4
Sexual Behavior and HIV/AIDS

This chapter discusses what we know about sexual behavior and HIV/AIDS in Africa. Given that the epidemic is being sustained by heterosexual transmission (see Chapter 3), information on sexual behavior is needed to help project the future course of the HIV/AIDS epidemic, to develop more effective prevention strategies, and to provide baseline data for evaluating the effectiveness of alternative prevention strategies. Consequently, this chapter provides important background information for the next chapter, which deals with prevention.

Published papers on sexual behavior and HIV/AIDS in sub-Saharan Africa show a remarkable uniformity in their point of departure and their destination. They tend to begin with the observation that in the absence of a vaccine or cure, changing sexual behavior is the only way to halt the spread of the HIV/AIDS epidemic in the region, and they end with a call for more research. What lies between diverges widely in methodology, focus, presentation of results, and conclusions. This chapter reviews some of this literature, attempting to identify common threads and define the boundaries of what we know. It concentrates on work dealing with general populations, although reference is made to some of the larger body of work on high-risk groups, such as commercial sex workers. The sections that follow address sources of information on sexual behavior in Africa, patterns of sexual activity, sex-related risk factors for HIV/AIDS, sexual practices and beliefs, AIDS awareness, the role of condoms, and behavior change. The chapter ends with conclusions and a set of recommendations for future research.



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Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences 4 Sexual Behavior and HIV/AIDS This chapter discusses what we know about sexual behavior and HIV/AIDS in Africa. Given that the epidemic is being sustained by heterosexual transmission (see Chapter 3), information on sexual behavior is needed to help project the future course of the HIV/AIDS epidemic, to develop more effective prevention strategies, and to provide baseline data for evaluating the effectiveness of alternative prevention strategies. Consequently, this chapter provides important background information for the next chapter, which deals with prevention. Published papers on sexual behavior and HIV/AIDS in sub-Saharan Africa show a remarkable uniformity in their point of departure and their destination. They tend to begin with the observation that in the absence of a vaccine or cure, changing sexual behavior is the only way to halt the spread of the HIV/AIDS epidemic in the region, and they end with a call for more research. What lies between diverges widely in methodology, focus, presentation of results, and conclusions. This chapter reviews some of this literature, attempting to identify common threads and define the boundaries of what we know. It concentrates on work dealing with general populations, although reference is made to some of the larger body of work on high-risk groups, such as commercial sex workers. The sections that follow address sources of information on sexual behavior in Africa, patterns of sexual activity, sex-related risk factors for HIV/AIDS, sexual practices and beliefs, AIDS awareness, the role of condoms, and behavior change. The chapter ends with conclusions and a set of recommendations for future research.

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Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences SOURCES OF INFORMATION Researchers have often noted the dearth of studies on sexual behavior in sub-Saharan Africa. According to Larson (1989:9), "data on actual practice [of extramarital sex] are extremely rare and probably worthless." What little was known about sexual behavior in Africa at the time was exhaustively reviewed by Standing and Kisekka (1989). Accordingly, while some mention is made here of the early ethnographic work they reviewed, this chapter focuses on work published subsequently. This chapter relies heavily on the results of a series of nine surveys coordinated by the World Health Organization/Global Programme on AIDS (WHO/GPA) that were carried out in 1989 and 1990. Eight of the surveys were national in coverage, while the ninth was conducted in Lusaka, Zambia. These surveys provide information on age at sexual initiation; broad patterns of sexual activity within and outside of stable unions; levels of commercial sex; and many other issues, such as perceived risk.1 QUESTIONS OF METHODOLOGY The two principal sources of information about sexual behavior are ethnographic accounts and survey methods. Ethnographic accounts typically focus on sexual behavior only insofar as it relates to family, marriage, and kinship. Anthropological research uses primarily qualitative methods and participant observation for data collection. The goal usually is not to quantify the behaviors, but to understand their intent and meanings. This research is important to the design of interventions, but says little about the number of times an event occurs, its duration, or other factors of concern to disease transmission models. Large-scale surveys are designed to provide information that is comparable across cultures, but are forced to use sweeping, standardized definitions for complex and highly varied concepts such as marriage. Increasingly, researchers are designing studies that aim to bridge the gap between detailed observation of particular societies and broad characterizations of patterns and trends, for instance by combining survey data with diaries and in-depth interviews. The principal danger with using survey methodology to collect data on sexual behavior is that respondents may simply say what they think researchers want to hear and that without elaborate probing, such methods may lead to a serious undercount of the true situation (Bleek, 1987). Women are believed to be particularly prone to giving normative answers. Indeed, women are sometimes excluded from surveys altogether for fear that their responses will be worthless 1    See Ferry (1995a) for more details regarding the characteristics of the WHO/GPA surveys and a detailed assessment of the data quality.

