Objective: To assess the pattern of condom use among HAART naive and experienced patients in north eastern Nigeria. Methods: An interviewer-administered questionnaire was used to assess the pattern of condom use among 201 HIV clients. Participants included for this comparative cross sectional study were divided into two group: HAART experienced participants that had been on therapy for at least 12 months and HAART naive participants that had been registered at least 3 months before the beginning of the study. Results: Almost half of the HAART naive and substantial proportion of HAART experienced couples never used condom. Few (13.4%) HAART experienced and 16.5% naive participants always used condom. Inconsistent condom use among HAART naive and experienced partners was 38.8% and 41.8% respectively. Spouse notification of HIV was significantly associated with the use of condoms (p = 0.02; OR 1.32, 95% CI: 1.06 - 1.64). The stepwise logistic regression indicated that female (OR 2.40; CI: 1.09 - 3.82), partner notification of HIV sero-positive status (OR 1.32; CI: 1.06 - 1.64, yes versus none), occupation as a civil servant (OR 1.40; CI: 0.15 - 1.05), are factors independently associated with condom use in our studied participants. Conclusion: We report that condom use is uncommon among HIV clients in our environment. Condom is significantly influenced by partner notification of HIV seropositive status, occupation as a civil servant and female gender. This study supports an absence of association between condom uptake and HAART use. Intensive and regular condom counselling for every HIV-positive outpatient who attends the clinic in our environment is expedient. We recommend interventions directed at increasing condom use among HIV clients in our environment.
Despite numerous efforts made over the last several years to halt HIV/AIDS epidemic through increased access to treatment, educational and policy changes, the burden of HIV/AIDS is enormous especially in sub-Saharan Africa, with >60% of all HIV infections in the world occurring in this region [
To provide effective measures that diminish HIV transmission, it is important to study the knowledge of mechanisms of HIV transmission, sexual behaviour and condom use among heterosexual HIV-positive patients.
With reported high prevalence of HIV infection in Nigeria and the dearth of information on condom use and other preventive measures such as pre-exposure prophylaxis, it becomes expedient to understand the pattern of condom use among HAART naive and experienced patients in North eastern Nigeria with the view of instituting appropriate secondary preventive measures.
A hospital based cross sectional study was conducted at HARVARD PEPFAR (Presidential Emergency Plan For AIDS Relief) supported HIV clinic at the University of Maiduguri Teaching Hospital, a tertiary health institution designated as a centre of excellence for infectious diseases in North eastern Nigeria.
The study participants were adult clients aged 18 years and above, attending an outpatient HIV clinic of the hospital. Patients included in this study were divided into two groups; HAART experienced participants that had been on therapy for at least 12 months and The HAART naive participants that had registered at least 3 months before the time of the study.
The dependent variable was “condom use” (use of condom in sexual act in the last three months prior to the study). The condom use was further stratified into consistent condom use (use of condom in every sexual act) and inconsistent condom use (use of condom in some sexual act). The independent variables include socio demographic characteristics such as age, sex, marital status, residence (urban/rural), employment status (employed/unemployed); relational and behavioural factors such as type of partners (spouse/friend/commercial partners), disclosure of HIV status to partner. Social habit (ever smoked/never smoked cigarette, regular drinker and social drinker of alcohol or wine/no ingestion of alcohol).
A structured interview administered questionnaire prepared in English was used to collect data. Information from participants that did not understand English language was obtained through an interpreter that understands their local languages. Trained counsellors interviewed the participants in an isolated private room within the clinic complex.
Data was entered and cleaned in Microsoft office excel version 2007 windows and analyzed by SPSS version 16. Bivariate analysis was carried out to determine the association of each independent variable on the dependent variable and those who had <0.2 level of significance were used in the final models. Stepwise multiple logistic regression analysis was used to determine the presence of association, with statistical significance set at <0.05. Odd ratio and 95% confidence interval were also determined.
Permission to conduct this study was obtained from the institutions ethical committee. Respondents were informed about the purpose, procedure, risks and benefits, and the private and confidential nature of the study. Participation was voluntary and verbal informed consent was obtained from each respondent.
A total of 201 clients were approached for this comparative cross sectional study. Out of these 170 participants participated, including 67 Highly Active Antiretroviral Therapy (HAART) naive and 103 HAART experienced. A total of 31 participants either refused to participate or declined to respond to some of the questions regarding their sexuality, and were excluded.
The sex distribution of the participants was not comparable; this trend was maintained with respect to HAART exposure. The mean ages of the studied participants was 35.83 ± 8.37 (20 - 63), HAART naive with mean age of 33.75 ± 7.79 were significantly younger than HAART experienced that had mean age of 37.22 ± 8.49, p < 0.05.
