Condoms Count for HIV Prevention

Promoting Condom Use by Married People and Couples In Union Proves Challenging, but Not Impossible, Particularly Among Discordant Couples

Consistent condom use remains largely uncommon among married couples and regular partners. An analysis of 23 Demographic and Health Surveys (DHS) from low and middle income countries conducted between 1994 and 2000 found that in eight of the 23 countries, fewer than five percent of women aged 15 to 49 used condoms to prevent STIs (Snelling et al, 2006).¹⁴²

There is a problem here, because he is your husband and so you can’t tell him to use a condom every time he comes home. You will bore him and make him go out to other women. Woman, nonuser of contraceptives, Kabazi, Kenya (Bauni and Jarabi, 2000: 73)¹⁴³

Condom use within long-term relationships or marriage is commonly perceived as a sign of infidelity, immorality and lack of trust.¹⁴⁴ Among married couples in Nigeria, researchers found that the perceived association of condoms with promiscuity is so strong that women find it difficult, if not impossible, to negotiate condom use.¹⁴⁵ In this context, condom use was dependent on appealing to men’s sense of responsibility to their families. In a study conducted among married and cohabitating couples in KwaZulu-Natal, South Africa, only 43 percent of men and 60 percent of women found it acceptable for a married woman to request that her husband use condoms.¹⁴⁶ In a qualitative study conducted in Ethiopia, Tanzania and Zambia, respondents reported that the stigma of infidelity and infection associated with condoms inhibits them from using or suggesting use of condoms.¹⁶¹ In rural Malawi, initiating a discussion of condom use for preventing infection in marriage is compared to “bringing an intruder into the domestic space.”¹⁶²

"I do not use a condom with my married partner…I trust her, so there is no need to use a condom with her." Rural male, South Africa (Maharaj and Cleland, 2004: 120)¹⁶³

Condom use may be compromised if women cannot negotiate their use for pregnancy prevention. Furthermore, in some places, risky behaviors of male partners can place pregnant women at tremendous risk. A survey of 279 husbands of women who had recently delivered in south-eastern Nigeria found that 28 percent of the men engaged in extra marital relationships while their wives were pregnant. A large percentage of the men reported that they believed sex during pregnancy causes miscarriage.¹⁶⁴ Condom use is also particularly uncommon as a form of dual protection with sterilization. In a review of the literature, no studies regarding condom use among men with vasectomies were found.¹⁶⁵ A study conducted in São Paulo, Brazil, showed that women who have undergone sterilization are less likely to use condoms than women using other methods of family planning, and that women who had previously used condoms for contraception stopped after sterilization.¹⁶⁶ Sterilization counseling in settings where HIV is prevalent should include counseling on condom use.¹⁶⁷

"A man wouldn’t agree to use a condom if the woman is already using another family planning method." Female contraceptive user, Langalanga, Kenya¹⁶⁸

However, evidence has shown that condom uptake can be successfully increased among married couples. In a comprehensive review of condom interventions, 11 studies reported on use within regular partnerships, and nine of those studies reported significant increases in condom use, although only two were among low-risk populations.¹⁶⁹ In these two low-risk studies—both conducted among married women in Thailand—one reported five percent consistent condom use at six month follow-up after clinic based-counseling (an increase from two percent consistent use at baseline).¹⁷⁰ The second study found that “more frequent” use of condoms with a spouse rose to 58 percent.¹⁷¹ While these findings are promising, the level of consistent condom use reported in the first study is still quite low, and despite being a randomized controlled trial, the second study applied a weak measure of condom use.

A qualitative study conducted among 39 married couples in Uganda who reported 100 percent condom use in the last three months provides insight into the negotiation of consistent condom use within marriage.¹⁷² For 22 of the 39 couples, condom use was proposed by the wife; in six cases, use was initiated by the husband and there was disagreement amongst the remaining couples as to which partner initiated discussions. The women reported that they were able to convince their partners to agree to consistent condom use by being insistent and persuasive, refusing sex, or proposing condom use for family planning or to safeguard their children from becoming orphans. Men reported agreeing to condom use to please their wives, to protect their wives and children, to protect themselves, and to be able to maintain other partnerships. Research from rural Malawi has shown that women talk to their husbands about the consequences for their children should both parents die of AIDS in order to encourage protective sexual behaviors.¹⁷³