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Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences (Hogsborg and Aaby, 1992; Orubuloye et al., 1992). Nevertheless, there is also evidence that people are not entirely swayed by social norms when reporting their own behavior. For instance, several studies report a large gap between proportions expressing disapproval of premarital sex (typically high) and those reporting virginity at marriage (frequently low) (see, for example, Anarfi, 1993). Public health researchers, independent of discipline, use both qualitative and quantitative methods to improve our understanding of behaviors. In an effort to verify independently the WHO/GPA estimates of sexual behavior, the WHO/GPA survey material is therefore supplemented here, as the authors of those studies urge, with less-generalizable surveys and information derived from ethnography, observational studies, serosurveys, and focus group interviews. Study designs differ substantially; those of the principal papers used in this chapter are summarized in Table 4-1. The following subsection makes some general observations about difficulties common to several studies. Concerns about large-scale comparative survey research include the selection, operationalization, and validation of responses to items in the questionnaire. For example, researchers frequently need to use broad and sometimes arbitrary categories for comparability across research sites (e.g., partner categories such as regular and casual). Many of the difficulties that arise in conducting survey research are compounded when one is conducting research about intimate topics such as sexuality (Bleek, 1987). In the quest for comparability, large-scale surveys sacrifice information that may help explain local differences in sexual networking. Nor are international surveys likely to contribute much to our understanding of motivations for behavioral change. However, such surveys can be useful in highlighting patterns that link sociodemographic variables and personal behavior. As the editors of the WHO/GPA volume observe, single-round surveys are also good at describing the climate of public opinion and measuring the incidence of certain behaviors (Cleland and Ferry, 1995). Moreover, repeated over time, nationally representative surveys can help track behavior change. Sampling proved problematic in many of the WHO/GPA studies reviewed. Although the WHO/GPA surveys covering the Central African Republic, Côte d'Ivoire, Guinea-Bissau, Togo, Burundi, Kenya, Lesotho, and Tanzania sought to be nationally representative, sampling difficulties appear to have led to an overrepresentation of women and urban residents in some cases. The remaining WHO/GPA survey in mainland sub-Saharan Africa, that in Lusaka, Zambia, leaned heavily toward the more educated. Family formation norms vary widely throughout the African continent, and marriage in many African societies has often been described as being more akin to a process than a discrete event. It has proved difficult to develop easily understood definitions for sexual partners, and many of the subtleties of various forms of marriage are lost when all forms of unions are coded using a small number of standardized categories. For example, the WHO/GPA surveys make no distinction between regular partnerships and marriages, "regular" partnership

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Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences TABLE 4-1 Details of Some Studies of Sexual Behavior Cited in This Chapter Reference Study Population Sample Size Main Methodology Limitations Anarfi (1993) Ghana, rural, urban 1,360 Cross-sectional survey Unclear reference periods Anarfi and Awusabo-Asare (1993) Ghana, various lineal groups 360 Cross-sectional survey Interviewers known to respondents; no clear definitions of marriage Hogsborg and Aaby (1992) Guinea-Bissau, urban (both sexes, but diary respondents all male) 422 25 Cross-sectional survey Diaries Diary men purposively chosen Hunter et al. (1994) Nairobi, Kenya, prenatal clinic attenders 4,401 Serosurvey   Irwin et al. (1991) Kinshasa, Zaire, male factory workers 1,796 Serosurvey, focus groups   Kisekka (no date) Hausa groups, Nigeria; Baganda, Uganda n.a. Focus groups   Konde-Lule (1993) Rakai, Uganda 35 groups of 8-12 respondents Focus groups   Lindan et al. (1991) Kigali, Rwanda prenatal clinic attenders 1,458 Serosurvey   Meekers (1994) DHS data, 7 African nations n.a. Survey data analysis   Messersmith et al. (1994) Ile-Ife, Nigeria (men aged 18-59, women aged 18-49) 1,149 Cross-sectional survey Excludes adolescents

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Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences Meursing et al. (forthcoming) Bulawayo, Zimbabwe, sexually abused children 54 Clinical examination, record review, focus groups   O'Toole Erwin (1993) Ado-Ekiti, Nigeria, prenatal clinic attenders 113 455 Clinical examination Cross-sectional survey   Ogbuagu and Charles (1993) Calabar, Nigeria 500 Cross-sectional survey High nonresponse rate; partnerships not clearly defined Orubuloye et al. (1991) Ekiti, Nigeria, urban and rural 400 Cross-sectional survey Unclear reference periods, denominators, and partner definitions; no cross-checking of spousal replies possible Orubuloye et al. (1992) Ekiti, Nigeria 488 ''The lawyer's cross-examination method of investigation by exhaustion"   Pickering et al. (1992) The Gambia, prostitutes (p) and clients (c) 248p 795c Prospective survey, diaries   Preston-Whyte (1994) Kwazulu/Natal, adolescents n.a. Focus groups, intervention All mixed-sex focus groups Schopper et al. (1993) Moyo, Uganda 1,486 Cross-sectional survey   Serwadda et al. (1992) Rakai, Uganda, trading towns, rural 1,292 Serosurvey   n.a. = not available DHS = Demographic and Health Surveys

