Preventing and Mitigating AIDS in Sub-Saharan Africa Research and Data Priorities for the Social and Behavioral Sciences (1996) / Chapter Skim
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4 SEXUAL BEHAVIOR AND HIV/AIDS
4 SEXUAL BEHAVIOR AND HIV/AIDS
Pages 105-154
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From page 105... ...
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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From page 106... ...
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. QUESTIONS OF METHODOLOGY The two principal sources of information about sexual behavior are ethnographic accounts and survey methods.
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From page 107... ...
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.
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From page 108... ...
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From page 109... ...
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From page 110... ...
a partner relations (PR) questionnaire that focused more narrowly on sexual behavior; and (c)
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From page 111... ...
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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From page 112... ...
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.
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From page 113... ...
, 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.
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From page 116... ...
If we look at sexual initiation regardless of marital status, rates of sexual activity recorded in the WHO/GPA surveys for men and women converge dramatically. In West Africa, sexual initiation tends to occur relatively early: in Cole d'Ivoire and the Central African Republic, 45 to 60 percent of both sexes are sexually active by the age of 15 (see Table 4-33.
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From page 117... ...
One-quarter of married women in Togo reported no sex with their regular partner in the 12 months preceding the study. (Figure 4-1 shows that women in Togo also average more months of postpartum abstinence than most other women in Africa.)
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From page 118... ...
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From page 119... ...
In a single month, 35 to 45 percent typically had no sexual contact with their spouse or regular partner. Extramarital and Casual Sex Given that marriage is difficult to define, defining what constitutes extramarital sex is also problematic.
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From page 120... ...
report that 68 percent of women observing postpartum abstinence or their male principal partners said the male partner had sex with others during that time. Levels of extramarital sex with nonregular partners vary, though once again comparisons are difficult because of differences in definition.6 WHO/GPA sur SMen in this situation may have been having sex with other regular partners during this time.
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From page 121... ...
. Women tend to report less than half of male levels of nonregular sexual activity (Figure 4-2~.
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From page 122... ...
This finding would suggest that where overall levels of sexual activity are high, women who have no sex outside regular partnerships will still be at increased risk for HIV. Stronger still is the correlation between men reporting casual sex and men not cohabiting with their regular partner (a figure that reaches 43 percent in Cote d'Ivoire and is lowest in Tanzania at 11 percent)
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From page 123... ...
(1992) note a profusion of sex workers incompatible with the low levels of commercial sex reported by men.
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From page 124... ...
Although the spectrum of women engaging in transactional sex is broad, commercial sex workers are often portrayed as hapless victims of extreme poverty and family breakdown in surveys and focus group interviews (Pickering et al., 1992~. However, in an extremely thorough prospective study of prostitutes and their clients in The Gambia that led to invitations to the commercial sex workers' family homes, the researchers reported that many of the women were from well-off families; their work appeared to be a life-style choice.
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From page 125... ...
This section examines sex-related risk factors associated with HIV/AIDS, including a high number of partners/commercial sex, perceived risk, age, education, marital status, residence, migration, STDs, circumcision and traditional medical practices, and alcohol.8 In analyzing the WHO/GPA survey data, researchers define "risk behavior" as having one or more nonregular partners in the last 12 months, while "high-risk behavior" is having "commercial" sex in that time period. Although the definitions may appear to capture a wide range of behavior, they are lent credence by serostudies.
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From page 126... ...
Age In the WHO/GPA surveys, risk behavior is associated with age. In some African societies, for example, Central African Republic, Guinea-Bissau, and Kenya, over half of all those aged 15 to 19 are already sexually experienced (Carael, 1995~.
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From page 127... ...
In the WHO/GPA surveys, formerly married women were typically more likely to report casual sex than married women, with single women being intermediate. Among the three surveys for which multivariate analyses were performed, however, a significant effect of marital status was found only in Cole d'Ivoire.
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From page 128... ...
In multivariate analysis of DHS data for several sub-Saharan African countries, Meekers (1994) shows little effect of urban/rural residence on age at first intercourse, although when asking retrospective questions in cross-sectional surveys, it is difficult to determine where first sex took place, or if onset of sexual activity might be linked in some way to migration.
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From page 129... ...
Responses about symptoms of STDs over the last 12 months in the WHO/ GPA surveys show a strong correlation between reported risk behavior and venereal infections. In many nations, those reporting STD symptoms are two or three times as likely to report casual sex as those apparently unaffected.
