ARTICLE
Factors associated with condom use in women of a testing and advice center for STD/AIDS of Bahia, Brazil

INTRODUCTION

Current epidemiological patterns show a trend of heterosexualization and feminization in acquired immunodeficiency syndrome (AIDS)¹. In Brazil, the incidence among women rose very quickly and the sex ratio rose from 18.9 men per 1 woman, in 1984, to 1.5:1 in 2004, reaching 0.9:1 at the age group of 13 to 19 years². From 2004 to 2008, the sex ratio has remained stable; from 2009 to 2013, there was an increased incidence among men and a downward trend among women, which caused an increase in the sex ratio, reaching 1.8:1 in 2013³, but maintaining the process of feminization from the beginning of the epidemic. The AIDS mortality coefficient follows the same upward trend in women, with an increase in 0.8% per year between 2002 and 2011, unlike observed in males, which showed a reduction of around 0.5% per year over the same period⁴.

The use of condoms during sexual intercourse, essential for the prevention of AIDS and other sexually transmitted infections (STIs), collides with complex issues whose approach requires overcoming social, cultural, and emotional barriers⁵. Addressing STIs involves the understanding of the social relations of gender and its implications for affective and sexual interactions⁵.

In adolescence, sexuality has a huge importance in the life of the young, as it is when, in general, sexual life begins, and behaviors assumed in this phase permeate attitudes that can establish behavior patterns throughout life⁶. However, since adolescence, women seem to have more difficulties with the use of condoms. A study conducted in São Paulo showed that 73.3% of boys reported knowing how to use condoms, whereas only 56.4% of the girls knew it; 66.7% boys and 52.4% girls claim to use condoms in all sexual relations; 19.8% girls claim to be ashamed to carry a condom, whereas among boys, the percentage was 4.7%⁶.

The use of the female condom, which could provide greater autonomy and freedom to women, has many obstacles. The near-zero outreach to the general population, the absence of free distribution at health centers (usually, when there is, it is limited to sex workers and to women living with the human immunodeficiency virus - HIV), and the high cost compared with male condoms, are some of the difficulties for the spread of the female condom use in the population⁷. A study found that 84% of women knew about the female condom, but only 8% have used it at least once in their life, which shows that the frequency of use is still low⁸.

The condition of poverty can make women more vulnerable to STIs because the socioeconomic and cultural issues interfere with their power to make decisions, including the choice of how and when to have sex. Moreover, these issues are directly linked to the ability to process information about ways to prevent HIV infection⁹. Poverty, coupled with violence, increases the risk of early and unprotected sexual initiation, and hence STIs, especially in adolescence¹⁰.

The role of Testing and Counseling Centers (TCCs) is of utmost importance in this context, to identify the most vulnerable segments of the population in its coverage area, keeping in mind the epidemiological, socioeconomic, and cultural aspects of the location. In addition to serological screening and distribution of prevention materials, counseling is conducted in TCCs. Its performance is important for the diagnosis of STIs and for health prevention and promotion in the community¹¹.

OBJECTIVE

To investigate the factors associated with the condom use with non-regular partners, in women users of a TCC for sexually transmitted disease (STD)/AIDS in Bahia, between 2006 and 2012.

METHODS

A cross-sectional observational, analytical, exploratory study was conducted using secondary data from the health services. The study was developed in the TCC of the Reference Center for STD/AIDS in Juazeiro (BA), which also runs the Specialized Care Service (SCS) in STD/HIV/AIDS, responsible for processing and monitoring seropositive users for STIs tested on the TCC.

The data sources were the TCC Information System Entry Forms, the clinical records of the SCS (for users with positive serology), and the Service Description Sheet, in which the service enters complementary sociodemographic data. The target population consisted of women registered between 2006 and 2012 in the previously mentioned TCC. The exclusion criteria used were age lower than 10 years, exclusively stable (regular) partner, blank forms/records, or no information about condom use with non-regular partners. In situations where the user had filled more than one form, the latest was adopted, observing the date of the interview.