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Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences being any union that continues or is expected to continue, however sporadically, for at least a year. "Casual" is anything outside that, and any partnership that lasts under a year and involves the exchange of money, gifts, or favors in exchange for sex is classified as "commercial." In the standard partner relations questionnaire,2 it is frequently difficult to distinguish one category from another, and secondary regular partners may be double-counted as casual, unless the interviewers were very skillful. In a study designed to test the validity of the WHO/GPA survey instrument, Schopper et al. (1993) showed that among 392 women whose answers could be cross-checked with those of their partner, 12 percent reported they had co-wives when their husbands declared themselves monogamously married, thus illustrating the difficulty of watertight categorization. Other surveys use entirely different definitions, so that even comparing data on premarital sex becomes fraught with difficulty. Discrepant reference periods do little to clear the confusion. Without defining the term "current," several West African studies make a distinction between current partners and partners within the previous week (e.g., Orubuloye et al., 1991; Anarfi, 1993). As documented by Orubuloye et al. (1991), consistently more men and women in both urban and rural areas reported abstinence in the last month (and, except for rural males, in the last 12 months) than reported abstinence currently, which leaves us with a puzzle for interpretation. That respondents are confused by definitions emerges also from a study by Ogbuagu and Charles (1993). In that study, 55 percent of women reported more than one current partner. However, when asked directly if they kept other partners outside their regular partnership, 66 percent answered no. Sources of bias are sometimes incompletely documented. Often studies state or imply significant levels of nonresponse, but give no information on possible refusal bias (Ogbuagu and Charles, 1993; Omorodion, 1993; Oyeneye and Kawonise, 1993). Bias can also arise from the injudicious or unclear use of denominators; for instance, excluding virgins from the denominator will bias downward the mean age of onset of sexual activity in the youngest cohorts (Konings et al., 1994). The question of age cut-offs is relevant to almost every study. Although overwhelming evidence of early sexual activity is provided in existing sources such as the Demographic and Health Surveys (DHS) series, the successor to the World Fertility Surveys (WFS), very few studies include people under age 15. Indeed, some investigate only the behavior of people over age 18 (e.g., Messersmith et al., 1994), and many exclude women after they reach age 50. 2    The WHO/GPA surveys used one of three questionnaire types: (a) a knowledge, attitudes, beliefs, and practice (KABP) questionnaire that investigated general attitudes and behaviors related to HIV/AIDS; (b) a partner relations (PR) questionnaire that focused more narrowly on sexual behavior; and (c) a combination of (a) and (b). In Tanzania, surveys of both types (a) and (b) were conducted.

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Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences Other shortcomings common across studies are a lack of information about economic status (education is often the only proxy for socioeconomic status) and a failure to include information about the content of public education campaigns, data that might help us understand local knowledge and attitudes. The Issue of Validity Self-reported data on sexual activity are of course more or less impossible to verify absolutely. But other checks can be made. For example, are study results consistent with what we know from other sources? The answer would appear to depend on the context. The age at first intercourse reported in the WHO/GPA surveys does not differ strikingly from the available DHS data (Schopper et al., 1993; Meekers, 1994). On occasion, however, reported condom use differs greatly, appearing much higher for a given country in the WHO/GPA surveys than in subsequent DHS surveys (Cleland and Ferry, 1995). This discrepancy may occur because people's answers differ according to the intent of the survey. Are data mutually consistent? In the WHO/GPA surveys, consistency is difficult to check because there is no device for linking two halves of a couple when each individual has been randomly selected. Since questions are not repeated within the same interview, internal consistency checks are difficult as well. There is, however, broad aggregate agreement between the sexes on coital frequency and number of regular partners. In Schopper et al. (1993), a study using the WHO/GPA survey instrument, 392 couples were identified among the 1,486 individuals randomly selected for interview. Although it was confirmed that results were good on an aggregate basis, there were significant disparities on the individual couple level in reports of coital frequency between monogamous couples reporting no outside partners.3 Similar results are cited by Rutenberg et al. (1994) using Tanzanian DHS data for 1991/1992; men reported on average 35 percent more sexual contacts than women. That study shows further that women are just as likely as men to report higher frequency than their partner. Studies on sexual behavior consistently find that men report more partners than women. For instance, Konings et al. (1994) show men reporting around 10 times as many partners as women. This discrepancy may occur because men overreport their partners, because women underreport theirs, or because a large number of men network with a small number of women who have a high turnover of partners. Many researchers point out that their study populations are unlikely to capture sex workers; few indicate whether they include men likely to be clients 3    This discrepancy is perhaps to be expected; recalling coital frequency is not easy. Differences in coital frequency, though apparently small, can add up to quite large differences in overall sexual activity (because a larger proportion of men is sexually active at any given time).

