Transcript Slide 1

The Need for Greater Emphasis on
Married or Cohabiting Couples in
Southern and East Africa
John Cleland
Scope of the Presentation
• Why the need for this greater emphasis?
• Is greater uptake of condoms by married
couples feasible?
• Is double-method protection or dual protection
by condoms alone more likely?
• What might be reproductive consequences of
massive switching from hormonal methods to
condoms?
Sources
• Ali, Cleland, Shah. Bulletin of World Health Organization
82(3):1-7.
• Pullum, Cleland, Shah. Paper presented at annual
meeting of Population Association of America, Boston
2004.
• Maharaj and Cleland. Studies in Family Planning (in
press June 2004) + work in progress.
• Foss, Watts, Vickerman, Kumaranayake – paper on
condom use, available from
[email protected]
• Ali and Cleland. Presentation at International
Conference, Mumbai, December 2003.
Why the Need for Greater Emphasis
• In mature generalised epidemics, about 50% of HIV infections may
occur to married/cohabiting individuals, because of infidelity/spousal
infection.
(Less true in late-marriage societies, such as South Africa,
Botswana)
• Similarly, 5%-20% of couples are HIV-Discordant.
• Advent of ARVs and greater uptake of VCT will vastly increase
demand for protection among couples
• While some positive evidence for increased uptake of condoms by
sexually active single, little evidence to date of similar trends among
married/cohabiting.
• HIV-prevention campaigns by reinforcing association between
condoms & illicit sex may have stiffened resistance to marital use
Trend in method mix for single women
A) West and central Africa
100%
80%
Other traditional
60%
PA
Other modern
Pill
40%
Condom
20%
0%
NG 1999
NG 1990
ML 2001
ML 1995/96
GH 1998/99
GH 1993/94
CM 1998
CM 1991
CI 1998/99
CI 1994
BN 2001
BN 1996
BF 1998/99
BF 1992/93
Trend in method mix for single women
B) East & Southern Africa
100%
80%
Other traditional
60%
PA
Other modern
Pill
40%
Condom
20%
0%
ZW 1999
ZW 1994
ZM 2001/02
ZM 1996/97
ZM 1992
TZ 1999
TZ 1996
TZ 1991/92
MD 1997
MD 1992
KE 1998
KE 1993
100
90
80
70
60
50
40
30
20
10
0
F
am aso
C
ot ero
e
o
d' n
Iv
Et oire
hi
op
G ia
ui
ne
Ke a
ny
M Ma a
oz
am l a w
bi i
q
R ue
So wa
ut nd
h
a
Af
Ta ric
nz a
an
ia
To
U go
ga
n
Z a da
Zi mb
m
ba ia
bw
e
% used
condom with
last casual
partner
C
Bu
rk
in
a
Percentage
Women of reproductive age in Sub-Saharan
Africa: reported condom use in last sex act*
% used
condom with
last main
partner
Country
*of women reporting such sex with specific partners in last 12 months
Source: Macro International behavioural surveillance surveys and
demographic health surveys; Measure Evaluation 1997-2002.
% used
condom at
last
commercial
sex
% used
condom with
last casual
partner
er
oo
C
ot
e
am
Fa
s
C
a
rk
in
Bu
d' n
Iv
oi
Et re
hi
op
ia
G
ui
ne
a
Ke
ny
a
M
M
al
oz
a
am wi
bi
qu
e
R
wa
n
T a da
nz
an
ia
To
go
U
ga
nd
Za a
m
bi
Zi
a
m
ba
bw
e
100
90
80
70
60
50
40
30
20
10
0
o
Percentage
Men of reproductive age in Sub-Saharan
Africa: reported condom use in last sex act*
Country
*of men reporting such sex with specific partners in last 12 months
Source: Macro International behavioural surveillance surveys and
demographic health surveys; Measure Evaluation 1997-2002.