The total number of users seen at the TCC in the period between 2006 and 2012 was 10,125. Of these, 3,029 were excluded because of blank forms and 48 by being younger than 10, leaving 7,048. Of these, 3,726 (52.87%) were women, and 2,465 (67.3%) reported having exclusively steady partner whereas 65 (1.7%) did not report the type of partnership. Both groups were excluded.

A total of 1,196 women with no regular partner were eligible for the study: 378 (31.6%) with exclusively non-regular partner and 818 (68.4%) with regular and non-regular partner. To define the outcome of the use of condoms with non-regular partner, 406 forms (33.0%) that did not contain this information (ignored or not reported) were excluded. Finally, the study was conducted with 790 participants. Data were collected in the service, during operational hours, by directly typing them. Before the beginning of the collection, there was a team training and calibration to standardize the procedures.

Statistical analysis identified the prevalence of condom use with non-regular partner (always, never, sometimes) and the main reasons reported for not using. The variable considered as the outcome was the use of condoms with non-regular partners (no, when never used or used eventually; yes, when always used, representing routine/consistent use).

The independent variables studied were sociodemographic (age, self-reported skin color, education level, marital status, employment status, and population group) and related to individual vulnerability (partner type, stable partner, number of sexual partners in the last year, contracted STDs in the last year, condom use during the last intercourse with a steady partner, condom use during the first intercourse, age during the first intercourse, and the serology results of the STI tested at the TCC). For the independent variables, the same categories used in the collection instruments were adopted, grouping those with very low frequencies to allow statistical analysis.

Data were entered in Microsoft Office Excel 2007 and they were submitted to a quality control process with coherence and consistency analysis to identify typos or errors in filling. Statistical analysis was performed using Stata 9.0 software, by means of bivariate and multivariate analyzes, using Poisson regression with robust variance, adopting the prevalence ratio as a measure of association with a 95% confidence interval (5% significance level). For association analysis, the ignored/not applicable categories in all variables were excluded.

This subproject is part of the study "Epidemiological survey in Testing and Counseling Center and Reference Unit for STD/AIDS in Juazeiro-BA," approved by the Ethics Committee on Human and Animal Research of Universidade Federal do Vale do São Francisco (Registration No. 0006/301111). Because this is a study with secondary data, the approval of the health service was obtained; secrecy and confidentiality were assured by the main researcher.

RESULTS

The average age of the participants was 27 years (standard deviation 10.3 years), ranging from 11 to 64 years. Table 1 shows the prevalence of condom use with non-regular partners and the main reasons reported for not using them. Consistent condom use was low and was used by little more than one-fourth of the participants (27.97%). The main reasons given were "not liking it," "partner not accepting/being unable to negotiate with the partner," "trusting the partner," and "not having one at the time."

Table 1:

Prevalence of condom use with non-regular partner and main reasons reported for not using, in women users of the Testing and Counseling Center. Juazeiro, Bahia (n=790).

*Considering only those who did not routinely use condoms (n=569).

Table 2 shows the prevalence of condom use with non-regular partners according to the sociodemographic characteristics and the result of the crude analysis between this group of variables and their outcome. There was a predominance of individuals with brown skin color, with 8 to 11 years of schooling, single, self-employed/employed, and that were part of the population group "general population". There was a statistically significant association between the marital status and the outcome. The other variables were not associated with the outcome.

Table 2:

Prevalence of condom use with non-regular partners, according to sociodemographic characteristics and results of the crude analysis with the outcome in women users of the Testing and Counseling Center in Juazeiro, Bahia (n=790).

PR: prevalence ratio; p: significance level (5%); 95%CI: 95% confidence interval; STD: sexually transmitted disease. *Number of observations lost (ignored/not informed).

Table 3 shows the distribution of the variables related to the individual vulnerability and the result of the gross analysis with the outcome. Most reported two to four partners in the last year, sexual initiation between 16 and 19 years of age, and not using a condom during the first intercourse. Among those who had positive serological results, syphilis was the most prevalent disease. Statistically significant association was observed between the outcome and the use of condom during the last intercourse with a regular partner, the number of sexual partners in the last year, STD in the last year, condom use during the first intercourse, and the age during the first intercourse.