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From page 130... ...
Lack of male circumcision has been associated with some sexually transmitted diseases, including chancroid, syphilis, and gonorrhea (Cook et al., 1994) , but there has been a good deal of debate in the recent literature on the link between lack of male circumcision and the risk of HIV infection.
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From page 131... ...
However, few studies have examined the effects of alcohol consumption on sexual behavior in sub-Saharan Africa, although some income expenditure studies show that a significant portion of disposable income is spent on the consumption of various forms of alcoholic beverages. Bars and nightclubs that sell alcohol are often popular meeting places and are frequented by people looking for commercial or casual sex.
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From page 132... ...
Although this high proportion may partly reflect the increased likelihood that a rape resulting in an STD will be reported, the risk for a young girl to be subjected to violent sex must be high in a population where STDs are common. Since STDs are a cofactor for HIV transmission, HIV, too, is a potential consequence of rape.
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From page 133... ...
Clinical examination showed that many of the methods had led to lesions or swellings in the vagina. In Blantyre, Malawi, a study of women attending an antenatal clinic, designed to assess the prevalence of dry sex practices and its association with HIV infection, found that 34 percent of the women had used an intravaginal agent for
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From page 134... ...
. Other studies give evidence of homosexual behavior among the Kikuyu in Kenya, the Hausa in Nigeria, and mine-workers in South Africa (Standing and Kisekka, 1989 J
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From page 135... ...
Half of the women in his sample reported contraceptive use, versus a national average of 13 percent among currently married women (Ghana Statistical Office and IRD/Macro Systems, 19891. However, repeated surveys sometimes contradict the conventional wisdom that postpartum abstinence is everywhere on the wane.
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From page 136... ...
Of those who knew of AIDS, women were nearly twice as likely as men to mention condom use and avoidance of sex workers, and were also slightly more likely to mention partner reduction. Men who had a history of contact with sex workers were less likely than those who did not to regard sex workers as a source of danger, and the proportion of men saying fewer partners could reduce the risk of HIV infection fell as their number of partners over the
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From page 137... ...
Prostitute = having sex with a prostitute Touch = touching someone with AIDS Vertical = mother-to-child transmission Mosquito = transmitted by mosquito bite Curable = AIDS is curable CAR = Central African Republic n.a. = not available SOURCE: Cleland and Ferry (1995)
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From page 138... ...
A study of AIDSrelated knowledge in Zimbabwe, undertaken in 1994, revealed that while virtually all Zimbabwean men and women have heard of AIDS, 15 percent of men and 26 percent of women do not believe that a healthy-looking person can carry the AIDS virus (Central Statistical Office [Zimbabwe] and Macro International Inc., 1995~.
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From page 139... ...
In two surveys, married women reported significantly higher risk than unmarried women, and in the third the difference was in the same direction, though not significant. However, in a study of sexually active women in Kigali, Rwanda, 84 percent of women who lived alone felt at risk of HIV infection, as compared with just onequarter of monogamously married women (Linden et al., 1991~.
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From page 140... ...
Factory workers in Kinshasa, Zaire, stated that anyone known to be HIV-positive would be shunned by his or her neighbors (Irwin et al., 1991) , while many respondents in the WHO/GPA survey in the Central African Republic thought AIDS patients deserved no care, and nearly one in five stated flatly that they should be killed.
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From page 141... ...
And in a recent study of female partners of AIDS patients in a hospital in Kampala, Uganda, only 12 percent of women correctly identified their husbands' diagnosis as "slim" or AIDS (Baingana et al., 1995~. Most women (54 percent)
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From page 142... ...
( 1994) confirm the negative correlation with age and the positive correlation with risk behavior (including contact with sex workers)
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From page 145... ...
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.
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From page 146... ...
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 onethird 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)
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From page 147... ...
,, : ma. ~ L Burundi CAR Cote Guinea- Kenya Lesotho Tanzania Togo Lusaka, d'lvoire Bissau Zambia · OK for casual sex ~ OK for spouse ~ Offensive to spouse FIGURE 4-4A Attitudes Toward Condoms Among Men Who Have Used Them.
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From page 148... ...
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.
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From page 149... ...
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.
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From page 150... ...
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.
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From page 151... ...
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.
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From page 152... ...
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.
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From page 153... ...
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.
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From page 154... ...
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.
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