In the South African province of KwaZulu-Natal, the proportions of married people who always or sometimes use condoms are relatively small, according to an analysis of data from a household survey conducted between August 1999 and January 2000.¹ Among respondents who were married or in a cohabiting relationship, 14% of men and 17% of women reported consistent or occasional condom use; the rest said they never used condoms or had used them only at the beginning of their relationship. For both men and women, urban residence and a secondary education or higher were positively associated with consistent or occasional condom use (odds ratios, 3.0-9.4). Among women, but not among men, those who believed they would be able to protect themselves against HIV, those who believed in the efficacy of condoms and those who perceived they were at risk of acquiring HIV from their partner had increased odds of always or sometimes using condoms (2.4-6.1).

To explore condom use within marital partnerships, researchers analyzed data from married or cohabiting adults who had participated in a survey of randomly selected households in two areas (one urban and one rural) of KwaZulu-Natal—"the province most severely affected by the AIDS epidemic in South Africa," the researchers note. The average age of the 289 women and 248 men was 35 years, and in some cases, both spouses participated. Using the 1996 census, the analysts weighted the data to reflect the proportions of the province's population living in rural and urban areas.

The first part of the study was concerned mainly with condom-related beliefs and attitudes, and sexual behavior. Overall, 95% of respondents had heard of condoms; of these, 92% knew where to obtain the method. Furthermore, large proportions agreed that condoms effectively prevent pregnancy (89% of men and 82% of women) and HIV infection (73-77%). Still, approval of condom use within a marriage was not universal (40-44%). A higher proportion of women than of men said it was acceptable for a married woman to ask her husband to use a condom (60% vs. 43%), whereas the proportion who said it was acceptable for an unmarried woman to ask her partner to use one was similar among women and men (79% and 80%, respectively).

Roughly three in 10 respondents believed that they would be able to take preventive measures to reduce their risk of HIV infection—both in general and, specifically, if their partner or spouse had been infected by an extramarital partner. Men more commonly reported having had two or more partners in the previous three years than did women (18% vs. 7%). However, women were more commonly concerned about contracting HIV from their spouse or cohabiting partner than were men (57% vs. 30%). Forty-one percent of men and of women said they knew someone who had AIDS or who had died of AIDS, or they had attended the funeral of someone who had died of the disease.

Because only 2% of men and 5% of women said they always used condoms, the analysts combined data for consistent and occasional condom use. In all, 14% of men and 17% of women fell into this category; in contrast, 86% of men and 83% of women had never used a condom or had done so only at the beginning of their marital or cohabiting relationship.

In multivariate logistic regression analyses that included variables related to condom use and behavior change (except attitudes toward condom use within and outside of marriage, "because of the extreme problem of causal interpretation"), urban respondents were more likely than rural ones to report consistent or occasional condom use (odds ratios, 4.3 for men and 3.0 for women). Respondents with a secondary education or higher were more likely than those with less education to report this (9.4 and 4.1). Among the women, but not the men, additional factors that were positively associated with always or sometimes using condoms were strong belief in the ability to adopt preventive measures against HIV infection (2.4), belief in the effectiveness of condoms to protect against both pregnancy and spread of HIV (2.9), and belief that the respondent was at risk of acquiring HIV from her partner (6.1).

On the basis of their findings, which they call "moderately positive," the analysts conclude that "barriers to condom use within marital and cohabiting partnerships may not be as immutable as many commentators have claimed," and women may not be as powerless to protect themselves from HIV as previously reported. Noting that past condom-promotion efforts have targeted people in premarital and nonmarital relationships, the researchers comment that "a pressing public health priority is to legitimate condom use within [marital and cohabiting] relationships."

—T. Lane

REFERENCE

1. Maharaj P and Cleland J, Condom use within marital and cohabiting partnerships in KwaZulu-Natal, South Africa, Studies in Family Planning, 2004, 35(2):116-124.