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Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences of sex workers, such as truck drivers or the military—highly mobile groups that might escape the sampler's net. One way of teasing bias out of a single-round survey is to supplement it with other methods. Repeated interviews at short intervals and respondent diaries have been shown to be effective in this regard. Using this method, studies in Guinea-Bissau and Senegal suggest overreporting of coital frequency in surveys, but underreporting of numbers of partners (Hogsborg and Aaby, 1992; Enel et al., 1994). Similarly, Pickering et al. (1992) used diaries to show that prostitutes in The Gambia consistently gave higher totals of client contacts in surveys than when reporting daily; comparison with questionnaires administered to clients emerging from their rooms showed that the women also overreported condom use in surveys. More cross-referencing of questions might help identify bias in normative responses. In focus group interviews of schoolgirls in Zimbabwe, most denied they had sugar daddies, that is, older men as boyfriends who gave them presents or money for sex; however, in answer to a later question, half volunteered ways of keeping presents from sugar daddies hidden from parents, indicating that their earlier responses may have been less than wholly honest (Vos, 1994). Individual interviews might have avoided this discrepancy. Ethnographic models may also be applied to resolve discrepancies in single-round survey results (Stone and Campbell, 1984). It is clearly premature to reach any firm conclusions about the reliability or validity of survey data on sexual behavior in developing countries. However, after a review of the evidence, Dare and Cleland (1994) are guardedly optimistic that the information gathered in most surveys is solid enough to allow broad conclusions to be drawn. PATTERNS OF SEXUAL ACTIVITY This section examines patterns of sexual activity in sub-Saharan cultures, including sexual initiation and premarital intercourse, sex within marriage or a stable union, extramarital and casual sex, and commercial sex. Sexual Initiation and Premarital Intercourse Marriage has long been considered a proxy for the onset of sexual activity. In cultures where female sexuality is strongly proscribed, an increase in premarital sex is often believed to be synonymous with the amoralizing influence of modernization. In premodern times, marriage for most sub-Saharan African women took place around puberty. Now, in some African societies, changes associated with modernization, such as increasing urbanization and greater emphasis on formal education for women, have led to an increase in the age at first marriage for women.

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Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences In some sub-Saharan African civilizations (although by no means universally), marriage has been an unfolding process rather than a salient event (Meekers, 1992). As Bledsoe (1990:118) writes: The first problem is that of defining when marriage begins and ends. African marriage is often a long, ambiguous process rather than a unitary event. It may extend over a period of months or even years, as partners and their families work cautiously toward more stable conjugal relationships. A girl, sometimes with her family's implicit permission, may test out potential relationships with several young men before establishing a more permanent one. This ambiguity presents researchers with an additional problem of interpretation, since the answer to the question "Were you a virgin at marriage?" clearly depends on how the respondent dates marriage. If a union turned out to be successful, the respondent may in retrospect date the marriage from the start of that union, even though it was at the time a tenuous and potentially transitory liaison (van de Walle, 1993). A substantial body of work addresses the question of premarital sex. Inevitably, definitions vary widely. In the WHO/GPA surveys, for instance, the term refers to any sex before first regular partnership. Other surveys define the term as any sexual activity before legally or traditionally sanctioned marriage, thus including early sex between people who subsequently go on to marry. Table 4-2 gives some of the findings reported by the various studies. As mentioned earlier, several studies show a discrepancy between a persistent ideal of virginity at marriage and actual levels of premarital activity, both now and in the past. In Anarfi (1993), three-quarters of both men and women said they believed women should be virgins at marriage, but barely 1 in 10 of either sex maintained that he or she was. Further, two-thirds of ever-married men and half of ever-married women reported having had two or more premarital partners. Some 40 percent of respondents in Ogbuagu and Charles' (1993) study in Calabar, Nigeria, said they hold virginity at marriage as an ideal, but fewer than half that proportion could report no sex before marriage. While Botswana and Kenya display strong evidence of a rise in premarital sex, Meekers (1994), using data from a variety of DHS studies, shows that there is generally a substantial fall in the proportions of single women currently reporting sexual activity as compared with the proportions of married women saying they experienced sex before marriage. While the figures are distorted by the fact that many single women who are still virgins may go on to have premarital sex, this observation also hints that it may be easier to report socially dubious behavior after the fact than at the time of its occurrence. Several researchers note that women sometimes feel under pressure to prove they are fertile by getting pregnant in order to increase their chances of marriage (e.g., Standing and Kisekka, 1989). Because of a ubiquitous age difference at marriage between men and women, any decline in polygyny—as long as populations

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Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences TABLE 4-2 Percentage of Respondents Reporting Premarital Sex in Various Studies         Percent Reporting Premarital Sex Reference Country Population Study Period Women Men Cleland and Ferry (1995) Burundi singles (15-19) 12 months 3 10 Meekers (1994) Burundi all single ever 5 n.a. Meekers (1994) Burundi all ever-married ever 20 n.a. Balépa et al. (1992) Cameroon all single ever 57 n.a. Cleland and Ferry (1995) CAR singles (15-19) 12 months 56 69 Cleland and Ferry (1995) Côte d'Ivoire singles (15-19) 12 months 28 43 Anarfi & Awusabo-Asare (1993) Ghana all respondents ever 75 90 Anarfi (1993) Ghana all respondents ever 87 n.a. Meekers (1994) Ghana all single ever 47 n.a. Meekers (1994) Ghana all ever-married ever 60 n.a. Cleland and Ferry (1995) Guinea-Bissau singles (15-19) 12 months 30 51 Cleland and Ferry (1995) Kenya singles (15-19) 12 months 44 54 Meekers (1994) Kenya all single ever 50 n.a. Meekers (1994) Kenya all ever-married ever 61 n.a. Cleland and Ferry (1995) Lesotho singles (15-19) 12 months 16 33

