Condom use and the accuracy of AIDS knowledge in Cote d'Ivoire

International Family Planning Perspectives, Mar 2003 by Zellner, Sara L

CONTEXT: Condom use remains low in Cote d'Ivoire, despite an increasing prevalence of HIV and widespread awareness of how the virus is transmitted. Information is needed about characteristics that predict condom use and about the role of AIDS knowledge and sex differences in the use of condoms.

METHODS: Data from the 1994 Cote d'Ivoire Demographic and Health Survey were analyzed for respondents who had had sex in the two months before the survey. Logistic regressions were performed separately by sex to determine whether the accuracy of men's and women's knowledge about AIDS predicted condom use at their most recent sexual intercourse.

RESULTS: Accuracy of knowledge about AIDS did not significantly predict condom use. For male respondents, the odds of condom use at last intercourse were significantly lower among those aged 35 or older than among those aged 15-19 (odds ratios, 0.3-0.5). The odds were also lower among married men (0.4) and those who reported friends, family or neighbors as their only source of AIDS knowledge (0.5). Compared with uneducated men, men with secondary or higher education were significantly more likely to report condom use (1.7). Among women, those aged 25 or older had significantly lower odds of condom use at last intercourse than those aged 15-19 (0.2-0.6). The odds of use were significantly reduced among women who were married (0.2) and those who had learned about AIDS from family, friends or neighbors or from television or radio (0.3-0.6); however, the odds were significantly higher for women with secondary or higher education than for uneducated women (2.2).

CONCLUSION: The level of accuracy of AIDS knowledge did not predict the likelihood of recent condom use in this sample. Efforts to increase educational attainment in Cote d'Ivoire may be more effective in increasing condom use than a focus on improving the accuracy of AIDS knowledge.

Given the AIDS pandemic across Africa, health professionals and researchers are trying to understand the social context in which people are likely to take precautions to protect themselves against HIV infection. Because HIV has spread across Africa mostly through sexual contact, research has focused on condom use-particularly in southern and eastern Africa, where as many as one in four adults are HIV-positive.1 Although the prevalence of HIV infection among adults in the West African nation of Cote d'Ivoire had reached approximately 10% by 1999,2 and only about 1% of Ivoirian adults reported using condoms,3 the determinants of condom use in the country have not been investigated extensively.

Descriptive statistics from the 1994 Demographic and Health Survey (DHS) conducted in Cote d'Ivoire reveal that when asked how HIV is contracted, 92% of men and 80% of women mentioned at least one means of sexual transmission. However, when asked about their inclination to use condoms, only 23% of Ivoirian men and 7% of Ivoirian women indicated that they had ever used a condom.4 Thus, information about links between knowledge and condom use is important for the development of appropriate interventions.

SOCIAL CONTEXT

Although family planning and AIDS awareness programs in Africa promote the use of condoms, studies have revealed many obstacles to use. Negative attitudes about condoms are a major barrier. For many Africans, condoms suggest unfaithfulness and mistrust.5 Because of such beliefs, personal and emotional concerns often supersede the choice to use condoms. And even if a man has a positive attitude about condoms, they may not be readily available to him. For example, a study in South Africa found that condom availability varied greatly according to the type of distributor, and could be hindered by short business hours and the attitudes of providers.6

Another barrier to condom use is that African men control much of the decision-making regarding sexual encounters. For example, a cohort of men from Zimbabwe expressed the belief that women need their partners' permission to use contraceptives,7 and a sample of men from Uganda conveyed concerns about retaining control over their female partner.8 As a result of this male-female power differential, women may find themselves in situations that increase their risk for sexually transmitted infections (STIs), including HIV infection, despite knowledge they may have about how to protect themselves.

Because of patriarchy and a history of polygamy, extramarital relationships are common in many African societies.9 The risk of such relationships is increased by the frequent migration of African men to seek seasonal or long-term employment. Meanwhile, the stigma associated with condom use inhibits persons in extramarital sexual relationships from protecting themselves and their partners. In a study of extramarital relations that focused mostly on countries in Sub-Saharan Africa, regular condom use during sexual encounters was uncommon.10 Moreover, Mbizvo and Bassett have reported that the risk and incidence of STIs in Sub-Saharan Africa increased as labor migration of husbands became necessary and, consequently, the number of male and female sexual partners increased.11 In addition, in a study of male truck drivers in Nigeria, 72% of married men reported having multiple extramarital sexual partners, and 60% reported being unwilling to use condoms because they did not like using them or were unaware of the risks of unprotected sex.12