Women's attitudes to condoms and female-controlled means of protection against HIV and STDs in south-western Uganda

Gender Equity and HIV/AIDS Prevention: Comparing Gender Differences in Sexual Practice and Beliefs among Zimbabwe University Students

We assess gender differences in HIV prevention knowledge, attitudes and practices with a focus on cultural, sociological, and economic variables. A randomized cross-sectional study was used in order to achieve high participation and broad comparative assessment. An eight-page questionnaire was administered to 933 randomly selected students at the University of Zimbabwe. Survey items addressed sexual decision-making, condom use, limiting sexual partners, cultural power dynamics and access to HIV testing. We found marked gender differences with men reporting beliefs of entitlement to dominate women, an assumed leadership in decision-making concerning condom use and an attitude that when a woman says “no” to sex, really, “it depends.” Women acknowledged gender-based cultural attitudes but are much more likely to support women's rights to sexual expression. A multi-faceted approach to gender equity training is needed to challenge men and women to change attitudes and increase social awareness that respects cultural traditions while still inspiring both men and women to champion justice and equality between genders.

Safety and Pharmacokinetics of Quick-Dissolving Polymeric Vaginal Films Delivering the Antiretroviral IQP-0528 for Preexposure Prophylaxis

For human immunodeficiency virus (HIV) prevention, microbicides or drugs delivered as quick-dissolving films may be more acceptable to women than gels because of their compact size, minimal waste, lack of an applicator, and easier storage and transport. This has the potential to improve adherence to promising products for preexposure prophylaxis. Vaginal films containing IQP-0528, a nonnucleoside reverse transcriptase inhibitor, were evaluated for their pharmacokinetics in pigtailed macaques. Polymeric films (22 by 44 by 0.1 mm; providing 75% of a human dose) containing IQP-0528 (1.5%, wt/wt) with and without poly(lactic-co-glycolic acid) (PLGA) nanoparticle encapsulation were inserted vaginally into pigtailed macaques in a crossover study design (n = 6). With unencapsulated drug, the median (range) vaginal fluid concentrations of IQP-0528 were 160.97 (2.73 to 2,104), 181.79 (1.86 to 15,800), and 484.50 (8.26 to 4,045) μg/ml at 1, 4, and 24 h after film application, respectively. Median vaginal tissue IQP-0528 concentrations at 24 h were 3.10 (0.03 to 222.58) μg/g. The values were similar at locations proximal, medial, and distal to the cervix. The IQP-0528 nanoparticle-formulated films delivered IQP-0528 in vaginal tissue and secretions at levels similar to those obtained with the unencapsulated formulation. A single application of either formulation did not disturb the vaginal microflora or the pH (7.24 ± 0.84 [mean ± standard deviation]). The high mucosal IQP-0528 levels delivered by both vaginal film formulations were between 1 and 5 log higher than the in vitro 90% inhibitory concentration (IC90) of 0.146 μg/ml. The excellent coverage and high mucosal levels of IQP-0528, well above the IC90, suggest that the films may be protective and warrant further evaluation in a vaginal repeated low dose simian-human immunodeficiency virus (SHIV) transmission study in macaques and clinically in women.

Knowledge, attitudes, practices and behaviors associated with female condoms in developing countries: a scoping review

Women in developing countries are at high risk of HIV, sexually transmitted infections, and unplanned pregnancy. The female condom (FC) is an effective dual protective method regarded as a tool for woman’s empowerment, yet supply and uptake are limited. Numerous individual, socioeconomic, and cultural factors influence uptake of new contraceptive methods. We reviewed studies of FC knowledge, attitudes, practices, and behaviors across developing countries, as well as available country-level survey data, in order to identify overarching trends and themes. High acceptability was documented in studies conducted in diverse settings among male and female FC users, with FCs frequently compared favorably to male condoms. Furthermore, FC introduction has been shown to increase the proportion of “protected” sex acts in study populations, by offering couples additional choice. However, available national survey data showed low uptake with no strong association with method awareness, as well as inconsistent patterns of use between countries. We identified a large number of method attributes and contextual factors influencing FC use/nonuse, most of which were perceived both positively and negatively by different groups and between settings. Male partner objection was the most pervasive factor preventing initial and continued use. Importantly, most problems could be overcome with practice and adequate support. These findings demonstrate the importance of accounting for contextual factors impacting demand in FC programming at a local level. Ongoing access to counseling for initial FC users and adopters is likely to play a critical role in successful introduction.

