Barriers to Preventing Human Immunodeficiency Virus in
Women: Experiences from KwaZulu-Natal, South Africa
By: Ouarraisha Abdool-Karim
Journal of the American medical women's association
December 2001
Objective: to determine barriers to the adoption of
safer sex practices in women in KwaZulu-Natal, South Africa. Methods: This
cross-sectional survey was conducted in a peri-urban and a rural community
in 1991 to 1993. A structured, pretested questionnaire was administered to
consenting women age 15 to 44 years who had been drawn randomly from a 10%
systematic sample of households. The questionnaire included the following
items: demographic characteristics, sexual relationships, knowledge of
human immunodeficiency virus (HIV) and acquired immune deficiency syndrome
(AIDS), perception of risk, knowledge of and skills with respect to safer
sex practices, and perceptions of rights to safer sex practices.
Results: A total of 219 interviews were conducted.
Most respondents had an average of 8 years of schooling and were seeking
employment. The majority of the respondents were sexually active (88.1%)
and had extensive knowledge of modes
of transmission and methods of preventing HIV/AIDS. Although most
respondents underestimated their risk of HIV infection, a key reason for
women not acting on their knowledge and perception of risk was that many
did not believe they had a right to refuse sex with their partners (48.8%)
or insist on condom use (46.1%). Most women thought their partners had a
right to multiple partners (62.2%). Only 35.2% of respondents had the
skills to object to their partners' having multiple partners, and 82.4%
lacked the skills to use condoms. Conclusion: Women in these communities
are at high risk of HIV infection. Their perceived lack of a right to
safer sex, lack of skills to adopt safer sex practices, financial
dependence on their sex partners, and the threat of violence influenced
their ability to reduce their risk of HIV infection. (JAMWA.
2001;56:193-196)
Women feature more strongly in this decade of the
human immunodeficiency virus (HIV) pandemic than they did in the first. [1]
Sub-Saharan Africa is unique in having more women than men infected with
HIV. Biological factors enhance the transmission of HIV from men to women.
[2,3]
Social
and contextual factors also increase vulnerability to HIV infection, [4-10]
although empirical data remain limited. In the absence of such biomedical
interventions as vaccines
and microbicides, alternative
strategies for reducing women's vulnerability to HIV infection are a
high priority. A deeper understanding of barriers to the adoption of such
safer sex practices as monogamy, abstinence, fewer partners, use of
condoms, and treatment of sexually transmitted diseases (STDs) is an
important first step in this regard.
HIV was rare in the heterosexual population in South
Africa before 1987, [11,12]
but today it is experiencing one of the fastest growing epidemics in the
world. [13]
The rapidity with which HIV is spreading in the black, heterosexual
population in South Africa is most reliably demonstrated by data from the
annual, anonymous prenatal surveys that have been conducted since 1990 in
selected public health facilities. The HIV
seroprevalence among first-time prenatal clinic attenders has risen
from 0.76% in 1990 to 10.44% in 1995 to 24.2% in 2000, with no signs of
having reached a plateau. [14]
HIV is distributed unevenly across the country, with the highest rates on
the East Coast of South Africa. The HIV epidemic is most advanced in the
province of KwaZulu-Natal,
where the prevalence in 2000 was 36.2%. Community-based seroprevalence
surveys conducted in rural South Africa between 1990 and 1992 found that
HIV infection was 4 times more prevalent among women (1.6%) than men
(0.4%), and that women become infected at younger ages. [15]
Although more recent studies have shown a decrease in the gender
difference over time (a 2.3-fold difference was observed in 1995), [16]
infection
remains substantially higher in women than in men. In the past 2
years, the increasing morbidity and mortality has transformed HIV
infection from a silent, asymptomatic epidemic to a very visible epidemic
that is devastating families and communities. [17,18]
The
South African government's response to this explosive spread of HIV
includes public awareness campaigns, condom promotion, syndromic
management of STDs, and life skills programs targeted at youth in school.
The extent to which these strategies are used varies within and between
urban and rural communities.
Against this epidemiological backdrop and as part of
a larger study to ascertain determinants of women's increased
vulnerability to HIV infection in KwaZulu-Natal, [19]
this study explored barriers to the adoption of safer sex practices in
women at high risk of HIV infection in KwaZulu-Natal, South Africa.
Methods
This study was conducted at 2 sites in the greater
Durban area: Nhlungwane, an informal urban settlement, and KwaXimba, a
rural community. Detailed descriptions of these sites have been previously
reported. [19]
All women age 15 to 44 in both communities were eligible to participate.
Women interviewed were drawn from a 10% systematic sample of households.
The first household was randomly selected and thereafter every tenth
household was visited. The interviewer ascertained the number of women in
each selected household and randomly selected 1 eligible woman for the
interview. Interviews were conducted after consent was obtained from the
selected individual.