Most of the patients were residents of urban areas (75.3%). A substantial proportion of the HAART naive cohort had secondary education (38.8%), while tertiary education was the predominant literacy level in HAART experienced cohort (46.6%). Married participants constituted 42.9% of the participants; they contributed the highest participants in both HAART naive and experienced cohort. Patients in the sample held a variety of jobs ranging from civil service self/private employment to unskilled or artisan. Civil servants constituted the majority in HAART experienced, while unemployed cohort constituted one out of every three HAART naive patients (32.8%). Socio-demographic and enrolment characteristics of the participants by HAART exposure is as shown in
At the time of the interview, 53.7% of HAART naive and 39.8% of HAART experienced participants had multiple sexual partners, excluding males married in polygamous setting. Mean numbers of sex partners were 3.06 ± 1.87 for men and 3.04 ± 1.51 for women. Significantly more females had multiple sexual partners in the HAART naive and males in the HAART experienced cohort. Ten men (14.9%) among HAART naive and 17 (16.5%) HAART experienced reported having paid for sex with a woman, and similar proportion of HAART naive and 24.3% of HAART experienced women reported having provided sex in exchange for money. Condom
. Participant’s enrolment, sociodemographic characteristics by HAART status.
Variables | HAART naive (n = 67) N (%) | HAART experienced (n = 103) N (%) | Total (n = 170) N (%) | ||
---|---|---|---|---|---|
Sex | |||||
Male | 29 (43.3) | 49 (47.6) | 78 (45.9) | ||
Female | 38 (56.7) | 54 (52.4) | 92 (54.1) | ||
Age group (years) | |||||
18 - 25 | 13 (19.4) | 08 (7.8) | 21 (12.4) | ||
26 - 35 | 29 (43.3) | 33 (32.0) | 62 (36.5) | ||
36 - 45 | 21 (31.3) | 43 (41.8) | 64 (37.7) | ||
46 - 55 | 04 (6.0) | 13 (12.6) | 17 (10.0) | ||
56 - 65 | 00 | 06 (5.8) | 06 (3.5) | ||
Mean age ± SD | 33.75 ± 7.79 (20 - 50) | 37.22 ± 8.49 (20 - 60) | 35.83 ± 8.37 (20 - 63) | ||
Residence | |||||
Urban | 45 (67.2) | 83 (80.6) | 128 (75.3) | ||
Rural | 22 (32.8) | 20 (19.4) | 42 (24.7) | ||
Educational status | |||||
No formal education | 14 (20.9) | 17 (16.5) | 31 (18.2) | ||
Primary | 11 (16.4) | 07 (6.8) | 18 (10.6) | ||
Secondary | 26 (38.8) | 31 (30.1) | 57 (33.5) | ||
Tertiary | 16 (23.9) | 48 (46.6) | 64 (37.7) | ||
Marital status | |||||
Married | 31 (46.7) | 42 (40.8) | 73 (42.9) | ||
Single | 17 (25.4) | 31 (30.1) | 48 (28.2) | ||
Widowed | 12 (17.9) | 19 (18.5) | 31 (18.2) | ||
Divorced | 07 (10.5) | 11 (10.7) | 18 (10.6) | ||
Occupation | |||||
Civil servant | 18 (26.9) | 47 (45.6) | 65 (38.2) | ||
Private employment | 16 (23.9) | 30 (29.1) | 46 (27.1) | ||
Artisan | 05 (7.5) | 06 (5.8) | 11 (6.5) | ||
Unemployed | 22 (32.8) | 12 (11.7) | 34 (20.0) | ||
Student | 06 (9.0) | 08 (7.8) | 14 (8.2) | ||
use was uncommon among study participants even among married couples, almost half of the HAART naive and substantial proportion of HAART experienced couples never used condom while having sex with their spouses. Few participants (13.4% vs. 16.5%) HAART naive and experienced respectively always used condom with their spouses. Inconsistent condom use among HAART naive and experienced partners was 38.8% and 41.8% respectively. The sexual behaviour, pattern of condom use among spouses, boyfriend/girl friend and those that engages in casual sex with others is as shown in
The prevalence of condoms use (always and inconsistent), was significantly higher among females (65.4%) than males (48.2%). The proportion of patients who reported condom use was similar across the age groups (p = 0.530). There was no difference in condom use between urban and rural dwellers (p = 0.931).
The level of condom use increases with literacy level, but fails to reach statistical significance (p = 0.088). Spouse notification of HIV sero-status was significantly associated with use of condoms p = 0.02; OR 1.32, 95% CI: 1.06 - 1.64.With respect to partners’ sero-status, condom use among discordant and sero-concordant partners
. Sexual behaviour and condom use among participants.