Community-level influences on women's experience of intimate partner violence and terminated pregnancy in Nigeria: a multilevel analysis

Background

Intimate partner violence (IPV) is a major public health problem with serious consequences for women’s physical, mental, sexual and reproductive health. Reproductive health outcomes such as unwanted and terminated pregnancies, fetal loss or child loss during infancy, non-use of family planning methods, and high fertility are increasingly recognized. However, little is known about the role of community influences on women's experience of IPV and its effect on terminated pregnancy, given the increased awareness of IPV being a product of social context. This study sought to examine the role of community-level norms and characteristics in the association between IPV and terminated pregnancy in Nigeria.

Methods

Multilevel logistic regression analyses were performed on nationally-representative cross-sectional data including 19,226 women aged 15–49 years in Nigeria. Data were collected by a stratified two-stage sampling technique, with 888 primary sampling units (PSUs) selected in the first sampling stage, and 7,864 households selected through probability sampling in the second sampling stage.

Results

Women who had experienced physical IPV, sexual IPV, and any IPV were more likely to have terminated a pregnancy compared to women who had not experienced these IPV types.

IPV types were significantly associated with factors reflecting relationship control, relationship inequalities, and socio-demographic characteristics. Characteristics of the women aggregated at the community level (mean education, justifying wife beating, mean age at first marriage, and contraceptive use) were significantly associated with IPV types and terminated pregnancy.

Conclusion

Findings indicate the role of community influence in the association between IPV-exposure and terminated pregnancy, and stress the need for screening women seeking abortions for a history of abuse.

Condoms in sub-Saharan Africa

Sub-Saharan Africa (SSA) is the region with the world’s highest rates of HIV and other sexually transmissible infections (STIs), yet numerous studies show that condom use is generally rare. This suggests a need for a better understanding of how condoms fit within sexual practices and relationships in SSA. This paper seeks to address this need by reviewing research published between the late 1980s and 2011 on use and factors influencing use of male condoms in SSA. What is evident from this research is that condom use involves complex social and interpersonal dynamics, with structural and cultural conditions exerting an influence through framing social cognitions and setting boundaries on autonomy that make the apparently irrational choice of eschewing condoms a rational decision. The influences of poverty; relationships with parents, peers and partners; limited, insufficient or absent information especially in rural areas and among men who have sex with men; gender and sexual norms, and the dynamics of gendered power; and beliefs and attitudes about HIV, condoms and sexuality all have been shown to work against condom use for a large proportion of Africa’s people. However, promising results are shown in trends towards increased condom use among single women in numerous countries, increasing acceptance and use of condoms among some university students, successes in producing potentially sustainable condom use resulting from select interventions, and resistance to succumbing to the dominant gender–power dynamics and structural–cultural impediments that women in groups have mobilised.

HIV prevention for young women of Uganda must now address poverty and gender inequalities

PURPOSE

This study seeks to explore the perspectives of young women in Uganda with the aim of better informing re HIV prevention.

DESIGN/METHODOLOGY/APPROACH

Group discussions and interviews were used to explore issues relating to HIV prevention. An inductive content analysis identified emerging themes and patterns in the participants' conversations.

FINDINGS

The study revealed that, although young women were informed and motivated to prevent HIV, poverty and inequality were significant barriers, limiting their power to protect themselves.

ORIGINALITY/VALUE

The research adds evidence to the current argument that failure to address the disempowering effects of poverty and gender inequality limits the effectiveness of current HIV prevention for young women. HIV prevention must now address poverty and gender vulnerabilities, promoting a protective environment, rather than focusing on influencing individual sexual behaviour.

Intimate partner violence and contraception use among women in Sub-Saharan Africa

OBJECTIVE

To determine the association between contraceptive use and intimate partner violence (IPV) in Sub-Saharan African women.

METHOD

The data analyzed were from national Demographic Health Surveys conducted between 2003 and 2006 in 6 Sub-Saharan African countries: Cameroon, Kenya, Malawi, Rwanda, Uganda, and Zimbabwe. Women of childbearing age completed surveys regarding the use of contraception and about their experience of physical, emotional, and sexual violence inflicted by their partners. Analyses were conducted using logistic regression.

RESULTS

Of the 24311 women who responded to the violence modules, 39.8% reported that they had experienced IPV. Women who had experienced IPV were significantly more likely to report that they had used contraception compared with women who had not experienced IPV (odds ratio 1.30; 95% confidence interval, 1.22-1.38).

CONCLUSION

Intimate partner violence appears to be associated with increased contraception use in the African setting. Among women who have experienced IPV, modern contraception is used more commonly than traditional and folkloric contraceptive methods.

