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Men in this situation may have been having sex with other regular partners during this time. The study does not distinguish regular from casual partners in this context. Nevertheless, levels are generally much higher than in non-African countries for which representative data are available the United States, the United Kingdom, France, Belgium, Singapore, Sri Lanka, and Mauritius see Cleland and Ferry, The only country shown thus far to have levels of nonmarital sex comparable to those of Africa is Thailand.
Women tend to report less than half of male levels of nonregular sexual activity Figure Beliefs about partners can be revealing: in high-HIV-prevalence Rwanda, nearly 9 women in 10 said they believed most married men are unfaithful, and 44 percent said they believed most married women are, too Lindan et al. It may also be noted that women are far more likely to have extramarital lovers if they are the younger wives in a polygynous marriage than if they are the only wife Orubuloye et al.
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With whom are the men having sex? In Ekiti, Nigeria, Orubuloye et al.
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And who are the men? This finding would suggest that where overall levels of sexual activity are high, women who have no sex outside regular partnerships will still be at increased risk for HIV. Not surprisingly, men reporting more than five casual partners in the last month are disproportionately likely to live in countries with generally high levels of sex outside regular partnerships.
Interestingly, there is no apparent correlation between levels of commercial sex reported and the proportion of men with five or more casual partners, though this surprising result may perhaps be explained by the imprecise definition of "commercial" sex in the surveys.
Interviewers were told that the term did not include relationships in which the exchange was not the prime motive or reason for sex. Use of this definition once again led to the possibility that the same sexual experience would be classified differently by the man and woman involved. However, in most sites, a higher proportion of all nonregular sex was classified as commercial by women than by men. The incidence of commercial sex during the past year. Kisekka and Otesanya , quoted in Standing and Kisekka, , report that commercial sex workers in Uganda impersonate schoolgirls to appear to have "low HIV risk.
The confusion surrounding transactional sex is apparent elsewhere. Only 1 percent of extramarital partners of men surveyed were reported to be sex workers, but 38 percent were classified as street traders, whom the authors describe as an important source of commercial sex. Further, the authors note that when a man visits a sex worker regularly, the relationship may cease, in his mind, to be one of commercial sex.
In another Nigerian study, a far higher proportion of men 14 percent reported having paid for sex with a sex worker Messersmith et al. Relatively high proportions 16 percent of schoolboys in Zimbabwe surveyed by Wilson et al. Many authors comment that economic hardship, particularly that caused by structural adjustment programs, has increased the need for and incidence of transactional sex e.
Although the spectrum of women engaging in transactional sex is broad, commercial sex workers are often portrayed as hapless victims of extreme poverty and family breakdown in surveys and focus group interviews Pickering et al. However, in an extremely thorough prospective study of prostitutes and their clients in The Gambia that led to invitations to the commercial sex workers' family homes, the researchers reported that many of the women were from well-off families; their work appeared to be a life-style choice.
A concurrent study Pickering and Wilkins, calls into question the common assumption that many widowed, divorced, or separated women, shorn of their partner's support, are obliged to turn to sex as a means of generating income. That these women. In the first, the HIV status of study participants is known, usually only after information on explanatory variables has been collected. In the second, analysts must rely on proxy markers of risk that have been determined by clinical studies of the first kind; these markers include high numbers of partners, unprotected sex with commercial sex workers, and the presence of STDs.
Although the definitions may appear to capture a wide range of behavior, they are lent credence by serostudies. Lindan et al. In Nairobi, Kenya, where overall prevalence is much lower, Hunter et al. The risk inherent in the rate of partner exchange is of course affected by the background prevalence of HIV infection. While the odds of being HIV-positive increase with the number of sexual partners in various urban and rural locations,.
Some observers have suggested that religion may play a significant role in shaping social and behavioral responses to the epidemic, but the role of religion has not been the subject of significant research. Because there would be significant policy implications if religion were found to be an important factor, research into the role of religion may well be a fruitful topic for future work.
Surprisingly, there does not seem to be a strong correlation between perceived risk and risk behavior. Conversely, Lindan et al. While this finding may dim hopes that knowledge will lead to behavior change, the relationship may be spuriously caused by the fact that formal schooling leads simultaneously to better AIDS awareness and a socioeconomic status that makes it easier to acquire more partners. Never-married men aged 15 to 19 reported that in the last 12 months they had had between 1. Condom use for sexually experienced men aged 20 to 24 varies from under 20 percent in Lesotho, Tanzania, and Togo to over 50 percent in Guinea-Bissau and Lusaka, Zambia Mehryar, Reported condom use for women in this age range was significantly lower.
Only in Lusaka, Zambia, did more than 20 percent of sexually experienced women in this age range report ever using a condom, and in Central African Republic, Togo, and Lesotho, fewer than 10 percent of women in this age range reported ever having used a condom Mehryar, The effect, which is most powerful when secondary education and primary or no schooling are compared, remains when the effects of other variables are controlled.
