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African Journal of AIDS Research Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/raar20

Condom brands, perceptions of condom efficacy and HIV prevention among university students in KwaZulu-Natal, South Africa a

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Abraham Kiprop Mulwo , Keyan G Tomaselli & Lynn Dalrymple

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Culture, Communication and Media Studies (CCMS), Howard College Campus , University of KwaZulu-Natal , Durban, 4041, South Africa Published online: 08 Apr 2010.

To cite this article: Abraham Kiprop Mulwo , Keyan G Tomaselli & Lynn Dalrymple (2009) Condom brands, perceptions of condom efficacy and HIV prevention among university students in KwaZulu-Natal, South Africa, African Journal of AIDS Research, 8:3, 311-320, DOI: 10.2989/AJAR.2009.8.3.7.928 To link to this article: http://dx.doi.org/10.2989/AJAR.2009.8.3.7.928

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African Journal of AIDS Research 2009, 8(3): 311–320 Printed in South Africa — All rights reserved

AJAR

ISSN 1608–5906 EISSN 1727–9445 doi: 10.2989/AJAR.2009.8.3.7.928

Condom brands, perceptions of condom efficacy and HIV prevention among university students in KwaZulu-Natal, South Africa Abraham Kiprop Mulwo*, Keyan G Tomaselli and Lynn Dalrymple

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Culture, Communication and Media Studies (CCMS), Howard College Campus, University of KwaZulu-Natal, Durban 4041, South Africa * Corresponding author, e-mail: [email protected] University students form an important constituency in interventions against HIV and AIDS. The majority of university students are between ages 18 and 30 years, which, according to recent surveys, is the age category at the highest risk of HIV infection. Even though there is currently no comprehensive statistical data on the HIV prevalence at South African institutions of higher learning, a number of studies have noted increasing AIDS-related deaths and sicknesses among students. This highlights the need for effective intervention against HIV infections within this community. Condom use remains the most effective intervention against HIV infection within sexually active populations. This paper examines perceptions of public-sector condoms and their impact on condom use among university students, based on the findings of research conducted at three universities in KwaZulu-Natal Province, South Africa. Study findings indicate that public-sector condoms are perceived as ineffective, smelly and even ‘infectious’ and are widely seen to be of lower status as compared to the commercial brands. These perceptions were found to influence condom use as some students preferred to engage in unprotected sex rather than use public-sector condoms. The paper highlights the need for communication programmes to demystify the misconceptions surrounding public-sector condoms and to provide reassurance of the quality of such condoms. Keywords: condom use, networks, public sector, sexual behaviour, young adults

Background HIV and AIDS among South African university students University students constitute an important community in interventions against HIV and AIDS. The majority of university students are between ages 18 and 30 years (Raijmakers & Pretorius, 2006), which is the age category reported in recent studies as being at the highest risk of HIV infection (Human Sciences Research Council [HSRC], 2002; Shisana, Rehle, Simbayi, Parker, Zuma, Bhana et al., 2005). In addition, residential universities are considered serious sources of new HIV infections, owing to the nature of sexual networking that takes place among students: Campuses constitute a potentially fertile breeding ground for HIV/AIDS. They bring together in physical proximity devoid of systematic supervision a large number of young adults at their peak years of sexual activity and experimentation. Combined with the readily available alcohol and perhaps drugs, together with divergent levels of economic resources, these circumstances create a very high-risk environment from an AIDS perspective (Saint, 2004, p. 6). There is, thus, a pressing need for a systematic analysis of the nature of sexual risk-taking and the factors that motivate students to engage in higher-risk sexual practices. Solid statistical evidence of HIV prevalence, and morbidity and mortality rates among students at South African institu-

tions of higher learning are not yet available, even though the danger posed by the HIV epidemic in this sector is widely acknowledged (Chetty & Michel, 2005; Raijmakers & Pretorius, 2006). No comprehensive HIV prevalence studies1 have been conducted at individual universities or across the South African higher-education sector. As a result, the current picture of HIV and AIDS at these institutions is mainly based on speculative projections and smallscale surveys. A study commissioned by the University of Natal (now the University of KwaZulu-Natal) in 1999, estimated that up to 240 students could develop AIDS illness at this institution by 2005. The study used the Metropolitan Doyle Model to analyse the profiles of staff and students, based on the national data. It was projected that about 4 850 students could be newly infected with HIV between 1998 and 2010 (Chetty, 2000). Another small-scale survey conducted among students at a South African higher education institution (with the institution not specified in the report) found general HIV prevalence among students at 22.86% (Ramrathan, 2003). The reliability of these findings is, however, in doubt, owing to the flaws in the research strategy used in the study. This analysis was based on the HIV test of saliva obtained from students who were willing to volunteer. However, just a few students from the Indian, White and Coloured race groups volunteered to participate in the study, hence, their records were excluded from the final analysis. The study, therefore, analysed saliva samples

