IN RESPONSE to the growing epidemics of HIV infection and other sexually transmitted diseases (STDs), 1 the numbers of male condoms distributed free to the public in South Africa has increased dramatically in recent years. 2 Condoms have been made available to the general public through a wide range of distribution points, including all public health facilities. No research has been conducted on the sexual behaviors of individuals procuring condoms distributed free to the public sector in South Africa, and as a result there is little information available for evaluating the potential role of condom distribution in combating the spread of HIV infection and other STDs. As part of a larger investigation of public sector use and waste of free condoms, 3 this study describes the sexual behavior and barriers to condom use among individuals procuring the free condoms provided to the South African public.
The methods of the study have been described in detail elsewhere. 3 Research was conducted at 12 public health facilities in four health regions of South Africa between June 1998 and March 1999. At each facility, consecutive individuals leaving with condoms over a 2-week period were approached by field workers who explained the nature of the study. For those who consented to participate, a semistructured baseline questionnaire was administered to collect data on demographics and recent sexual behavior. Immediately after this interview, the condom procurers were recruited for two follow-up interviews held over the next 5 weeks.
In follow-up interviews, subjects used calendars to report each sexual contact since the previous interview. For each sexual contact, condom use, type of sexual partner, and other aspects of sexual behavior were recorded. All interviews were conducted by trained field workers in the participants’ home language in a private room at the health facilities.
Data were analyzed with use of statistical software (Stata; Stata Corp., College Station, Texas). Logistic regression was used to model the predictors of condom use during a single sexual contact. We used a mixed-model formulation in which sexual contacts were treated as random effects nested within subject to incorporate both subject-specific and sexual contact–specific independent variables. The selected model was fitted to the data separately in each region because of substantial effect modification caused by regional differences.
Of 594 individuals procuring condoms from all the study sites, 554 (93%) agreed to participate in the baseline interview, and 384 (69%) of those interviewed in the baseline study returned for follow-up interviews; the median follow-up period was 35 days. Compared with those lost to follow-up, subjects who were observed were more likely to be male, slightly more likely to be better educated, more likely to have used a condom at their last sexual event before the study, and more likely to report having more than one sexual partner in the previous month. 3
The 367 subjects (96%) who were sexually active during the 5-week study reported a total of 3263 sexual contacts, a median of 9 per person (Table 1); 92 men (41%) and 14 women (10%) reported having sex with more than 1 partner during the study period. Most sexual contacts (2362, or 72%) took place with a regular sex partners (defined as someone with whom the participant had been sexually active for more than 6 months before the study); irregular partners were significantly more likely to be perceived at risk of HIV infection and STD than were regular partners (68% versus 48%; Pearson chi-square P < 0.01). Alcohol consumption before sexual intercourse was more common when an irregular partner was involved than when a regular partner was involved (24% versus 17%; Pearson chi-square P < 0.01).
Slightly fewer than one-third of participants (114, or 31%) reported at least one unprotected sexual intercourse event during the study period, and 2637 sexual contacts documented by the study (81%) involved protection with a condom. In multivariate analysis (Table 2), no single variable appeared statistically significant in all four regions, although the direction of the associations was consistent across all regions for two risk factors: alcohol consumption before sex was negatively associated with condom use, and increased participant education was associated with increased condom use. Other factors significantly associated with increased condom use during sex in at least one region include male sex, fewer sex partners during the study period, intercourse with an irregular partner, intercourse with a partner perceived to be at risk of HIV infection or other STDs, and lack of use of other forms of contraception.
Reported condom use is relatively high among this group of individuals procuring free condoms, and the results of multivariate analysis suggest that their condom use may take place more often with irregular sex partners and those perceived to be at increased risk of HIV infection or other STDs. Despite these encouraging findings, condom use was inconsistent over this short (5-week) period for almost one-third of participants, and we anticipate that the proportion of individuals reporting at least one unprotected sexual event would increase with longer follow-up.
These findings demonstrate several significant barriers to condom use in this population. Alcohol consumption before sex was consistently associated with decreased condom use across all regions. This association has been reported elsewhere in sub-Saharan Africa and is particularly problematic because casual sex partners are often met in settings where alcohol is consumed. 4,5 Female gender was often associated with a lower probability of condom use during sex, in keeping with a growing body of research demonstrating women's sexual disempowerment in southern Africa. 6,7
In addition, these data show that the use of contraceptives other than condoms—in this setting, primarily injectable contraceptives—may be associated with decreased levels of condom use. This finding may present a setback to dual-method–use strategies (the joint use of condoms and another form of contraception) that are being promoted in health care policies for South Africa and many other countries for prophylaxis against both sexually transmitted infections and unwanted pregnancies. 8,9
These data are subject to two possible sources of bias that are common to most behavioral research on condom use practices. 10 First, there were significant differences between those observed and lost to follow-up, which may mean that participants were more likely to report condom use than the source population of condom procurers. Second, subjects’ potential perceptions of the social desirability of reported condom use may have induced them to falsely overreport their condom use in follow-up interviews. 11 We made every effort to avoid this problem by repeatedly assuring subjects that their participation in the study was not related in any way to their self-reported sexual behaviors.
Several of the factors associated with decreased condom use appear heterogeneous across study regions, demonstrating the potentially diverse range of barriers to condom use across South Africa. This implies that the emphasis of interventions aimed at promoting higher levels of consistent condom use in different settings may need to be varied according to which barriers are most important locally. Finally, in light of the high overall levels of condom use in this population of individuals who procured condoms, these data underscore the importance of improving the availability and accessibility of condoms in South Africa and other developing countries.
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