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Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences Meekers (1994) Liberia all single ever 81 n.a. Meekers (1994) Liberia all ever-married ever 59 n.a. Meekers (1994) Mali all single ever 6 n.a. Meekers (1994) Mali all ever-married ever 13 n.a. Kourguéni et al. (1993) Niger all single ever 10 n.a. Messersmith (1994) Nigeria all respondents ever 53 85 Ogbuagu and Charles (1993) Nigeria all respondents ever 82 83 Federal Office of Statistics (1992) Nigeria all single ever 41 n.a. Barrère et al. (1994) Rwanda all single ever 12 n.a. Cleland and Ferry (1995) Tanzania singles (15-19) 12 months 24 37 Rutenberg (1994) Tanzania all single ever 44 72 Cleland and Ferry (1995) Togo singles (15-19) 12 months 3 18 Meekers (1994) Togo all single ever 61 n.a. Meekers (1994) Togo all ever-married ever 65 n.a. Cleland and Ferry (1995) Lusaka, Zambia singles (15-19) 12 months 10 16 Meekers (1994) Zimbabwe all single ever 26 n.a. Meekers (1994) Zimbabwe all ever-married ever 48 n.a. n.a. = not available CAR = Central African Republic

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Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences TABLE 4-6B Percentage of Sexually Active Women Who Have Ever Used Condoms Age Burundi CAR Côte d'Ivoire Guinea-Bissau Kenya Lesotho Tanzania Togo Lusaka, Zambia 15-19 11 10 16 21 11 9 5 8 31 20-24 10 8 15 11 12 7 10 9 29 25-39 8 5 7 14 9 10 10 6 20 40-49 4 3 1 4 6 5 8 2 14 50+ n.a. n.a. n.a. n.a. 3 5 2 3 n.a. All 7.3 6.8 9.3 12.3 8.7 8.0 8.5 5.9 24.2 n.a. = not available CAR = Central African Republic SOURCE: Cleland and Ferry (1995).

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Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences gives limited grounds for hope (Pickering et al., 1992). Although in urban areas women reported using condoms with four clients out of five (a higher rate than that reported by the clients themselves), condom use fell as the number of clients per woman rose. At peak periods such as holidays, when women were recording over 11 clients a night, condom use fell below 50 percent (Pickering et al., 1992). Condoms and STD and HIV Prevention Notwithstanding Messersmith's finding that more people knew of condoms as a contraceptive, a substantial majority also knew of their properties in preventing STDs. The proportions of the latter were highest for single men and for single and separated women. Even in multivariate analysis, men with five or more partners were far more likely than those with fewer partners to know that condoms could prevent STD transmission. The number of partners was not an independent predictor of that knowledge in women (Messersmith et al., 1994). For both sexes, there was a strong correlation between those who had heard of AIDS and those who knew that condoms could prevent the spread of STDs. This result is not, however, necessarily a cause for great optimism. A range of studies show that if a person knows of AIDS, knows that it is sexually transmitted, and knows that condoms can protect against STDs, it does not seem to follow that he or she will also believe that condoms protect against HIV. Indeed, the STD connection may be a dangerous one. Kisekka (no date) notes that commercial sex workers in Nigeria dismiss the need to adopt condoms because they already self-medicate to protect themselves from STDs. In fact, fewer than half of those who reported knowing of condoms in the WHO/GPA surveys in all the countries except Guinea-Bissau believed condoms were effective in preventing HIV transmission. In focus groups, people frequently scoffed at the idea that something as flimsy as a condom could protect against a disease as deadly as AIDS (Irwin et al., 1991; Konde-Lule, 1993; Kisekka, no date). Orubuloye et al. (1991) report that in Nigeria this view was common even among bar girls. It is worth considering whether this perception arises from overkill in AIDS awareness campaigns. Virologists have shown that HIV is not very infectious; while it is important to stress that, once contracted, AIDS is lethal, it would be wrong to suggest that it is all-powerful and cannot be kept at bay by fairly simple precautions. Attitudes Toward Condoms In strongly pronatalist societies, the fact that condoms prevent conception may weigh heavily against their use to prevent transmission of STDs and HIV/AIDS. Other barriers to condom use, expressed both in surveys and more clearly in qualitative studies, are rife. The single most common feeling expressed was

