1. Determinants of condom use among young adults aged 15-24 years in Africa Centre DSA, KwaZulu Natal, South Africa, 2005 Natsayi Z Chimbindi - Agincourt Dr Kobus Herbst - Africa Centre Dr Khin San Tint - Wits SPH

2. Introduction Young people are most affected and infected by HIV/AIDS pandemic especially in Sub-Sahara [Welz et al 2006; UNAIDS 2006] Correct and consistent use of condoms is estimated to reduce HIV transmission by 80-90% [Pool et al 2006; Steiner, Cates 2006] High HIV prevalence is associated with low condom use [Pettifor et al.2005; Gregson et al 2006] Condom use rates among young adults are relatively low, have not nearly reached 100% [MacPhail, Campbell 2001]

3. Problem statement In South Africa, condom use is low : at last sex (12%) among females 15-49 yrs [Camlin, Chimbwete South African Demographic Health 1998 Data] Ever using condoms on average (50%) among young adults [Pettifor et al 2005; Shisana et al 2002; Health Systems Trust 2004] Knowledge about condoms and HIV prevention is high but general perception of risk to infection and vulnerability is low (70% believed that they were at no risk or low risk of HIV infection)  low condom use [Maharaj 2006; MacPhail, Campbell 2001]

4. Research question What are the factors associated with condom use and its consistency of use among young adults aged 15-24 years in the Africa Centre Demographic Surveillance Area (ACDSA)?

5. Definition of terms Condom use Proportion who reported ever using a condom with the most recent partner in the last year Q. “Have you and your partner ever used a condom? (IF YES) How often do you use condoms?”. “sometimes” or “always”  “condom users” “never”  “non-condom users” Consistent condom use Proportion of “condom users” who reported either “always”  “consistent” use of condoms “sometimes”  “inconsistent” “never” used were excluded from analysis

6. Objectives General objective To determine the factors associated with condom use Specific objectives 1.To describe the levels and patterns of condom use in young adults 2. To compare factors affecting condom use and non- condom use among young adults 3.To compare factors associated with consistent condom use among young adults

7. Methodology Study design is Analytical Cross Sectional Primary outcome variable is condom use Secondary data analysis [2005 surveys data] Demographic Surveillance Survey Household Socio-Economic Survey HIV Survey Inclusion/exclusion criteria - age 15-24years [as on 1st Jan 2005] - residence [as on 1st Jan 2005] - ever had sex

8. Summary of sampling 14 946 Resident+15-24 yrs Ever had sex? 1 447(9.7%) Other n/a, dnt knw, missing, rfsd 4 966(33.2%) No 4 178 (28.0%) Yes 4 355 (29.1%) No response Ever used condom? 4 157 (99.5%) Yes/No Sample size 21(0.5%) Other 3missing,10rfsd,8na 2 151 Yes (51.7%) 2 006 No (48.3%) 2 413 (55.4%) Not contacted 1 942 (44.6%) Externally migrated /died

9. Data management & Analysis [STATA 9.2] Data Cleaning Data Analysis - descriptive Frequency tables, mean, median, proportions - univariate analysis t-test was used for continuous variables chi-square test for categorical variables - multivariate analysis Stratified by sex for both condom use and consistency of use Included both significant and insignificant variables from univariate

10. Data management & Analysis… Factors controlled for in multivariate analysis for both condom use and consistency: Sex Age Assets Education Type of relationship Partner age difference Residence of partner Partners in last month HIV status

11. Descriptive data n=4157 4157- ever had sex 2151- reported ever used a condom with most recent partner 1122 - reported always using condoms with most recent partner

12. Descriptive findings Female - 57% Male - 43% Median age 20 years Condom usage rate - 51.7% 15 -19yrs - 52.51% 20 - 24yrs - 51.11% Females - 47.63% Males - 57.26% Of those using condoms, consistent use rate - 52.2%

13. Results

14. Results…

15. Adjusted OR for condom use Socio-demographic & Socio-economic variables VariableAdjusted OR Both sexes Adjusted OR Females Adjusted OR Males AOR (95% CI) AOR (95% CI) AOR (95% CI) Sex Males Females 1.00 0.89(0.68-1.18) -- Age 15 - 19 20 - 24 1.00 0.97(0.95-1.00)0.96(0.93-1.00)0.99(0.94-1.03) Assets < 7 assets >=7 assets 1.00 1.56(1.37-1.79) 1.00 1.51(1.27-1.81) 1.00 1.67(1.36-2.06)

