The people of Zimbabwe are highly aware of AIDS, modes of transmission of HIV and HIV prevention strategies, but they do not act on their knowledge at similarly high rates, particularly if they are married.1 According to the 1994 Zimbabwe Demographic and Health Survey (DHS), more than two-thirds of urban women and men reported knowing that the transmission of HIV can be prevented by the use of male condoms.2 However, of the women who had intercourse with a spouse in the four weeks preceding the survey, only 7% reported having used a male condom at least once during that period. In contrast, during the same time period, condoms were used by 38% of women who had had intercourse with a partner who was not a spouse.
Being monogamous is not an effective HIV prevention strategy for all Zimbabwean women, as their male partners are not always faithful to them. Eleven percent of married men reported having extramarital liaisons during the four weeks preceding the DHS survey, as did 0.2% of married women. In addition, 7% of men reported that they had paid for sex during the same time period.
It seems unlikely that in the near future levels of male condom use, abstinence or adherence to mutually faithful relationships will increase so significantly in Zimbabwe that the HIV epidemic will be slowed or stopped.3 Given the previous success of female-controlled methods of contraception such as oral contraceptives and injectables in Zimbabwe,* female-controlled methods of HIV and sexually transmitted disease (STD) prevention may be more successful than male-controlled methods. Such methods may include vaginal microbicides, which could be applied directly inside the vagina in the form of a gel, film, sponge, foaming tablet or suppository.
A safe vaginal microbicide that effectively protects women from HIV is not currently available. Clinical trials have demonstrated that commercially available spermicides containing nonoxynol-9 can reduce the risk of both gonorrhea and chlamydial infection,4 but the evidence regarding their effectiveness against HIV is inconclusive.5
Several newly developed vaginal microbicides have shown activity against HIV in vitro and in animal tests, but these either are still under development or have only recently entered safety testing in humans. Examples include BufferGel (an aqueous gel with sufficient buffer capacity to acidify approximately three times its own volume in human semen), protegrins and defensins (which are naturally occurring antibiotic peptides isolated from white blood cells), breast milk lipids (which have antibiotic properties), plant extracts, a Lactobacillus crispatus suppository, sulfated polysaccharides (which block pathogen entry) and antiretroviral compounds.6
A potential advantage of vaginal microbicides over all other female-controlled barrier methods (such as the diaphragm, female condom and cervical cap) is that women may be able to use them without their male partner's knowledge, cooperation or consent. However, such products may have some disadvantages as well. For example, in Zimbabwe, a widespread cultural belief holds that the vagina should be dry and tight.7 To achieve this, many Zimbabwean women engage in a variety of intravaginal practices, including washing and wiping out the vagina up to three times a day with paper, cloth or cotton wool and tightening the vagina by inserting traditional herbs.8 These practices may not only interfere with the acceptability of vaginal microbicides, but also with their effectiveness in preventing HIV and other STDs.
In Zimbabwe, men make most decisions regarding sex.9 In previous studies with Zimbabwean women, it was common for married women to insist on asking their husbands for permission before committing to participate.10 Thus, women's acceptance of new products such as microbicides (as well as their willingness to enroll in the clinical trials of such products) could be dependent on men's attitudes.
However, little is known about men's attitudes and beliefs about such practices, or how these might influence the acceptance and use of vaginal microbicides. To prepare for clinical trials of vaginal microbicides, we conducted five focus-group discussions with Zimbabwean men.
Methods
Study Designs
The University of Zimbabwe-University of California at San Francisco (UZ-UCSF) Collaborative Research Programme in Women's Health is currently conducting an early safety trial of a buffered microbicidal gel (BufferGel) and will begin conducting a randomized, placebo-controlled trial of a gel containing 100 mg of nonoxynol-9 (Conceptrol) in Zimbabwe in the spring of 1999. In preparation for these trials, we conducted four focus-group discussions between May and September 1997 to explore such issues as the attitudes of urban and rural men toward communication about sex in their relationships, their own risk for HIV, currently available risk-reduction strategies, traditional vaginal practices, vaginal microbicides and their wives' participation in microbicide trials.