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obtained from 385 Black students, out of a total population of approximately 8 000 students, hence the findings may not provide a representative picture of the actual situation concerning HIV and AIDS at this institution, or in the higher education sector in general (Ramrathan, 2003). Studies have also noted increasing AIDS-related deaths and sicknesses among students in South African universities even though proper records on AIDS mortality and morbidity do not exist in most higher education institutions (Dube & Ochola, 2005). Rising numbers of cases of tuberculosis (which is often associated with HIV and AIDS) have been reported in some universities, while the numbers of students dropping out of university due to AIDS-related issues are reported to be on the increase (Kelly, 2001). Researchers have also pointed out that most students who become HIV-infected are infected just a few years before they join their university or in the course of study at the university, hence most of those infected succumb to the epidemic a few years after graduating (Chetty, 2000; Coombe, 2000; Kelly, 2001; Van der Merwe & Gouws, 2005). Sexual networking and HIV/AIDS in southern Africa Recent studies suggest that the East African and southern African HIV epidemics are mainly driven by high levels of multiple and concurrent sexual partnerships coupled with a lack of male circumcision and inconsistent condom usage (Epstein, 2007; Halperin & Epstein, 2007; Parker, Makhubele, Ntabalati & Connolly, 2007; Soul City, 2007). Having multiple and concurrent sexual partnerships means an individual engages in sex with overlapping sexual partners over a period of time. This contrasts with sequential or serial monogamy where an individual is involved in one sexual relationship with one partner without any overlaps in time with subsequent partners (UNAIDS/Soul City, 2008). The nature of sexual networking resulting from multiple and concurrent sexual partnerships provides an avenue through which HIV could be easily transmitted within a community. In contrast, the absence of a sexual network in a sequentially monogamous relationship minimises the spread of HIV (see Figure 1). A study conducted by Soul City Institute established that approximately 45% of males and 28% of females aged 15–19, and approximately 36% of males and 21% of females aged 20–24, report concurrent sexual partnerships in South Africa (Soul City, 2007). Another study conducted by the Centre for AIDS Development, Research and Evaluation (CADRE), established that the high prevalence of multiple and concurrent sexual partnerships among 20- to 30-year-olds in South Africa was mainly driven by a complex web of socio-economic and cultural realities, together with individual psychological factors relating to issues such as self-esteem and fatalism. The study noted that young people framed their understanding of sex and love differently: The concepts of sex and love are often separated, as is sex with love for the ‘main’ partner, and sex without love for ‘other’ partners. [This] results in recategorisation of the concept of faithfulness, whereby being ‘faithful’ shifts in meaning from de facto fidelity to a concept where keeping infidelity

Mulwo, Tomaselli and Dalrymple

secret is a sufficient criterion for considering oneself to be faithful (Parker et al., 2007, p. 8). The findings of these, and other recent studies, have informed the development of intervention programmes, such as Soul City’s ‘Onelove’ campaign and the ‘Scrutinize’ campaigns Johns Hopkins Health and Education in South Africa (JHHESA), which mainly aim at encouraging partner reduction. Nevertheless, condom promotion remains the cornerstone of HIV-prevention campaigns among sexually active communities. HIV prevention: condom use In South Africa, several approaches that mainly use mass media channels have been initiated in an attempt to encourage sexual behaviour change especially among young people (Parker, 2006). These include media entertainment/education programmes like Soul City, Tsha Tsha and Khomanani; television, radio and billboard advertisements; condom social-marketing and distribution programmes; interpersonal communication interventions, such as Drama in AIDS Education (DramAidE), Soul Buddyz clubs, peer education programmes; and a variety of other approaches implemented especially at schools and other institutions of learning (Department of Education, 2001; Deutsch & Swartz, 2003). The slogans ‘Abstain, Be faithful, Condomise’ and ‘Know your status (VCT)’ remain the rallying call for most communication campaigns. However, condom use remains the most realistic option in preventing HIV transmission among sexually active population groups, especially in the context of high levels of sexual networking. Socio-demographic and cultural factors, such as early average age of sexual debut, transactional sex and trans-generational sex, often render abstinence and partner fidelity options irrelevant in some contexts. Thus, communication campaigns targeting sexually active young adults, such as university students, often emphasise condom use as the key strategy for reducing the chances of HIV infection (with the exception of some religious-based organisations, and campaigns funded under the United States President’s Emergency Fund for AIDS Relief [PEPFAR]). Following intensified condom-promotion campaigns and the government’s efforts to provide wide access to condoms, recent statistics indicate a rapid increase in condom distribution in South Africa. This has been interpreted as a sign of increased prevalence of condom use. According to the South African National AIDS Council (SANAC), about 350 million condoms were being distributed annually “on demand” across South Africa (SANAC, 2007, p. 41). Some researchers have, however, challenged the use of condom distribution patterns as indicators of condom use, arguing instead for an investigation into estimations of the actual number of sexual acts in which a condom was used in relation to the number of unprotected sexual acts (cf. Meekers & Van Rossem, 2005). Inconsistent and incorrect use of condoms has also been suggested as one of the key reasons for high HIV prevalence. A number of studies have shown, for instance, that people who use condoms inconsistently were at more risk of HIV infection than those who did not use condoms at all (cf. Ahmed, Lutalo, Wawer,

