Younger women in Africa have increased condom use

The sense of failure surrounding HIV prevention efforts in Sub-Saharan Africa is unjustified, as there has been a significant increase in recent years in the proportion of young women reporting both condom use and sexual abstinence, according to a study published in the November 18^th edition of The Lancet. The authors found that a motivation for increased use of condoms was often contraception and argue that “programmes promoting family planning and HIV prevention have common interests.”

The continuing spread of HIV in low- and middle-income countries has led many researchers and policy makers to become pessimistic about approaches adopted to HIV prevention and to engage in bitter and, often ideological, debates about the merits of various approaches to HIV prevention.

In much of the world a so-called ABC (A for abstinence; B for be faithful; C for condoms) approach to HIV prevention has been adopted. Investigators from the London School of Hygiene and the World Health Organization conducted an analysis of results obtained from almost 133,000 single women aged between 15 and 24 years in 18 Sub-Saharan Africa through national Demographic and Health surveys to determine changes in levels of abstinence or condom use between 1990 and 2004.

The investigators focused on changing levels of primary abstinence (virginity); secondary abstinence (no sex within the previous three months); and use of contraception, including condoms, in the previous three months.

Overall, there was no real shift in the period of analysis in the number of young women reporting themselves virgins – the increased levels of virginity found in seven countries being offset by falls in reported virginity in six other countries. Only in Cameroon and Ghana were there 10% or greater increases in the proportion of self-reported virgins.

The level of secondary abstinence did increase from a median of 44% to 49%. The increase in secondary abstinence was statistically significant in seven countries, and exceeded 10% in five. In seven countries, however, abstinence trends were erratic, and in Burkina Faso, the proportion of women reporting secondary abstinence actually fell significantly (p = 0.003).

Of the women reporting any sex within the previous three months, the proportion saying that they used any contraception increased from 33% to 37%. Use of less effective methods of contraception, such as periodic abstinence, fell significantly, but the proportion of women saying that they used highly effective methods of birth control, such as oral contraceptives, remained stable.

The investigators then looked at condom use. They found that condom use increased from a median of 5% to 19%. This rise in condom use was statistically significant in 13 countries and over 10% in nine countries. Interestingly, increased levels of condom use did not appear to be linked to the severity of the local HIV epidemic, with countries in west Africa recording the largest increase in condom use, with use in the harder-hit eastern and southern African countries remaining lower.

When the investigators looked at self reported condom use for most recent intercourse, they found that this increased from 20% to 28%, with significant increases seen in seven countries, with six seeing an increase of above 10%. The authors point out that, across the study period, this amounts to an annualised increase of around 1-4% a year, squarely in line with the uptake of all forms of contraception in the industrialised world between 1965 and 1998.

"Behavioural change on a large scale tends to take time, since it needs to be preceded by a period in which unfamiliar messages become assimilated into local social networks," the authors comment.

The investigators wished to try and further understand women’s motivations for using condoms. A median of 59% of women said that their primary motivation for using condoms was pregnancy prevention.

“We noted a substantial rise in the use of condoms reported by young, sexually active single women in Sub-Saharan Africa”, write the investigators. They add, “our findings suggest that at least 60% of single women who used a condom for most recent coitus did so mainly, or partly for prevention of pregnancy.” They believe that this finding could have important implications for the way condom use is promoted in HIV prevention campaigns. They write, “a young woman might find it easier to negotiate use of condoms with a partner for prevention of pregnancy than for protection against HIV transmission.”

"Fewer than 10% of sexually active single women stated that they would like to have a child in the next 12 months [in the DHS surveys]," the authors note, highlighting the fact that abortion is illegal in many African countries and that unsafe abortion is more frequent in Africa than any other part of the world.

"The fear of unwanted pregnancy might be as great as the fear of AIDS for many young women in West and Central Africa," they go on.

The investigators emphasise that levels of abstinence changed less than condom use, but there was an increase in secondary abstinence that they attribute to more cautious partner selection, reduced frequency of sex, or a combination of both.

“Our central conclusion is that the sense of failure pervading HIV prevention efforts in Africa is unjustified and that investment in condom promotion and marketing have had an appreciable effect, at least for young single women.”