It is likely that the effect of education is confounded by the fact that for men, education opens the door to resources, and resources can make it easier to acquire access to commercial or casual sex. In Rakai, Uganda, seropositivity shows a linear rise with education and with occupational status for both sexes, with the exception of female bar and hotel workers Kivumbi, In Nairobi, single sexually active women were found twice as likely and formerly married women three times as likely as married women to be HIV-positive.
The high rates among the formerly married are not altogether unexpected. In high-prevalence areas, the formerly married may well be AIDS widows and therefore at extremely high risk of exposure. Alternatively, some women may have been divorced because they were suspected to be HIV-positive. In terms of risk behavior, Rutenberg et al. Among men, marital status in these three countries appears to be a less important influence on risk behavior. In a result that surprised researchers, however, the effect of residence evaporated in multivariate analysis, suggesting that it is greatly confounded by other variables, such as education, marital status, and age Cleland and Ferry, Thus there is little support for the hypothesis that sexual life-styles are divided merely across urban-rural lines.
Orubuloye et al. Rutenberg et al.
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Anarfi reports earlier sex in urban than in rural areas of Ghana. A widening rural-urban gap in income and availability of social services and a subregional variability in development have generated large movements of people in Africa. Increasing urbanization is associated with a lower proportion of customary marriages relative to consensual unions Caldwell et al. Such conjugal situations often weaken the financial security of women and their children. Because migrants are most often young adult men, one outcome of migration is a very high ratio of men to women at the points of destination.
In such settings, high sex ratios in favor of men have generated growing demand for commercial sex, which is often satisfied by widowed, divorced, and single women because of their bleak economic situation Anarfi, Mining or industrial centers often have particularly high concentrations of young men who have migrated to seek employment; these sites are highly vulnerable to the spread of HIV infection. Lesotho, Swaziland, and several other countries in Southern Africa face the dual challenge of sustaining economies that are largely dependent on their export of labor to South Africa and. Migration in Africa commonly takes the form of people leaving their villages on a seasonal or temporary basis in search of work, hoping to move back eventually to their place of origin.
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In Ghana, the risk is heightened in rural areas by a tendency among returning migrants to flaunt wealth and acquire partners Anarfi, The same study showed that international migrants are more likely than internal migrants to report high numbers of partners Anarfi, In many nations, those reporting STD symptoms are two or three times as likely to report casual sex as those apparently unaffected. The correlation grows stronger as partner numbers increase, and stronger yet with a history of contact with commercial sex workers.
Treatment often of both partners can be crucial in limiting the importance of STDs as a cofactor for HIV transmission. In Cameroon, one-quarter of STD patients in one study continued sexual relations during their illness, and of those nearly two-thirds stated that they used condoms on every occasion IRESCO, Caldwell et al.
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Doubtless other large-scale movements of refugees, such as those associated with famine, civil unrest, and military coups, also contributed to the rapid spread of the epidemic, but such situations rarely lend themselves to careful study see Chapter 2. In a Nigerian study, a sizeable majority of STD sufferers said they had sought treatment in hospitals or with private doctors, though turning to traditional healers and self-medication was not uncommon.
In Nigeria, abstention and effective treatment were much more common among women who knew their illness to be sexually transmitted than among those who thought it ''natural" O'Toole Erwin, Where levels of STD-induced sterility are high and the connection between the two is well known, single women may refrain from seeking treatment for fear of being stigmatized and jeopardizing their chances of marriage. The high cost of treatment, lack of available services, and the attitude of the staff toward the client may also be further reasons to deter women from attending STD clinics.
In a society where fertility is an all-important key to family support and resources, barrenness may drive women to towns and to commercial sex work Southall, , cited in Standing and Kisekka, Generally, male circumcision is thought to be protective against HIV transmission and female circumcision a risk factor, although some dispute these claims.
Female circumcision continues to be widely practiced among some groups throughout Africa Kouba and Muasher, There have been no studies that have actually attempted to examine the relationship between female circumcision and HIV transmission, although the practice may put women at risk if unsterile instruments are used; it is also likely to increase the risk of bleeding during intercourse and therefore of HIV transmission.
Lack of male circumcision has been associated with some sexually transmitted diseases, including chancroid, syphilis, and gonorrhea Cook et al. On one side, Bongaarts et al. Using micro-level data, Hunter et al. Adopting a more cautious tone, others argue that the causal relation is far from proven, and that confounding factors such as behavioral differences may account for these findings de Vincenzi and Mertens, ; Conant, For instance, a study of. Although circumcision is found to be protective, the authors do not investigate whether there are behavioral factors associated with being Moslem that might also be protective.
Drinking is often thought to be associated with lower self-control and greater risk-taking behavior with regard to sex.