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CONCURRENCY

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CONCURRENCY

May

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SERIAL MONOGAMY

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SERIAL MONOGAMY

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Figure 1: Schematic representation of the potential for HIV transmission within concurrent relationships as compared to serial monogamy (adapted with permission from Epstein, 2007, pp. 61–85)

Serwadda, Sewankambo, Nalugoda et al., 2001; Darrow, 1989; Mann, Nzilambi, Piot, Bosenge, Kalala, Francis et al., 1988; Meekers & Van Rossem, 2005). This, perhaps, is due to increased involvement in casual sex among those who use condoms inconsistently as compared to those who do not use condoms at all (Meekers & Van Rossem, 2005). Contextual challenges to condom use Studies have demonstrated that among South African youth there is a near universal awareness of HIV/AIDS and methods through which HIV infection can be prevented (e.g. HSRC, 2002; Shisana et al., 2005; Parker, 2006). Nevertheless, this awareness has not influenced behaviour changes as evidenced by high levels of self-reported lack of, or inconsistent, use of condoms, and the high levels of HIV infection. Social science HIV/AIDS researchers have therefore focused on establishing the contextual factors that render HIV-prevention efforts irrelevant, especially with regard to the adoption of condom use. A review by Leclerc-Madlala (2002) highlights women’s fertility as one of the major concerns addressed in the early 1990s by researchers, such as Preston-Whyte (1994 and 1999) and Preston-Whyte & Zondi (1991 and 1992). These researchers identified the desire by women to prove their fertility as a barrier not only towards delayed sexual debut, but also towards the use of condoms as protection against HIV infection. The term ‘fertility conundrum’ was coined to describe the common dilemma, especially among African women, between abstaining or using condoms to prevent HIV infection and the desire to become pregnant (Preston-

Whyte, 1999; Rutenberg, Kaufman, Macintyre, Brown & Karim, 2003). Another study by Hoosen & Collins (2004) focused on the role of socially constructed norms about power and gender roles in decision-making regarding safer sex. The study found out that women in the study in KwaZulu-Natal were not always in a position to make rational choices about using condoms, since such decisions were often placed at the prerogative of men who were often socially constructed as figures of authority. Social discourses constructed women as being “subordinate, submissive, and passive subjects who are encouraged to comply with men’s demands for sex, irrespective of their own desire” (p. 493). Similar norms are also described in the works of Harrison (2005) and Pettifor, Rees, Steffenson, Hlongwa-Madikizela, MacPhail, Vermaak & Kleinschmidt (2004). Sexual violence and rape have also been identified as key factors influencing inconsistent condom use among young South Africans. Gender violence is a common phenomenon in South Africa, where a recent national survey estimates that about 13% of women have experienced gender violence (Abdool Karim, 2005). Another study conducted by Kalichman, Simbayi, Kaufman, Cain, Chauncey, Jooste & Mathiti (2005) established that more than 40% of women and 16% of men who participated in their study had been sexually assaulted. There is also evidence suggesting that violence or a fear of violence prevents women from discussing HIV and AIDS with their partners or requesting them to use condoms (Jewkes & Levin, 2003; Abdool Karim, 2005; Swanepoel, 2005).

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A number of studies have also focused on the socioeconomic conditions that enhance the spread of HIV in South Africa. With widespread economic hardship among the majority of the South African population — which has been worsened by the spread of HIV — sexuality has been re-conceptualised as a resource that can be utilised for economic purposes (Leclerc-Madlala, 1999, 2002 and 2004; Nyanzi, Kinsman & Pool, 2001; Wojcicki & Malala, 2001; Thorpe, 2002; Hunter, 2004; Wight, Plummer, Mshana, Wamoyi, Salamba & Ross, 2006). Research done by these authors has demonstrated that even though sex exchange may be motivated by the desire to fulfil daily needs, some women also enter into sexual relationships in pursuit of a “modern successful life” (Leclerc-Madlala, 2004, p. 2). The desire to maintain such lifestyles exposes women to the risks of unprotected sex because their clients often control the decision on condom use.

was achieved through a hermeneutical analysis of language used, and the statements, explanations and stories generated from interviews conducted with the sampled students, in order to understand how concepts of sex, HIV/ AIDS and HIV prevention were represented among the students. Data generated through the interviews were not conceived as the participants’ personal perceptions, but as “manifestations of discourses, outcrops of representations of events upon the terrain of social life [which] have their origin not in the personal private experience, but in discursive culture that those [students] inhabit” (Burr, 2003, p. 66). They were seen in this study to constitute the discourses that represent the way young people make sense of their sexual behaviours and of the different HIV-prevention options. These meanings may serve to explain the discordance between the reported sexual behaviours and the students’ knowledge, attitudes and practices.

