HIV This Week

Everywhere you go, everyone is saying condom, condom. But are they being used consistently? Reflections of South African male students about male and female condom use

Mantell JE, Smit JA, Beksinska M, Scorgie F, Milford C, Balch E, Mabude Z, Smith E, Adams-Skinner J, Exner TM, Hoffman S, Stein ZA. Health Educ Res. 2011 Jun 21. [Epub ahead of print]

Young men in South Africa can play a critical role in preventing new human immunodeficiency virus (HIV) infections, yet are seldom targeted for HIV prevention. While reported condom use at last sex has increased considerably among young people, consistent condom use remains a challenge. In this study, 74 male higher education students gave their perspectives on male and female condoms in 10 focus group discussions. All believed that condoms should be used when wanting to prevent conception and protect against HIV, although many indicated that consistent condom use was seldom attained, if at all. Three possible situations for not using condoms were noted: (i) when sex happens in the heat of the moment and condoms are unavailable, (ii) when sexual partnerships have matured and (iii) when female partners implicitly accept unprotected sex. Men viewed it as their responsibility to have male condoms available, but attitudes about whose decision it was to initiate condom use were mixed. Almost all sexually active men had male condom experience; however, very few had used female condoms. Prevention initiatives should challenge traditional gendered norms that underpin poor condom uptake and continued use and build on the apparent shifts in these norms that are allowing women greater sexual agency.

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Editor’s note: This article’s verbatim quotes from the focus group discussions among male students at a higher education institution in South Africa make for interesting reading. The overall sexual script that emerges is that men expect women to refuse or resist sex without a condom. They understand that women expect men to acquire, carry, and use the male condom, whether or not it is discussed or requested beforehand. However, a woman not asking if the man has a condom implies that she is not sufficiently worried about HIV risks and doesn’t care. If sex proceeds without condom use, women who then propose it later in the relationship may be signifying mistrust or having been unfaithful. As for the female condom, its use should be initiated by the woman because ‘until girls are proud of the female condom we will never use them’. However, some men believed that condom use was no longer exclusively their responsibility, reflecting a reshaping of gender norms in this age group that has grown up half under Apartheid and half in the transition to democracy. Recognising women’s growing independence and power in post-Apartheid South Africa, the researchers recommend concrete actions to strengthen HIV prevention among young people, including reinforcing positive, less risky forms of masculinity and increasing women’s agency and bargaining power over their sexual lives.

Community-level gender equity and extramarital sexual risk-taking among married men in eight African countries

Stephenson R. Int Perspect Sex Reprod Health. 2010 Dec;36(4):178-88

In many parts of Africa, women are most likely to become infected with HIV by having unprotected sex with their husbands, who may have acquired the virus through extramarital sex. However, the ways in which aspects of community environments—particularly those related to gender equity—shape men's extramarital sexual risk-taking are not well understood. Demographic and Health Survey data from eight African countries (Chad, Ghana, Malawi, Nigeria, Tanzania, Uganda, Zambia and Zimbabwe) were used to examine associations between married men's engaging in risky extramarital sex (i.e., having had both unprotected sex and extramarital sex) and indicators of gender equity and other community characteristics. Separate multilevel logistic regression models that incorporated individual, household, and community measures were created for each country. In five countries, men who lived in communities with more equal ratios of women to men with at least a primary education were less likely to report risky extramarital sexual activity (odds ratios, 0.4-0.6). A similar relationship was found in four countries for the ratio of women to men who were employed (0.4-0.5). In three countries, men who lived in communities with more conservative attitudes toward wife-beating or male decision making had elevated odds of extramarital sexual risk-taking (1.1-1.5). While HIV prevention programmes should focus on reducing gender inequities, they also need to recognize the conservative cultural factors that influence the formation of men's masculine identities and, in turn, affect their sexual behaviour.

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Editors’ note: Men will play a key role in reducing HIV transmission in Africa when they understand the extent to which their concepts of masculinity and masculine identity have been socioculturally and economically defined and they decide to do something about it. This interesting analysis explored the factors associated with men’s risky extramarital sex in 8 countries—behaviour that is often more about ideas of masculinity than about sex. This study found that community dimensions of gender equity and economics define a social environment that encourages and facilitates risky extramarital sex—or protect against it. Traditional masculinities that prescribe greater autonomy for men and the financial and social dependence of women on them are sustained by the lack of opportunities for women in education and employment. For example, when early marriage and childbearing are encouraged there are opportunity costs for women because it is more difficult for them to accrue social capital, reflected in two community measures of social capital—gender ratios in employment and education. Women are better able to take advantage of opportunities for economic and social advancement when they marry later and delay their first birth. This study found that living in a community with a more equal ratio of employed women to employed men was associated with a decreased odds of men reporting risky extramarital sex in Chad, Nigeria, Tanzania, and Zimbabwe. The extent of men’s engagement in risky extramarital sex varied significantly across the 8 countries and it was not possible to fully explain the range of factors shaping men’s sexual risk-taking. However, programmes that focus on countering the differential access to resources for men and women need to be complemented by efforts to recognize and address cultural influences on men’s identity formation and sexual behaviour for communities to initiate new sexual norms to reduce HIV transmission.