Evidence-based planning of a randomized controlled trial on diaphragm use for prevention of sexually transmitted infections

OBJECTIVES

We conducted formative research to evaluate the acceptability and feasibility of continuous diaphragm use among low-income women highly exposed to sexually transmitted infections (STIs) in Madagascar.

GOAL

To identify potential obstacles to researching the effectiveness of diaphragm use for STI prevention in a randomized controlled trial.

STUDY DESIGN

Mixed methods to collect complex information. In a quantitative pilot study, women were asked to use diaphragms continuously (removing once daily for cleaning) for 8 weeks and promote consistent male condom use; they were interviewed and examined clinically during follow-up. Focus group discussions (FGDs) were conducted pre-/postpilot study. Audiotaped FGDs were transcribed, translated, coded, and analyzed.

RESULTS

Ninety-three women participated in prepilot FGDs, 91 in the pilot study, and 82 in postpilot FGDs. Diaphragm use was acceptable and feasible, but participants reported lower condom use in FGDs than during interviews. Most participants reported in interviews that they used their diaphragms continuously, but FGDs revealed that extensive intravaginal hygiene practices may impede effective continuous diaphragm use. Despite counseling by study staff, FGDs revealed that participants believed the diaphragm provided effective protection against STIs and pregnancy.

CONCLUSIONS

Mixed methods formative research generated information that the prospective pilot study alone could not provide and revealed contradictory findings. Results have methodological and ethical implications that affect trial design including provision of free hormonal contraceptives, and additional instructions for vaginal hygiene to avoid displacing the diaphragm. Mixed methods formative research should be encouraged to promote evidence-based study design and implementation.

Female condom uptake and acceptability in Zimbabwe

As the first phase of a two-phase prospective cohort study to assess the acceptability of the diaphragm as a potential HIV/STI prevention method, we conducted a 2-month prospective study and examined the effect of a male and female condom intervention on female condom (FC) use among 379 sexually active women in Harare, Zimbabwe. Reported use of FC increased from 1.1% at baseline to 70.6% at 2-month follow-up. Predictors of FC uptake immediately following the intervention included interest in using FC, liking FC better than male condoms, and believing one could use them more consistently than male condoms. Women reported 28.8% of sex acts protected by FC in the 2 weeks prior to last study visit. Though FC may not be the preferred method for the majority of women, with access, proper education, and promotion they may be a valuable option for some Zimbabwean women.

Women in the time of AIDS: barriers, bargains, and benefits

We comment here on the implications of new HIV prevention technologies (physical and chemical barriers) for women's health and women's rights. Four relevant themes are selected that have emerged in the social and behavioral science literature: structural factors (global and national) limiting the availability of female condoms, control and empowerment with female-initiated HIV prevention technologies, covert use of female-initiated HIV prevention technologies, and male partners as part of the bargain for barriers. There is now a rich and diverse literature on all of these issues, relevant and informative (much is addressed in this issue), which we draw together in this commentary. Discussion of these themes suggests guidelines for policy, research, and action. First, the misconceptions, biases, and prejudices of global and national leaders, including donors, necessitate that we persevere in presenting data to them and engaging them in discussion. Second, we need to support women within their local social contexts to negotiate for their rights, balancing pragmatic approaches to their partners in their initiation of protection, and applying according to each situation as appropriate, a continuum from discretion and clandestine use to deception. Third, men have to be brought in as active participants, and their positive and negative experiences and interests inserted into practices and policies.

The importance of discreet use of the diaphragm to Zimbabwean women and their partners

We conducted a 6-month acceptability study of diaphragms as a potential HIV/STI prevention method among Zimbabwean women. We examined partner involvement in diaphragm use, and importance of discreet use (use without partner awareness). Of the 181 women who completed the study, 45% said discreet use was "very or extremely important" and in multivariate logistic regression, women were more likely to value discretion if their partners: had other partners; drank alcohol; or were believed to prefer condoms to diaphragms. Qualitative data confirmed these findings. Both women and their partners reported that diaphragms can be used discreetly and saw this as advantageous, for both sexual pleasure and female control. However, many were concerned that use without partner approval could lead to marital problems. Discreet use should be considered in development of barrier methods and in diaphragm promotion, if proven effective against HIV/STI.

