ART is being increasingly recognized as one of the methods of reducing the risk of HIV transmission. Although increasing access to ART in a generalized HIV epidemic has been greatly supported, this could lead to unprotected sex by PHAs on ART. This view is supported by evidence from both developed and developing countries where unprotected sex by PHAs on ART, with sex partners who are HIV-negative or whose HIV status is not known, has been reported (17
). This fear has already been raised in Uganda which has a generalized HIV-epidemic and has also greatly expanded access to ART (26
). As ART is becoming widely available in high-prevalence societies, more knowledge on the effect of ART on consistent use of condom by PHAs is required to address HIV prevention efforts by and among people who are infected. This study, therefore, investigated rates and predictors of consistent use of condom by sexually-active PHAs after initiation of ART in Uganda.
Overall, this study did not find sufficient evidence to suggest that ART could cause HIV risk compensation through inconsistent use of condom. This is because the study found that the majority of PHAs on ART consistently used condom after initiating ART. This finding agrees with two earlier studies in Uganda (27
) and a number of meta-analytic studies and systematic reviews in developed and other developing countries (10
). Furthermore, consistent use of condom was not influenced by the clinics the PHAs attended, implying that all three clinics provided AIDS treatment and care, using the same standards prescribed by the HIV/AIDS and the antiretroviral policies in Uganda.
The level of education had the greatest impact on consistent use of condom by PHAs on ART compared to any other indicator in these analyses. Having secondary- or tertiary-level education significantly increased the likelihood of consistent use of condom. This finding is consistent with two earlier studies (31
). This is likely because of the high self-efficacy for condom-use among people who have secondary- or tertiary-level education (33
). Educated people are also more likely to be well informed about sexual intercourse as the main route of HIV transmission, making them use condom consistently to prevent transmission of HIV (35
The study also found that fewer PHAs reported having more than one sex partner in the 12 months preceding the study. Those who reported having more than one sex partner in the reference period were mostly men who were more likely to have used condom consistently. This finding agrees with three previous studies (13
). This result suggests that PHAs wanted to protect their HIV-negative partners and partners with unknown HIV status from infection. It also supports the view that PHAs could have wanted to protect themselves and their HIV-positive partners from re-infection, which agrees with a previous study (36
). Consistent use of condom by people with more than one sex partner, whether in the form of serial monogamy or multiple concurrent partnerships (not examined in this analysis), is important in preventing the spread of HIV and re-infection by drug-resistant HIV strains (37
). Supporting and reinforcing safe sex in the context of multiple sexual partnerships is particularly important where one of the partners is HIV-positive.
However, this analysis found evidence supporting the view that some PHAs on ART use condom inconsistently. Occupation and level of income are two related factors associated with inconsistent use of condom. PHAs on ART working in the informal sector were less likely to have used condom consistently. This finding is in line with some condom-use studies which found that people working in the informal sector and belonging to the low-income group used condom inconsistently (38
). Some studies attributed this to the money or materials used to solicit sex, which may compromise use of condom by people in the low-socioeconomic groups, most of whom are in the informal sector (39
). Sex workers and young women have also been found to receive money and other gifts from clients and older sex partners respectively in exchange of unprotected sex (21
). Some studies have attributed unprotected sex involving people of the same or different HIV serostatus to the use of alcohol (40
In Uganda, however, the informal sector includes people in business, who constitute a significant proportion of the middle- and higher-income groups. Before ART was rolled out, most people in the middle- and higher-income brackets, who could afford ART, were engaged in business. It is likely that some of them could have engaged in unprotected sex with their spouses or solicited sex in exchange of money or gifts (39
). The concern emanating from this finding is the possibility that some of these PHAs may have had unprotected sex with people who were HIV-negative or whose HIV status was not known, which has serious implications for HIV transmission. This calls for measures that encourage PHAs to use condom consistently.
Consistent condom-use was also found to be less likely among married PHAs on ART. This finding can be attributed to a number of factors, including partner's objection and inconvenience (41
); unwillingness to commit to a lifetime consistent use of condom for reasons, including desire and pressure to bear children (42
); and lack of control over sexual decisions and reproductive, economic and social insecurity (43
). The perception that condom-use is associated with infidelity could also contribute to the inability to negotiate consistent use of condom in marriage (44
). PHAs might have also believed that their usual sex partner was already infected and, therefore, concluded that there was no need to continue using condom. It was also possible that PHAs in marriage had used condom for a long time and might have experienced fatigue in condom-use. Other important barriers to condom-use that have been identified in almost all contexts, including marriage, are stigma and discrimination, and fear of marital and familial instability.
