Condom use consistency among South African HIV serodiscordant couples following an HIV risk-reduction intervention

Abstract

Background: Although there are several ways to transmit HIV, condomless sex remains the primary mode in sub-Saharan Africa, including South Africa, with KwaZulu-Natal Province being one of the epicentres of HIV infection. This study explored the use of condoms in serodiscordant couples who were exposed to an HIV-risk reduction intervention that aimed to improve condom use and reduce the spread of HIV.

Methods: A Total of 30 couples completed a paper-based questionnaire on their demographics and general health at baseline and 3 months, plus a semi-structured questionnaire with four domains. An analysis of HIV knowledge, condom use, condom use attitudes and protection perceptions about how other serodiscordant couples behave was conducted following a 12-week HIV risk reduction intervention. Participants were randomised 2:1 into intervention and control groups.

Results: Condom use increased from 55% at baseline to 73.7% (p = .0047) at 3 months for the intervention group and condom use in the last 7 days increased from 53% to 86% (p = .0117). For the control group, condom use remained low at the 3 months follow up period (p = .625). HIV knowledge improved significantly from baseline to 3 months for the intervention group (p < .0001), as well as the control group (p = .0005). Negative HIV condom use attitude scores in both groups decreased significantly from baseline to 3 months; intervention group (p = .0059) and control group (p = .0007).

Conclusion: HIV knowledge and condom use improved significantly, while negative condom use attitudes and HIV protection perceptions decreased significantly following exposure to a risk-reduction intervention, suggesting that HIV preventive interventions should focus on partnership interventions.

Keywords

Condoms HIV high-risk behaviour Africa sexual behaviour

Introduction

UNAIDS and the global community called for a 75% reduction in new HIV infections and AIDS deaths over a 10-year period (2010 and 2020) by achieving the 90–90–90 HIV testing, treatment and viral suppression targets, as well as implementing effective HIV primary prevention to reduce its continuing spread.¹ To further reduce HIV incidence and mortality in sub-Saharan Africa, several effective and cost-efficient behavioural preventative methods have been introduced to support all individuals living with HIV, retain people once they are in care, and promote antiretroviral therapy adherence and condom use. However, lack of condom use remains a serious barrier to controlling new HIV infections worldwide,² more so in HIV serodiscordant couples, who are a significant source of new HIV infections.³

In South Africa, KwaZulu-Natal Province is one of the epicentres of HIV infection in the country, with a strong commitment being required to test and implement behavioural interventions to significantly reduce HIV infections. In designing such interventions it is important that they be aligned with the local cultural context in which they are applied. Previous research also demonstrates the need to consider the couple as a unit when examining factors that affect condom use.⁴ The aim of this study is to explore the consistency of condom use amongst HIV serodiscordant couples following exposure to a behavioural intervention that provided educational material on their use. Consistent condom use in committed long-term relationships is a complex and dynamic phenomenon that relates to various factors, such as interpersonal dynamics, cultural norms, health systems and broader socio-economic and political contexts. The interaction of these factors makes the promotion of condom use and HIV risk reduction in high-risk populations, such as serodiscordant couples, a complex health issue.

Effective communication and appropriate health information are said to be some of the most important determinants of a good outcome in most doctor patient relationships, suggesting that improved communication may enhance adherence.⁵ Several local and international studies have emphasised the importance of people having accurate knowledge about HIV to change their behaviour.^6,7 However, the influence of factors such as attitudes, motivation and interpersonal issues may interfere with the reception of the information and its translation into behaviour change. Reports of high-risk behaviours or their preventive interventions may also be contaminated by the social desirability of responses, especially within an environment that provides continuous educational messages.⁸ While communication components have been used in several adherence interventions, the combination of information, communication, behavioural and cognitive processes that are culturally congruent have been indicated to improve the outcomes^9,10 and confidence to discuss condom use with sexual partners also contributed to increased condom use.¹¹ In this behavioural risk reduction intervention, three intersecting but complementary theoretical perspectives were used to inform its design and delivery by integrating elements of the ecological perspective, social cognitive theory and the Afrocentric paradigm.^12–16 The intervention curriculum design included its cultural adaptation to suit the local context and address some of the beliefs that may influence people’s behaviour, including power dynamics and social reputations. The participants’ backgrounds, the dyadic context on their interaction, and broader cultural values and beliefs that shaped the relationship context in which the HIV risk behaviours occur were taken into consideration in its development.

The study aim

This study explored the pattern of condom use over time, HIV knowledge and perceptions in a group of serodiscordant couples who were exposed to an HIV-risk reduction intervention that aimed to improve condom use and thus reduce the spread of HIV by providing them with information and behavioural techniques.

