situation of gender power imbalance, self-efficacy would be a more salient correlate of intended condom use for females, while for males’ attitude to condoms and subjective norm would be more important. This study employed a cross-sectional questionnaire design. Male participants (N=94) and female participants (N=101) from Venda, South Africa completed standard, multi-item, reliable measures of Theory of Planned Behaviour constructs (condom-related attitude, subjective norm, perceived behavioural control, intention) and Protection Motivation Theory constructs (vulnerability, severity, fear, response-efficacy, self-efficacy) and reported their past condom use behaviour. Regression analysis indicated that among males, attitude to condoms and subjective norm were significantly related to intended condom use. Among females, attitude to condoms and self-efficacy were significantly related to intended condom use. The findings indicate that in a situation of gender power imbalance, psychosocial correlates of intended condom use differ for males and females. Gender-specific analysis of determinants of condom use may be more appropriate in a situation of gender power imbalance.

Editors’ note: The authors’ hypothesis was confirmed: perceived norm is most important for men while for women their level of confidence to propose or insist on condom use is most related to intentions to use condoms. Now if we can increase women’s confidence and create the social norms such that men expect that condoms will be used, we may get high condom use levels yet!