HIV and AIDS prevention: Discussion on existing knowledge and next steps
Culture and condom use
Von Eliudi Eliakimu
Condom use is one of the elements in ABC-strategy: Abstinence, Be-faithful and Condom use. As the ABC-strategy was implemented, it came clear that it had little regard with local cultures. Despite having much knowledge on HIV and AIDS people still have unprotected sex with partners. This discussion paper found from literature that risk behaviours in any population are shaped by social, structural and cultural factors. Furthermore, it is clear now that cultural norms as well as cultural assumptions about the relations between men and women influence the decision to use condoms.
Sub-Saharan Africa remains the region most heavily affected by HIV, accounting for 67% of the people living with HIV and AIDS (PLWHIV).( UNAIDS 2008)The HIV infection in the African region is transmitted mostly through heterosexual intercourse and parenteral route. Socio-cultural contexts are important domains of understanding sexual behaviour and pathways of HIV-infection. (Undi et al, 2007) During the 1980s and 1990s the focus of HIV prevention targeted risk-groups such as sex workers, migrants, members of the military, track drivers, injecting drug users (IDU) and risk behaviours such as unprotected sex. (Ramin 2007)
The help of anthropologists has helped to shift the focus from risk groups to vulnerable groups which include women and youths as well as other members of the groups initially referred to as “risk”. (Ramin 2007) The basis for this was that there is no empirically bounded risk-groups but rather the behaviour of unprotected sex that puts people at risk (Ramin 2007) Two strategies abbreviated as “ABC” have been widely used to prevent HIV spread; one advocating for “Abstinence” and “Be-faithful (monogamy)” and another promoting “Condom use”; but both had little regard to local cultures of the people. The purpose of this paper is to discuss condom use and culture basing on available facts and synthesize an outline of the next steps in promoting condom use for prevention of HIV and AIDS.
Literature for building the discussion was obtained from the Bio-Med Central (BMC) citing articles using two key words – condom use and culture. Nine articles were conveniently taken to synthesize the factual discussion and next steps in promoting condom use. The United Nations Joint programme on AIDS (UNAIDS) – 2008 global report on the AIDS epidemic was also cited.
Condom use and culture
Condom use forms one of the three elements of the ABC-strategy. Even the United Nations Joint programme on AIDS (UNAIDS) declares that condoms are a key to preventing the spread of HIV and AIDS. Studies show that knowledge on HIV and AIDS do not coincide with sexual behaviour (Liverpool et al, 2002). .Several factors have been identified that contribute to “no” or “inconsistent” condom use as shown in table 1.
|Tabel 1: Factors associated with no or inconsistent condom use|
|Condom use interrupt foreplay and sexual intercourse|
|Condom makes sex un-enjoyable|
|Condoms leads to being uncomfortable and inconvenient|
|Females lack condom negotiation skills|
|Condom use in trusted or long-term relationships not necessary|
|Cultural norms such as the need for having children|
|Pregnant women because are not worried about pregnancy|
|Poor sex communication among partners|
|Condom use seen as distrust|
|Reported problems on using condoms|
|Religion – for example the notion that promoting condom use is to undermine abstinence and that it is equal to telling people that you can’t control your sexual urge|
|Cultural practices such as polygamy|
|Perceiving condoms as ineffective|
|Feelings that condoms are porous to HIV (it’s like golf-ball in basketball loop)|
|Negative attitudes towards condom such as: condoms are not African; condoms will promote promiscuity and moral lassitude; condoms are ploy to control population size; and condoms kill women.|
Ramin, an advocate of the role of anthropology in HIV and AIDS prevention, clearly asserted the value of anthropology in understanding local cultures in the prevention efforts. (Ramin 2007) The complex interplay of social, structural (political and economic), and cultural factors mediate the structure of risk in every population group. Therefore the decision of people on whether to use condoms or not is shaped by the above factors including culture as mentioned.
Interesting thing in the efforts to promote condom use is the apparent disparity between people’s knowledge and awareness of HIV and AIDS and the extent to which they take measures to protect themselves. (Ramin 2007) It has been further shown that education about risk of infection is not sufficient because cultural determinants of health behaviours serve as important barriers to health behaviour change. Some cultural norms in table 2 have been cited as important barriers to condom use. (Magee et al; Absalom et al)
|Tabel 2: Cultural Norms affecting condom use|
|Definition of sex (ejaculate into a woman or to receive a man’s sperm)|
|Importance of the notion: flesh-to-flesh in promoting intimacy|
|Trust to partners (using condom imply that one’s partner was a carrier or that one’s own sexual behaviour was sordid and risky|
|Cultural assumptions about relations between men and women|
|The need for having children|
The use of condoms in HIV prevention is affected by social, cultural, and economic factors. Anthropologists have been even more conclusive by showing that the ultimate barrier to condom use is poverty; not because of its cost-implications but also due to the broader culture of education; risk-taking; and self-preservation. (Ramin 2007)
Next steps in condom use promotion
Proposed next steps in promoting condom use can be divided into five categories:
- Promoting condom use
From the information available on condom use, I propose a framework in figure-1 to guide promotion activities on use of condoms. Importantly, the framework emphasizes on equal promotion of female condoms as is the case with male condoms; also it emphasizes on logistics aspects, monitoring and evaluation and research (basic and operational).