Two discussions were held with urban taxi drivers: One group consisted of drivers working for a taxi company, and the other group consisted of independent drivers working from a downtown hotel. The other two discussions were conducted with rural farm workers on two large commercial farms approximately 40 km outside of Harare. Each focus group was conducted in a private room close to the men's workplaces, with the permission of the general managers of their respective employers.
One additional focus-group discussion, which focused on men's attitudes toward their wives' participation in microbicide trials, was held after the first four focus-group discussions had been completed. At the time of this discussion, early research on the buffered microbicidal gel was underway in the United States and was about to be conducted in four additional countries, including Zimbabwe. Standardized pretrial focus-group discussions with men and women were conducted in all five trial sites. The discussion presented here took place with urban men in Epworth, a poor, high-density area adjacent to Harare, in the home of a female community health worker.
A convenience sample of the first 8-10 men to volunteer for participation was selected at each site. Men who had taken part in other research projects regarding STDs, including AIDS, were excluded. We obtained written informed consent from all participants, and emphasized confidentiality by identifying each participant with a number only.
An indigenous man moderated the discussions in Shona, which is the most widely spoken language in Zimbabwe. He was trained in using a discussion guide containing major discussion topics, subdivided into open-ended questions. The focus-group guide used with the farm workers and taxi drivers was developed at the Population Council in New York. The guide used in Epworth was developed by social scientists at the UZ-UCSF Collaborative Research Programme in Women's Health and at Johns Hopkins University. A Shona-speaking Zimbabwean recorded the discussions on audiocassette tapes and took notes.
Data Analysis
Indigenous Shona speakers who were fluent in English transcribed the tapes of all discussions verbatim and translated the transcriptions into English. The English translations were coded—using the Q.S.R. NUD*IST software program for qualitative data analysis (revision 3.0.4. for Windows)—and sorted by topic. The coding closely followed the focus-group guides with major discussion topics subdivided into specific questions, but emerging themes were also explored. Responses to individual questions were not quantified.
Focus-Group Characteristics
A total of 19 taxi drivers (nine in one group, 10 in the other), 16 farm workers (eight in each group) and eight men from Epworth participated in the discussions. The taxi drivers' mean age was 40 (ranging from 24 to 65), the farm workers' mean age was 39 (18-66) and the Epworth men's mean age was 36 (22-54). All men in all groups were married, except for two taxi drivers and one Epworth man. All married men had children, except for two farm workers aged 18 and 19.
All participants spoke at least once during a session. The focus groups involving the taxi drivers and Epworth men were open and lively. In contrast, discussions with the farm workers were less spontaneous and followed the focus-group guide closely. In this article, we present the results of the four discussions with the taxi drivers and farm workers first, by topic category; these are followed by the results of the Epworth discussion, which was focused on participation in safety trials.
General Attitudes
Communication About Sex in Relationships
•In a typical relationship, is it hard for men to talk about sexual health issues, such as AIDS, STDs and contraception?
This topic generated a lot of discussion, particularly among the taxi drivers. The majority of the taxi drivers felt that discussing AIDS, STDs and condom use with their wives would be extremely difficult. In contrast, many farm workers thought that it would not be a problem, because "the man is the head of the household." There was consensus in all groups that discussing contraceptive use (mainly for child spacing) is much easier than discussing condom use for the prevention of AIDS and STDs. There was also consensus that it is easier to talk to family members in a general way about AIDS and STDs than to discuss condom use within the family for the prevention of AIDS and STDs.
Most men thought that it would be difficult to discuss condom use within the context of a marriage. One said, "For me to find a reason for [my wife] to use condoms is difficult, because I am supposed to be faithful to her and she is supposed to be honest [with] me." Another commented: "When it comes to talking about sex, you become suspicious of each other....Maybe the husband has extramarital affairs or maybe the wife thinks that her husband [suspects] that she has extramarital affairs." According to one participant, "Women think that when a man starts using condoms, it means he already has AIDS."