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Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences that condoms reduce sexual pleasure. Both sexes surveyed in WHO/GPA study areas were more likely to say that condoms made sex less enjoyable if they had used them than if they had no experience of condom use. In all countries but one, over half of all men who had ever used a condom said doing so made sex less fun (Mehryar, 1995). The exception was Lesotho, the country with the highest prevalence of condom use among those who had ever heard of the device.17 Annoyances such as the interruption of spontaneity, especially among those professing a habit of serial ejaculation, and the problem of disposal contributed to a distaste for condom use (Konde-Lule, 1993; Kisekka, no date; Preston-Whyte, 1994). There is a general association of condoms with prostitutes and promiscuity (possibly engendered by AIDS awareness campaigns). Both men and women say that asking a partner to use a condom is tantamount to admitting one's own promiscuity or accusing one's partner of sleeping around (Irwin et al., 1991; Hogsborg and Aaby, 1992; Kisekka, no date; Preston-Whyte, 1994). Konde-Lule (1993) reports that some bar girls in Uganda said they were loath to suggest condom use for fear of getting a reputation as a prostitute. Although reports of condom use with "commercial" partners were infrequent in the WHO/GPA surveys, over three-quarters of men who reported ever using condoms said they thought them appropriate for casual partners (Figure 4-4A). Women with a history of condom use and male respondents who knew of condoms but had never tried them were only slightly less likely to agree. Not surprisingly, the percentage of people reporting that condoms were suitable for use within marriage or a regular partnership was correspondingly low, not rising much higher than one-third of male condom users; the exception was Lesotho, where over three-quarters of respondents were happy to use condoms with their wives (Figure 4-4A). Those who had never used condoms were consistently less likely to think use with a regular partner appropriate. Women did not differ substantially from men in their views except in Togo and Burundi, where female users (Figure 4-4B) and nonusers were both substantially more willing than men to contemplate condom use with their spouses. However, women in Togo were also far more likely than men to think that their regular partners would be offended by condom use; in all other study areas, men were more likely than women to think condom use would offend their partners. The results suggest that there is substantial lack of communication between regular partners on the issue of condom use. Some people also reported in group discussions that they believed condom use might encourage promiscuity, especially among the young (Irwin et al., 1991; 17    It is tempting to infer that, whatever the direction of the relationship, the more men have experience of condom use, the less disdainful they are on the count of reduced pleasure. However, the country that follows Lesotho in prevalence of condom use among those who know of condoms, Guinea-Bissau, had the highest proportion complaining that condoms reduce pleasure.

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Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences FIGURE 4-4A Attitudes Toward Condoms Among Men Who Have Used Them. SOURCE: Cleland and Ferry (1995). Preston-Whyte, 1994). It will be important to address these concerns when designing socially and politically acceptable programs targeted at adolescents. Concerns over the safety of condoms, particularly for women, surfaced in study after study (Irwin et al., 1991; Lindan et al., 1991; Kisekka, no date; Hogsborg and Aaby, 1992; Konde-Lule, 1993). In focus groups, people frequently tell the story of a friend or local woman known to have died because of a wayward condom. The WHO/GPA surveys showed that a high proportion of people who had used condoms still believed they could "climb up into the womb or stomach." In Côte d'Ivoire, for instance, 61 percent of condom users believed this myth, while in Togo the figure was 46 percent (Mehryar, 1995). Orubuloye et al. (1991:71) report that in Ekiti district in Nigeria, "many believe they [condoms] are as dangerous as AIDS." Erroneous health concerns aside, the social stress on fertility and the consequent quest for pregnancy can be important in determining women's propensity to disdain condoms. In areas where STDs are common, women may have to choose between not using condoms and exposing themselves to STDs (and

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Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences FIGURE 4-4B Attitudes Toward Condoms Among Women Who Have Used Them. SOURCE: Cleland and Ferry (1995). thereby the possibility of sterility) or using condoms and foregoing the chance of pregnancy in the short term (O'Toole Erwin, 1993; Preston-Whyte, 1994). Obviously, condoms are useful only if they are within people's means. In the WHO/GPA surveys, cost was considered a barrier to regular use by fewer than one-quarter of men who had ever used them, except in Côte d'Ivoire, where two-fifths thought them too expensive. In most study areas, female users were slightly more likely than men to consider regular use financially out of reach; this differential may be a reflection on women's relatively lower earning power in the areas in question. In Rakai district, Uganda, the availability and affordability of condoms have been shown in four annual surveys to have little effect on the decision to use them (Kivumbi, 1993). BEHAVIOR CHANGE As this chapter demonstrates, measuring sexual behavior is no straightforward matter and is a science in its infancy. Without a large body of evidence

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Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences accumulated by measuring current behavior over several years, it is almost impossible to determine what changes have taken place. The WHO/GPA surveys represent a step in establishing such a body of evidence. Although they do include questions on changes in behavior, single-round cross-sectional surveys are singularly inappropriate for establishing the causality of any changes that may have taken place in the past. Given that the section on behavior change in the WHO/GPA surveys comes after a long section focusing on the threats and dangers of AIDS, replies are quite likely to reflect what respondents perceive the interviewers want to hear. That said, the answers may give some indication of the types of behavioral change that people consider most plausible. Over half of all men in every country surveyed by WHO/GPA (and up to 90 percent in the Central African Republic and 70 percent in Côte d'Ivoire) reported having changed their sexual behavior in response to the HIV/AIDS epidemic. Women reported lower levels of change in all populations but Lesotho. No clear link emerges between a sense of personal vulnerability and reported behavior change. Cleland (1995) maintains that risk reduction is usually incomplete, so some risk behavior will remain, and a positive correlation should be expected. It might equally be argued, however, that people would bother to reduce their risk behavior only if they thought doing so would be effective and would in consequence feel less vulnerable. The survey data show a positive correlation between risk behavior and reported risk reduction over the last 12 months. If this association were interpreted as a change from previous higher levels of sexual activity to a level still considered high risk in the survey classification, it would provide support for Cleland's hypothesis. An alternative explanation of the empirical evidence might be that behavior changed very recently and was thus not fully captured in the 12-month reference period. Of behavior changes reported, few were related to casual transmission beliefs, with reduction of partners the most frequently reported measure. Nowhere except Guinea-Bissau was condom use reported as a specific change by more than 7 percent of those who reported any change.18 However, some of these respondents had reported earlier in the survey that they had never used a condom. Certainly the level of potentially effective behavior change reported is not reflected in other markers of safer sexual activity, such as a decrease in the prevalence of STDs. In-depth interviews conducted in Guinea-Bissau revealed that only two of seven men who had reported in surveys that they had started using condoms because of AIDS turned out to have done so (Hogsborg and Aaby, 1992). The 18    In Guinea-Bissau, 25 percent of men and 23 percent of women reporting change said they had increased use of condoms. However, no details are given on the content of public health campaigns in the country in the period preceding the survey.

