Prevention efforts are working better than many think, according to a recent article in The Lancet, as there has been a significant increase in the number of young women in Africa reporting both increased condom use and sexual abstinance. The authors found that a motivation for increased use of condoms was often contraception and argue that ‘programmes promoting family planning and HIV prevention have common interests.'
Investigators from the London School of Hygiene and Tropical Medicine and the World Health Organisation looked at almost 133,000 single women aged between 15 and 24 years in 18 sub-Saharan African countries, using national Demographic and Health surveys to determine changes in levels of abstinence or condom use between 1990 and 2004.
The investigators focused on changing levels of primary abstinence (virginity); secondary abstinence (no sex within the previous 3 months); and use of contraception, including condoms, in the previous 3 months.
Overall, there was no real shift in the number of young women reporting themselves virgins – the increased levels of virginity found in 7 countries being offset by a reduction in reported virginity in 6 other countries. Only in Cameroon and Ghana were there 10% or greater increases in the proportion of self-reported virgins.
The level of secondary abstinence did increase from a median of 44% to 49%. The increase in secondary abstinence was statistically significant in 7 countries, and exceeded 10% in 5. In 7 countries, however, abstinence trends were erratic, and in Burkina Faso, the proportion of women reporting secondary abstinence actually fell significantly.
Of the women reporting any sex within the previous 3 months, the proportion saying that they used any contraception increased from 33% to 37%. Use of less effective methods of contraception, such as periodic abstinence, fell significantly, but the proportion of women saying that they used highly effective methods of birth control, such as oral contraceptives, remained stable.
The investigators then looked at condom use. They found that condom use increased from a median of 5% to 19%. This rise in condom use was statistically significant in 13 countries and over 10% in 9 countries. Interestingly, increased levels of condom use did not appear to be linked to the severity of the local HIV epidemic, with countries in west Africa recording the largest increase in condom use, with use in the harder-hit eastern and southern African countries remaining lower.
When the investigators looked at self reported condom use for most recent intercourse, they found that this increased from 20% to 28%, with significant increases seen in 7 countries, with 6 seeing an increase of above 10%. The authors point out that, across the study period, this amounts to an annualised increase of around 1-4% a year, squarely in line with the uptake of all forms of contraception in the industrialised world between 1965 and 1998.
A median of 59% of women said that their primary motivation for using condoms was pregnancy prevention.
'Fewer than 10% of sexually active single women stated that they would like to have a child in the next 12 months [in the DHS surveys],' the authors note, highlighting the fact that abortion is illegal in many African countries and that unsafe abortion is more frequent in Africa than any other part of the world. It appears that the fear of unwanted pregnancy might be as great as the fear of AIDS for many young women in West and Central Africa.
The investigators emphasise that levels of abstinence changed less than condom use, but there was an increase in secondary abstinence that they attribute to more cautious partner selection, reduced frequency of sex, or a combination of both.
'Our central conclusion is that the sense of failure pervading HIV prevention efforts in Africa is unjustified and that investment in condom promotion and marketing have had an appreciable effect, at least for young single women.'
Cleland J et al. Lancet 2006 368: 1788 – 1793