Findings of a WHO-sponsored study conducted in six African countries suggest that the influence of husbands and wives on condom use is approximately equal in Kenya, Uganda and South Africa.¹⁷⁴ Data from South Africa show that the wife’s fear of HIV infection was the most powerful predictor of condom use.¹⁷⁵ These results demonstrate that couples are willing to use condoms at least sometimes if there is a perceived risk of HIV infection. While these results are promising for increasing the acceptability of condom use among married couples, use must be consistent to protect against HIV transmission. Furthermore, a review of 62 studies found that condom use ultimately depends on male cooperation.¹⁷⁶

"The reason why we decided to use the condom is that when we sat and discussed it, we got scared of getting unwanted pregnancies on top of the children we already have. After that, we talked about the disease (HIV). My wife cautioned me about getting other women since I am a bodaboda rider (bicycle taxi driver) and spend some nights on the streets of Kampala. She developed this feeling I would be tempted to get another woman, use that woman and then come back home then infect her. She then suggested we use the condom on the premise that our children would not be left alone if I were to die. I saw it as easy and continued using the condom.” Ugandan husband, age 25 (Williamson, et al, 2006: 94¹⁷⁷

Condom use within partnerships may be rising, but use is not necessarily consistent. In a study conducted among married and cohabitating couples in KwaZulu-Natal, South Africa, about 20 percent of both men and women had tried condoms with their partners, and only around three percent are using condoms ‘always’ and 12 percent ‘occasionally.’ A WHO study in three African countries—Kenya, Uganda and South Africa—found that occasional condom use among couples ranged between 10 and 21 percent.¹⁷⁸ Because inconsistent use of condoms does not offer effective prevention, more needs to be done to promote consistent use among couples. Given persistently low rates of consistent condom use in marriage and other civil unions (other than among discordant couples), it may be more effective to target programmatic efforts toward promoting condom use in casual partnerships.

Condom Promotion Works Among Discordant Couples

In countries where sex outside of marriage is common, sex without condoms within marriage is inherently risky. Data from around the world suggest that married women’s greatest risk of contracting HIV is through sexual intercourse with their husbands.¹⁷⁹ HIV discordance among married and cohabiting couples in sub-Saharan Africa is high, ranging from three to 20 percent in the general population^{180 181 182} and 20 to 35 percent in couples where one partner seeks HIV services.^{183 184 185} Because the majority of these couples are not aware of their discordance,¹⁸⁶ promotion of monogamy within marriage without mention of HIV-testing or condom use may actually increase HIV transmission among discordant couples. In mature epidemics, a high proportion of new HIV infections in the region is occurring within married discordant couples,^{187 188} but few interventions are currently targeting couples.¹⁸⁹

"I didn’t understand how I, as a submissive woman, could be infected, having been faithful to the one man in my life." An HIV positive woman, Burkina Faso¹⁹⁰

A qualitative study conducted among discordant couples in Uganda found condom use to be the most common and preferred method of HIV prevention. Some couples transitioned to condom use after failing to abstain or reduce their frequency of sex.¹⁹¹ Women living with HIV who want to become pregnant also need counseling on the safest times to forego using condoms (and other contraceptives), such as when they are on Highly Active Anti-Retroviral Therapy (HAART) and with low viral loads, as well as times when they are most likely to conceive [see Section IV].

Discordant couples who have received Voluntary Counseling and Testing (VCT) have lower seroconversion rates.¹⁹² Reported use of condoms increased among men and women living with HIV who underwent VCT in Mozambique.¹⁹³ However, seroconversion within discordant couples who receive VCT remains high, ranging between three and eight percent annually, although the desire for children may partially explain persistent incidence.^{194 195} A cross-sectional and nationally representative study in Uganda found that only 21 percent of adults knew their HIV status and nine percent knew their partner’s. Of cohabiting HIV-infected respondents, 40 percent had an HIV-negative spouse. Respondents who knew their status were three times more likely to use a condom at last sexual encounter, and those who knew their partner’s HIV status were 2.3 times more likely to use condoms.¹⁹⁶ An increase in VCT coverage is urgently needed to make more couples aware of their HIV discordance and thus the greater need for condom use in stable partnerships. VCT also provides an important opportunity to combat perceptions that seroconversion is inevitable among discordant couples. Box 6 shows that programs targeted to sero-discordant couples can successfully increase condom use.

Please refer to the Appendix for end notes.