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Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences researchers further reported that men who said they would use condoms with casual partners did not in fact do so, explaining in each case that the circumstances were special because the woman was respectable. The researchers concluded that focusing campaigns on condom use with unknown partners who are assumed to be strangers is useless in a context in which people do not consider any partners to be unknown. In focus group interviews conducted in Rakai district, Uganda, after several years of vigorous campaigns to promote AIDS awareness and behavior change, people in rural areas did believe that risky sexual activity was on the wane. Optimists might think this finding reflects a new, lower-level, post-AIDS norm. In urban areas, however, people thought their neighbors were just as active as ever but more discreet, a change that might also translate into an increasing tendency to underreport the numbers of partners in surveys (Konde-Lule, 1993). Adolescent groups were especially unlikely to think sexual activity had diminished. Working in the same area, Obbo (1993b) reports an interesting attempt to ''map" sexual networks.19 The work shows that even if people reduce their partner numbers to a small band of people they know well, such as old classmates, they are still at considerable risk of infection. Of 15 people in two interlinked urban networks in 1989, only 2 had survived by 1992. The failure of awareness programs and interventions to effect more substantial change in condom use should be judged in context. Despite initial willingness among adolescents in Durban, South Africa, to try condoms with their partners, few had positive experiences, challenging widely held notions of male sexual prowess, love, and accepted patterns of interpersonal communication between the sexes (Preston-Whyte, 1994). In a culture where condoms are uncommon and have a rather sordid image, such an outcome is hardly surprising. Focus groups illuminate the frightening possibility that behavior change may be in the wrong direction. An overwhelming majority of schoolchildren involved in an essay-writing exercise in Uganda thought it likely that those who found out they were seropositive would deliberately go out and spread the disease (Obbo, 1993a). Konde-Lule (1993) reports similar findings, and IRESCO (1995) describes the same dynamic in relation to STDs in Cameroon. Authors frequently observe that knowing how to reduce risk effectively is not in itself enough to change behavior; people must have the power to make the required changes. Ulin (1992) suggests that the failure of AIDS campaigns to recognize this fact can be fatal to their impact. The WHO/GPA surveys attempted to determine how "empowered" people felt by asking whether they believed AIDS could be avoided by behavior change. Consistently high proportions 19    The networks are discovered through what amounts to gossip (albeit from several sources), so it is difficult to judge how accurate the information is.

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Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences of those who had heard of AIDS said yes. However, since the question was asked impersonally, a positive response does not tell us whether people felt they were in a position to make those changes themselves, much less whether they felt able to urge changes on their partners. In the HIV/AIDS literature, the discussion of power within a relationship usually turns on women's ability to refuse sex or enforce condom use. Women may have more chance of taking either action where a strong tradition of postpartum abstinence allows them to refuse sex at certain times, such as in West African societies, where a woman can rely on her natal kin for support if her insistence on behavior change results in the breakdown of the relationship (Awusabo-Asare et al., 1993; Orubuloye et al., 1993; O'Toole Erwin, 1993). Women are often in a fairly strong position to refuse sex with regular partners if they know their partner has contracted an STD, but attempts to "punish" men for infidelity are viewed with less sympathy. For instance, for women in Zambia, a husband's infidelity is not grounds for divorce, but women can and do seek divorce if they contract an STD from their husbands (Parapart, 1988, quoted in Standing and Kisekka, 1989). Women who rely on sex or sexual attachments for all or most of their income are among those who have least leverage over their partners. If they are commercial sex workers, they are also those most frequently exposed to the risk of infection. CONCLUSIONS What, then, have we learned from the WHO/GPA surveys and other work on sexual behavior in sub-Saharan Africa, and what are the implications? The following conclusions can be drawn: There is considerable diversity among African countries in reports of nonmarital sex. Multiple partnerships remain common, and marriages are in many places inherently unstable. A high proportion of regular partnerships are noncohabiting, even at older ages; noncohabitation is associated with casual sexual contacts. While there is generally more casual sex occurring in towns and cities than in villages, levels of sexual activity are remarkably similar across the urban/rural divide in a given country, and rural areas should not be neglected in planning campaigns to arrest the spread of HIV. AIDS is widely known and feared, and governments should not assume they will encounter opposition if they put the issue high on the national agenda. People know that HIV is sexually transmitted, but many still believe that mosquitoes and social contact can spread the disease as well. The concept of infection by an apparently healthy person is poorly understood and should be stressed in educational campaigns. From the point of view of program planners, health beliefs fall into three categories: those that are likely to prove supportive to interventions and behavior