In addition to suspicion being introduced into the marriage, many men were worried that discussing condom use with one's wife would generate gossip among relatives and neighbors. One farm worker said that he would rather infect his wife than tell her that he has an STD. Others thought that it would be impossible to hide an STD from their wives. Besides, if sick, some men said that they would want their wives to care for them.
Several taxi drivers stated that prostitutes and girlfriends would never admit to having an infection because they would worry about losing income. Some men acknowledged that, despite these difficulties, it is necessary to discuss AIDS and STDs with their partners.
Perceptions of HIV Risk
All taxi drivers in the focus groups were aware of AIDS and knew several people who had died of AIDS, including some of their colleagues. In contrast, most farm workers said that they had heard about AIDS from health educators, but that they had never personally seen or known a person with AIDS. Most men in all groups thought that it is difficult to tell who is infected.
•Do you think you could ever get infected with a disease such as AIDS?
Most taxi drivers and farm workers thought that it would be possible for them to become infected with HIV. Only a few farm workers denied being at risk. Most men thought that they were at risk because of their own extramarital affairs, even when condoms are used, because "condoms can burst or slip." The taxi drivers talked about extramarital affairs with prostitutes and girlfriends, whereas farm workers mentioned girlfriends only. Farm workers referred to having unprotected extramarital sex as "mixing of blood," and they believe that this causes illness. The taxi drivers, on the other hand, had an accurate understanding of how HIV is transmitted and how it causes illness.
•Do you suspect that you can get this infection from your partner?
Most taxi drivers thought that they would be able to get the infection from their current partners, especially from a current girlfriend. One taxi driver said: "She is a girlfriend for whom you [pay] rent. But you are not alone. There will be [another] man who pays for the...groceries." The taxi drivers admitted that they used condoms the first few times they had sex with a new girlfriend, but that they would stop doing so after trust has been established.
Wives were not considered risk-free. One taxi driver mentioned that many employed women are forced to have sex with their employers, and another said that a wife could have become infected before marriage. Most men believed, however, that their wives would not have any extramarital affairs. In particular, the taxi drivers repeatedly stated that they expected their wives to be faithful and trustworthy.
•Are you aware of anything men can do to protect themselves against AIDS or other STDs?
The first prevention strategy mentioned in all groups was to "stick to one partner." Only a few men recognized the need for both partners in a couple to stick to each other in order for monogamy to be an effective STD prevention technique.
One taxi driver thought it important for spouses to have the same rate of sexual desire in order to prevent extramarital affairs. Another taxi driver said that men should marry early to avoid having several girlfriends before marriage. Abandoning the practice of "inheritance" was also mentioned as a prevention strategy.
Condom use with prostitutes and girlfriends was mentioned as a prevention strategy, but all men considered condom use with wives to be out of the question. In addition to the widespread feeling that condom use introduces an element of distrust in a marital relationship, several taxi drivers expressed a strong dislike for condoms, saying that they can cause allergic reactions, can burst or slip, prevent pregnancy and reduce sensation during sex.
•If a wife suspects that her husband has been having sex with other women, can she influence him to use condoms with his other sexual partners?
Not much was said in response to this question. One taxi driver objected to a woman asking her husband to use condoms with girlfriends because he thought it would seem as though a wife would be condoning her husband's behavior. Another taxi driver thought that girlfriends and prostitutes, not their boyfriends or clients, should be the ones making sure that condoms are used during intercourse.
•If a wife suspects that her husband has been having sex with other women, should she insist that he use a condom when he has sex with her?
In contrast, this question provoked a lively debate, particularly among the taxi drivers. Most men in all four groups would not object to their wives asking them to use condoms for childspacing and for hygienic reasons during their menstrual periods, but they strongly objected to being asked to use condoms for HIV and STD prevention. Some men claimed that such a request could break up a marriage, and that the most important reason for this was that such behavior introduced suspicion into the relationship.