Preparing for microbicide trials in Rwanda: focus group discussions with Rwandan women and men

The acceptability and feasibility of microbicide studies and future microbicide use are influenced by existing norms and values regarding sexual and contraceptive behaviour. In preparation for microbicide research in Rwanda, focus group discussions were conducted to assess sexual and contraceptive behaviour, preferences for vaginal lubrication, and hypothetical acceptability of microbicides among Rwandan women and men. Seven focus group discussions were conducted among sexually active married women, unmarried women, sex workers, female students, older women and men living in Kigali, Rwanda, and an additional group of women living in a rural area. The results indicate that condom use is low among Rwandan men and women and that condoms are mainly used by men during commercial sex. Women have limited power to negotiate condom or family planning use. Vaginal hygiene practices are very common and consist primarily of washing with water. Lubrication during sex is highly preferred by both men and women. Hypothetical microbicide acceptability after an explanation of what microbicides are and a demonstration with lubricant jelly was high.

Challenges to microbicide introduction in South Africa

Qualitative research was conducted in South Africa to determine perceptions about intra-vaginal microbicides in order to better understand the socioeconomic, cultural and structural contexts for the support of future introduction of this new HIV prevention method. Focus group discussions and in-depth interviews were conducted at community, health service, and policy levels of inquiry. The main study site was a black working class urban area close to Cape Town. "Desperation" in response to the HIV/AIDS epidemic, rape, sexual coercion and unplanned consensual sex emerged as major reasons to support microbicides, while concerns about the partial effectiveness of microbicide protection and its hypothetical nature elicited a more cautious approach. Other key findings included the likelihood that microbicides would be "mainstream", the possible impact on sexual practices and gender norms, issues of condom substitution/migration and potential avenues for education and distribution. We found that microbicides have the potential to meet diverse needs beyond that suggested by prior research. This included a desire for products that could protect against HIV infection following rape, sexual coercion and unplanned sex, and the finding that a wider range of people than previously suggested would potentially use microbicides. The challenge for microbicide introduction will be to develop products that can meet diverse needs not only in South Africa, but also in the broader global context.

Farming with your hoe in a sack: condom attitudes, access, and use in rural Tanzania

This study examines condom knowledge, attitudes, access, and practices in rural Mwanza, Tanzania. From 1999-2002, six researchers carried out participant observation in nine villagesfor a total of 158 person-weeks. Many villagers perceived condoms negatively for multiple reasons, for example, the method's association with infection or promiscuity, reduced male sexual pleasure, and cultural understandings of meaningful sex. Men controlled the terms of sexual encounters and reported that they would use condoms only with risky partners, but few perceived their partners as such. Use of condoms appeared to be very low, primarily as a result of limited demand, although barriers to access also existed. These qualitative findings contrast with inconsistent survey reports of relatively high condom use in the same population. Intervention efforts should address the tradeoff between possible short- and long-term consequences of condom use, particularly for men, for example, reduced pleasure versus reduced HIV risk. If possible, surveys should assess the validity of reported condom use through comparison with other data, including qualitative findings and distribution/sales records.

An examination of knowledge, attitudes and practices related to HIV/AIDS prevention in Zimbabwean university students: Comparing intervention program participants and non-participants

OBJECTIVES

This study represents a comprehensive assessment of differences between participants in an HIV/AIDS prevention program (SHAPE: Sustainability, Hope, Action, Prevention, Education) and non-participants in knowledge, attitudes and practices with a focus on cultural, sociological and economic variables.

METHODS

We developed an eight-page questionnaire that was administered to 933 randomly selected students at the University of Zimbabwe. Survey items addressed sexual decision-making, condom use, limiting sexual partners, cultural power dynamics and access to HIV testing.

RESULTS

Results show participants are statistically more likely to report being sexually abstinent, and understand the prevention benefits of condom use. SHAPE members had fewer sexual partners in the previous year than non-SHAPE members (1.4 vs. 2.2). SHAPE members were significantly more likely (67%) than non-SHAPE respondents (48%) to indicate that they knew their HIV sero-status and to state that they knew their status because they had been tested (85% vs. 71%).

DISCUSSION

Though we found differences between the groups suggesting that program participation increases awareness concerning gender equity, there continue to be many intractable cultural attitudes in this age group. Findings suggest that the attitudes and practices of young men and women are changing, but that progress in some areas does not assure progress in all areas.

Barrier method preferences and perceptions among Zimbabwean women and their partners

In Zimbabwe, adult HIV prevalence is over 25% and acceptable prevention methods are urgently needed. Sixty-eight Zimbabwean women who had completed a barrier-methods study and 34 of their male partners participated in focus group discussions and in-depth interviews to qualitatively explore acceptability of male condoms, female condoms and diaphragms. Most men and about half of women preferred diaphragms because they are female-controlled and do not detract from sexual pleasure or carry stigma. Unknown efficacy and reuse were concerns and some women reported feeling unclean when leaving the diaphragm in for six hours following sex. Nearly half of women and some men preferred male condoms because they are effective and limit women's exposure to semen, although they reportedly detract from sexual pleasure and carry social stigma. Female condoms were least preferred because of obviousness and partial coverage of outer-genitalia that interfered with sexual pleasure.