HAART naive No (67) | HAART experienced No (103) | p-value | |
---|---|---|---|
Had multiple sex partners | |||
No | 31 (46.3) | 63 (61.2) | 0.080 |
Yes | 36 (53.7) | 41 (39.8) | 0.105 |
Mean no of sexual partners | 3.06 ± 1.87 (2 - 10) | 3.04 ± 1.51 (2 - 8) | |
Males | 2.59 ± 1.23 (2 - 7) | 3.19 ± 1.52 (2 - 8) | |
Females | 3.67 ± 2.35 (2 - 10) | 2.91 ± 1.63 (2 - 8) | |
Partner enrolment | |||
yes | 23 (34.3) | 36 (35.0) | 0.999 |
Discordant | 07 (10.5) | 12 (11.7) | 0.999 |
Smoking | 07 (10.5) | 12 (11.7) | 0.999 |
Alcohol | 06 (9.0) | 13 (12.6) | 0.632 |
Mean time of illness to Diagnosis (months) | 9.54 ± 7.84 (2 - 24) | 16.31 ± 22.60 (1 - 96) | |
Exchange sex for money | |||
No | 52 (77.6) | 72 (69.9) | 0.354 |
Yes No comment | 10 (14.9) 05 (7.5) | 25 (24.3) 09 (8.7) | 0.198 0.999 |
Exchanged money for sex | |||
No | 54 (80.6) | 73 (70.9) | 0.214 |
Yes No comment | 10 (14.9) 03 (4.5) | 17 (16.5) 13 (12.6) | 0.949 0.134 |
Condom use | |||
Sex with spouse | |||
Never used condom | 32 (47.8) | 41 (39.8) | 0.384 |
Sometimes use condom | 26 (38.8) | 43 (41.8) | 0.819 |
Always use condom | 09 (13.4) | 17 (16.5) | 0.741 |
Sex with boyfriend/girl friend | No = 31 | No = 62 | |
Never used condom | 13 (41.9) | 26 (41.9) | 0.999 |
Sometimes use condom | 16 (51.6) | 25 (40.3) | 0.416 |
Always use condom | 02 (06.5) | 11 (17.7) | 0.250 |
Sex with others | No = 26 | No = 47 | |
Never used condom | 12 (46.2) | 22 (46.8) | 0.999 |
Sometimes use condom | 13 (50.0) | 18 (38.3) | 0.417 |
Always use condom | 01 (3.8) | 07 (14.9) | 0.297 |
was similar (p = 0.889). In terms of occupation, the highest rate of condom use was found among public/civil servants (68.9%). Smoking and alcohol consumption was not associated with condom use in our cohort. The stepwise logistic regression indicated that female gender (OR 2.40; CI: 1.09 - 3.82), partner notification of HIV seropositive status (OR 1.32; CI: 1.06 - 1.64, yes versus none), occupation as a civil servant (OR 1.40; CI: 0.15 - 1.05), are factors independently associated with condom use in our studied participants.
. Report of condom use according to selected characteristics among all study participants.
Variable | No (%) | SE | Wald | Exp (B) | 95%CI for Exp (B) | p-value |
---|---|---|---|---|---|---|
(Lower - upper) | ||||||
Sex | ||||||
Male | 40 (48.2) | 1 | ||||
Female | 53 (65.4) | 0.32 | 4.91 | 2.04 | 1.09 - 3.82 | 0.027* |
Age group | ||||||
18 - 25 | 12 (63.2) | 1 | ||||
26 - 35 | 35 (52.2) | 0.66 | 1.44 | 0.45 | 0.12 - 1.65 | 0.530 |
36 - 45 | 34 (55.7) | 0.79 | 2.98 | 0.26 | 0.55 - 1.20 | |
45 - 55 | 07 (58.3) | 1.04 | 0.74 | 0.41 | 0.53 - 3.14 | |
46 - 65 | 04 (100) | - | - | - | ||
Residence | ||||||
Urban | 71 (56.4) | 1 | ||||
Rural | 24 (58.5) | 0.31 | 0.01 | 0.97 | 0.46 - 2.05 | 0.931 |
Educational status | ||||||
None | 11 (37.9) | 1 | ||||
Primary | 09 (52.9) | 0.83 | 1.27 | 1.63 | 0.40 - 6.60 | 0.088 |
Secondary | 38 (67.9) | 0.59 | 5.90 | 0.77 | 0.18 - 3.38 | |
Tertiary | 35 (56.7) | 0.65 | 1.15 | 0.39 | 0.78 - 1.97 | |
Partner HIV status notification | ||||||
yes | 40 (70.0) | 1.32 | 1.06 - 1.64 | 0.020* | ||
no | 53 (49.5) | 1 | ||||
Partner serostatus | ||||||
Discordant | 11 (57.9) | 0.51 | 0.02 | 1.07 | 0.39 - 2.91 | 0.889 |
seroconcordant | 84 (56.8) | |||||
Smoking | ||||||
yes | 12 (63.2) | 0.52 | 0.23 | 1.29 | 0.46 - 3.63 | 0.631 |
no | 83 (56.7) | |||||
Alcohol | ||||||
yes | 12 (63.2) | 0.53 | 0.18 | 1.25 | 0.44 - 3.57 | 0.672 |
no | 82 (56.2) | 1 | ||||
Occupation | ||||||
Civil servant | 42 (68.9) | |||||
Private employment | 23 (50.0) | 0.49 | 3.49 | 0.40 | 0.15 - 1.05 | 0.034* |
Artisan | 06 (54.6) | 0.83 | 3.72 | 0.20 | 0.04 - 1.03 | |
Unemployed | 12 (40.0) | 0.64 | 8.73 | 0.15 | 0.04 - 0.53 | |
Student | 06 (50.0) | 0.82 | 2.97 | 0.24 | 0.05 - 1.22 |
There is dearth of reports on condom use and uptake among HIV clients in Nigeria. To our knowledge, this is the first hospital based cross sectional study designed to provide insight into the practice of condom use and associated risk factors among HIV positive clients in north-eastern Nigeria.