Data were collected in both Nhlungwane and KwaXimba
from November 1991 to March 1993, using pretested structured
questionnaires administered by trained field staff in the respondent's
choice of either English or Zulu. The questionnaire was based on focus
group discussions with men and women in both communities [19]
and included items on: sociodemographic characteristics, knowledge of HIV
and acquired immune deficiency syndrome (AIDS), safer sex practices,
skills to adopt safer sex practices, relationship dynamics, perception of
self and partner risk of HIV, perceptions of self and community values and
norms relating to sexual behavior and sexual rights, and sexual decision
making.
Open-ended questions were coded for content and
analyzed as categorical variables. Univariate analysis of the data was
undertaken using EpiInfo (CDC, Atlanta).
The study was approved by the Ethics and Professional
Standards Committee of the Faculty of Medicine, University
of Natal.
Results
A total of 219 women were interviewed: 111 from
Nhlungwane and 108 from KwaXimba. The demographic characteristics of
respondents were similar, so aggregate data are presented. The average age
of respondents was 25.8 years (range: 16-44, SD=8.6). Respondents had an
average of 8 years of schooling; 56.1% were seeking employment, 19.7% were
employed, and 24.2% were students.
All respondents had heard of HIV and AIDS. Although
correct knowledge of modes of transmission was high, there were a few
common misconceptions, including that transmission can occur through
sharing utensils (38.8%) and donating blood (59.8%). Many women (79.9%)
believed that AIDS could be cured. Only 4.1% knew someone who was infected
with HIV, although 12.3% thought that there were people with HIV in their
community.
Most of the respondents in both communities were
sexually active (88.1%). The majority of the sex partners of respondents
(73%) were semi- or unskilled laborers who also supported them
financially. Ninety-seven percent of sexually active respondents reported
that they received money from their sex partners. Marriage was rare in
both communities (24.6%), with the majority of the sexually active women
in relationships that varied from a few months to several years. The
majority of the sexually active respondents in the peri-urban community
saw their partners daily, and those in the rural community saw their sex
partners less frequently (at least once a week). Sex partners of
respondents from the rural community tended to be migrant workers in the
larger cities.
Although self-reporting of current (11.4%) and past
(16.6%) multiple partners was low, 53% of the respondents from both
communities thought that it was common for women to have multiple sex
partners simultaneously for the following reasons: need for money (53.4%),
need for housing (6.0%), retribution for partner's infidelity (13.8%), and
sexual satisfaction (11.2%). Nearly 55% of respondents believed that men
have a right to multiple partners.
About a third of sexually active respondents (n=193)
perceived themselves to be at risk of HIV infection (33.3% in Nhlungwane
and 27.8% in KwaXimba). In contrast, 55% of respondents from Nhlungwane
and 37.0% from KwaXimba perceived their partners to be at risk of HIV
infection.
Thirty-six percent of the sexually active respondents
(n=193) had discussed HIV/ AIDS with their partners, and none had
discussed AIDS with their children. All of these participants and their
partners were under 25.
Although the condom's role in HIV prevention was
widely recognized (94.5%), condom use was rare in both communities. Only
12.8% of respondents had ever used a condom, and about a third (30.6%) had
never seen a condom. Reasons for condom use among regular users (n=21)
were fertility control or disease prevention or both. It was more likely
for partners (n=14) to have suggested condom use than it was for
respondents (n=7) or for the couple to have decided together (n=7).
Partners obtained condoms from public health facilities.
Ninety-six of the 165 respondents who were sexually
active but not currently using condoms (58.2%) would have liked their
partners to use condoms. Yet 93.9% of these respondents believed that
asking their partners to use condoms indicated a lack of trust, 26.1%
believed that condoms harm women, 70.9% thought that their partners would
think that they were unfaithful, and 54.5% indicated that they would have
difficulty disposing of used condoms. However, 52.1% of the respondents
indicated that if their partners suggested condom use they would agree.
Sixty-six percent of respondents who were not condom
users indicated that they would have difficulty asking their partners to
use condoms, and 82.4% did not know how to use condoms. Fifty-three
percent of the women reported that their partners usually consume alcohol
before sex, which made discussion of safer sex practices difficult. About
half the women (51.5%) said their partners would get angry if they were
asked to use condoms, 29.7% said their partners would leave them, and
28.5% said their partners would threaten violence.
Reasons respondents cited for not wanting their
partners to use condoms (n=69) included partner would disagree (29%),
partner dislikes condoms (23.2%), and there was no need as they were not
at risk (47.8%).