Methods

A total of 30 HIV serodiscordant couples were purposively recruited through healthcare providers in private health facilities in Durban. Permission to conduct the study was granted by the Institutional Review Board of the University of California (IRB #14-000854) and the Biomedical Research Ethics Committee of the University of KwaZulu-Natal (BREC #166/15). Demographic, behavioural, biological and feasibility characteristics were recorded at baseline and at 3 months. Serodiscordance was determined by a negative ELISA test¹⁷ in one partner, and a positive ELISA test, CD4 count and viral load test were obtained (not older than 3 months) for the partner living with HIV. Written informed consent for participation in the study was obtained from each partner individually. Participants were included if they were 18 years and older; self-identified heterosexuals; able to read and write in English as measured by minimum Grade 8 education; reported having unprotected sex at least once in the past 90 days; were both aware of the HIV status of the other, had been in a relationship for at least 3 months and had no plans to relocate from the study site during the next year. Participants who met the inclusion criteria were scheduled for a comprehensive baseline assessment before starting the intervention. Participants were randomised 2:1 in the order in which they were enrolled into the study for the intervention or a control groups, which meant a 3-months waitlist period for the control group, followed by the 12-week intervention in order to provide the intervention to all participants. This design allowed for a comparison of the relative effectiveness of the intervention between couples who received the intervention immediately and those who were waitlisted for 3 months as the control group. Couple members completed paper-based questions on demographics, health questions, sexual communication, knowledge of HIV and condom use efficacy at baseline and 3 months when the intervention group had completed the program. Other important parameters such as biological outcomes and fidelity to the intervention that were assessed in this cohort are discussed elsewhere.¹⁸

The intervention

The intervention consisted of sessions with individual couples, single gender and couples groups. The initial meeting with a couple provided an overview of the group therapy process, after which they were invited to participate in group workshops that were conducted in English. Three subsequent meetings were held with each group, which consisted of 3–5 couples and six-hour workshops held on Saturdays every 4 weeks over a period of 12 weeks. The workshops consisted of three sessions, each lasting 2 hours, with 15-minute tea and comfort breaks in between and lunch at the end of the day. The participants were provided with a workbook for each workshop, the sessions being designed to maximise interaction amongst and between the couples. There was a specific emphasis on skills-building through modelling and by practising problem-solving strategies using real-life situations that were reported by the participants. The intention was to build their self-efficacy and promote a belief in the ability to learn and implement new behaviours in order to produce a desirable outcome. The details of the modules provided during this intervention are published elsewhere.¹⁹

Study methods

Assessments

The study instrument was a semi-structured questionnaire that first collected their demographic details, then data related to the four domains of proportion of condom use, HIV knowledge, condom use attitudes and HIV serodiscordance protection perceptions for both groups. The data for the four domains was collected again for both groups following an HIV risk reduction intervention that was offered to the intervention group at 3 months to establish any changes. Domain 1 related to the proportion of condom use was established by the number of times both members of the couple used (male and female) condoms within a set period of time, that is, current use, use in the last 7 days and 30 days. Domain 2 related to their knowledge of HIV, and was assessed using a 10-statement questionnaire that included questions on transmission, treatment, viral load measures, STI’s and the correct use of condoms with lubricants. Participants could answer ‘true’, ‘false’ or ‘don’t know’, being scored as the total number of correctly answered questions. In domain 3 questions on condom use attitudes related to their use of male or female condoms all the time, taking responsibility for protecting each other from HIV and finding new ways to make safer sex fun. Participants could answer ‘none’, ‘a few’, ‘most’ or ‘all couples’. Condom use attitudes were the sum score of the eight questions, with two items being reverse coded. A high score on condom use attitude indicated a negative attitude towards condom use. Domain 4 explored their HIV protection perceptions for serodiscordant couples using an eight-question scale on how participants thought other couples behaved when one partner was HIV positive and the other HIV negative.

Statistical methods

Statistical tests were performed to test the difference in subject characteristics between the control and intervention groups with Wilcoxon rank-sum (WMW) test for the continuous measures (e.g. age, length of relationship with study partner, monthly income, number of dependants), and chi-square test to test for categorical measure (e.g. education levels and employment status). Wilcoxon signed rank sum test was used to test if the changes in outcomes from baseline to 3-months are significant within each group (control vs intervention). For the categorical variables in Table 1, we used chi-square test to test the group differences.

Table 1.

Baseline demographic characteristics of the 30 serodiscordant couples.

