Couple communication, sexual coercion and HIV risk reduction in Kigali, Rwanda

Abstract

Objective: To describe sexual interaction and HIV-related communication in Rwandan couples and to examine their relationship to HIV testing and condom use.

Study design: Cross-sectional survey of a longitudinal cohort.

Methods: In 1988, women recruited for an epidemiological study of HIV, and interested male partners, received confidential HIV testing and counseling. Two years after enrollment, 876 women reporting one steady partner in the past year completed a questionnaire addressing sexual and HIV-related communication, sexual motivation and violence in the partnership.

Results: Men control sexual decision making, and coercive sex and violence between partners is not uncommon. HIV-positive women were more likely to report coercive sex and less likely to have discussed their test results with their partner. Women with HIV-positive partners were more likely to report being physically abused. Condom use was more common if the man had been previously tested, and if women reported discussing or negotiating condom use. HIV-negative women with untested or seronegative partners were the least likely to use condoms or to discuss or attempt to negotiate condom use.

Conclusions: Participation of the male partner is crucial for successful HIV risk reduction in couples. HIV testing and counseling of couples has beneficial long term effects on condom use and HIV-related communication. Couple communication is associated with condom use, but only when the discussion is specific (sexually transmitted disease risks and using condoms). Seronegative women with untested partners are at increased risk for HIV as they are the least likely to discuss or attempt to negotiate condom use.

PIP: The salience of couple communication to the prevention of human immunodeficiency virus (HIV) was demonstrated in a study of 876 Rwandan women with one steady sexual partner in the preceding year. These women were part of a longitudinal study of the natural history of HIV infection involving 1458 mothers recruited from prenatal and pediatric clinics at a Kigali Hospital in 1988. At study entry, 234 (27%) of the 876 monogamous women were HIV-positive; 45 additional women had seroconverted by the time of the two-year follow-up. Among the 855 sexually active subjects, only 196 (23%) were using condoms. Condom use was substantially higher among HIV-positive women (39%) than their HIV-negative counterparts (17%). In addition, condom use was significantly more likely if the woman had discussed condoms with her partner or if the male partner had agreed to an HIV test. Seronegative women with untested or HIV-negative partners were the least likely to discuss or use condoms. Notable was a pattern of male control of sexual decision making and female responsibility for condom provision, coercive sex, and domestic violence. 33% of women had been forced to have sex with their partner against their will and 21% had been beaten; these rates were even higher among HIV-positive women or HIV-negative women with infected partners. Given the disproportionate power of men in sexual relations in many African societies, efforts to strengthen women's condom negotiation skills may be counterproductive. Recommended, instead, are interventions that increase male involvement in HIV testing and counseling.