Poverty Linked to Early Sexual Debut and Low Condom Use in Africa
In Burkina Faso, Ghana and Malawi, female adolescents from poor households are more likely than their wealthiest counterparts to have had sex, according to an analysis of nationally representative data from four countries in Sub-Saharan Africa.1 Moreover, in Ghana, Malawi and Uganda, sexually active adolescents of both genders who come from poorer families are only about half as likely as their wealthiest peers to have used a condom the last time they had sex (odds ratio, 0.4– 0.6).
The analysis was designed to help sort out the associations between wealth and some of the risky behaviors that contribute to HIV transmission among adolescents. Researchers analyzed data from interviews with 19,500 adolescents aged 12–19 in Burkina Faso, Ghana, Malawi and Uganda. The countries were chosen to reflect a variety of HIV prevalence rates and contexts; in 2003, the prevalence of HIV among adults ranged from 2% in Burkina Faso and Ghana to 7% in Uganda and 14% in Malawi. Multistage cluster sampling was used to obtain nationally representative samples of adolescents in each country. Respondents were asked about their sexual experiences, socioeconomic status, education, childbearing, contraceptive use and HIV knowledge. Household wealth was categorized into quintiles based on ownership of selected assets and was determined separately for urban and rural respondents. For each country, discrete-time hazard models were used to determine the likelihood of first sex by a given age; separate models were created for males and females. For sexually experienced respondents, logistic regression analysis was used to examine the associations between selected characteristics and condom use at last sex and number of sex partners in the past year; in these analyses, the male and female data for each country were pooled.
Overall, more than half of respondents were aged 15–19, and the majority were unmarried. Among those who were unmarried, 24% of males and 16% of females had had sexual intercourse; the proportions ranged from 9% (Ghana) to 40% (Malawi) among males and from 13% (Uganda and Malawi) to 21% (Burkina Faso) among females. In Malawi and Uganda, males were more likely than females to have had sexual intercourse; the opposite was true in Burkina Faso and Ghana.
Household wealth was associated with having had sex among females in Burkina Faso and Ghana and among members of both genders in Malawi. Young women in the poorest and second poorest quintiles were more likely than those in the wealthiest quintile to have had sex in Ghana (odds ratios, 2.7 and 1.9, respectively) and Malawi (1.9 and 2.6, respectively); the odds of having had sex were also elevated among young women in the second wealthiest quintiles in Ghana (1.8) and Malawi (2.0). In Burkina Faso, only females in the second poorest quintile had elevated odds of having had sex (2.0). Among males in Malawi, those in the second poorest (1.3) and middle (1.6) quintiles had increased odds of having had sex. Young men in all four countries and young women in three of the countries were more likely to have had their sexual debut while attending school than while not attending school (1.7–3.3); the exception was Burkina Faso, where 63% of female respondents had never attended school.
Among respondents who had been sexually active in the year prior to the survey, 43% reported that they had used a condom the last time they had sex. In Malawi and Uganda, adolescents aged 15–19 were more likely than those aged 12–14 to report having used a condom at last sex (odds ratios, 3.3 and 3.8, respectively). However, adolescents in the poorest and second poorest quintiles were less likely than those in the wealthiest quintile to have used a condom, in both Malawi (0.4 and 0.5, respectively) and Uganda (0.4 and 0.5). In addition, in Burkina Faso, Malawi and Uganda, rural residence was associated with decreased odds of condom use at last sex compared with urban residence (0.2–0.5).
Twelve percent of sexually experienced males and 5% of sexually experienced females reported having had two or more sex partners in the year before the survey; 20% of sexually experienced females and 34% of sexually experienced males reported having had no sex partners in the preceding year. Wealth was not associated with number of partners in any of the four countries; however, there were interactions between wealth and gender in Ghana and Uganda, such that males in the middle wealth quintile had the highest risk of having had multiple partners in the preceding year. Although no socioeconomic or demographic characteristic was associated with multiple partnerships in every one of the four countries, in at least one of the countries the odds of having had more than one partner were reduced among females, married respondents, Muslims and those who had had sex for the first time between the ages of 15 and 19.
Overall, the findings indicate that in parts of Sub-Saharan Africa, poverty is associated with early sexual debut (particularly among females) and that the poor are less likely than their wealthier peers to use condoms. Thus, the researchers note, it seems likely that "poverty, by influencing sexual behavior and access to services, can influence the transmission of HIV infection." They conclude that "HIV prevention programmes must identify ways of making the poor less vulnerable to risky sexual behavior and devise strategies for improving condom usage among the poorest."—L. Melhado
1. Madise N, Zulu E and Ciera J, Is poverty a driver for risky sexual behaviour? evidence from national surveys of adolescents in four African countries, African Journal of Reproductive Health, 2007, 11(3):83–98.