Failure to use condom consistently by married PHAs had implications for transmitting HIV to an HIV-negative partner or a partner of unknown HIV status. A study in Eastern Africa among married people with HIV found that two-thirds had a partner who was uninfected (45
). Unprotected sex in marriage could explain the finding by another study that almost half of new HIV infections in Uganda occur within marriage (24
). The level of vulnerability to HIV infection in marriage was higher for women because of their subordinate status in relation to men and inability to exert effective control over their sexuality.
The worrying finding in this study is inconsistent condom-use by PHAs on ART, with sex partners who were HIV-negative or whose HIV status was not known. This can occur in several contexts, including marriage, casual sex, and commercial sex. This behaviour has been explained by a feeling of invulnerability, especially if the HIV-negative partner remained uninfected for a long time. This was observed among HIV-negative men who refused to use condom with HIV-positive primary female partners (46
). Alcohol and drug-use can also contribute to unprotected sex by PHAs on ART, with HIV-negative partners and partners of unknown HIV status (40
). In sub-Saharan Africa, inconsistent condom-use was found to be common in marriage where one of the sex partners was HIV-negative or whose HIV status was unknown (47
). This has been attributed to stigma and discrimination associated with disclosure of HIV-positive status (48
). Their vulnerability to HIV infection greatly increased where partners with negative and unknown HIV status could not negotiate consistent condom-use because of their young age and being a woman or poor (49
). Engaging in unprotected sex with HIV-positive individuals knowingly or unknowingly is a very high-risk sexual behaviour for HIV transmission. This calls for the involvement of PHAs in HIV prevention, which could be effective in changing risk behaviour in generalized HIV epidemics. Involvement of PHAs has the potential for disclosure of fact by HIV-positive individuals, which can encourage their sex partners to test for HIV and ensure that they remain uninfected by consistently using condom with their HIV-positive sex partners.
Inconsistent use of condom by PHAs on ART was also found to be higher among those who had a good self-perception of health. The fact that ART improves the health of PHAs to a level where they become socially productive and sexually active is good but these could be perceived as reduced risk of HIV transmission or even that ART cures AIDS (7
). This observation has been reinforced by the finding that PHAs who have been on ART for less than 1 year and 1-2 year(s) were also less likely to have used condom consistently, which agrees with the finding from a previous study (50
). These results suggest that ART might have contributed to inconsistent condom-use by PHAs, which could be attributed to the spontaneous processes of sexual activity and the negative effect of condom on sexual satisfaction for PHAs who recently regained their sexual desires. This requires counselling to enable PHAs on ART with necessary skills to use condom consistently as they become healthier and more sexually active.
Although this study has identified some variables that significantly affect consistent use of condom by PHAs on ART, it has some limitations. These include: the small sample-size and purposive selection of study sites; not including PHAs who are not on ART for comparison; self-reporting of condom-use that could have been affected by social desirability bias; and the cross-sectional design which cannot explain changes in condom-use behaviour over time. Nevertheless, analyzing condom-use behaviour of PHAs on ART is very important to understand the main predictors of consistent and inconsistent condom-use. This knowledge is required for developing strategies to prevent HIV transmission by PHAs on ART. It is recommended that studies involving larger samples and PHAs not on ART be conducted in Uganda. The study should use a longitudinal design so that changes in condom-use behaviour in the course of antiretroviral treatment can be examined.
This study concludes there is no strong reason to suggest that being on ART could lead to HIV risk compensation by adversely affecting consistent use of condom by PHAs in Uganda. This is because the majority of PHAs on ART reported that they consistently used condom after initiating ART. PHAs could have consistently used condom after initiating ART to protect their sex partners from infection. This is likely if PHAs know that their partners are HIV-negative or did not know the HIV status of their sex partners. Conversely, PHAs could have used condom consistently to protect themselves or their HIV-positive partner from re-infection with other strains of HIV. However, the potential for PHAs on ART to engage in unprotected sex has also been observed in one-third of the PHAs analyzed. PHAs who were married, who perceived that ART reduces HIV-infectivity, who had a good self-perception of their own health, and had partners with negative and unknown HIV status used condom inconsistently. The desire to bear children, fatigue in using condom, stigma, and lack of condoms could have contributed the declining trend in inconsistent use of condom in these groups.
It is, therefore, important to acknowledge the aspirations of PHAs and support them in experiencing a satisfying sexual and family life and assist them in adopting and sustaining safe sexual practices. It is recommended that HIV prevention strategies for and by HIV-positive individuals be emphasized in Uganda. These strategies should include counselling on consistent use of condom and provision of free distribution of condoms among PHAs during ART administration.