Transcript Condom Use Behaviors and Correlates of Condom Use in the

Condom Use Behaviors and
Correlates of Condom Use
in the Botswana Defence Force
Major Mooketsi Ditsela
Botswana Defence Force
16th Annual ICASA Meeting
8 December 2011
Addis Ababa, Ethiopia
1
Background



Botswana has one of the highest HIV prevalence
rates (17.6%) in the world1
Correct and consistent condom use is shown to be
highly effective in preventing HIV infection2
Condom use among military personnel is generally
inconsistent

Condom use during last sexual encounter with CSW


1.
2.
3.
4.
59% of Nigerian military3
54% of Angolan military4
Botswana AIDS Impact Survey III (2008)
Roper W, Peterson H, Curran J (1993)
Nwokoji U, Ajuwon A (2004)
Bing E, Ortiz D, Ovalle-Bahamon R, et al (2008)
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Rationale

Research investigating condom use behaviors and
correlates of condom use in military populations is
needed to


Monitor effectiveness of existing HIV prevention
programs
Develop new interventions
3
Study Purpose



Quantify condom use
Describe condom use behaviors
Examine correlates of condom use
4
Participants

BDF sexually active men, aged 18 to 30




Recruited for an intervention study assessing condom
wrapper graphics in the Botswana Defence Force
October 2010
4 military sites
211 men
5
Methods

Self-completed paper-based survey administered in
group setting for baseline study

Questions were read aloud
by a trained survey administrator
while participants followed along
and marked their responses on
their paper survey
6
Correlates of Interest

Demographics

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Sexual behavior history

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
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Knowledge of HIV status, knowledge of others in unit who are HIV
positive, ever cared for HIV positive person
HIV transmission knowledge (scores calculated based on
correct responses to 8 questions)
Condoms


Age of sexual debut, number of lifetime, regular, casual partners,
more than 1 sexual partner in past 3 months
HIV risk perception


Age, education, marital status, rank, years of military service
Opinions, problems with use, frequency of carrying condoms
Alcohol use (Alcohol Use Disorders Identification Test - AUDIT)
7
Circumcision status
Outcome of Interest

Condom use frequency in last 3 months
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