Condom brands and social meanings: investigating students’ perceptions From a review of previous social science research on condom use in South Africa, it is clear that a huge amount of scholarly attention has focused on the contextual factors that militate against condom use. The results of these studies have informed the development of guidelines that are mainly aimed at addressing the social and economic conditions that may hinder individuals’ intentions to practice safer sex. Such guidelines include, for instance, institutional policies against rape and gender-based violence, economic empowerment of vulnerable groups, and affirmative action to foster gender equality especially at workplaces and institutions. The South African government has further ensured wider access to condoms by establishing nationwide networks involving the public and private sector for distributing free condoms (SANAC, 2007). In spite of these interventions, inconsistent condom use, coupled with high levels of multiple concurrent sexual partnerships and lack of male circumcision, remain the key drivers of the HIV epidemic among young people in southern Africa (Halperin & Epstein, 2007; Soul City, 2007). This therefore calls for an alternative approach towards understanding adoption/lack of adoption of consistent condom use by the youth.

Methods

Objectives of the research This paper examines the determinants of condom use among university students based on the findings of doctoral research conducted at three universities in KwaZulu-Natal Province, South Africa (five campuses at the University of KwaZulu-Natal and one campus each at the University of Zululand and Durban University of Technology). The study was set to analyse the structures and processes of meaning-production within social groups with regard to sex and HIV/AIDS, and how the produced meanings affect the interpretation and impact of HIV-prevention texts. Using social constructionism theory and reception theory, this study investigated the social meanings of the terms ‘abstinence,’ ‘be faithful,’ ‘condomise’ and ‘voluntary counselling and testing (VCT),’ and the meanings of sex and various sexual practices among university students. This

A multi-method approach involving a questionnaire survey, in-depth interviews and non-participant observation were used to obtain data for the study. A sample of 1 400 students drawn from each of the seven campuses in KwaZulu-Natal Province (200 students from each campus) was selected through a multi-stage sampling technique to participate in the researcher-administered questionnaire survey. Student populations at each of the campuses involved were stratified into four categories: 1st, 2nd, 3rd-year and postgraduate students. One faculty was then randomly chosen from each of the undergraduate programmes and, thereafter, one academic programme with more than 50 students was randomly selected to participate in the study. Students in the selected programmes were then briefed of the objectives of the study during a class/tutorial session. Thereafter, the research assistants made arrangements with 50 willing participants about the time and convenient venue where the questionnaire was administered. To select the postgraduate students, a convenient sampling technique was utilised, where research assistants selected the first 50 postgraduate students (honours, masters or PhD level) that they had access to on their respective campuses, and who were willing to participate in the study. The survey questions focused on the student’s knowledge, attitudes and practices with regard to HIV/ AIDS, their access to HIV-prevention campaigns, and their attitudes towards HIV-prevention messages. Results of the survey were captured using SPSS software, which facilitated easy analysis of the descriptive data. Due to ethical considerations, the participants were informed in advance of their right to withdraw from the study at any stage, or to decline to respond to whichever questions they felt uncomfortable with. Thus, a small proportion of participants declined to answer some questions, especially those dealing with sexual practices. For some, certain questions were not relevant, depending on how they had responded to previous questions. Thus, the analysis of their responses according to percentages was based on the total number of participants who had responded to particular questions, rather than the total sample size.

African Journal of AIDS Research 2009, 8(3): 311–320

Based on the information emerging from the questionnaire survey, further in-depth interviews were conducted with 24 students drawn from the seven campuses, plus three HIV/AIDS coordinators drawn from the three universities. Interviews with the students took between 45 and 90 minutes each and centred on how the individual made sense of HIV/AIDS and the communication campaigns regarding HIV prevention. Interviews with the HIV/AIDS coordinators mainly focused on how the HIV-prevention interventions at each of the three universities were deployed. The discussion here is limited to the study findings relating to the ‘condomise’ approach.

