Men's condom use in higher-risk sex: trends in five sub-Saharan African countries

Journal of Population Research, May, 2008 by Timothy Adair

This paper analyses trends in men's condom use at last higher-risk sex (i.e., with a non-marital, non-cohabiting partner) using the two most recent Demographic and Health Surveys (DHS) in five sub-Saharan African countries: Cameroon, Kenya, Tanzania, Zambia and Burkina Faso. Condom use is an important method of preventing HW transmission. Encouragingly, higher-risk sex has declined in four of the five countries, while condom use rose substantially in Cameroon, Tanzania and Burkina Faso but only had a minor increase in Kenya and Zambia, where use at last higher-risk sex remains below 50 per cent. There are no clear patterns of change across countries in the predictive strength of the explanatory variables between the two most recent surveys, although evidence of a widening gap in use by education in Cameroon is identified. In each country, lack of education remains a strong barrier to condom use in higher-risk sex.

Keywords: condom, HIV/AIDS, higher-risk sex, sexual behaviour, sexually transmitted diseases, socio-economic differentials, sub-Saharan Africa

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A reduction in HIV incidence in sub-Saharan Africa requires not only a fall in the level of higher-risk sex (1), that is, sex with a non-marital and non-cohabiting partner; a rise in condom use during higher-risk sex above the present low levels is necessary for the potential effectiveness of condoms to be realized. The consistent and correct use of condoms is estimated to reduce the risk of HIV transmission by 80 to 90 per cent (Weller and Davis 2002; Hearst and Chen 2004). To aid efforts to increase condom use during higher-risk sex, this paper examines trends and determinants of reported condom use by men in higher-risk sex in recent Demographic and Health Surveys (DHS) in five sub-Saharan African countries: Cameroon, Kenya, Tanzania, Zambia, and Burkina Faso.

Past literature has identified gaps in condom use by different population groups in various settings. In particular, the least-educated have consistently been found to be the least likely to use a condom for both non-marital and all partners, including in Cameroon, Tanzania and Zambia (Agha 1998; Ahmed et al. 2001; Lagarde et al. 2001; Amouzou 2003; Kapiga and Lugalla 2003; Meekers et al. 2003; Benefo 2004; Glynn et al. 2004). More-educated people are more likely to be aware of and able to access condoms. The findings for economic status are less clear: both positive and non-significant relationships have been revealed for both non-marital and all partners (Adetunji and Meekers 2001; Meekers and Klein 2002; Agha and Kusanthan 2003; Ukwuani et al. 2003). Urban residence has usually been associated with a higher level of condom use, although other studies revealed it to have no effect (Adetunji and Meekers 2001; Amouzou 2003; Kapiga and Lugalla 2003; Benefo 2004; Prata et al. 2005). Lower condom use in rural areas may reflect inequality of condom provision by place of residence.

Younger people have generally been found to be more likely than their older counterparts to use a condom for both non-marital and all partners (Mnyika et al. 1997; Agha 1998; Ahmed et al. 2001). Many social marketing campaigns are aimed at young people. In the cities of Yaounde and Douala, Cameroon, a social marketing campaign entitled '100% Jeune' promoted consistent condom use among youth. Following the program's introduction in these cities, for males aged 15-24 years condom use with a regular partner increased from 44 per cent in 2000 to 61 per cent in 2002, and use with a casual partner increased from 60 per cent to 68 per cent (Meekers et al. 2005).

A potential constraint on condom use is their adequate provision. In sub-Saharan Africa the majority of condoms are bought with donor funds, although national funds are often used and there is also a small commercial sector (Shelton and Johnson 2001). Data provided by UNFPA presented in Table I show an increase in donor provision of condoms in each country from 1998-2000 to 2001-2004. This paper addresses the approximate period that this increase in donor provision of condoms occurred; hence the findings can be discussed in the context of these supply issues.

The severity of the HIV epidemic in each country varies. Table 2 shows that, according to the most recent DHS or AIDS Indicator Survey (AIS), the HIV prevalence rate among males 15-49 years is 12.9 per cent in Zambia, compared with 6.3 per cent in Tanzania, 4.6 per cent in Kenya, 4.1 per cent in Cameroon and 1.9 per cent in Burkina Faso. By analysing five countries with epidemics of differing severity, this paper is able to provide a comprehensive examination of condom use in higher-risk sex across sub-Saharan Africa.

This paper seeks to analyse the two most recent DHS in each of these countries to determine the change in the percentage of men who used a condom at last higher-risk sex; and the change in the predictive strength of each socio-demographic factor.

These findings will help to enable planning for future programs aimed at broadening the use of condoms among men engaging in higher-risk sex.