Variable	Characteristic	AllN = 30 couples	Immediate interventionN = 20 couples	ControlN = 10 couples
Variable	Characteristic	No. (%)
Age		39.3 (9.2)	39.7 (9.4)	39.0 (9.2)
Education*	< Grade 12,	7 (11.7)	5 (25%)	2 (5%)
	Grade 12 +	53 (88.3%)	15 (75%)	38 (95%)
Employment	Unemployed	8 (13.3%)	1 (5%)	7 (17.5%)
	Employed	52 (86.7%)	19 (95%)	33 (82.5%)
Marital status	Married	28 (46.7%)	7 (35%)	21 (52.5%)
	Not married	32 (53.3%)	13 (65%)	19 (47.5%)
Married to study partner	Yes	35 (58.3%)	10 (50%)	25 (62.5%)
Married to study partner	No	25 (41.7%)	10 (50%)	15 (37.5%)
Length of relationship with study partner (months)		82.7 (SD 61.3)Months	101.8 (SD 67.9)Months	73.2 (SD 56.3)Months
Monthly income ZAR		R1 0106.4 (SD 7 707.2)	R7 705.9 (SD 4011.9)	R11 466.7 (SD 8947.1)
Number of dependants note: * p < .05		2.3 (SD 1.6)	2.6 (SD 1.6)	2.1 (SD 1.6)
CD4 count		557.6 (SD274.5)	558.2 (SD 210)	556.2 (SD 398.7)
Viral load		Detectable8 (27.59%)Undetectable21 (72.41%)	Detectable6 (30%)Undetectable14 (70%)	Detectable2 (22.2%)Undetectable7 (77.8%)

Results

The results are presented with respect to the participants’ demographic details, then each of the four domains.

Demographic details

Table 1 presents the characteristics of the 30 participating couples, with the majority (73.3%) being 30–49 years of age, the average age being 39.3 years. More females were HIV positive (60.0%) than males (40.0%), and most participants (88.3%) had a Grade 12 level of education. The employment rate was 86.7%, with no significant differences between men and women, and almost half (53.3%) had been in the current relationship for over 5 years.

Condom use

Table 2 shows the proportion of condom use by the couples over certain time frames at baseline and 3 months. Information on consistency of condom use was based on a set of questions asking about the frequency of their use within a given time frame for each intimate partner (current, the last seven and 30°days), that is, always, most times, sometimes, rarely or never. For the intervention group, condom use increased from 55% at baseline to 73.7% at 3 months (p = .0047). In the control group, condom use also increased significantly (p = .0455) in the 3 months waitlist period. There was also a significant difference between the intervention and the control groups at 3 months (chi square = 6.3216, p = .0119), which was the point at which only the intervention group had received the intervention. Condom use in the last 30 days only improved from 58% to 68% at the 3 months follow-up for the intervention group and this was not statistically significant (p = .3125).

Table 2.

Four domains at baseline and 3 months.

Domains	Group	Baseline	3°months
Domain 1 (A)Current condom use	Control group	20	37.5 (p = .0455)
Domain 1 (A)Current condom use	Intervention group	55	73.7 (p = .0047)
Domain 1 (B)Condom use in the last 7 days	Control group	40	56 (p = .3506)
Domain 1 (B)Condom use in the last 7 days	InterventionGroup	53	86 (p = .0086)
Domain 1 (C)Condom use in the last 30 days	Control group	35	49 (p = .5221)
Domain 1 (C)Condom use in the last 30 days	InterventionGroup	58	68 (0.1932)
Domain 2HIV knowledge	Control group	4.6 (2.4)	7.8 (1.56; p < .0001)
Domain 2HIV knowledge	InterventionGroup	5.9 (2.1)	8.7 (1.46; p < .0001)
Domain 3HIV protection perceptions	ControlGroup	10.6 (6.2)	12.2 (6.1; p = .4728)
Domain 3HIV protection perceptions	InterventionGroup	10.3 (5.4)	10.3 (5.1; p = .9624)
Domain 4Condom use attitude	Control group	23.6 (4.4)	19.8 (2.6; p = .0006)
Domain 4Condom use attitude	InterventionGroup	20.3 (6.3)	17.8 (4; p = .0042)

HIV knowledge

HIV knowledge in the intervention group showed a significant increase from baseline to 3 months (p < .0001). Similarly, HIV knowledge also increased for the control group during the 3 months waitlist period (p = .0005).

HIV condom use attitude

For the intervention group, the HIV condom use attitude score significantly decreased from baseline to 3 months (p = .0059). For the control group, the HIV condom use attitude score significantly decreased from baseline to 3 months (p = .0007).

HIV serodiscordance protection perception

Regarding their perceptions about how other couples behave when one partner is HIV positive and the other partner is HIV negative, there were no significant changes or improvement of perceptions from baseline to 3 months for both groups (p = .8959).