•What other things can women do to protect themselves?
Most men in all groups thought that women could protect themselves by being hygienic, faithful and respectful of their husband, and by satisfying his sexual needs. Some taxi drivers thought that wives should be allowed to carry condoms with them, but others strongly disagreed. Those who disagreed said that women who carry condoms in their handbags are prostitutes: a wife with condoms has a license to have sex with other men.
Views on Vaginal Products
•Can anyone give examples of vaginal products you have heard of? What do you think are some reasons as to why women use such products? Do you think that men are generally aware when women are using such products? Under what circumstances are such products typically used?
The taxi drivers had heard of tampons and female condoms. All groups were aware that women used herbal preparations, but did not know any details about their use. The men speculated that women insert herbs in the vagina to prevent pregnancy, to prevent STDs, to give sexual pleasure to the husband, to constrict the vagina and to increase the woman's sex drive.
According to these men, women learn about the use of such preparations from female relatives and never talk to men about the subject. Some men said that they could feel the difference when their wives had inserted herbs. They thought that herbs are inserted in anticipation of sex and after giving birth. Similarly, men consume aphrodisiacs to increase their own sexual performance without telling the women.
•Do men encourage or object to their use?
There were mixed feelings about encouraging herb use. One taxi driver encouraged it because it would make sex with his wife more pleasurable, which would stop him from going to prostitutes. A farm worker encouraged it because he feared that "women would accumulate semen inside when not using certain herbs."
Other men were concerned that vaginal use of herbs might have adverse health effects for both men (experiencing pain during sex or developing a rash on the penis after sex) and women (causing "infection of the woman's body parts"). A Christian taxi driver stated that Christians do not allow herb use because men and women should be satisfied with what God has given them. A few farm workers stated that it doesn't really matter what men think: Intravaginal herb use is a traditional practice among women that gets passed on from generation to generation, regardless of men's opinions.
Views on Microbicides
•The moderator explained what a vaginal microbicide is and showed examples of microbicidal gels, film and suppositories. He clearly stated that the effectiveness of vaginal microbicides against HIV and STDs has not yet been demonstrated. Then he asked, if we could be sure that a microbicide was safe and effective against HIV, do you think women would use such a product?
The farm workers asked hardly any questions about the microbicides. In contrast, both taxi driver groups were very skeptical about product safety, fearing that a microbicide could make both the man and the woman permanently infertile. They believed that many traditional and Western medicines cause side effects, and that it can take up to 30 years for such side effects to appear.
After a long discussion about the possible mechanisms of action and probable safety of microbicides, the moderator reassured the taxi drivers that microbicides, if spermicidal, would only kill the sperm present in the ejaculate. After that, all taxi drivers and farm workers thought that women and men in Zimbabwe would be happy to use microbicides to prevent infection. One taxi driver stated that microbicides would probably be preferred over condoms, because condoms disrupt the sex act and reduce sensation. A few men pointed out that some women would not use spermicidal microbicides, no matter how safe and effective they are in preventing HIV infection, because they would want to have children.
•Who do you think would use such a product the most? Do you think men would mind if their partner were to use a microbicide? Would they need his permission?
The taxi drivers thought that prostitutes would mainly use microbicides and the farm workers mentioned girlfriends. Most men stated that they would not use microbicides with their wives. Almost all men said that a woman would need her partner's permission to use a microbicide. A few taxi drivers thought that it would be possible for women to use microbicides in secret, like oral contraceptives. These men would, however, disapprove of such secret use, and would be angry if they found out about it.
The taxi drivers pointed out that some Zimbabwean men might not accept microbicides that excessively lubricate the vagina. They unanimously thought that "wet sex" is not desirable, because it reduces friction and sensation during intercourse, prevents the vagina from "heating up" and causes an annoying sound; they added that the fluids smell bad and carry germs. One taxi driver said: "When you manufacture this product, make sure it does not promote wet sex, because the women who use it might be thrown out of their homes."
