Academic journal article Bulletin of the World Health Organization

Condom Use within Marriage: A Neglected HIV Intervention

Academic journal article Bulletin of the World Health Organization

Condom Use within Marriage: A Neglected HIV Intervention

Article excerpt

Voir page 185 le resume en francais. En la pagina 185 figura un resumen en espanol.

Introduction

Greater condom use remains one of the most effective ways of checking the human immunodeficiency virus (HIV) pandemic in developing countries. Over the past decade huge efforts have been made to make condoms more widely accessible and acceptable. The major emphasis has been on their use outside marriage and some success has been achieved in this regard (1). In countries with low-level or concentrated HIV epidemics, this preventive strategy makes good sense. However, in countries with generalized heterosexual epidemics, the number of which has grown from 25 in 1990 to 55 in 2000 (2), the almost exclusive emphasis on condom use for non-marital sexual contacts is no longer adequate and may even be counterproductive by reinforcing its association with illicit sex. In such settings, marriage and cohabitation cannot be regarded as a safe haven. Many individuals acquire HIV because of prior infection or infidelity. In rural areas of the United Republic of Tanzania, for instance, the seroincidence rate for men in stable sexual partnerships was found to be 0.45 per 100 person-years and the rate for women with an infected partner was 10 per 100 person-years (3).

The promotion of condoms for use within marriage for explicit disease-prevention purposes is most unlikely to succeed because of its direct imputation of mistrust. Its promotion as a method of family planning, with an implicit, even unspoken, recognition of its dual protection properties is more feasible. Greater use of condoms within marriage would bring direct benefits in terms of reduced interspousal HIV transmission. The indirect benefits of a renewed emphasis on condoms as contraceptives might be greater, because it is much easier for sexually active never-married persons to discuss, negotiate, and adopt the condom as a contraceptive than as a disease-prevention measure.

Over the past 30 years, contraceptive use among married or cohabiting couples in developing countries has risen from 9% to 60% (4, 5). Countries in east and southern Africa that are most severely affected by HIV now also record high levels of contraception. Typically, highly effective methods have been promoted at the expense of less-effective barrier methods. In 30 countries with generalized HIV epidemics, the percentage of contracepting couples using condoms remained static at about 8% between 1983 and 1997 (5). The reasons for this unpopularity within stable relationships are well understood (6-9). Some would no doubt argue that the barriers to condom use within marriage are so severe that condom promotion in this context would be a lost cause. However, there is a danger of exaggeration. The family-planning literature of the 1960s and 1970s contains many warnings that contraception would be unacceptable for cultural and social reasons. Events of the past 30 years have shown these pessimistic prognostications to be largely unwarranted. Similarly, the admittedly strong resistance to condom use within marriage in many societies may not be immurable. After all, condoms are commonly used by married couples in a wide range of societies, accounting for 20% or more of users in at least 16 countries, including Costa Rica, Jamaica, Japan, Pakistan Singapore and the United Kingdom (5). Moreover, extreme circumstances, an apt description of many HIV epidemics, can force radical changes in behaviour, including greater condom use within marriage.

The potential contribution that family-planning services can make to HIV control has not gone unnoticed (10); however, little evidence exists that family-planning staff have made serious and sustained attempts to legitimize and promote condoms. One understandable reason for this reluctance no doubt stems from a fear that widespread switching flora highly effective hormonal and other contraceptive methods to less-effective condoms would lead to a deluge of unintended pregnancies and fuel the demand for induced abortion. …

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