% used
condom with
last main
partner
Use of contraceptive method before and after marriage or cohabitation
currently married women aged 15-24: Zimbabwe 1999
100%
percentage
80%
60%
Traditional
Other modern
Pill
Condom
40%
20%
0%
-3
-2
-1
0
Time to marriage of cohabitation
1
2
3
Percentage of married contraceptive users
relying on condoms, by stage of HIV epidemic
HIV
prevalence
No. of
countries
1983
1990
1994
1997
Low
24
11.1%
11.0%
11.2%
11.7%
Concentrated
28
12.8%
13..5%
14.5%
15.5%
Generalised
30
7.2%
7.9%
8.0%
8.2%
-
12.3%
11.6%
4.9%
6.4%
India
Source: United Nations
Is condom use within marriage a realistic proposition: results from
WHO multi-site study (married or cohabiting women)
Condom use
Urban
Rural
Current use for FP
8.7
5.2
Consistent/occasional use with partner
31.3
11.1
Current use for FP
2.2
1.7
Consistent/occasional use with partner
14.5
11.6
Current use for FP
5.6
3.1
Consistent/occasional use with partner
21.8
11.0
South Africa
Kenya
Uganda
Profile of Condom Use and Related Attitudinal Factors
in Three Strata (South Africa)
Strata
Factors
Urban
More Educated
Intermediate
Rural
Less Educated
Wife
33.9
17.6
10.9*
Husband
29.3
15.7
7.8*
Wife
79.7
54.9
28.1*
Husband
75.9
40.0
30.5*
Wife
57.6
62.5
35.2*
Husband
33.9
30.0
27.0
Wife
89.7
86.3
76.0*
Husband
91.5
92.2
86.6
Consistent/Occasional condom use
Discussed condoms with spouse
Favourable attitude to condoms
Belief in condom efficacy
Profile of Condom Use and Related Attitudinal Factors
in Three Strata (South Africa) Cont’d
Strata
Factors
Urban
More Educated
Intermediate
Rural
Less Educated
Wife
55.9
54.9
58.3
Husband
10.3
28.0
25.0*
Wife
37.9
23.5
22.2*
Husband
37.3
31.4
31.3
94
52
92
Perceived risk of HIV from Spouse
High perceived self-efficacy
Number of couples (unweighted)
*Strata difference significant at 95% confidence level
Predictors of Condom Use Reported by Wives
(South Africa)
Unadjusted ORs
Adjusted ORs
Urban v rural
3.17
2.26
Wife secondary + sch. V less
4.42
2.47
Husband secondary + sch. V less
3.81
2.24
Wife’s high/medium perceived risk of
HIV v. low/no risk
4.17
3.92
Wife’s high belief in condom efficacy
v low
5.53
4.55
husband’s positive attitude to
condoms v negative
4.29
1.56
Also in the model: marital status, length of relationship: fertility intentions
Significant effects in red
Dual-protection from condoms or double-method
protection?
South Africa (high contraceptive use setting)
Use status
Needs FP
& HIV
protection
Needs HIVprotection
only
Needs
FP only
No need
%
%
%
%
No method
13
24
16
49
Non-barrier method
only
60
35
71
44
Condom only
4
8
2
2
Both
23
32
12
5
(75)
(74)
(61)
(57)
(N)
Kenya (moderate contraceptive use setting)
Use status
Needs FP
& HIV
protection
Needs HIVprotection
only
Needs
FP only
No need
Use status
%
%
%
%
No method
22
26
21
39
Non-barrier method
only
69
50
68
51
Condom only
0
2
2
2
Both
9
23
9
8
(58)
(93)
(167)
(197)
(N)
Uganda (low contraceptive use setting)
Use status
Needs FP
& HIV
protection
Needs HIVprotection
only
Needs
FP only
No need
Use status
%
%
%
%
No method
53
64
68
69
Non-barrier method
only
35
18
22
15
Condom only
8
14
5
8
Both
4
4
5
8
(156)
(225)
(41)
(88)
(N)
Estimating the Reproductive Consequences of Massive Switching
from High Effective Contraceptive methods to Condoms
Use DHS contraceptive calendar data for 16 high use
countries, linked to data on intendedness of recent
births.
Compare failure/discontinuation rates for pill and condom
Assess consequences/sequelae of failure/discontinuation
in terms of switching to another method, abortion, birth of
unwanted/mistimed child.
Using pooled data for all 16 countries, reverse the number
of condom episodes (n=4786) and number of pill
episodes (n=20875)
Evaluate the expected numbers of unwanted births etc
under this counterfactual reversal and compare with
observed (real life) numbers
Observed and hypothetical numbers of
unwanted births
Proximate cause of
unwanted births
Observed
number
Hypothetical
number
Ratio
hypothetical/
observed
Pill
961
194
0.20
Condom
158
786
4.98
1,799
1,799
1.00
Non-use
8,636
8,636
1.00
Total
11,554
11,415
0.99
Failure/discontinuation of:
Other methods
Conclusions
• The HIV-prevention needs of the married have been neglected
• These needs will increase as HIV-epidemics mature and as uptake
of VCT increases
• The barriers to condom use within marriage are not as immutable as
often assumed (though consistent use is elusive)
• Women may have much more influence on condom use than often
assumed
• In higher contraceptive use countries, double-method protection
appears more common than condom use alone
• The desire to avoid pregnancy appears to reduce the chances of
double-method protection.
• Massive switching from hormonal FP methods to condom would
have surprisingly little effect on incidence of unwanted
pregnancies/abortions