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

2. 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?

3. 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 2004. Maharaj and Cleland. Studies in Family Planning (in press June 2004) + work in progress. Foss, Watts, Vickerman, Kumaranayake – paper on condom use, available from Charlotte.Watts@lshtm.ac.uk Charlotte.Watts@lshtm.ac.uk Ali and Cleland. Presentation at International Conference, Mumbai, December 2003.

4. 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

7. 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 1997-2002. *of women reporting such sex with specific partners in last 12 months

8. 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 1997-2002. *of men reporting such sex with specific partners in last 12 months

10. Percentage of married contraceptive users relying on condoms, by stage of HIV epidemic HIV prevalence No. of countries 1983199019941997 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

11. 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 FP8.75.2 Consistent/occasional use with partner31.311.1 Kenya Current use for FP2.21.7 Consistent/occasional use with partner14.511.6 Uganda Current use for FP5.63.1 Consistent/occasional use with partner21.811.0

12. 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 Wife33.917.610.9* Husband29.315.77.8* Discussed condoms with spouse Wife79.754.928.1* Husband75.940.030.5* Favourable attitude to condoms Wife57.662.535.2* Husband33.930.027.0 Belief in condom efficacy Wife89.786.376.0* Husband91.592.286.6

13. 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 Wife55.954.958.3 Husband10.328.025.0* High perceived self-efficacy Wife37.923.522.2* Husband37.331.431.3 Number of couples (unweighted)945292 *Strata difference significant at 95% confidence level

14. Predictors of Condom Use Reported by Wives (South Africa) Unadjusted ORsAdjusted ORs Urban v rural 3.172.26 Wife secondary + sch. V less 4.422.47 Husband secondary + sch. V less 3.812.24 Wife’s high/medium perceived risk of HIV v. low/no risk 4.173.92 Wife’s high belief in condom efficacy v low 5.534.55 husband’s positive attitude to condoms v negative 4.291.56 Also in the model: marital status, length of relationship: fertility intentions Significant effects in red

15. 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 method13241649 Non-barrier method only 60357144 Condom only4822 Both2332125 (N)(75)(74)(61)(57)

16. Kenya (moderate contraceptive use setting) Use statusNeeds FP & HIV protection Needs HIV- protection only Needs FP only No need Use status%% No method22262139 Non-barrier method only 69506851 Condom only0222 Both92398 (N)(58)(93)(167)(197)

17. Uganda (low contraceptive use setting) Use statusNeeds FP & HIV protection Needs HIV- protection only Needs FP only No need Use status%% No method53646869 Non-barrier method only 35182215 Condom only81458 Both4458 (N)(156)(225)(41)(88)

18. 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

19. Observed and hypothetical numbers of unwanted births Proximate cause of unwanted births Observed number Hypothetical number Ratio hypothetical/ observed Failure/discontinuation of: Pill9611940.20 Condom1587864.98 Other methods1,799 1.00 Non-use8,636 1.00 Total11,55411,4150.99

20. 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