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Findings A total of 1 400 students participated in the study. However, six questionnaires were rejected at the data-cleaning stage because the participants withdrew from the study after answering just a few questions. Almost equal proportions of males (46.9%) and females (53.1%) participated in the study. Of these, 68.1% were black, 20.9% Indian, 8.6% white and 2.4% colored. Close to half of the participants (44.4%) resided in a university residence, whereas 28.6% lived off campus with their parents, 18.3% lived in a rental room/house off campus, and 8.6% lived off campus with friends or relatives. The average age of the participants was 21 years. Sexual experiences The majority of the participants (69.6%) indicated that they had engaged in sex previously. This is strikingly consistent with the findings of research conducted by Raijmakers & Pretorius (2006) at a South African university (institution not specified in the article) where 69.5% of the participants reported having engaged in sex. The age at sexual debut for the majority of students in the current study was 18, which coincides with the average age for the majority of first-year university students. This is also consistent with the average age of sexual debut in the general population as reflected in the national survey conducted by the Human Sciences Research Council (HSRC) (see Shisana et al., 2005). Multiple and concurrent sexual partnerships were common among the students. Nearly two in every five (39%) of the participants who indicated having had sex in the previous 12 months had more than one sexual partner during the same period (see Table 1). While only 22.2% of those who had engaged in sex previously indicated being sexually active at the moment, close to half of them (48.5%) indicating that they currently had more than one sexual partner (see Table 2). High levels of multiple and concurrent sexual partnerships increase the risk of HIV infection among students. In the light of intensified HIV/AIDS-awareness campaigns, it was thus necessary to investigate the students’ perceptions regarding the risk of HIV infection. Perceptions of HIV-risk In spite of the risks of HIV infection associated with multiple concurrent sexual partnerships, empirical evidence from this study suggests that the majority of students do not consider the HIV epidemic a threat to them. Slightly more

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than half the participants (55.3%) were in agreement with a statement saying ‘students in my campus do not take HIV/AIDS seriously.’ Others disagreed (26%), strongly disagreed (4.2%) or indicated ‘don’t know/not applicable’ (14.5%). In response to another statement saying ‘Students in my campus are joining together to help people with HIV/ AIDS,’ only 4.6% strongly agreed and 26.2% agreed, while the majority either disagreed (32.6%), strongly disagree (9.2%) or indicated ‘don’t know/not applicable’ (27.5%). When asked to respond to the statement, ‘Students in my campus frequently talk about HIV/AIDS in their ordinary conversations,’ the majority of the participants disagreed (34.1%), and many strongly disagreed (13.8%) or indicated ‘don’t know/not applicable’ (17.4%). Relatively few strongly agreed (8.1%), but 26.5% agreed with the statement. Further inquiry through in-depth interviews revealed that the general disinterest in HIV/AIDS issues was associated with prevalent perceptions of invulnerability among students. Even though students acknowledged the seriousness of HIV and AIDS, there was a prevalent view that the disease was a problem for ‘other’ people, as Sithole,2 a second-year, black male student at Howard College explains: ‘…Upper class students, they don’t take it seriously enough…it’s something they know about but they can never get it. It’s just one of those — Them but not us. It’s their issue, not ours.’ 3 A high prevalence of instances of pregnancy was cited by the majority of the interviewees as a clear indicator of the prevalent perceptions of invulnerability among students, hence the high levels of inconsistent condom use. Other reasons given by interviewees regarding the general lack of interest in HIV/AIDS issues included information overload and a common perception of fatalism.

Table 1: Reported numbers of sexual partners among the respondents who said they had sex in the past 12 months (n = 756 university students in KwaZulu-Natal, South Africa) Number of partners over last 12 months 1 2 3 4 5 6 >6 Total no. of respondents

Frequency 461 157 64 28 16 10 20 756

Percentage 61 20.8 8.5 3.7 2.1 1.3 2.6 100

Table 2: The reported numbers of current sexual partners among the respondents said they were currently sexually active (n = 309 university students in KwaZulu-Natal, South Africa) Number of current partners 1 2 3 >3 Total no. of respondents

