Abstract
A hospital-based cross-sectional survey was conducted among 705 HIV-positive individuals. The result showed that 24% of the participants reported unprotected intercourse in their most recent sexual episode. Nine percent of these events were with partners perceived to be HIV-negative and 39% with those of unknown HIV status. Protected sex at recent episode was independently associated with knowing a partner's HIV status, disclosing HIV status to a partner, receipt of antiretroviral treatment and perceiving HIV as less stigmatizing. This highlights the need for interventions among HIV-positive individuals that will assist them in attaining and maintaining safer sex practices.
Introduction
Ethiopia is one of the countries most affected by the HIV/AIDS epidemic. In 2007, there were an estimated 977,394 people living with the virus and 71,902 deaths. 1 According to the Ethiopian Demographic and Health Survey of 2005 the prevalence of HIV among couples was 2.1% and most (85.7%) were discordant. 2 In 2007, 258,264 men, women and children needed ART (antiretroviral treatment) and free ART is being scaled up. 1 In June 2007, there were 70,256 individuals receiving ART treatment. 3
Consistent condom use among HIV-positive individuals is crucial in order to curb the spread of the epidemic. However, there has been little work on this issue in Ethiopia. This study was therefore conducted in order to estimate the prevalence of unprotected sex and to identify factors associated with condom use among HIV-positive individuals.
Methods
The study was conducted in Jimma University Specialized Hospital in southwest Ethiopia. As of 25 December 2006 a total of 2036 people living with HIV/AIDS (PLWHA) were using the various ongoing services in the hospital: 915 were taking ART and the others were on pre-ART services. Data were collected from 15 January 2007 to 15 March 2007. A sample of 705 (353 women and 352 men) were selected from 856 sexually active PLWHA. The inclusion criteria was HIV-positive individuals aged 18 years or older who were sexually active at the time of the study and who were not terminally ill.
Trained data collectors (counsellors) explained the aim of the study; took informed consent and interviewed each participant in a separate room using a pretested questionnaire. The dependent variable (condom use) was measured using two questions, condom use at last sex and condom use since receiving an HIV-positive diagnosis. Consistent condom use was estimated based on the consistent use of a condom since the diagnosis. A questionnaire was used to gather sociodemographic information, relational factors, illness-related factors, service-related factors and psychosocial factors. Depression was assessed with Beck depression inventory (BDI)-13 and a cut-off point of 10 was used. 4 Drawing from previous scales of stigma among PLWHA 5 a set of 23 Likert scale questions addressing the perception of stigma and HIV were grouped into a composite index. The composite index was calculated as the mean of the 23 Likert scale questions combined and dichotomized.
Data was edited, cleaned, coded and analysed using SPSS version-12.0.1 for windows. Two logistic regression models were produced for condom use at recent sexual intercourse and consistent condom use since diagnosis. The P value ≤0.05 was used to enter a variable in the model and ≥0.1 to remove a variable from the model. The study was approved by the Ethical Committee of Jimma University.
Results
Sociodemographic characteristics
A total of 705 (353 women and 352 men) respondents were interviewed and their demographics appear in Table 1. All had had sex in the previous three months and 169 (24%) of the HIV-positive sample reported having unprotected sex (not using a condom) during their most recent sexual intercourse. Sixteen of the unprotected sex events (9.4%) were with partners perceived to be HIV-negative and 65 (38.5%) with partners with an unknown HIV status. Moreover, 268 (38.0%) used condoms inconsistently since receiving an HIV diagnosis, 20 (7.5%) with partners perceived to be HIV-negative and 80 (29.9%) with partners of an unknown status.
Sociodemographic characteristics of the respondents versus condom use during recent sexual intercourse at Jimma University Specialized Hospital during March 2007
In multivariate analysis, those who knew their partner's HIV status (odds ratio [OR] [95% confidence interval [CI]] = 2.0 [1.2–3.4]), those who were on ART (OR [95% CI] = 2.3 [1.6–3.6]), those who disclosed their results (OR [95% CI] = 3.3 [1.3–8.2]) and those who perceived HIV to be less stigmatizing (OR [95% CI] = 1.6 [1.1–2.4]) were more likely to use a condom in their recent sexual episode than their counterparts.
In the second model of logistic regression analysis, those who consistently use condoms:
did not depend financially on others (OR [95% CI] = 1.5 [1.1–2.4]); disclosed the result of their diagnosis to their partner (OR [95%] = 4.4 [1.7–11.5]); perceived HIV as being less stigmatizing (OR [95%] = 1.9 [1.3–3.0]) and were antiretroviral treatment recipients (OR [95%] = 2.5 [1.6–3.8]) (Table 2). Variables associated with condom use at the most recent intercourse, and consistent condom use since diagnosis, among people living with HIV/AIDS in Jimma University Specialized Hospital in May 2007 OR, odds ratio; CI, confidence interval; ART, antiretroviral treatment
aAlways using condoms since HIV diagnosis
Reasons for not using a condom
The most common reason given by respondents for not using a condom includes:
my partner is also HIV-positive (59, 40.7%); it makes my partner suspicious of my positive status (29, 20%); condoms take away the romance in sex (26, 17.9%); it is difficult to discuss using condoms (9, 6.2%); I did not have them with me (7, 4.8%); we do not want to use them (7, 4.8%); my partner refused to use one (5, 3.4%); I find them difficult to use (1, 0.7%) and we are in marital relationship (1, 0.7%).
Only 0.7% of gave the desire to have children as a barrier to condom use.
Discussion
This analysis indicated that there are many opportunities for the sexual transmission of HIV from an HIV-positive partner to an uninfected partner. At least a quarter of those who were positive had unprotected sex with at-risk partner.
The rate of unprotected sex among PLWHAs in this study is lower than that found in South Africa 6 and comparable with that reported from Swaziland. 7 The differences with South African might be the measurement strategies or due to cultural and contextual factors.
The key finding of the analysis is the significantly higher likelihood of unprotected sex with partners of unknown serostatus than with those whose status is known. This is consistent with a report by Eisele et al. 8 from South Africa. Efforts to promote disclosure, both by asking and telling may improve the knowledge of a partner's serostatus that could aid informed decisions about condom use. Contrary to the assumption of the impact of antiretroviral drugs on unprotected sexual behaviour in sub-Saharan Africa, 9 patients who are on antiretroviral drugs engaged in less unprotected sex than those who were not taking antiretroviral drugs. A study by Kiene et al. 10 reported similar results.
Patients who perceive HIV as a highly stigmatizing disease were less likely to use a condom. Every effort should therefore be made to continue to fight the HIV/AIDS stigma in order to achieve the desired sexual behaviour among PLHA. A partner being HIV-positive was the most reported reason for not using condom and, therefore, the risks connected with unprotected sex should be emphasized in all counselling sessions.
These findings must be considered in light of the study limitations: self-reports, social-desirability bias and generalizing the results to PLWHAs outside clinical care. We did not measure the intention to become pregnant among women which was associated with unprotected sex in a previous study. 8 Nevertheless, only a few participants in this study reported a desire to have children as barrier to condom use.
In the light of these limitations, however, the current findings underline the need to identify innovative, effective and realistic prevention strategies to help PLWHAs reduce the number of unprotected sex events. These interventions should focus on the importance of mutual HIV status disclosure, ART uptake and the need to fight against the stigma of the diagnosis.
Footnotes
Acknowledgement
This study was carried out with the financial support of the Netherlands Government Multi-Country Support Program on Social Science Research in the field of HIV/AIDS through Children Aid – Ethiopia.