- Designing and implementing cultural specific interventions
Focus on “HIV risk behaviour” alone can not explain the disproportionate HIV rates among certain populations but rather it requires a combined attention to socio-cultural challenges facing the respective population(s). (Williams et al, 2009) Therefore, focus on local cultures of people should guide the advocacy process for condom use.
- Advocacy and involvement of religious leaders
There is a need for more and sustained advocacy and involvement of religious leaders on convincing their followers to use condoms whenever abstinence and be-faithful fails. Here distinction on two lines of thoughts is essential: one is on condom use as contraceptive (example abortion) and the second is on condom use to prevent people dying. (Genrich et al, 2005)
- More emphasis on risk behaviour prevention
Strengthening interventions towards behaviour prevention is extremely important as the success to have effective vaccine and microbicides are far from being reached. A distinguished researcher and psychiatrists at the US National Institute for Mental Health describes “behaviour prevention is today’s vaccine”. Risk behaviour prevention especially having unprotected sex among the vulnerable groups is important in sustaining prevention efforts.
- Using a rights-based approach to sexuality education
The rights–based Approach (RBA) to sexuality education should take into account the needs of various population groups such as young people and women. (Undie et al, 2007) It entails education on their rights; listening to their views; and exploring methods that allow the target group to express their experiences, aspirations and concerns around sexuality and risk for HIV infection.
Although cultures influence the decision of people to use or not to use condoms, it is not the only critical category of factors as political and economic factors are shown to shape much the behaviours of people. In promoting condom use, it is important that structural factors (political and economic) are taken into account on top of the local cultures of people. In this way, the much achieved benefits of the ABC-strategy will be more improved and sustained. Poverty is the ultimate barrier to condom use, hence reducing poverty through a multi-sectoral policy to alleviate policy should be a focus. Lastly, human rights education to young people and women is equally important and hence human rights-based approach to sexuality is an important tool in promoting: safer-sex behaviours (including condom use); rational-decision making; and women empowerment; as well as improving sex communication between partners.
*Dr Eliudi Eliakimu is Senior Medical Officer at the Health Services Inspectorate Unit (HSIU), Ministry of Health and Social Welfare (MoHSW) Dar es Salaam, Tanzania. He also is a Programme Officer in Infection Prevention and Control – Injection Safety (IPC-IS) Programme. Contact: firstname.lastname@example.org.
UNAIDS 2008 Report on the Global AIDS Epidemic
- Chi-Chi Undie, Joanna Crichton, and Eliya Zulu; Metaphor we Love by: Conceptualization of sex among young people in Malawi; Afri. J. Reprod Health 2007; 11(3): 221-235.
- Brodie Ramin; Anthropology speaks to medicine: The case of HIV/AIDS in Africa. McGill Journal of Medicine2007 Vol. 10(2)
- Joan Liverpool, Melisa McGhee, Charlie, Melanie Beckford, and David Levine; Knowledge, Attitudes and Behaviour of Homeless African-American Adolescents; Implications for HIV prevention. Atlanta, Georgia – Journal of the National Medical Association, Vol94, No.4, April 2002, Pg.257-263.
- S.B. Kennedy, S. Nolen, J. Applewhite, E. Waiters and J. Vanderhoff; Condom use behaviours among 18-24 old urban African American males: a qualitative study. AIDS care. 2007 September; 19(8): 1032-1038.
- Edward M. Magee, Maria Small, Rikerdy Federic, Gabriel Joseph, and Trace Kershaw. Determinants of HIV/AIDS Risk Behaviours in Expectant Fathers in Haiti. Journal of Urban Health Bulletin of the New York Academy of Medicine, Vol.83, No.4. Pg625-636.
- Sennen H. Hounton, Helen Carabin and Neil J. Henderson. Towards an Understanding of Barriers to Condom use in Rural Benin using the Health Belief Model: A Cross-Sectional Survey. BMC Public Health 2005, 5:8. http://www.biomedcentral.com/1471-2458/5/8
- Gilian L. Genrich and Brader A. Brathwaite. Response of Religious Groups to HIV/AIDS as a Sexually Transmitted Infection in Trinidad. BMC Public Health 2005, 5:121. http://www.biomedcentral.com/1471-2458/5/121
- Judith Absalom; Phyllis Della-Latta; Fan Wu; and Wafaa M. El-Sadr. Sexual Behaviours and Condom Use of HIV-infected Men and Women of Colour Attending a Treatment and Care Clinic. Journal of National Medical Association Vol.97, No.7, July 2005. Pg.255-315.
- John Williams, Hema C. Ramamurthi, Cleo Manago, and Nina T. Harawa. Learning from Successful Interventions: A Culturally Congruent HIV Risk – Reduction Intervention for African – American Men Who Have Sex with Men and Women. American Journal of Public Health, June 2009, Vol.99, No.6. Published ahead of print on April 16, 2009, as 10.2105/ATPH.2009.140558.