Frequency 159 90 36 24 309

Percentage 51.5 29.1 11.7 7.8 100

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Perceptions and practice of condom use The study established that the majority of the students perceived condom use as a more realistic approach to HIV prevention as compared to abstaining from sex or ‘being faithful.’ More than one in every three (34.1%) participants strongly agreed with the statement saying ‘Using condoms is a realistic HIV-prevention option among students.’ Another 50.6% agreed, 8% disagreed and 2.9% strongly disagreed, while only 4.4% said they didn’t know or it was not applicable. Interviews with students established that sex was socially accepted as ‘cool,’ hence students who were abstaining were socially ostracised by their peers as they were considered ‘uncool.’ Furthermore, the study established that having multiple and concurrent sexual partnerships was socially sanctioned among students. Some male students perceived engagement in concurrent multiple sexual partnerships as a means of acquiring a higher social status among their peers, while others, including some female students, perceived having such partnerships as an ‘opportunity to sample variety.’ These reasons perhaps influenced the general perception of condom use as the most effective way of preventing HIV infection. Nevertheless, the results show that a significant number of students did not use condoms consistently. Close to one-third (27.4%) of those who indicated having engaged in sex previously hadn’t used condoms with their most recent sexual partner. In response to a similar question asking how often they used condoms, slightly more than half (i.e. 54.9%) of the participants who had had sex previously indicated that they used condoms always; 22.7% of these indicated most of the time; 13.6% said they used condoms sometimes; and 8.8% said they seldom or never used condoms (see Table 3). These survey results generated intriguing questions that were pursued further in the in-depth interviews with students. While the vast majority of students perceived condom use as the most effective strategy against prevent HIV infection, the information gathered showed high levels of lack of condom use for last sexual encounter and high levels of inconsistent condom use. The reasons for use or non-use of condoms among students, therefore, became a core component of the qualitative inquiry. The analysis of the interviews focused on the representation of condom use in the predominant discourses of sex and HIV prevention among university students. ‘Government condoms’ are ‘unsafe’ The interviews and non-participant observations revealed that students had easy access to public-sector condoms, Table 3: The estimated frequency of condom use among the respondents who said they previously had sex (n = 921 university students in KwaZulu-Natal, South Africa) Statement gauging condom use ‘I always use a condom’ ‘I use condoms most of the time’ ‘I use condoms sometimes’ ‘I seldom or never use condoms’ Total no. of respondents

Frequency 506 209 125 81 921

Percentage 54.9 22.7 13.6 8.8 100

which were distributed freely in toilets around the university and through clinics and the campus HIV/AIDS units. However, these condoms were often considered ineffective and were therefore not used by the majority of the participants interviewed. The free (Choice brand) condoms, popularly referred to by the participants as ‘government condoms,’ were usually described as ‘unsafe,’ ‘smelly’ and ‘infectious.’ It was not immediately clear whether the infectiousness of the condoms referred to allergic reactions to latex condoms, which has been reported among some users (Silverberg, 2006). Nonetheless, the view of ‘government condoms’ as being of poor quality was firmly established within the student’s social system, as the majority of them reported having heard about the condoms’ weaknesses from their peers. Just a few participants acknowledged having personally experienced problems with public-sector condoms, which suggests that the perceptions of the weaknesses of public-sector condoms derived mainly from the predominant discourse within the students’ social systems. The participant named Sinhle, for example, believed that commercial brands of condoms, such as Lovers Plus, offer better protection against HIV infection compared to the ‘government condom’: ‘I think they should make them [condoms] available, but not the government ones. Better ones that have got much better protection, maybe the Lovers Plus. Maybe the university should go to the pharmacies and work together on some kind of some partnerships, mmh, and make those condoms available; maybe that one will be much better.’ 4 Like Sinhle, the majority of the participants interviewed considered public-sector condoms as offering less protection as compared to the commercial brands: ‘Lovers Plus are much better than these ones.’ 5 Some of the participants, such as Jabu, who reported having used both the ‘government condoms’ and the commercial brands, indicated that the free condoms were not only smelly but also infectious: ‘One thing I know is in South Africa condoms have been provided for free. Yeah, but the Choice ones, they are nonsense. They smell bad, they are infectious at the same time and they are not comfortable to use at all. Like I used them one time, eeem like its, its kinda personal, I’d love to explain more but [long pause] they are not good to use.’ 6 These perspectives may partly explain the inconsistencies in condom use among the sexually active students. Since students had free access only to Choice condoms, the negative perceptions towards this brand may have partly contributed to the high levels of lack of, or inconsistent, condom use. Condom brands and social status The majority of the interview participants associated the public-sector condoms with a lower social status. In contrast, the commercial brands were socially constructed as being ‘professional,’ indicating an association with an upper class. Consequently these symbolic meanings influenced the male students’ choice of condoms where commercial brands

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African Journal of AIDS Research 2009, 8(3): 311–320