The sexual and reproductive health of young people in Adjumani district, Uganda: qualitative study of the role of formal, informal and traditional health providers

This qualitative study of young people and health care workers in Adjumani, northern Uganda, found that young people are generally very knowledgeable about STD spread and prevention as well as methods for prevention of pregnancy. Health workers are the most important category of people providing information on sexual and reproductive health (SRH) for young people. However, many health workers are conservative with regard to adolescent sexuality. There is a lack of training in and guidelines for working with adolescents. This, along with inadequate access to SRH services for young people, accounts for the failure to adequately deal with young people's problems. Physical, social, psychological and economic factors create barriers to service accessibility. Socio-economic, religious and cultural factors affect sexual behaviour and outcomes in Adjumani district, making some young people vulnerable, particularly young women. In an effort to find alternative services that meet their needs better, young people visit informal and traditional health care providers despite having to pay for these services. The confidentiality and privacy that they offer could be a lesson for formal health care providers. Further training and integration of traditional health care providers is essential as they already play a major part in SRH service delivery to young people.

Women who sell sex in a Ugandan trading town: life histories, survival strategies and risk

Little is known about the background of commercial sex workers in Africa. This study investigated how women in a trading town on the trans-Africa highway in southwest Uganda become involved in commercial sex work, which factors contribute to their economic success or lack of success, and what effect life trajectories and economic success have on negotiating power and risk behaviour. Over the course of two years detailed life histories of 34 women were collected through recording open, in-depth interviews, the collection of sexual and income and expenditure diaries, visits to the women's native villages, and participant observation. The women share similar disadvantaged backgrounds and this has played a role in their move into commercial sex. They have divergent experiences, however, in their utilisation of opportunities and in the level of success they achieve. They have developed different life styles and a variety of ways of dealing with sexual relationships. Three groups of women were identified: (1) women who work in the back-street bars, have no capital of their own and are almost entirely dependent on selling sex for their livelihood; (2) waitresses in the bars along the main road who engage in a more institutionalised kind of commercial sex, often mediated by middlemen and (3) the more successful entrepreneurs who earn money from their own bars as well as from commercial sex. The three groups had different risk profiles. Due partly to their financial independence from men, women in the latter group have taken control of sexual relationships and can negotiate good sexual deals for themselves, both financially and in terms of safe sex. The poorer women were more vulnerable and less able to negotiate safer sex. A disadvantaged background and restricted access to economic resources are the major reasons for women gravitating to commercial sex work. Various aspects of personality play a role in utilising income from commercial sex to set up an economic basis that then makes the selling of sex unnecessary. This has implications for interventions, and part of the longer-term solution should lie in improving the economic position of women vis-à-vis men.

Acceptability research on female-controlled barrier methods to prevent heterosexual transmission of HIV: Where have we been? Where are we going?

Acceptability research is an important component of any product development process. As researchers move into a new, accelerated phase of vaginal microbicide development, it is important to take stock of the acceptability research conducted to date and determine future research priorities. In this paper, we review findings from acceptability research conducted to date in four categories: hypothetical product acceptability research, existing product research (spermicide acceptability studies), acceptability research within the context of clinical trials, and postmarketing acceptability research conducted around the female condom. Finally, we highlight areas where additional research is needed in light of recent progress in microbicide development and discuss a possible framework for the introduction and acceptability of new sexually transmitted disease (STD) prevention technologies.

Female control of sexuality: illusion or reality? Use of vaginal products in south west Uganda

This paper reports on a trial of vaginal products that were distributed and used by 131 women and 21 men in south west Uganda. It focuses specifically upon the issue of female control in heterosexual relationships and examines whether methods which are ostensibly under women's control, will in practice give women greater control of their sexual health. Participants were invited to select two from a range of vaginal products that included the female condom, contraceptive sponge, film, tablets, foam and gel, and use each for five weeks and their favourite product for a further three months. They were interviewed up to seven times over a five-month period. Although the women perceived that a major advantage of the products (with the exception of the female condom) was that they could be used secretly, less than 40% were using the products without their partner's knowledge after one week and this proportion declined over time with only 22% using the products secretly after ten weeks. In the main male partners were told as women felt it their duty to inform them. In general the women were very much more positive about the products than they were about the male condom, as were the men. A contributory factor to their popularity among women was the greater control they gave them. Even though, use of these products in practice often involved negotiation with male partners, the fact that use was contingent on women's action was empowering and increased somewhat their ability to control their sexual health.