Always
Most times
Occasionally
Never
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Characteristics of Participants
n
(%)
Age (years), Mean (SD)
25.1
(2.4)
Education
Junior (secondary)
Senior (secondary)
Tertiary
Vocational
1
157
44
9
(0.4)
(74.4)
(20.9)
(4.3)
Marital status
Single
Married/Cohabitating
173
38
(82.0)
(18.0)
Rank
Private
Junior non-commissioned officer
Junior officer
108
92
11
(51.2)
(43.6)
(5.2)
Years of military service, Mean (SD)
4.1
(2.4)
9
Characteristics of Condom Use
Correlates
Sexual history
n
(%)
17.5
(2.7)
Median number (range) of
Lifetime partners
Regular partners
Casual partners
10
3
3
(5-200)
(1-35)
(1-115)
> 1 sexual partner in past 3 months
143
(69.1)
Age at first sexual debut, Mean (SD)
10
Characteristics of Condom Use
Correlates
HIV risk perception & HIV knowledge
n
(%)
Knowledge of HIV status
155
(75.2)
Knowledge of someone in unit with
HIV/AIDS
49
(47.1)
Ever cared for or lived with an HIVpositive person
Scored 85% or higher on HIV knowledge
questions
80
(40.4)
159
(75.4)
HIV knowledge score, Mean (SD)
87.9
(12.5)
11
Characteristics of Condom Use
Correlates
Circumcision status & Alcohol use
n
(%)
Circumcision status
Not circumcised
Circumcised
164
46
(78.1)
(21.9)
Alcohol use
Non-drinkers (AUDIT score = 0)
Mild drinkers (AUDIT score < 8)
Problem drinkers (AUDIT score > 8)
51
34
122
(24.6)
(16.4)
(58.9)
12
Characteristics of Condom Use
Correlates
Opinions about condoms (agreement with each statement)
n
(%)
Using a condom shows you care for your partner
204
(99.0)
Alright for a married woman to ask her husband to use a condom
195
(98.0)
Alright for a married man to use a condom with his wife
197
(97.5)
Condoms are effective in preventing HIV infection
189
(90.9)
I would use condoms more often if they were available for free
159
(81.5)
Condoms are quite convenient to use
136
(74.3)
Buying and handling condoms is the man’s responsibility
55
(26.3)
It is embarrassing to buy condoms
25
(12.1)
One condom can be used more than once
A man would lose respect if he suggested to a woman that they
use a condom
A woman would lose respect if she asked a man to use a
condom
4
(1.9)
3
(1.5)
3
(1.5)13
Characteristics of Condom Use
Correlates
Reported reasons for not using condoms
n
(%)
Condoms make sex less enjoyable
37
(17.5)
I trust my partner(s)
29
(13.7)
Condoms smell bad
13
(6.2)
Condoms dampen the mood
11
(5.2)
Other reasons
7
(3.3)
Condoms break easily
4
(1.9)
Partner does not want me to use one
4
(1.9)
Condoms don’t fit properly
3
(1.4)
I don’t have the right brand
3
(1.4)
14
Characteristics of Condom Use
Correlates
Frequency of carrying condoms
n
(%)
Always
19
(9.1)
Most times
40
(19.1)
Occasionally
79
(37.8)
Never
71
(34.0)
15
Condom Use Frequency in
Last 3 Months
60
51.2
50
Percent
40
35.1
30
20
13.7
10
0
Always
Most times
Occasionally/never
Frequency of Condom Use
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Condom Use by Partner Type
1 Regular, 1 Casual Partner
(n=79)
Regular
Condom Use
Always
Most times
Occasionally/ Never
Casual
n
(%)
n
(%)
31
24
23
(39.7)
(30.8)
(29.5)
67
8
4
(84.8)
(10.1)
(5.1)
17
Condom Use by Partner Type
1 Regular, 1 Casual Partner
(n=79)
Regular
Condom Use
Always
Most times
Occasionally/ Never
Casual
n
(%)
n
(%)
31
24
23
(39.7)
(30.8)
(29.5)
67
8
4
(84.8)
(10.1)
(5.1)
18
Correlates of Condom Use †
p-value
HIV knowledge score
0.06
Circumcision status
0.06
Alcohol use (AUDIT)
<0.01
Opinions towards condoms
Condoms convenient to use
Condoms effective against HIV infection
Woman would lose respect if she asked a man to
use a condom
0.11
0.13
0.13
Reported reasons for not using condoms
Condoms make sex less enjoyable
Condoms break easily
Condoms smell bad
I trust my partner
I do not have the right brand
†
<0.01
0.12
0.03
<0.01
0.13
Results of univariate ordinal regression (p<0.15)
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Correlates of Condom Use †
p-value
HIV knowledge score
0.08
Circumcision status
0.06
Alcohol use (AUDIT)
<0.01
Opinions towards condoms
Condoms convenient to use
Condoms effective against HIV infection
Woman would lose respect if she asked a man to
use a condom
0.18
0.15
0.10
Reported reasons for not using condoms
Condoms make sex less enjoyable
Condoms break easily
Condoms smell bad
I trust my partner
I do not have the right brand
†
<0.01
0.08
0.03
<0.01
0.11
Results of individual multivariate ordinal regression models, adjusting for age and marital status
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Correlates of Condom Use †
Decreasing Odds of
Always Using
Condoms
OR
95% CI
Age
0.92
(0.81–1.05)
Married vs. Single
2.15
(0.96-4.80)
HIV transmission knowledge score
0.97*
(0.95-0.99)
Circumcised vs. Not circumcised
0.42*
(0.20-0.90)
Problem drinking (AUDIT score > 8) vs.
Non/mild drinking (AUDIT score <8)
2.27*
(1.22 – 4.23)
Agreed a woman would lost respect if she
asked a man to use a condom
8.73
(0.73-104.07)
Reported condoms make sex less enjoyable
4.06*
(1.83 – 9.03)
Trusted the sexual partner
3.76*
(1.64 –8.65)
†
Results of multivariate ordinal regression, adjusting for age and marital status (n=201)
* p<0.05
21
Correlates of Condom Use †
Decreasing Odds of
Always Using
Condoms
OR
95% CI
Age
0.92
(0.81–1.05)
Married vs. Single
2.15
(0.96-4.80)
HIV transmission knowledge score
0.97*
(0.95-0.99)
Circumcised vs. Not circumcised
0.42*
(0.20-0.90)
Problem drinking (AUDIT score > 8) vs.
Non/mild drinking (AUDIT score <8)
2.27*
(1.22 – 4.23)
Agreed a woman would lost respect if she
asked a man to use a condom
8.73
(0.73-104.07)
Reported condoms make sex less enjoyable
4.06*
(1.83 – 9.03)
Trusted their partner
3.76*
(1.64 –8.65)
†
Results of multivariate ordinal regression, adjusting for age and marital status (n=201)
* p<0.05
22
Alcohol Consumption and
Condom Use
Last 3 months*
n
(%)
Frequency of alcohol use < 2 hours before sex
Never
Seldom
Occasionally
Often
Always
63
15
47
10
4
(45.3)
(10.8)
(33.8)
(7.2)
(2.9)
Alcohol use prevented condom use
Yes
No
25
125
(15.9)
(84.1)
Alcohol use prevented correct condom use
Yes
No
12
137
(8.1)
(91.9)
*Among those who reported alcohol use
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Alcohol Consumption and
Condom Use
Last 3 months*
n
(%)
Frequency of alcohol use < 2 hours before sex
Never
Seldom
Occasionally
Often
Always
63
15
47
10
4
(45.3)
(10.8)
(33.8)
(7.2)
(2.9)
Alcohol use prevented condom use
Yes
No
25
125
(15.9)
(84.1)
Alcohol use prevented correct condom use
Yes
No
12
137
(8.1)
(91.9)
*Among those who reported alcohol use
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Alcohol Consumption and
Condom Use
Last 3 months*
n
(%)
Frequency of alcohol use < 2 hours before sex
Never
Seldom
Occasionally
Often
Always
63
15
47
10
4
(45.3)
(10.8)
(33.8)
(7.2)
(2.9)
Alcohol use prevented condom use
Yes
No
25
125
(15.9)
(84.1)
Alcohol use prevented correct condom use
Yes
No
12
137
(8.1)
(91.9)
*Among those who reported alcohol use
25
Alcohol Consumption and
Condom Use
Last 3 months*
n
(%)
Frequency of alcohol use < 2 hours before sex
Never
Seldom
Occasionally
Often
Always
63
15
47
10
4
(45.3)
(10.8)
(33.8)
(7.2)
(2.9)
Alcohol use prevented condom use
Yes
No
25
125
(15.9)
(84.1)
Alcohol use prevented correct condom use
Yes
No
12
137
(8.1)
(91.9)
*Among those who reported alcohol use
26
Alcohol Consumption and
Condom Use
Last 3 months*
n
(%)
Frequency of alcohol use < 2 hours before sex
Never
Seldom
Occasionally
Often
Always
63
15
47
10
4
(45.3)
(10.8)
(33.8)
(7.2)
(2.9)
Alcohol use prevented condom use
Yes
No
25
125
(15.9)
(84.1)
Alcohol use prevented correct condom use
Yes
No
12
137
(8.1)
(91.9)
*Among those who reported alcohol use
27
Alcohol Consumption and
Condom Use
Last 3 months*
n
(%)
Frequency of alcohol use < 2 hours before sex
Never
Seldom
Occasionally
Often
Always
63
15
47
10
4
(45.3)
(10.8)
(33.8)
(7.2)
(2.9)
Alcohol use prevented condom use
Yes
No
25
125
(15.9)
(84.1)
Alcohol use prevented correct condom use
Yes
No
12
137
(8.1)
(91.9)
*Among those who reported alcohol use
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Limitations & Strengths