About half of the women felt they had the right to
refuse sex (51.2%) or to insist on condom use (53.9%) with partners who
put them at risk of HIV. Other factors that influenced women staying with
partners who placed them at high risk of HIV infection included: financial
dependence on partners to support their children (25.2%), fear of
rejection by family (5.2%), and love (18.7%).
Discussion
Women in both these communities are at high risk of
HIV infection because of their own and their partners' sexual behavior. We
found that the high levels of correct knowledge of HIV did not influence
the adoption of safer sex practices, as have other studies. [20,21]
Women's perceptions of their right to safer sex
practices are critically important to reducing sexual risk. [22]
About half the respondents in this study did not believe that they have a
right to such safer sex practices as refusing to have sex with their
partners or insisting on condom use if they thought they were at risk of
HIV infection. Furthermore, about half of the women in the peri-urban
settlement and more than half of the women in the rural community believed
that men have a right to multiple partners. Researchers in other African
countries [23-25]
have also found that a prevailing belief that sex is a man's prerogative
is a major barrier to the successful adoption of HIV risk reduction
measures. We found, as have several others, [26,27]
that violence or the threat of violence is a strong deterrent to adopting
risk reduction measures. Alcohol consumption has been shown to be
associated with riskier sexual practices, [28]
and women from both the peri-urban and rural communities reported that
their partners usually consumed alcohol before sex, which made discussions
about safer sex practices difficult.
The low perception of personal risk could be
influenced partly by the prevalent belief that AIDS can be cured and by
inadequate recognition that if your partner is at risk, so are you.
Recognizing personal risk is important to adopting preventive measures, [29,30]
and the denial of personal risk in this study is cause for concern.
Although 88.1% of the women were sexually active, few
were in mutually faithful, lifelong relationships (as indicated by the
proxy marker of marriage). An HIV seroprevalence survey in another rural
community in KwaZulu-Natal found that women who saw their sex partners
less than 10 days a month were 15 times more likely to be infected with
HIV than were women who saw their partners more frequently. About half [31]
of the women in the peri-urban community and about three-quarters of the
women in the rural community saw their sex partners less than 10 days a
month. Limited economic opportunities force men to seek employment away
from their homes and communities. This separates partners and families for
varying lengths of time and encourages the establishment of sexual
relationships at the place of employment, thus facilitating the spread of
STDs between communities. [32]
Condom use was rare and inconsistent in both
communities, and the majority of women in both communities lacked skills
in condom use. An important tension identified in relation to condom use
was that between the women's health and intimacy and trust. An additional
issue is the importance of childbearing in these communities, which is a
strong deterrent to condom use. Other research has shown that a woman's
ability to have children is central to her
status and worth in the relationship, [33,34]
and the use of condoms in stable partnerships undermines this fundamental
basis of the relationship.
The majority of the women in both communities
received money from their partners, and these relationships form part of
their survival strategy. Their exclusion from the formal economy, high
rates of unemployment, and few years of education limited their
opportunities for economic independence.
More in-depth and longitudinal data on the factors
that influence sexual debut, partner acquisition, sexual networking and
partner selection, stability and exclusivity of relationships, and
initiation into risky sexual behaviors, from both male and female
perspectives, will be needed to identify strategies for risk reduction.
Research on men and couples could add substantially to a deeper
understanding of the issues highlighted in this study.
Qualitative studies conducted more recently in South
Africa have found that the intersection
of gender and race, class, and culture appears to play a significant
role in the way women in South Africa have been infected and affected by
HIV/AIDS. [36-39]
Although this cross-sectional study was undertaken when the HIV epidemic
was largely silent in KwaZulu-Natal and South Africa and it provides data
from women only, it does provide some important clues to the challenges
that face these women with respect to adopting safer sex practices.
Increasing women's access to power and resources is the ultimate strategy
to reduce women's
vulnerability to HIV.
The contributions of Drs. E. Preston-Whyte, N. C.
Dhlamini-Zuma, I. Susser, Z. Stein, and S. S. Abdool Karim and of Ms. N.
Morar are gratefully acknowledged. My appreciation to the 3 anonymous
reviewers for their invaluable comments on an earlier draft of this paper.
This study was supported in part by the International Center for Research
on Women through a grant from the Offices of Health and Women in
Development, Bureau of Global Programs, Program and Support and Research; US
Agency for International Development (DPE-5972-A-00-0036-00); the
Fogarty International Center (TWO-0231); and the South
African Medical Research Council.
Additional Links on Gender, HIV and/or South Africa
 Women's
Vulnerability to HIV
Recommendations
for the development of Vaginal Microbicides
HIV/AIDS
and the South African Government Response
Cultural
Traditions and in Asia and Africa Leave Women More Vulnerable to HIV/AIDS
Key
Materials on 'Gender and HIV/AIDS'
Office
of Health and Women in Development
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