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Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences change, those that are merely benign or neutral, and those that are dangerous. An example of this last category is the belief that links sex with a "cleansing" of sexual diseases. If such views are determined to be common, ways must be found of eroding them without spreading them further through suggestion. Levels of condom use are low and access is limited in many countries, although this picture is changing rapidly across the continent as governments and international organizations commit more resources to social marketing, family planning, and the control of STDs. Where condoms are known, their image is often still poor, sometimes for reasons that are inherent to the product and sometimes based on misconceptions. One of the most common of the latter, that condoms are dangerous to women, should be urgently redressed. AIDS awareness campaigns have focused on use of condoms with strangers and casual partners. This focus may jeopardize their use with regular partners, as well as with acquaintances who may belong to high-risk groups. There is no shortage of evidence that coercive sex, including rape, takes place and that schoolgirls are especially likely to be victims. As a human rights issue, this should stand alone; in areas where STDs and HIV/AIDS are prevalent, it is also a public health issue. Work should be initiated to determine the magnitude of the problem and address the forces that promote it, including silence.20 Women consistently report fewer sexual partners than do men. Ways must be devised of discovering whether this discrepancy is the result of normative underreporting; if so, alternatives to survey methods of data collection for quantification of women's sexual activity must be developed. RECOMMENDATIONS The discussion in this chapter and the conclusions offered above lead to the following recommendations for future research related to sexual behavior and HIV/AIDS. Recommendation 4-1. Research on sexual networks is critical. Population-based research is needed to collect and analyze data on both the variables that describe individual sexual behavior and the possible socioeconomic determinants of the decision to have sex with a new partner or forgo protection. Since the details of interconnected sexual networks are difficult to 20    In July 1991 at St. Kizito school in Kenya, 19 girls were killed and 71 reported raped by their fellow students. Following the incident, the deputy headmistress commented that "the boys did not mean the girls any harm. They only wanted to rape" (Okie, 1993:A15).

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Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences deduce from the answers to individual questionnaires, there is also an important role for social network research. Recommendation 4-2. Researchers need to develop more reliable ways of collecting information on sexual behavior and to find ways of testing its validity. There appears to be a much greater willingness to report sexual behavior than was believed until recently, but this field of research requires sensitivity. The challenge is to develop definitions and appropriate vocabulary, such as for categories of relationships, that are both specific enough to be clear to respondents and generalizable enough to be useful to analysts and program planners. The challenge is likely to grow as information about high-risk behavior spreads, increasing the likelihood that respondents will seek to give the "right" answers on questionnaires and in interviews. Hybrid research strategies involving both qualitative and quantitative approaches are essential. Where appropriate, and when both privacy and confidentiality can be ensured, biological markers of sexual activity (such as HIV or STD status) should periodically be incorporated into behavioral surveys to allow assessment of the validity of questionnaire responses and the extent to which the latter provide adequate information on risk. Recommendation 4-3. Research is needed on patterns of sexual initiation and on the formation of sexual norms and attitudes. The sexual habits of a lifetime may well be influenced by a socialization process that starts at or before puberty, often before sexual activity begins. A better understanding of the early influences on sexual norms and attitudes and of patterns of sexual initiation may prove essential to promoting safer behavior. For this recommended research to be successful, studies must include children and prepubescent youths, as well as sexually active adolescents and their partners. Recognition that sexuality is socially constructed and changing rapidly is essential to broadening the research agenda and improving interventions. Recommendation 4-4. More work is needed to clarify the frequency of specific sexual practices. Because the epidemic in sub-Saharan Africa is being sustained by heterosexual transmission, information on sexual behavior is needed to help develop more effective prevention strategies, as well as to provide baseline data to evaluate their effectiveness. Specific sexual practices—dry sex, oral sex, and anal sex being but a few examples—may impede the success of particular interventions,

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Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences yet information about such practices is necessary for encouraging behavioral change. Recommendation 4-5. Research on coercive sex, especially among adolescents, is critical. The magnitude of the problem of coercive sex is all but unknown, as are the circumstances under which forced sex or rape takes place. How frequently does it happen and why? Do the aggressors or the victims share characteristics that might suggest a path for preventive or protective interventions? Research on community attitudes, mores, and gender expectations that may serve to encourage or inhibit coercive sex is urgently needed in order to determine how to enlist community support for the curtailment of such practices. Recommendation 4-6. Research aimed at achieving a better understanding of perceptions about the dual roles of condoms is required. Condoms help prevent the spread of HIV/AIDS; they also prevent pregnancy. How aware are people of these dual roles, and what weight do they give each when deciding whether to use condoms? How often are these roles in concord and how often in conflict? Do partners discuss this issue, and if so, what are the negotiating mechanisms used? Recommendation 4-7. Research on attitudes and beliefs about and behavioral responses to sexually transmitted diseases is required. To develop effective strategies for the treatment of STDs, understanding is needed about social and cultural responses to STDs, including stigmatization. Much more knowledge about the health-seeking behaviors of people infected with STDs, and whether their sexual habits are altered by knowledge of infection, is also needed. Recommendation 4-8. Research on acceptance of and behavioral responses to HIV vaccination is urgently needed. Because vaccine trials are likely to begin with vaccines of limited efficacy, there is an urgent need to learn whether individuals who are vaccinated increase their exposure to HIV through riskier behavior, and if so, to determine how to mitigate this response.