were preferred if the female that one intended to have sex with was considered to be of a higher class. Interestingly, some males preferred to engage in unprotected sex rather than propose the use of public sector condoms, especially if the female partner was considered to be of ‘high class’: ‘It’s about status; if you use that government condom to a lady who is like eeh, who is too much gorgeous, beautiful and who has eeh nice clothes, who is glamorous and you come with eeh government’s condom, she will be like — This guy what’s that, government condom? it smells, it’s got a bad smelling, Jeez…. In your mind something tells you that no, no, no, I can not have sex with that girl with eeh a government condom. I have to buy a condom somewhere [or] get some, my friends, to give some Lovers Plus, yeah. Not the regular ones because she will think I’m cheap or I’m poor or something; she has to see that I have certain status myself, I’m using, eeh, good condoms, professional ones.’ 7 According to Mnqanyi, even women preferred to have skhunu, a slang word for unprotected sex, instead of using public sector condoms: ‘…Most of these chics doesn’t [sic] like these condoms, they’re saying that — You won’t have it with me with the Choice, no you must go and buy some condoms. You are like wow I doesn’t [sic] have them so what must I do? And they say [to myself] aii you must maybe end up having skhunu here, like stick in flesh to flesh.’ 8 The perceived symbolic status of the various condom brands, together with the common view of free condoms as unsafe, greatly influenced the students’ preference for commercial condom brands. The sustained use of commercial condom brands was nevertheless hindered by the financial implications. The economic realities among some students, according to Vusi, often forced students who wanted to have protected sex to use the free condoms against their preference: ‘If you are unemployed and you are a student, you are compelled to use Choice, the government condoms, because if you are speaking about Lovers [Plus], Lovers [Plus] are expensive, and other condoms as well…it’s five rand actually. In fact with five rand I can buy bread instead of condoms. I’d rather use the government condoms and use the five rand to buy bread.’ 9 The cost of purchasing the commercial brands of condoms frequently, coupled with the negative perceptions associated with the public-sector brands, may thus have contributed to the reported high levels of inconsistent, or lack of, condom use. Where one is not able to purchase a commercial condom brand, and is not willing to use the public-sector brands, it is highly possible that such individuals will engage in unprotected sex. Discussion Based on the interviews discussed above, it is evident that in spite of easy access to free public-sector condoms, the popular discourses on efficacy of public-sector condoms

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have a significant influence on the students’ choices on whether to use or not to use them. This could partly explain the reported high levels of inconsistent or lack of condom use. A review of documented information regarding condom efficacy and effectiveness, however, clearly indicates that public-sector condoms offer equal protection as the commercial brands and that the public-sector condoms are distributed freely as a result of a huge investment in resources by the government (cf. Parker, Nkosi, Birdsall & Hajiyiannis, 2004). The perception that public-sector condoms are of poor quality is thus a myth whose origin needs to be examined. Non-participant observations and in-depth interviews with students pointed to three reasons as possible sources of the ‘government condom myth’: 1) the recall of a specific brand of Choice condoms by the Ministry of Health in 2007; 2) the conflicting messages emerging from condom promotion and condom branding campaigns; or 3) the price as an indicator of a product’s quality. In mid-2007, the South African Ministry of Health recalled millions of Choice brand condoms manufactured by Zalatex, which had earlier been distributed nationally, after it was discovered that an official at the South African Bureau of Standards (SABS) was bribed to approve this particular batch as meeting the required SABS safety standard.10 Following this recall, a statement released by the University of KwaZulu-Natal’s Campus HIV/AIDS Support Unit (CHASU), on 28 August 2007, notified students of the recall of Zalatex condoms Batch Code: 4308/ZLX. This was followed shortly thereafter by another notice, on 12 October 2007, of another recall of Choice condoms, Batch Code: Med, manufactured by Kohrs Medical Supplies. Students who had taken these brands to their rooms were asked to hand them back to CHASU or a university clinic, while those who suspected they had used the said brand were advised to go for voluntary counseling and testing (VCT). Since then, no information has been passed on to the students to confirm that the current Choice brand condoms being distributed have been properly checked for quality purposes. This could be the cause of mistrust of the public-sector condoms, as the interview participant Amina explained: ‘I think early this year we were told that those condoms that I get in toilets are not good. Those government condoms. Now I don’t know whether it was just a sabotage or, I don’t know that, ok, we were warned, so that means we were warned not to use them. People were convinced that we were warned not to use them because they were ineffective, they were not well made.’11 Secondly, the myth that free condoms were ineffective could also be a result of the competing ideological conflict emerging from condom promotion on the one hand, and condom branding on the other. Condom promotion seeks to promote condom use generally as the most effective strategy against HIV infection and STIs for sexually active individuals. Condom-promotion advertisements are often not associated with particular brands. On the contrary, commercial condom branding seeks to promote particular brands of condoms as being ‘most effective,’ thus casting other brands as being less effective. Branding seeks to define a

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product or service in a manner that enables the potential buyer to perceive its unique characteristics (De Chernatony & McDonald, 1992). The ideological conflict emerging from these advertisements is perhaps responsible for the perception among the majority of students that the commercial condom brands are good or professional, while the free condoms appear ineffective, infectious or weak. Finally, myths surrounding the quality of public-sector condoms could be associated with the discourse of quality and pricing. From a business perspective, price is often regarded as an indicator of the quality of a product in relation to other competing products. This philosophy seemed to inform the students’ perceptions of the quality of various condom brands. Students perceived free Choice condoms as being of poorer quality compared to other pricey brands. The philosophy here seemed to be that ‘nothing so good comes for free,’ as explained by Jabu: ‘Of course there’s confidence in the condom that you buy because you think that they will work for you, and the ones that you get for free you ask yourself the following: why must I get this one for free and this one is being sold? What is so less about this one?’ 12 These factors may in part explain the students’ high levels of engagement in unprotected sex, as evidenced in the high proportion (27.4%) of participants who said they had not used a condom during their most recent sexual encounter.