Discussion

HIV remains a serious public health problem in Africa, and by far the commonest mode of transmission is heterosexual contact.²⁰ For prevention of intimate partner transmission, consistent use of condoms during sexual intercourse is the most effective behavioural measure to prevent HIV infection. Despite the widespread promotion of condom use to prevent the spread of HIV in long-term partnerships, their consistent use remains a big challenge.^21,22 This study explored the pattern of condom use in a group of serodiscordant couples who were exposed to an HIV-risk reduction intervention that aimed to improve condom use and thus reduce the spread of HIV by providing couples with information and behavioural techniques. We further explored the participants’ attitudes towards condom use, as well as their perceptions about what other serodiscordant couples may be doing to protect each other from HIV. In this sample, more females than males were HIV positive, most participants had a high school education and were employed. Furthermore, our results show that over half of our participants had been in the current relationship for over 5 years.

Condom use

In the intervention group, condom use improved significantly from baseline to 3 months, suggesting that the intervention had a positive effect on condom use. Condom use also improved for the control group, although to a lesser extent, indicating that being enrolled into a risk-reduction intervention could have sensitised them to the need for safer sex. Higher rates of condom use would be expected following such an intensive behavioural risk reduction intervention,^23,24 although some studies have demonstrated that providing people with appropriate information on HIV may not necessarily translate to behaviour change.²¹ While some studies have associated a higher level of education with increased condom use, consistent use requires a high level of commitment and self-discipline.²⁵

HIV knowledge

Overall, the intervention group had a greater improvement in HIV knowledge from the inception of the intervention, compared to the control group. Despite the seeming advantages of exposing couples to information that would empower them to navigate condom use challenges, several problems continued to exist, such as reluctance of one of the partners to use condoms. This study demonstrates the need to consider the couple as a unit when examining factors that affect condom use.^10,26 The study further demonstrates the need for ongoing educational and behavioural sessions for couples on how to engage in safer sex, to find an alternative reminder system and constantly review and correct inappropriate behaviour because after 3 months of information sharing, there were still a few couples that did not engage in safer sex. An analysis of all the reports on barriers to safer sex should be undertaken to improve the general knowledge about fidelity to condom use.

HIV serodiscordance protection perceptions

Serodiscordant couples are an important source of new HIV infections, which makes them a target for HIV prevention.³ We asked questions about what our participants thought other serodisocrdant couples were doing in their relationships in order to protect each other from being infected with HIV. In this sample, there was no significant change over time for both groups with regards to HIV serodiscordance protection perceptions. Although the intervention was completed over a 12-week period for each couple, it may take some time for the intervention effect to show, as people discuss and reflect on the content before implementing any meaningful change in perception. Information on use of pre-exposure prophylaxis (PrEP) was very low in this population, with only two couples using this prevention method in an effort to conceive in a safer manner. This finding is very significant, given that the use of PrEP is highly indicated for HIV serodiscordant couples. The World Health Organization (WHO) recommends PrEP for all persons at substantial risk for HIV, including HIV negative partners in serodiscordant relationships in resource limited settings.²⁷ This reveals a serious gap that needs to be brought to the attention of policy makers to promote the use of PrEP in South African serodiscordant couples.

HIV condom use attitudes

Attitudes towards condom use are influenced by various factors in both males and females, such as stigma, peer pressure, desire for child bearing and ease of access. Negative condom use attitudes decreased for both groups from baseline to 3 months. This was an unexpected finding, in that at baseline, the control group did not receive any intervention. However, there are several possible explanations for this, with the first screening meeting of 90 min entailing information sharing on HIV serodiscordance and the importance of risk reduction towards curbing the spread of HIV. Second, due to the high level of education, some of the participants possibly explored this issue after the first contact with the research team.

Limitations

Due to the relatively small sample size, we did not have sufficient statistical power to obtain significant results for some of the findings.

Footnotes

Acknowledgements

This study was supported by a student exchange fellowship grant from the NIH and UCLA Phodiso program: MH093230. Implementing EBAN, An Evidence Based Intervention for Serodiscordant Couples. We also wish to acknowledge the contribution of UKZN through the Research development grant CHS.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This project was funded by The University of KwaZulu-Natal, College of Health Sciences Research Division Ref: TR 78.

Availability of data and material

Data used in this study can be obtained from the corresponding author following an email request mashaphus@ukzn.ac.za

Code availability

Not applicable

Ethics approval

Permission to conduct the study was granted by the Institutional Review Board of the University of California (IRB #14-000854) and the Biomedical Research Ethics of the University of KwaZulu-Natal (BREC #166/15).

Consent to participate

Written informed consent was obtained from all participants for taking part in the study and for information sharing and dissemination.

ORCID iD

Sibongile Mashaphu

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