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.


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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