16. Adjusted OR for condom use Sexual History & Behaviour variables VariableAdjusted OR Both sexes Adjusted OR Females Adjusted OR Males AOR (95% CI) AOR (95% CI) AOR (95% CI) Type of relationship Non-marital Marital 1.00 0.95(0.81- 1.12) 1.00 0.75(0.59- 0.95) 1.00 1.15(0.94-1.44) Partner age difference Same age Older Younger 1.00 0.67(0.52-0.86) 0.94(0.73-1.20) 1.00 0.71(0.52-0.96) 0.85(0.35-2.05) 1.00 0.51(0.31-0.83) 0.87(0.66-1.16) Residence of partner with member outside isigodi in isigodi 1.00 1.62(1.24-2.14) 1.54(1.16-2.04) 1.00 1.62(1.13-2.32) 1.33(0.90-1.95) 1.00 1.61(1.06-2.45) 1.79(1.18-2.72) HIV status negative positive unknown 1.00 1.35(1.09-1.67) 1.18(1.02-1.37) 1.00 1.37(1.07-1.74) 1.11(0.91-1.36) 1.00 1.16(0.70-1.92) 1.30(1.04-1.61)

17. Adjusted OR for consistency of condom use Socio-demographic & Socio-economic variables VariableAdjusted OR Both sexes Adjusted OR Females Adjusted OR Males AOR (95% CI) AOR (95% CI) AOR (95% CI) Sex Males Females 1.00 0.63(0.43-0.93) -- Age 15 - 19 20 - 24 1.00 0.89(0.86-0.93)0.88(0.83-0.93)0.90(0.84-0.95)

18. Adjusted OR for consistency of condom use Sexual History & Behaviour variables VariableAdjusted OR Both sexes Adjusted OR Females Adjusted OR Males AOR (95% CI) AOR (95% CI) AOR (95% CI) Type of relationship Non-marital Marital 1.00 0.68(0.54-0.85) 1.00 0.74(0.53-1.05) 1.00 0.64(0.47-0.88) Partner age difference Same age Older Younger 1.00 0.77(0.54-1.09) 0.85(0.61-1.19) 1.00 0.62(0.41-0.93) 0.22(0.05-0.88) 1.00 1.20(0.56-2.57) 0.98(0.68-1.43)

19. Discussion 1.Condom use rate consistent with other studies Though its low, indication that HIV/AIDS awareness campaigns and programmes are having a positive effect [Shisana et. al HSRC Study 2002; SADHS 2003] 2.Significant differences in condom use and consistency of use between males and females male-determined method high rate of modern non-barrier contraception use among females Barriers to access of condoms for young girls – attitudes, norms [Garenne et al 2004; Morroni et al 2003] 3.Consistent condom use decreases with age formation of more stable relationships intended to lead to marriage Need for children

20. Discussion… 4. Owning more assets a positive determinant of condom use the better the young adults are socio-economically the better they relate in relationships [Kaufman et al 2004] Affordability of condoms [MacPhail, Campbell 2001] 5.Lower condom use in females, and consistent use in males, within marital relationships condom use varies with the type of relationships, trusting partner [Maharaj; Cleland 2004; Gabriela et al 2005; Prata 2005] 6.Older partner associated with lower condom use Age differentials and gender power inequalities in sexual relationships which affect relationship control in negotiating for safer sex [Gregson et al 2002; Glynn et al 2001]

21. Discussion… 7.Condom use more likely with those not residing with partners an indication of some risk assessment and taking precautions with partners who do not reside close to them 8.Having a +ve or unknown HIV status was associated with more likelihood to use condoms possible reasons for increased condom use: a high perception of risk high knowledge of HIV prevention; health service accessibility exposure to HIV/AIDS awareness programmes VCT counseling to prevent re-infection or infection of partner. [Maharaj; Cleland 2004; Simbayi et al 2005]

22. Conclusion 1. Positive determinants of condom use and consistency: (1) not residing with partner (2) having more assets (3) +ve/unknown HIV status 2. Negative determinants of condom use and consistency were: (1) being female (2) increase in age (3) marital relationship (4) having an older partner Research recommendation: Further investigation should be done on other behavioral factors eg power relations, substance use, cultural beliefs and norms not investigated in this study

23. Policy & Programme Recommendations 1. Develop a strategy to promote gender equality and empowerment of women to reduce poverty that will give a synergy effect to combat HIV/AIDS [United Nations Millennium Development Goals] 2. Promote consistent use of condoms with both marital and non-marital relationships especially where HIV status of partner(s) is unknown 3. Promote correct and consistent condom use and encourage youths to go for VCT  a significant reduction in HIV prevalence has not yet been observed 4. Public health education should target young adults and discuss the evidence of the extent of HIV transmission within older partners relationships 5. Develop programmes e.g. micro-financing to improve the SES of young adults especially women to create income and reduce economic dependency, hence improve their negotiation skills

24. Acknowledgements Dr Khin San Tint & Dr Kobus Herbst – supervisors CCETSA & BTC – financial support Director & Staff at Africa Centre – datasets and support INDEPTH for the MSc course University of Wits; Agincourt Health and Population Unit Staff and lecturers – Wits School of Public Health Friends and family

25. Thank you … 1991 President Museveni of Uganda declared to his parliament: ‘They are telling us that a thin piece of rubber stands between us and the future of our continent!’ (Museveni 1997).