The Need for Greater Emphasis on Married or Cohabiting Couples in Southern and East Africa John Cleland

Scope of the Presentation Why the need for this greater emphasis? Is greater uptake of condoms by married couples feasible? Is double-method protection or dual protection by condoms alone more likely? What might be reproductive consequences of massive switching from hormonal methods to condoms?

Sources Ali, Cleland, Shah. Bulletin of World Health Organization 82(3):1-7. Pullum, Cleland, Shah. Paper presented at annual meeting of Population Association of America, Boston Maharaj and Cleland. Studies in Family Planning (in press June 2004) + work in progress. Foss, Watts, Vickerman, Kumaranayake – paper on condom use, available from Ali and Cleland. Presentation at International Conference, Mumbai, December 2003.

Why the Need for Greater Emphasis In mature generalised epidemics, about 50% of HIV infections may occur to married/cohabiting individuals, because of infidelity/spousal infection. (Less true in late-marriage societies, such as South Africa, Botswana) Similarly, 5%-20% of couples are HIV-Discordant. Advent of ARVs and greater uptake of VCT will vastly increase demand for protection among couples While some positive evidence for increased uptake of condoms by sexually active single, little evidence to date of similar trends among married/cohabiting. HIV-prevention campaigns by reinforcing association between condoms & illicit sex may have stiffened resistance to marital use

Women of reproductive age in Sub-Saharan Africa: reported condom use in last sex act * Source: Macro International behavioural surveillance surveys and demographic health surveys; Measure Evaluation *of women reporting such sex with specific partners in last 12 months

Men of reproductive age in Sub-Saharan Africa: reported condom use in last sex act* Source: Macro International behavioural surveillance surveys and demographic health surveys; Measure Evaluation *of men reporting such sex with specific partners in last 12 months

Percentage of married contraceptive users relying on condoms, by stage of HIV epidemic HIV prevalence No. of countries Low2411.1%11.0%11.2%11.7% Concentrated2812.8%13..5%14.5%15.5% Generalised307.2%7.9%8.0%8.2% India-12.3%11.6%4.9%6.4% Source: United Nations

Is condom use within marriage a realistic proposition: results from WHO multi-site study (married or cohabiting women) Condom useUrbanRural South Africa Current use for FP Consistent/occasional use with partner Kenya Current use for FP Consistent/occasional use with partner Uganda Current use for FP Consistent/occasional use with partner

Profile of Condom Use and Related Attitudinal Factors in Three Strata (South Africa) Factors Strata Urban More EducatedIntermediate Rural Less Educated Consistent/Occasional condom use Wife * Husband * Discussed condoms with spouse Wife * Husband * Favourable attitude to condoms Wife * Husband Belief in condom efficacy Wife * Husband

Profile of Condom Use and Related Attitudinal Factors in Three Strata (South Africa) Cont’d Factors Strata Urban More EducatedIntermediate Rural Less Educated Perceived risk of HIV from Spouse Wife Husband * High perceived self-efficacy Wife * Husband Number of couples (unweighted) *Strata difference significant at 95% confidence level

Predictors of Condom Use Reported by Wives (South Africa) Unadjusted ORsAdjusted ORs Urban v rural Wife secondary + sch. V less Husband secondary + sch. V less Wife’s high/medium perceived risk of HIV v. low/no risk Wife’s high belief in condom efficacy v low husband’s positive attitude to condoms v negative Also in the model: marital status, length of relationship: fertility intentions Significant effects in red

Dual-protection from condoms or double-method protection? South Africa (high contraceptive use setting) Use statusNeeds FP & HIV protection Needs HIV- protection only Needs FP only No need %% No method Non-barrier method only Condom only4822 Both (N)(75)(74)(61)(57)

Kenya (moderate contraceptive use setting) Use statusNeeds FP & HIV protection Needs HIV- protection only Needs FP only No need Use status%% No method Non-barrier method only Condom only0222 Both92398 (N)(58)(93)(167)(197)

Uganda (low contraceptive use setting) Use statusNeeds FP & HIV protection Needs HIV- protection only Needs FP only No need Use status%% No method Non-barrier method only Condom only81458 Both4458 (N)(156)(225)(41)(88)

Estimating the Reproductive Consequences of Massive Switching from High Effective Contraceptive methods to Condoms Use DHS contraceptive calendar data for 16 high use countries, linked to data on intendedness of recent births. Compare failure/discontinuation rates for pill and condom Assess consequences/sequelae of failure/discontinuation in terms of switching to another method, abortion, birth of unwanted/mistimed child. Using pooled data for all 16 countries, reverse the number of condom episodes (n=4786) and number of pill episodes (n=20875) Evaluate the expected numbers of unwanted births etc under this counterfactual reversal and compare with observed (real life) numbers

Observed and hypothetical numbers of unwanted births Proximate cause of unwanted births Observed number Hypothetical number Ratio hypothetical/ observed Failure/discontinuation of: Pill Condom Other methods1, Non-use8, Total11,55411,

Conclusions The HIV-prevention needs of the married have been neglected These needs will increase as HIV-epidemics mature and as uptake of VCT increases The barriers to condom use within marriage are not as immutable as often assumed (though consistent use is elusive) Women may have much more influence on condom use than often assumed In higher contraceptive use countries, double-method protection appears more common than condom use alone The desire to avoid pregnancy appears to reduce the chances of double-method protection. Massive switching from hormonal FP methods to condom would have surprisingly little effect on incidence of unwanted pregnancies/abortions