Mulwo, Tomaselli and Dalrymple

of poor quality is not a phenomenon unique to university students. In a study of condom-related calls to the National AIDS Helpline, Parker et al. (2004) noted strikingly similar perceptions of public-sector condoms among the callers. Like the university students in this sample, callers were often concerned with the quality of public-sector condoms, which they similarly referred to as ‘government condoms.’ Parker et al. (2004) proposed a number of solutions that included the introduction of branded public-sector condoms, emphasis by communication campaigns on the quality of public-sector condoms, and that campaigns should highlight the fact that public-sector condoms are available free of charge as a result of a huge investment of funds from the government. In the light of the findings of this study, however, it would appear that these recommendations have not been successfully implemented. There is urgent need for condom-use campaigns to respond to popular discourses on the various brands of condoms, with particular emphasis on the quality of publicsector condoms. Providing a variety of condom brands might contribute towards re-establishing trust for publicsector condoms. In addition, there is also an urgent need for institutions to reassure the public that the current brands of public-sector condoms have been properly tested and have passed quality assurance standards. Notes

Conclusions 1

Although the level of HIV infection among students at South African universities is still unclear, the findings of this and other previous studies clearly indicate high levels of sexual risk-taking. The sexual culture among university students reflects a widespread phenomenon observed by social science researchers in southern Africa, which is characterised by high levels of multiple concurrent sexual partnerships and inconsistent condom usage. This indicates the possibility of high levels of HIV infection among university students. Promotion of consistent condom use remains the cornerstone in a response to HIV/AIDS within contexts of intense sexual activity, such as at residential universities. However, consistency in condom usage depends on a clear understanding of the risk of HIV infection from unprotected sex and of the role of condoms in HIV prevention, as well as positive attitudes towards the use of condoms, access to a constant supply of condoms, and an enabling environment for decision-making about condom use among both sexual partners. Based on the findings of this study, it seems that condom use is widely accepted among South African university students as the most effective strategy for preventing HIV infection. It is also evident that there is wide access to public-sector condoms within the university environment, which is also an enabling environment for consensual sex. Nevertheless, consistency in condom use remains a huge problem. Close to one-third (27.4%) of the sexually active students in the study did not use a condom in their last sexual encounter. In part, this could be associated with their negative perceptions of public-sector condoms. The representation of public-sector condoms as being

2

3 4 5 6 7 8 9 10

11 12

The Centre for AIDS Development, Research and Education (CADRE) in conjunction with Epicenter and Constella Futures are currently involved in a national study that involves establishing the prevalence of HIV among university students and staff at 22 universities in South Africa. The study began in August 2008. Names used in this study are not the real names of the interview participants. Sithole, in-depth interview, March 2008, transcript p. 2. Sinhle, in-depth interview, April 2008, transcript p. 15. Vusi, in-depth interview, April 2008, transcript p. 8. Jabu, in-depth interview, March 2008, transcript p. 10. Sinhle, in-depth interview, April 2008, transcript p. 11. Mnqanyi, in-depth interview, June 2008, transcript p. 8. Vusi, in-depth interview, April 2008, transcript p. 6. Carter, C. & Ngalwa, S. (2007) ‘State set to act on faulty condoms.’ The Star, 19 October 2007, p. 3. Retrieved from: http://www.iol.co.za/index.php?set_id=1&click_id=13&art_ id=vn20071019043532373C728402. Amina, in-depth interview, July 2008, transcript p. 20. Jabu, in-depth interview, March 2008, transcript p. 11.

Acknowledgements — Our thanks go to the Johns Hopkins Health and Education in South Africa (JHHESA) programme for funding this study, and to JHHESA’s research partner, Culture, Communication and Media Studies (CCMS) at the University of KwaZulu-Natal, for directing the overall project. The opinions expressed herein are those of the authors and do not necessarily reflect the views of JHHESA. The authors — Abraham Kiprop Mulwo is a lecturer at Moi University (Kenya) and currently a postdoctoral fellow at the Centre for Culture, Communication and Media Studies (CCMS), University of KwaZulu-Natal (South Africa). This research was conducted as part of his PhD dissertation, which has been accepted by the university’s board of examiners.

African Journal of AIDS Research 2009, 8(3): 311–320

Keyan Tomaselli is a senior professor and programme director at the CCMS graduate programme, University of KwaZulu-Natal; he was a co-supervisor of this PhD-based research. Lynn Dalrymple is a research affiliate in the CCMS graduate programme, University of KwaZulu-Natal; she was a co-supervisor of this PhD-based research.

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Condom brands, perceptions of condom efficacy and HIV prevention among university students in KwaZulu-Natal, South Africa.

University students form an important constituency in interventions against HIV and AIDS. The majority of university students are between ages 18 and ...
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