Elsevier

The Lancet

Volume 368, Issue 9549, 18–24 November 2006, Pages 1788-1793
The Lancet

Articles
Sexual abstinence, contraception, and condom use by young African women: a secondary analysis of survey data

https://doi.org/10.1016/S0140-6736(06)69738-9Get rights and content

Summary

Background

Drug therapy for people with AIDS is a humanitarian priority but prevention of HIV infection remains essential. Focusing on young single African women, we aimed to assess trends in a set of behaviours—sexual abstinence, contraceptive use, and condom use—that are known to affect the rates of HIV transmission.

Methods

We did a secondary analysis of public-access data sets in 18 African countries (132 800 women), and calculated changes in a set of behavioural indicators over time. We standardised these trends from nationally representative surveys to adjust for within-country changes in age, education, and type of residential location.

Findings

Between about 1993 and 2001, the percentage of women reporting no sexual experience changed little. During the same period, the percentage of sexually experienced women who reported no sexual intercourse in the previous 3 months (secondary abstinence) rose significantly in seven of 18 countries and the median for all 18 countries increased from 43·8% to 49·2%. Use of condoms for pregnancy prevention rose significantly in 13 of 18 countries and the median proportion increased from 5·3% to 18·8%. The median rate of annual increase of condom use was 1·41 percentage points (95% CI 1·12–2·25). In the 13 countries with available data, condom use at most recent coitus rose from a median of 19·3% to 28·4%. Over half (58·5%) of condom users were motivated, at least in part, by a wish to avoid pregnancy.

Interpretation

Condom promotion campaigns in sub-Saharan Africa have affected the behaviour of young single women; the pace of change has matched the rise in contraceptive use by married couples in developing countries over recent decades. Thus continuing efforts to promote condom use with emphasis on pregnancy prevention are justified.

Introduction

An aura of disappointment and frustration surrounds global efforts to check the spread of HIV in most low-income and middle-income countries. Despite substantial investment in the promotion of safe sex and marketing of condoms, only Thailand and Uganda have clearly succeeded in stemming epidemics in the general population, though other countries in Africa and the Caribbean also show some signs of progress.1 Even the most intensive interventions, targeted at young people or at specific localities, have not achieved all of their aims.2, 3, 4 Two responses to this perceived impasse have predominated. The first is to conclude that the necessary changes in sexual behaviour will only occur as a result of fundamental changes that reduce poverty and gender inequality.5, 6, 7, 8 The other response is to hope that increased access to drug therapy for AIDS will present new opportunities for effective prevention.9, 10

Abstinence and condom use are two of the three elements promoted by major preventive programmes that emphasise the ABC (abstain, be faithful, and use condoms) approach. The relative importance of abstinence and condom use for HIV control has been controversial. In the USA the issue is further complicated by moral arguments surrounding the President's Emergency Plan for AIDS Relief (PEPFAR), which emphasises abstinence.11, 12, 13, 14 We do not seek to engage with this debate; rather, we examine modification of behaviour in view of the threat of AIDS and the inseparable risk of unwanted pregnancies.

We aimed to assess the evidence for behavioural change by young women in sub-Saharan Africa, which is the region most affected by HIV/AIDS. Our report complements detailed analyses of change in specific countries or small groups of countries, especially those of the MEASURE (Monitoring and Evaluation to Assess and Use Results) project,15 by examining changes in a few behavioural indicators in a large sample of African countries. Specifically, we analysed trends in sexual abstinence, contraception, and condom use by single women aged 15–24 years, in countries that had done two or more comparable surveys between 1990 and 2004.

Section snippets

Methods

We analysed data from Demographic and Health Surveys (DHS), which use nationally representative samples, and standard instruments and procedures for collection and processing of data. The survey design of DHS is generally stratified, with a first-stage selection of geographical clusters, followed by random selection of households within each cluster to identify women aged 15–49 years. These women, the primary respondents, were interviewed by trained female staff using a structured instrument

Results

Figure 1 shows the standardised trend in the percentage of young single women who reported no experience of sexual intercourse. The median value of all survey estimates remained essentially unchanged, at about 60%, though the dispersion of values contracted over time. The proportion of young women declaring themselves to be virgins rose significantly in seven of 18 countries and fell significantly in six countries. The changes in proportion exceeded 10% only in Cameroon and Ghana (webtable 1).

Discussion

Self-reported sexual behaviour is commonly regarded with scepticism, which is partly justified by the risk that survey respondents censor their answers, especially as public-health messages intensify. We cannot validate the trends we have identified in reported behaviour, because there is no evidence on the incidence of sexually transmitted infections that is disaggregated by marital status, and because of the difficulty of comparing condom sales with reported use.17 Thus an extreme

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