There is few data regarding practice of condom use among HIV positive clients in Ethiopia. This hospital based comparative cross sectional study thus provides important information regarding the practice of condom use among HIV positive clients as well as the associated risk factors.
About half the people living with HIV were sexually active (47.4% of ART experienced and 50.4% of ART naïve). This is in line with data from Thailand (56% in the previous 6
] and African countries like rural Uganda (47% at base line and 53% at follow-up) [16
], Kampala (ART experienced: 55% ART naive: 45%) [17
], Kenya (47.5% in the previous 12
]. However it is far less than the study done in South Africa [19
] where 90% men and 81% of women reported being sexually active in the previous 3
months and India (63.2%) [20
] . Hence receiving ART was not associated with increased sexual activity among Ethiopian study participants which may indirectly informs us the effectiveness of the HIV prevention program in the country.
On multivariate analysis, ART naïve respondents were more likely to use condom inconsistently than its counterpart. Hence ART was actually associated with reduced sexual risk behavior. A similar study from South Africa encompassing rural and urban clinics demonstrated that sexual risk behavior significantly decreased after ART initiation among HIV-infected South African men and women in primary care program [9
]. These finding is also consistent with the results of a meta-analysis of literature from developed countries [7
] . And developing countries [8
] which found that the likelihood of engaging in unprotected sexual behavior was not higher among persons receiving ART compared to those not receiving ART. This could be due to the more robust HIV prevention programs and counseling among ART experienced patients compared to those who were ART-naïve.
The major reason given for not using condom consistantly were partner refusal (27.9%) and desire of having children (21.6%). This finding was in line with other Ethiopian studies [21
]. So efforts should be strengthen on sexual health intervention focusing on the couple than the individual and monitoring of client’s attitudes and practice on their follow up period.
CD4 level and WHO stage did not show significant association with inconsistent condom use in this study. This is consistent with research done in Thailand [15
]. This may be due to the selective enrolment of those patients who were on follow-up for at least one year.
In the study those who were a member of association of people living with HIV/AIDS were 40% lower at risk of using condom inconsistently than its counterpart for both ART experienced and naive groups. This result was in line with the survey done in Cameroon [23
]. Hence, this finding may indicate greater access and utilization of prevention messages by members of PLWHA associations. The study also showed that those participants who thought HIV transmission can occur while taking ART were 65% lower at risk of using inconsistent condom than those who did not think so. The misconception may happen either by ignoring the ART information communicated or lack ART knowledge by HIV positive persons which made them engaged in unprotected sex. Hence, counselors are recommended to discuss the effect of ART on HIV transmission in order to avoid the misconception.
Respondents who perceived to be none stigmatized were 65% lower at risk of using condom inconsistently than its counterpart. This finding is consistent with studies done in Ethiopia and Kenya [21
]. Hence, Counselors need the means to assist patients to cope with stigmatization and discontinue the sexual risk behavior.
Among ART experienced groups, those who did not take substances had 86% lower risk of practicing inconsistent condom use than who use substance. In a study done in Addis Ababa those who consumed alcohol were more likely to have engaged in risky sexual practice [22
]. Similarly a meta analysis by Shuper and his colleagues Based on 27 studies demonstrated that any alcohol consumption, problematic drinking, and alcohol use in sexual contexts were all found to be significantly associated with unprotected sex among PLWHA [25
]. This may be due to the restricted cognitive capacity stemming from alcohol consumption which causes one to focus only on impelling immediate cues [26
]. So effort should be strengthen towards reduction of substance use among these particular clients.
This study has some limitations. Sexual behavior was self-reported and subject to both recall and social desirability bias. In order to minimize the recall bias we used 3
month recall period. We also tried to address social desirability bias by assigning male data collectors for male subjects and female data collectors for female subjects. Still we believe that the traditional reluctance to discuss sexual behavior may result in underreporting. Finally, being cross-sectional study it may not show the trend of sexual risk behavior over a period of undergoing ARV therapy.
In summary, though this study supports an absence of association between ART use and recent sexual intercourse we found that use of ARV therapy was associated with a decline in risky sexual behavior among sexually active individuals living with HIV. Therefore, these results are of high importance in order to design tailored interventions.