Our participants consisted of both HAART naive and experienced, this gave us an opportunity to make comparison and observe the effect of highly active antiretroviral therapy on modifications in their sexual behaviour.
Distribution of condom use according to literacy level
Most of our patients were residents of urban areas (75.3%). A substantial proportion of the HAART naive cohort had secondary education (38.8%), while Tertiary education was the predominant literacy level in HAART experienced cohort (46.6%). Civil servants constituted the majority in HAART experienced, while unemployed cohort constituted one out of every three HAART naive patients (32.8%). This finding suggests literacy level and gainful employment have a positive impact on accessing and continuing HIV care in our setting.
Married participants constituted 42.9% of the participants; they contributed the highest participants in both HAART naive and experienced cohort. At the time of the interview, 53.7% of HAART naive and 39.8% of HAART experienced participants had multiple sexual partners, with most of them in marital union. Condom use was uncommon among study participants even among married couples, almost half of the HAART naive and substantial proportion of HAART experienced never used condom while having sex. The finding of low condom use among the HAART experienced cohort in this study was surprising, considering the fact that regular counselling on adherence and condom use are provided to clients at initial assessment, commencement of HAART and as part of health talk at each clinic visit. Condom provided by the United State Government through the PEPFAR (Presidential Emergency Plan for AIDS Relief in Africa) is available free of charge on demand by clients in our HIV clinic. The low prevalence of condom use in our cohort is however similar to the proportion in HAART naive reported in south-western Nigeria [
When they were asked to cite the reasons for not using a condom in the past 3 months, the main reasons given was that their partner did not want to use it because its use decreases sexual satisfaction or desire to have a child. Low condom uptake among HIV clients has a negative impact in HIV/AIDS prevention.
Overall, although risky sexual behaviour was observed among the study participants, there was no difference in the pattern of risky behaviour with respect to gender within a group. When subjects reported having casual partners, in all cases interviewed, they did not know their HIV sero-status. We observed that male participants continue or increase their risky sexual behaviour after knowing their HIV sero-status as significantly more females had multiple sexual partners in the HAART naive and males in the HAART experienced cohort. Female patients among HAART naive group were more prone to high-risk behaviour. This may be a result of poor socioeconomic status and lack of bargaining power of women and those who are not in a stable union. For instance, it may be difficult for a female who provided sex for money to negotiate condom use.
The level of condom use increased with literacy level, our finding is in agreement with similar studies in sub- Saharan Africa, [
Our data showed a strong association between disclosure of HIV status and protective patterns of condom use. This finding is consistent with previous studies that found that disclosure was associated with reduced transmission risk behaviours [
In terms of occupation, the highest rate of condom use was found among public/civil servants (68.9%). In this population, it appears that smoking and alcohol do not affect condom use, as reported in other studies conducted in other countries [
Sexual behaviour was self-reported and subject to both recall and social desirability bias. In order to minimize the recall bias, we used 3-month recall period. We also tried to address social desirability bias by assigning male data collectors for male subjects and female data collectors for female subjects. Still we believe that the traditional reluctance to discuss sexual behaviour, especially homosexuality, is regarded as a taboo that may have resulted in underreporting.
We report that condom use is uncommon among HIV clients in our environment. Condom use is significantly influenced by partner notification, occupation as a civil servant and female. This study supports an absence of association between condom uptake and HAART use.
Factors militating against condom use among HIV clients should be individually and confidentially addressed during counselling, with greater emphasis on its positive impact and strengthening condom use negotiation. We recommend interventions directed at increasing condom use among HIV clients in our environment.