Anand A, Shiraishi RW, Bunnell RE, et al. Knowledge of HIV status, sexual risk behaviors and contraceptive need among people living with HIV in Kenya and Malawi. AIDS. 2009 Jun 17.
Efforts to increase access to antiretroviral therapy in developing sub-Saharan African countries have decreased HIV-related mortality. With a greater number of persons living longer with HIV, efforts to reduce transmission from persons aware of their infection take on greater importance. Studies done in parts of sub-Saharan Africa have documented substantial sexual risk among persons diagnosed with HIV,(1) and prevention efforts focused on persons living with HIV have shown success in reducing the risk of HIV transmission.(2) In addition to prioritizing HIV prevention among infected persons, the World Health Organization (WHO) recommends reductions in unintended pregnancies among infected women as one method of reducing mother-to-child transmissions.(3)
To determine sexual risk behaviors, knowledge of HIV status, and contraceptive use among HIV-infected persons
Kenya and Malawi
Men and women aged 15-49 years
Sexual activity and condom use
Two household surveys were conducted: the Malawi Demographic and Health Survey (MDHS) and the Kenya Demographic and Health Survey (KDHS), both of which were household surveys designed to be nationally representative. The MDHS was conducted in 2004-2005 and the KDHS was conducted in 2003. In the KDHS, all women (15-49 years of age) and all men (15-54 years of age) in every second household were eligible for interview. In the MDHS, all women (15-49 years of age) in the selected households and all men (15-54 years of age) in every third household were eligible for the interview. In both surveys, female and male participants were eligible for HIV testing only in those households selected for men's interview. Both surveys collected blood samples for HIV testing from eligible and consenting survey participants. This analysis was restricted to HIV-infected persons, and the results were weighted based upon the individual sampling weight of HIV. Participants who reported having had sex in the past month were classified as recently sexually active.
In the KDHS, interviews were completed by 8195 women (94% of eligible) and 3578 men (86% of eligible). Seventy-six percent of the 4303 eligible women and 70% of 4183 eligible men agreed to participate in HIV testing. In MDHS, interviews were completed with 11,698 women (95.7% of eligible) and 3261 men (85.9% of eligible), and 70% of 4071 eligible women and 63% of 3797 eligible men agreed to participate in HIV testing. The final sample consisted of 412 HIV-infected persons from Kenya and 664 HIV-infected persons from Malawi.
Married or cohabiting participants accounted for 62% of subjects in Kenya and 78% of subjects in Malawi. Sexual activity in the past month was reported by 62% of Kenyan men, 53% of Kenyan women, 76% of Malawian men, and 56% of Malawian women, and for most of these participants, the most recent sexual activity occurred with their spouse/cohabiting partner. Married or cohabiting participants were significantly more likely to be sexually active compared with never-married participants in Kenya (adjusted odds ratio [AOR]: 36.49; 95% confidence interval [CI]: 13.55-98.27) as well as in Malawi (AOR: 13.40; 95% CI: 3.62-49.65). In Kenya, widowed and divorced participants were significantly more likely to be sexually active than were those who had never married (AOR: 5.96; 95% CI: 1.59-22.39). Condom use was infrequent among persons whose last intercourse was with their spouse or cohabiting partner; 3% in Kenya and 6% in Malawi used a condom at their last intercourse. In multivariate analysis of condom use at last sexual encounter, Kenyan respondents who were married or had cohabiting partners (AOR: 0.04; 95% CI: 0.01-0.13) or those who were widowed or divorced (AOR: 0.10; 95% CI: 0.01-0.89) were less likely to use condom. In Malawi, participants who were married or living with a partner (AOR: 0.04; 95% CI: 0.01-0.18) were significantly less likely to use a condom at last sexual intercourse.
Only 20% of HIV-infected persons in Kenya and 16% in Malawi were aware of their infection. Among those who had tested before the survey, receipt of results was reported by 89% of Kenyans and 87% of Malawians.
Fifty-four percent of HIV-infected women in Kenya and 40% in Malawi reported that their last child was unintended or unwanted. Contraceptive use was reported by 26% of women in Kenya and 19% in Malawi. Among the women who did not want a child ever or in the next two years, less than one third in Kenya and less than one fifth in Malawi reported contraceptive use.
Among sexually active HIV-infected men and women in Kenya and Malawi, few are aware of their infection, and use of condoms and other contraceptives is infrequent, even among those who do not desire pregnancy.
This is a very well designed and analyzed study. It presents relatively up-to-date information on nationally representative samples of men and women in two sub-Saharan African countries that have high prevalence rates of HIV.
The low testing rates and use of contraception, even among those who do not desire pregnancy, suggest an urgent need to expand testing and family planning services. Over 80% of the HIV-infected adults in these surveys were aware of their infection, allowing for on-going transmission and preventing the opportunity for effective treatment. The move towards opt-out and home-based HIV testing are methods that may increase testing acceptance.(4, 5) These as well as any other promising methods to increase HIV testing must be expanded.
- Simbayi LC, Kalichman SC, Strebel A, Cloete A, Henda N, Mqeketo A. Disclosure of HIV status to sex partners and sexual risk behaviours among HIV-positive men and women, Cape Town, South Africa. Sex Transm Infect 2007;83:29-34.
- Bunnell R, Opio A, Musinguzi J, et al. HIV transmission risk behavior among HIV-infected adults in Uganda: results of a nationally representative survey. AIDS 2008;22:617-24.
- World Health Organization. Strategic approaches to the prevention of HIV infection in infants. Switzerland, Geneva; 20-22 March 2002. Abstract not available.
- Matovu JK, Kigozi G, Nalugoda F, Wabwire-Mangen F, Gray RH. The Rakai project counselling programme experience. Trop Med Int Health 2002;7:1064-7.
- Were W, Mermin J, Bunnell R, Ekwaru JP, Kaharuza F. Homebased model for HIV voluntary counselling and testing. Lancet 2003;361:1569.