Limitations
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
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Cross-sectional
Relatively small
sample size
Reporting bias
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However, confidentiality
measures implemented

Strengths

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High participation rates
Many correlates of
condom use examined
Very little missing data
from survey
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Discussion

Higher levels of HIV knowledge associated
with more frequent condom use
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While nearly 100% correctly answered that HIV
transmission can be reduced by using condoms,
only 51% reported always using condoms
consistently


HIV knowledge alone not enough to prevent HIV
infection
HIV knowledge education should be coupled with
messages of correct and consistent condom use and
the provision of appealing condoms that may increase
30
usage
Discussion

Higher levels of condom use found among
men who reported they were circumcised

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BDF prevention messages regarding correct and
consistent condom use after male circumcision
(MC) may be highly effective
BDF should continue to promote consistent
condom use after MC and provide appealing
condoms at each base to keep condom use high
31
Discussion

High percentage (59%) of problem alcohol use in
the BDF and its association with lower levels of
condom use
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What can be done?
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HIV prevention messages should address alcohol abuse
and risky behavior, including condom use
Limit alcohol availability on bases
Provide free condoms where alcohol sold
Create policy on alcohol and other substance abuse
Bolster and increase alcohol abuse prevention, treatment,
and rehabilitation programs
32
Discussion

Lower rates of condom use were found among
participants who indicated that condoms make sex less
enjoyable




Preference for skin-to-skin contact
Act of putting on condom dampens mood
Physical attributes of condom discourage use
What can be done?


Prevention messages should include correct and
consistent condom use as effective and important HIV
prevention tool
Develop innovative ways to increase condom use
33
Discussion

Association between reporting trust for a sexual
partner and lower condom use was interesting


While nearly 100% agreed that using a condom
shows you care for your partner, data show that most
were not using condoms consistently
What can be done?



HIV prevention messages should address importance of
correct and consistent condom use with all sexual
partners, especially among those with multiple partners
Encourage couples HIV counseling and testing so
individuals and their partner(s) know their HIV status
Encourage and support disclosure of HIV status to
partners
34
Conclusions

Rates of condom use relatively low in BDF

Only 50% reported always using condoms, regardless of
partner type

Problem alcohol use, belief that condoms made sex less
enjoyable, and trust in the sexual partner associated with
lower levels of condom use

Higher HIV knowledge scores and self-reports of MC
associated with higher levels of condom use

Low condom use can be addressed through targeted
prevention programs
35
Acknowledgments

Botswana Defence Force






Maj. Mooketsi Ditsela
Maj. Timothy Maje
Capt Segolame Phirinyane
Lt. Moitshepi Sepopo
Lt. Zibanani Elias
Col. Robert Phetogo

US Embassy Botswana


DHAPP





Population Services
International (PSI)




Cate O’Kane
Iris Hallsdordottir
Irene Kedisang
Mogomotsi Kgari

David Kelapile
Bonnie Tran
Anne Thomas
Richard Shaffer
Epidemiology Team
SDSU/UCSD



Florin Vaida
Christina Chambers
Richard Haubrich
36
THANK YOU!
KE A LEBOGA!
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