The role of partnership dynamics in determining the acceptability of condoms and microbicides.

Microbicides are a class of substances under development that could reduce the sexual transmission of HIV and other sexually transmitted diseases when applied locally to genital mucosal surfaces. Microbicide acceptability research has largely focused on product characteristics, rather than processes of negotiation within relationships about use. Gender relations, decision-making power and communication within sexual relationships are recognised as important determinants of condom and contraceptive use, and are likely to determine microbicide use also. As part of social science research linked to the Microbicides Development Programme (MDP) we combine relationship-based theories with anthropological work conducted with women and men using a placebo gel. We explore communication and decision-making in gel and condom use, including constructions of risk and trust. During the MDP301 Phase III pilot study, in-depth interviews were conducted at sites in South Africa, Tanzania, Uganda and Zambia. Following four weeks of placebo gel use, women and their partners were asked about gel use and acceptability, partner involvement, sexual practices and condom use. Data from 45 couples at five sites were analysed using a grounded theory approach in NVivo. Participation in the study did not require women to inform their partners, yet our data shows women seeking permission from their partners, negotiating disclosure, exchanging information and persuading or motivating for gel use. Although gel was supposedly 'woman-controlled', men exercised considerable influence in determining whether and how it was used. Despite this, negotiations around use were largely successful, since the gel increased sexual pleasure and provided opportunities for intimate communication and the building of trust. Decisions about condom and microbicide use are made in a dyadic context and involve a complex negotiation of risk and trust. Whilst preferences relating to product characteristics are largely individual, use itself is dependent on partnership dynamics and the broader social context in which sexual risk management occurs.

Condom use with casual partners by men in Kampala, Uganda.

OBJECTIVE: To estimate the prevalence and correlates of condom use with casual sex partners by men in urban Uganda and to identify barriers to condom use that are amenable to intervention. DESIGN: Cross-sectional, door-to-door survey of men residing in a poor area of Kampala, Uganda. SUBJECTS AND METHODS: A multistage, probability sample was approximated by recruiting participants within randomly selected neighborhoods. A total of 301 men between the ages of 18 and 45 years answered questions about condom knowledge, attitudes, beliefs and practices. The respondents also provided demographic and HIV risk-related information. RESULTS: Condom use was higher than previously found in studies in Uganda: 46% of men reported using a condom at the last casual sexual encounter; 31% reported always using condoms with casual partners. In multivariate analysis, independent correlates of condom use included higher condom self-efficacy (4-item scale, odds ratio 1.3 per scale point), lower embarrassment around condoms (3-item scale, odds ratio 0.44 per scale point), knowing where to buy a condom (odds ratio 3.9), knowing how to use a condom (8-item scale, odds ratio 1.4 per scale point), and increasing number of casual sex partners (odds ratio 1.4 per partner). CONCLUSIONS: These data suggest that condom use may be further increased in this population by conducting demonstrations of condom use skills, preparing individuals to anticipate circumstances that make using condoms difficult and using a variety of outlets to dispense condoms.

Human immunodeficiency virus (HIV-1) seropositivity among children in a rural population of south-west Uganda: probable routes of exposure.

Serological studies on 7796 rural Ugandans showed 377 (4.8%) were HIV-1 antibody-positive, of whom 343 (8.2%) were adults, ten (0.4%) 5-12-year-olds and 24 (1.7%) under 5 years of age. Serological tests done on 18 mothers of the under-5s showed 17 to be HIV-1-positive. One mother was persistently negative. Her child had a history of multiple injections. Structured interviews with parents or guardians of the ten HIV-1-seropositive children aged 5-12 years to determine possible sources of exposure revealed that six were vertically infected and that blood transfusion, injections and sexual exposure each accounted for one case. It was not possible to identify a source of exposure in one instance. There was no evidence that casual household contact or scarifications played a role in the transmission of HIV-1 in children in this population. Our data show that in this rural population HIV-1 seropositivity in children is mainly associated with seropositivity in the mothers and that HIV-1 infection in children aged between 5 and 12 years is rare.