•Would you recommend that such a product be promoted to women or men? How would you promote it to get men to want to use it?
Most men thought that microbicides should be promoted to women, because women are the ones who have to insert them. Several taxi drivers laughed at the idea of carrying a tube around to use when visiting girlfriends or prostitutes. They also pointed out that some men get drunk before having sex and would forget to use protection.
Some of the taxi drivers mentioned radio and magazines as effective ways of advertising to them, while the farm workers preferred to receive information from visiting health workers. The farm workers wanted use of the product to be thoroughly explained. One said: "Just talk on the radio, without actually having seen the product, would not satisfy me. Now, here [during the focus group] we have discussed it, and I have found that they are good products."
Attitudes toward Safety Trials
The Epworth men's attitudes toward relationships, AIDS and condom use were similar to those of the taxi drivers. They too indicated that discussing AIDS, STDs and condom use with their wives would be difficult, and that they would not use condoms with their wives. Several men expressed a strong dislike for condoms, for the same reasons mentioned by the taxi drivers. All men expressed a preference for "dry sex" and knew that women insert herbs inside their vaginas to achieve this feeling.
•The moderator described the study protocol and requirements for participation in the safety trial and then asked: How would you feel if your wife participates in a study like this?
Many men asked questions about the safety and mechanism of action of the vaginal microbicide. The men particularly wanted to know if they would benefit from the microbicide as well, or whether only the woman inserting it would be protected. After another thorough explanation by the moderator, most men said that they would support their wives' use of this trial product, provided that adequate medical care and insurance coverage would be available in case of side effects. The majority of men indicated that their wives should ask them for permission to enroll in the study and that they would be angry if their wives did not do so. They also said they would like to be approached about the study by the researchers, not only by their wives, to avoid suspicions about extramarital affairs.
•The men were told that the women enrolled in the study should insert the microbicide twice per day for 14 days, should not insert anything else inside the vagina besides the microbicide for the duration of the study, should keep a daily diary, should have sex at least twice per week and should use unlubricated condoms when having sex. (Unlubricated condoms had to be used to prevent HIV transmission and to prevent exposure of the penis to the trial product, since the trial product's safety in men and its efficacy against HIV had not yet been established.) The men were then asked: Would you be able to comply with the study guidelines? Would you remind your wife about study requirements?
If they were asked for permission before their wives were enrolled, the men said they would cooperate with the study and would remind their wives of the study requirements. Most men expressed some worry that the participants would not be able to wash their vaginas during the study, that the microbicide might lubricate the vagina too much and that they would have to use condoms. Most men acknowledged, however, that they would be willing to try the microbicide and see for themselves whether the microbicide increases slipperiness during sex.
Discussion
The focus groups reveal striking differences between urban and rural men's sexual knowledge, attitudes and practices. The urban men had a better understanding of how HIV is transmitted and how it causes illness, were more aware of their risk of acquiring HIV and were more likely to know people who had died of AIDS. A few urban men even suspected that they were already infected with HIV themselves. The urban men were therefore much more emotional than the rural men about the topics under discussion.
The sexual behavior of the urban men differed somewhat from that of the rural men. While the urban men talked about both prostitutes and girlfriends (and mentioned financial support of these women), the rural men talked about girlfriends only. Furthermore, while almost all men acknowledged that it is difficult to discuss STDs and condom use with a wife, the urban men expressed more difficulty with this issue than did rural men. This may be due to the fact that more urban men had personal experience with bringing home an STD than did rural men.
There were also some similarities between the two groups. Both expressed a strong desire for their partner to be faithful, clean and willing to provide "dry sex." Furthermore, both groups thought that condom use with wives is out of the question, except when used for childspacing or purposes of hygiene. The three most important reasons mentioned to explain this attitude were the perceived association between condom use and distrust, the importance of childbearing within heterosexual relationships and a dislike for condoms. The urban men expressed a stronger dislike for condoms than the rural men, which may be due to urban men's greater experience with condom use (with prostitutes and girlfriends) than rural men's.