Age at menarche, schooling, and sexual debut in northern Malawi

Glynn JR, Kayuni N, Floyd S, Banda E, Francis-Chizororo M, Tanton C, Molesworth A, Hemmings J, Crampin AC, French N. PLoS One. 2010 Dec 9;5(12):e15334

Age at sexual debut is a key behavioural indicator used in HIV behavioural surveillance. Early age at menarche may precipitate early sex through perceived readiness for sex, or through school drop-out, but this is rarely studied. Glynn and colleagues investigated trends and circumstances of sexual debut in relation to schooling and age at menarche. A cross-sectional sexual behaviour survey was conducted on all individuals age 15-59 within a demographic surveillance site in Karonga District, Malawi. Time trends were assessed using birth cohorts. Survival analysis was used to estimate the median age at menarche, sexual debut and first marriage. The 25(th) centile was used to define "early" sex, and analyses of risk factors for early sex were restricted to those who had reached that age, and were done using logistic regression. Of the 8232 women and 7338 men resident in the area, 88% and 78%, respectively, were seen, and, 94% and 92% of these were interviewed. The median reported age at first sex was 17.5 for women and 18.8 for men. For women, ages at menarche, sexual debut and first marriage did not differ by birth cohort. For men, age at sexual debut and first marriage decreased slightly in later birth cohorts. For both men and women increased schooling was associated with later sexual debut and a longer delay between sexual debut and first marriage, but the associations were stronger for women. Earlier age at menarche was strongly associated with earlier sexual debut and marriage and lower schooling levels. In women early sexual debut (<16 years) was less likely in those with menarche at age 14-15 (odds ratio (OR) 0.31, 95%CI 0.26-0.36), and ≥16 (OR 0.04, 95%CI 0.02-0.05) compared to those with menarche at <14. The proportion of women who completed primary school was 46% in those with menarche at <14, 60% in those with menarche at 14-15 and 70% in those with menarche at ≥16. The association between age at menarche and schooling was partly explained by age at sexual debut. The association between age at menarche and early sex was not altered by adjusting for schooling. Women with early menarche start sex and marry early, leading to school drop-out. It is important to find ways to support those who reach menarche early to access the same opportunities as other young women.

Abstract: 

Editor’s note: This study used information from fourth birth cohorts (born before 1965, 1965-74, 1975-84, 1985-94) to examine trends in age at first sex, types of partners, age at marriage, and time between first sex and marriage. There were no significant changes over time for women while for men there was a slight decrease in age at sexual debut and an increase in delay between first sex and marriage. Encouragingly, condom use with the first sexual partner, excluding those whose spouse was the first sexual partner, increased from 0% in the oldest women to 41% in the youngest cohort of women (54% in the youngest cohort of men). Striking findings were found in women: although age at onset of menstruation (menarche), age at first sex, and age at first marriage had not changed, in those with early menarche the likelihood of earlier sex increased with later birth cohort. Early sexual debut was associated with decreased schooling. Menstruation is an indication of physical maturity and the transition to womanhood but it also has practical implications for continued schooling where disposable pads are unaffordable, toilet facilities are poor, and privacy is at a premium. More than half the girls with early menarche before age 14 failed to finish primary school, had sex before they were 16, and married before 17 while 70% of girls who started menstruating at age 16 or older finished primary school (many went on to secondary school), started sex after age 18, and married after age 19. It is unclear how exactly age at menarche, age at first sex, and schooling are interacting but improving school facilities, keeping girls in school, and reducing expectations about early sexual debut after onset of menstruation are all needed to overcome individual and social pressures on girls that lead to them losing the advantages that education can bring.

Scaling up circumcision programmes in southern Africa: the potential impact of gender disparities and changes in condom use behaviours on heterosexual HIV transmission

Andersson KM, Owens DK, Paltiel AD. AIDS Behav. 2010 Sep 11.

Circumcision significantly reduces female-to-male transmission of HIV infection, but changes in behaviour may influence the overall impact on transmission. Andersson and colleagues sought to explore these effects, particularly for societies where women have less power to negotiate safe sex. They developed a compartmental epidemic model to simulate the population-level impact of various circumcision programmes on heterosexual HIV transmission in Soweto. The authors incorporated gender-specific negotiation of condom use in sexual partnerships and explored post-circumcision changes in condom use. A 5-year prevention programme in which only an additional 10% of uncircumcised males undergo circumcision each year, for example, would prevent 13% of the expected new HIV infections over 20 years. Outcomes were sensitive to potential changes in behaviour and differed by gender. For southern Africa, even modest programmes offering circumcision would result in significant benefits. Because decreases in male condom use could diminish these benefits, particularly for women, circumcision programmes should emphasize risk-reduction counselling.

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Editors’ note: When a novel HIV prevention modality provides direct benefit to a fraction of the population, as is the case for male circumcision for men and eventually would be the case for 1% tenofovir gel for women, any increases or decreases in condom use can influence the overall impact of its introduction for both sexes. This model assumed exclusive male negotiation of condom use and found that only very large declines in condom use (more than 50%) would offset the net benefits to the overall population of scaling up male circumcision services. However, behind the numbers are individual women who might become infected if men who get circumcised enhance their own risk as well as that of their partners by abandoning condom use. The good news is that adult male circumcision programmes to date in sub-Saharan Africa include both risk reduction counselling for men undergoing circumcision and tailored communication campaigns to reinforce the message of combination prevention. As a young man in an Orange Farm video says: ‘I understand that circumcision provides 60% protection – the rest I have to do myself’. Monitoring risk compensation/enhancement in the wider community, as well as among the men undergoing circumcision, is essential to tracking outcomes and making adjustments to male circumcision programmes for maximum impact on the epidemic. To read more about women’s qualified support for and desire to be engaged with male circumcision scale-up in Kenya, Namibia, South Africa, Swaziland, and Uganda, go to www.avac.org/whipt for the recently released AVAC/ATHENA report ‘Making Medical Male Circumcision Work for Women’.