Table 3:

Prevalence of condom use with non-regular partners, according to variables related to individual vulnerability, and results of the Poisson regression with the outcome, in women users of the Testing and Counseling Center in Juazeiro, Bahia (n=790).

PR: prevalence ratio; p: significance level (5%); 95%CI: 95% confidence interval; STD: sexually transmitted disease; HIV: human immunodeficiency virus. *Number of observations lost (ignored/not informed); **considering only those who were tested for HIV (n=81).

The result of the adjusted analysis of the outcome and independent variables associated in the crude analysis can be seen in Table 4. The following variables maintained a statistically significant association with the outcome: condom use during the last intercourse with a steady partner, and age at the first intercourse.

With regard to condom use during the last intercourse with a steady partner, women who reported not having used it presented a 49% lower frequency of use with non-regular partners, in relation to those who reported using condoms with a steady partner.

Table 4:

Results of the Poisson regression adjusted between the independent variables and the outcome in women users of the Testing and Counseling Center in Juazeiro, Bahia (n=790).

PR: prevalence ratio; p: significance level (5%); 95%CI: 95% confidence interval; STD: sexually transmitted disease.

As for the age at first intercourse, subjects who initiated sexual life under the age of 14 years or between 14 and 15 years reported the use of condoms with a non-regular partner 57% (p=0.05) and 73% (p=0.012) lower, respectively, compared to those who initiated with 19 years of age or older.

The other variables have lost association. The age during the first sexual intercourse was identified as a confounder of the association between condom use during the first intercourse and the outcome.

DISCUSSION

The study results show that the use of condoms with non-regular partner is not a routine behavior and is associated with the use during the last relationship with a regular partner and the age during the first sexual intercourse.

Although low, the prevalence of condom use observed in this population was higher than in the users of the TCC in Canoas, Rio Grande do Sul, considering non-regular partners (17%)¹². In the same region of that study, a population-based study showed a condom use frequency similar to this study (29%), but almost half of those who used it aimed at preventing pregnancy, and not STDs ¹³. Another study carried out in São Paulo found that 33.5% of the women reported to be always using condoms¹⁴, but it should be considered that the participants were users of the SCS and already had positive serologic results for any of the STI tested at TCC, which may have led to an increase in their use.

Major factors contributing to justify the lack of use were "not liking it," "the partner not accepting/not being able to negotiate with the partner," and "trusting the partner," which were different from the study by Maciel and Bizanni, which points "partner did not have the time," "not liking it," and "thinking that the partner does not have HIV," as the main reasons reported for not using condoms, with confidence in the partner not being reported by any of the women with non-regular partners¹².

The fact of not liking to use condoms may be related to misinformation, myths, or annoyance, which shows that it is still necessary to raise awareness on the importance and effectiveness of use, especially among the most vulnerable populations. The decision to not to use condom is influenced by the belief that condom interferes with sexual pleasure and that it compromises the male-female interaction¹⁵. There is still the idea that pleasure is directly linked to the naturalness of sexual practice and, as condoms are artificial devices, people are conditioned to refuse to use them¹⁶. In this scenario, the Popular Education in Health constitutes a great tool to demonstrate that the benefits of condom use outweigh the annoyances and thus spread the practice.

Low adherence to the consistent use of condoms during the sexual intercourse is also linked to nonacceptance by the partner and the difficulty that women have to negotiate, as pointed out by previous studies⁵. Inequalities in gender relations, with the submission of women to men, are still very much present in our society, and this, coupled with the fact that many men do not like to use condoms, results in the predominance of the male desire. One must understand the relationships of gender and their social implications, because while women do not find ways to act as protagonists during sexual relations, it will be continuously difficult to convince or reach an agreement with their partners. Also in this context, the use of the female condom can offer women a different method of protection, in addition to giving them more autonomy. However, the female condom potential is still untapped, because of its high cost and almost nonexistent disclosure to the general population⁷.