Most men in all groups thought that women could protect themselves from HIV by being hygienic, by being faithful and by satisfying the husband's sexual needs. They did not mention that many women are at risk of acquiring HIV from their husbands, and that these women can protect themselves only by refusing to have sex or by using condoms.
These results, along with those of other studies in Zimbabwe11 and elsewhere in Africa,12 suggest that many African women may have great difficulty in challenging their partner's fidelity or in negotiating male condom use. Even when women are able to raise the issue of condom use, their partner may refuse. Women generally have limited power to negotiate further in such a situation because they are economically and socially dependent on their male partner.
If vaginal microbicides are proven to be safe and effective, they could offer a solution to this dilemma. First, men may prefer them to condoms because they make skin-to-skin contact during sex possible. Most men in our focus groups expressed a strong dislike for condoms, but were quite enthusiastic about microbicides once the concept had been explained to them, provided that the microbicides are efficacious and safe. Several men stated that they might prefer microbicides to condoms.
Second, because microbicides are female-controlled, they could be used without the male partner's knowledge, cooperation or consent. A few men conceded that secret use by their wives might be possible and that microbicides should be promoted to women, not men. On the other hand, most men said that they would be angry if they found out that their wives were using such products without asking for permission first. A recent study of preferences for microbicide formulations in Zimbabwe showed that most women were not interested in hiding microbicide use from their husbands, because they considered it too risky.13
Third, the focus-group participants confirmed what other studies have already shown: Many women in Zimbabwe insert liquids, paper, cloth and traditional herbs in their vaginas, for a variety of reasons.14 Reasons mentioned were to dry and tighten the vagina, to prevent pregnancy and STD, to increase the woman's sex drive and to increase the man's sexual pleasure.15 The popularity of these intravaginal practices suggests that Zimbabwean women may not object to inserting vaginal microbicides because they are already used to inserting things into their vaginas. On the other hand, such practices could interfere with vaginal microbicide use because the lubricant quality of microbicides may cause women to wash and wipe out their vaginas, thus compromising the effectiveness of this method.
In addition to worrying about excessive lubrication, the men were concerned that vaginal microbicides might prevent pregnancy and cause infertility. In Zimbabwe, all marriages are expected to produce offspring, and a man's status in society is partly determined by his number of children. Thus, most men believed that spermicidal vaginal microbicides would not be used consistently within stable relationships.
Thus, safe and effective microbicides that do not substantially lubricate the vagina or act as a contraceptive could have great potential in Zimbabwe. Such microbicides are currently under development: Microbicides containing antiretroviral compounds may not be spermicidal, and microbicides in film format may not lubricate the vagina. Further research in this area is of utmost importance.
In the meantime, clinical trials of potential vaginal microbicides, even those that are less than perfect, should move forward, given the severity of the HIV epidemic in Zimbabwe and the resistance to condom use. It is important to determine how much lubrication Zimbabwean men and women are willing to accept in exchange for potential protection against HIV.
Our data suggest several lessons regarding the implementation of clinical trials of vaginal microbicides in Zimbabwe. The focus-group discussions revealed that men in general, and urban men in particular, are wary of potential side effects and quite skeptical of clinical trials. Most men said that they would support their wives' participation in microbicide trials, provided that they themselves are also actively involved in the trials.
Both men and women, then, need to be fully informed about the safety and mechanism of action of the microbicide under study, and about the availability of treatment for side effects. In addition, the study guidelines should be explained not only to the women in the trial, but also to their male partners, to minimize domestic conflicts over condom use, lubrication during sex and motivation to participate, and to increase compliance and follow-up rates. This can be achieved by carrying out pretrial focus-group discussions or in-depth information and counseling sessions with male partners and by enrolling couples or consenting male partners.