Prolonged postpartum sexual abstinence may increase the risk of HIV through an associated increase in male extramarital sexual contacts, but this has never been demonstrated. As part of a study of antenatal clinic HIV surveillance, we collected information on HIV status and duration of postpartum abstinence in women in three African cities. In Yaoundé, Cameroon, prolonged abstinence was common and was associated with a higher prevalence of HIV. In Kisumu, Kenya, and Ndola, Zambia, the practice was much less common and no such association was found.
Prolonged postpartum sexual abstinence could be a risk factor for HIV in women as it encourages husbands to seek extramarital partners. On the other hand it could be protective because it reduces the number of episodes of sexual intercourse for the wife, and may therefore reduce the risk of transmission if the husband is HIV positive . An increase in extramarital sexual contacts associated with postpartum sexual abstinence has been reported among men in Benin  and Nigeria , but no studies have shown associations between postpartum sexual abstinence and HIV status. As part of a multisite study on antenatal clinic HIV surveillance, we collected information on the duration of postpartum abstinence since the last birth, as one of several factors that may affect the birth interval.
The study was conducted in six antenatal clinics in Yaoundé, Cameroon, two in Kisumu, Kenya, and five in Ndola, Zambia, from October to December 1998 . In each city procedures followed routine sentinel surveillance procedures but used a longer questionnaire. HIV status was assessed on anonymized blood specimens remaining from syphilis testing at the first antenatal clinic visit. Initial screening used an enzyme-linked immunosorbent assay, with confirmation of positive results using a rapid test. Ethical permission for the study was received from appropriate authorities in each country, the London School of Hygiene and Tropical Medicine, UK, and the Institute of Tropical Medicine, Antwerp, Belgium.
The prevalence of HIV among antenatal women was 5.5% (85/1532) in Yaoundé, 30.6% (453/1480) in Kisumu, and 27.3% (279/1021) in Ndola. Half the women in Yaoundé reported postpartum abstinence after the last birth of more than 6 months, and 23% more than 12 months, compared with 17 and 8% in Kisumu, and 13 and 4% in Ndola, respectively. In all sites, abstinence was shorter in currently married women than in never married or divorced or widowed women, but was similar for those in monogamous and polygamous marriages.
In Yaoundé, HIV seropositivity was strongly associated with the duration of postpartum abstinence overall and after restricting to currently married women, but the association was of borderline significance after additionally restricting to those who were married to their current husband at the time of the last birth (Table 1). The trend persisted after adjusting for age, monogamy/polygamy, the number of previous births, schooling, occupation, ethnic group, religion, clinic, and the duration of postpartum amenorrhoea, but remained of borderline statistical significance. Of these factors, only postpartum amenorrhoea and ethnic group were associated with the duration of postpartum abstinence: abstinence was longer in those with prolonged postpartum amenorrhoea and among the Pahouin ethnic groups.
In Kisumu, there was no evidence of an association between the duration of postpartum abstinence and HIV status overall or after restricting to married women. Among those who were married to their current husband at the time of the last birth there was a trend towards decreased risk with longer abstinence. The highest prevalence of HIV infection (15/38, 39.5%) was in those who had resumed sexual intercourse within 2 weeks, but this was not significantly different from the prevalence in those resuming later (180/605, 29.8%). The trend was no longer significant after adjusting for ethnic group. In Ndola, there was a slight increase in the proportion of HIV positivity with an increased duration of abstinence overall, but this was lost after restricting to married women.
Prolonged postpartum abstinence in west Africa is well recognized . It was frequently reported by the antenatal clinic attenders in Yaoundé, and the proportion with prolonged abstinence in the population will be even higher, because women with prolonged abstinence are under-represented in antenatal clinics. The duration was similar in women of different ages, suggesting little change in practice over time.
Postpartum abstinence was much shorter in Kisumu and Ndola than in Yaoundé. In both Kisumu and Ndola, there were very few women with prolonged postpartum abstinence among those who were married to their current husband at the time of the last birth. This suggests that the major reason for prolonged abstinence was partner change. In Kisumu, 78% of the women were Luo, and traditionally the Luo practise ritual sex within a few days of birth . This was not asked about specifically in this study, and the women may or may not have counted this as ending postpartum abstinence. Sexual intercourse soon after birth may be a risk factor for HIV transmission , and was associated with the highest prevalence of HIV in Kisumu. Very few women in the other cities resumed sexual intercourse before 2 weeks. There was no evidence that prolonged postpartum abstinence was associated with HIV status in Kisumu or Ndola, but given the small numbers of women with prolonged abstinence in these cities, the study had limited power to detect such trends.
In Yaoundé, a strong association between prolonged female postpartum abstinence and HIV status overall was apparently partly caused by the inclusion of women who were not married to their current husband at the time of the previous birth, who might have had longer abstinence (and a higher risk of acquiring HIV) as a result of partner change. Among those with continuing marriages, the trend of increased HIV risk associated with prolonged abstinence persisted, but was of borderline statistical significance. In this cross-sectional study the timing of the acquisition of HIV is unknown. The inclusion of women who were already HIV positive before the previous birth is likely to have led to the underestimation of any association with postpartum abstinence. We only asked about abstinence after the most recent birth. However, culturally determined prolonged abstinence is likely to be similar after each birth, and restricting the analysis to those with only one previous birth gave similar trends.
The results should be interpreted cautiously. The association between prolonged abstinence and HIV in Yaoundé may be a chance finding. The study was not designed to look at this issue, and the association was noticed in the course of other analyses. However, the possibility of such an association had been suggested previously, and this is the first study to demonstrate it directly.
Judith R. Glynna
Isaac B. Macauleyd
Rosemary M. Musondaf
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