Abstract
Critical to preventing the spread of HIV is promoting condom use among HIV-positive individuals. Previous studies suggest that gender norms (social and cultural constructions of the ways that women and men are expected to behave) may be an important determinant of condom use. However, the relationship has not been evaluated among HIV-positive women and men in South Africa. We examined gender norms and condom use at last sex among 550 partnerships reported by 530 sexually-active HIV-positive women (372) and men (158) who had sought care, but not yet initiated antiretroviral therapy in a high HIV-prevalence rural setting in KwaZulu-Natal, South Africa between January 2009 and March 2011. Participants enrolled in the cohort study completed a baseline questionnaire that detailed their socio-demographic characteristics, socio-economic circumstances, religion, HIV testing history and disclosure of HIV status, stigma, social capital, gender norms and self-efficacy. Gender norms did not statistically differ between women and men (p = 0.18). Overall, condoms were used at last sex in 58% of partnerships. Although participants disclosed their HIV status in 66% of the partnerships, 60% did not have knowledge of their partner’s HIV status. In multivariable logistic regression, run separately for each sex, women younger than 26 years with more equitable gender norms were significantly more likely to have used a condom at last sex than those of the same age group with inequitable gender norms (OR = 8.88, 95% CI 2.95–26.75); the association between condom use and gender norms among women aged 26+ years and men of all ages was not statistically significant. Strategies to address gender inequity should be integrated into positive prevention interventions, particularly for younger women, and supported by efforts at a societal level to decrease gender inequality.
Highlights
In 2013, over 6 million adults were living with HIV in South Africa [1]; numbers are increasing following the scale-up of antiretroviral therapy (ART) [2]
Just over half of the participants in our study reported using a condom at their last sex act, consistent with data on condom use with regular partners from the population-based surveillance programme in the same area [13], and data collected among rural HIV-positive adults elsewhere in KwaZulu-Natal [7]
Our findings demonstrate that both HIV-positive women and men who disclosed their status to their partner or who knew their partner’s HIV status were significantly more likely to use a condom at last sex [7,9,10,29]
Summary
In 2013, over 6 million adults were living with HIV in South Africa [1]; numbers are increasing following the scale-up of antiretroviral therapy (ART) [2]. In South Africa, KwaZulu-Natal has the highest adult HIV prevalence at an estimated 29% among adults aged 15–49 years old in a rural area in 2011 [2]. While an estimated 75% of eligible individuals received ART in South Africa in 2011, overall less than a third of HIV-positive adults are on treatment [6]; as such, condom use remains an important positive prevention strategy. Reported condom use among HIV-positive women and men in South Africa is higher than in the general population [7,8,9,10,11,12]. In South Africa, higher levels of condom use among HIV-positive women and men have been associated with being male, younger age, higher education, and urban residency [7,10,14]. HIVpositive adults’ lack of condom use has been associated with having a casual partner, sex with a positive partner, alcohol use ever or before sex, substance abuse in the past month or before sex, a history of forced sex (for women and men), and with coping strategies characterised by HIV denial and HIV-related stigma [7,9,11,14,19]
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