In this study, the fact that trusting the partner was one of the main reasons for not using condoms is worrying, as all the women analyzed had no fixed partner. Research indicates that women consider monogamy as an STD protection factor, leading to neglect the use of condom because of their trust in the partner¹⁷, which cannot be applied among users with no fixed partner. However, confidence in the partner can also be explained by the affective marital issues. A study conducted on adolescents, addressing the aspects of love/passion, demonstrated the difficulty in making informed decisions in situations involving feelings¹⁸. This can reflect directly on the practice of condom use, as emotions are more intense at the time of the sexual activity because of the hormones and psychological factors, and it may overlap reason and knowledge of the risks.

Women who did not use condoms in relations with a steady partner also made less use with casual partners, compared with those who used them. This may be showing that women have a tendency to reproduce, in their casual relationships, the same behavior adopted with their regular partners, which ends up creating a situation of great vulnerability to STI for all those who are involved. It is also important to consider that women who do not use condoms with their regular partners may have difficulty negotiating in any relationship, because they are not accustomed to its use and probably to arguing with their partners about the need to use it.

The study also showed that the age of onset of sexual life can have an influence on subsequent behavior, as those who started early (before the age of 16 years) made less use of condoms with non-regular partners than those who started later (after the age of 19 years). Early sexual initiation, when women have no maturity, information, and skills to make their own decisions for a healthy sexual practice, implies difficulty to address gender issues, and increase exposure to STIs¹⁹. There is evidence of an increase in early sexual activity among women mainly because of the need to adapt to the social universe in which she is inserted, contributing to exposure to unprotected sex²⁰.

It is worth pointing out that, since the beginning of sexual life, women are at a disadvantage because, while boys need to prove their masculinity, girls take on a more submissive role, which makes the partner's will as to whether to use or not use a condom to prevail⁶. Another factor that exposes women who initiate sex life early to unprotected sex is the relationship with older men, which also reduces the possibility of negotiation by women¹⁶. Because adolescence is a period of intense physical, psychological, and social changes, when the young are defining their values, behaviors assumed at this stage tend to be reproduced in future relationships. This makes this age group a strategic one for the development of health promotion activities to raise awareness for the adoption of self-preservation sexual practices²¹.

Currently, some strategies have been adopted for the control of HIV, such as postexposure prophylaxis, which, when indicated, expands the possibilities of action to prevent new HIV infections²². Preexposure prophylaxis is also promising to help reduce transmission in groups at high risk of HIV infection²³. Moreover, the promotion of early access to diagnosis has been increased more incisively, so that the individuals infected with HIV can initiate antiretroviral therapy earlier, thereby reducing the risk of transmission.

However, the use of condoms is the safest method to prevent transmission of both HIV as well as other STIs, which reinforces the need to encourage their use and, where necessary, to associate it with these strategies, which should be viewed as complementary, not substitutive. In addition, other alternatives than the biomedical ones should be valued, including the approach of gender, social, and economic inequalities and combating stigma and discrimination²⁵.

It is important to mention the limitations in this cross-sectional study, such as timelessness, which does not establish causal relationships, and the homogeneity of the sample, which was composed only of TCC users, making it difficult to identify significant differences between the groups. In addition, the use of secondary data may have compromised its reliability, as the turnover of professionals who make the records creates a lack of standardization in filling. The large amount of blank or uninformed responses, representing a loss of information, and the lack of clarity of some questions contained in the forms, which made them difficult for users to understand, can also be seen as limitations.

However, the multivariate analysis that allowed the control of confounding factors gives greater reliability to the results. By including only women who have relationships with non-regular partners, this study provides new and relevant information for the understanding of the issue, as in general, surveys do not distinguish between the type of partnership, although the aspects involved in relationships with regular and non-regular partners are different.

CONCLUSION

This study found low prevalence of condom use with non-regular partners and the existence of association of this outcome with the age of sexual initiation and the condom use during the last intercourse with a steady partner.

The findings provide valuable information about the knowledge and understanding of the reality of women receiving care in TTCs, generating subsidies for the planning of coping actions against diseases resulting from unprotected sex, both in specialized care and in primary health care, through the enhancement of individual and collective empowerment strategies.