African Journal of AIDS Research 2005, 4(2): 99–102 Printed in South Africa — All rights reserved
Copyright © NISC Pty Ltd
AJAR EISSN 1727–9445
Prevalence of HIV infection among premarital couples in southeast Nigeria Odie Ugochukwa Umeora* and Chidi Esike Department of Obstetrics & Gynaecology, Ebonyi State University Teaching Hospital, PO Box 980, Abakaliki 480001, Ebonyi State, Nigeria * Corresponding author, e-mail: [email protected]
The Catholic Church in Nigeria offers premarital HIV screening to couples, yet instances of voluntary screening are rare in southeast Nigeria. This study examines the contribution of such tests to HIV detection, and evaluates the prevalence of HIV infection in southeast Nigeria among couples who are planning to marry. Out of 858 individuals (or 429 couples) tested for HIV, 52 individuals were found to be HIV-positive (overall prevalence 6.1%), and females were marginally more affected than males. In both sexes, prevalence was higher in younger age groups. Prevalence among adolescent females was 10.7%. Although no male adolescents were screened, prevalence for the group aged 20 to 29 years was 6.3% for females and 10.8% for males. The prevalence estimate was slightly higher for rural dwellers (6.2%) than for urban residents (5.9%), but this was not statistically significant. We propose that screening apparently healthy individuals, such as couples intending to marry, and who are otherwise not members of a group considered at high risk for HIV infection, can serve an important role in HIV detection in the general population. Keywords: Africa, church, counselling, testing and screening, seropositive partners
Introduction
Methodology
Since the 1980s, HIV-related illnesses have been the leading cause of death among young women in Africa (Lindan, Allen & Serufilira, 1992). This trend has grave implications to African society where women are often the primary earners, the custodians of family values, and the primary educators and caregivers of young and old alike (WHO, 1999). A delay in the detection and management of HIV infection is directly linked to such deaths, as many individuals, and their health-care providers, do not perceive themselves as at-risk (Apodaca & Maslow, 2001). Over the years, recommendations for HIV testing among women have evolved from initial testing offered especially to those identified as high risk, to broader voluntary counselling and testing (VCT). In an effort to de-stigmatize HIV testing and increase the rate of testing and identification of HIV-positive women, the American Institute of Medicine recommended a shift from counselling and VCT to universal HIV testing with patient notification as a routine component of prenatal care (Center for Disease Control, 1995). This recommendation was endorsed by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists (1999) and has been in practice in the United Kingdom since 2000 (Wallace, 2004). More recently, there appear to be increasing rates of premarital sexual activity in developing countries (Gage, 1999). The Roman Catholic Church in Nigeria offers HIV screening to all premarital couples. This has provided an opportunity to screen an apparently healthy component of the population, who are considered not at risk of HIV infection. This study aimed to assess HIV prevalence among couples so screened.
Background to the study Preparatory to marriage Catholic couples are required to attend premarital classes on family life. Included in such a course is haematological screening for blood group and genotype. Couples are also taught about HIV/AIDS; following pre-test counselling they are sent for HIV screening at one of the Catholic or recognised government hospitals in their locality. The Mater Misericordiae Hospital in Afikpo and St. Vincent’s Hospital in Ndubia are Catholic hospitals in Ebonyi State, southeast Nigeria. The former is accredited by both the Nigerian National and West African postgraduate medical colleges for training in obstetrics and gynaecology, while the latter serves as a training centre for community healthextension workers. Both run efficient laboratory services with facilities for HIV testing for clients originating within or outside the hospitals. Patients attend these hospitals from areas throughout Ebonyi State as well as from parts of the neighbouring Abia and Cross River states. Study population This is a review of retrospective data relating to all premarital couples who underwent HIV testing at the two hospitals over a five-year period (2000–2004). The couples usually arrived together, with a letter from the Catholic parish requesting screening. The couples were counselled earlier as part of the mandatory marriage course organised by their parish. On arrival, they obtained a hospital folder where their bio-data, including age and place of residence, were recorded. Other pre-test counselling was not mandatory at this stage.
100
HIV testing procedure A 5ml sample of blood was collected from each client and sent to the laboratory for screening by the ELISA technique. Reactive tests were repeated in duplicate, and any one that turned reactive again was declared positive. Post-test counselling was undertaken by the medical officer on duty before disclosure of the result to the couple, individually and confidentially. Individuals testing HIV-positive were encouraged to go for confirmatory tests. Results of the screening were documented and kept in the hospital’s central records department. Statistics We retrieved case records from the central records department of the two hospitals. Data extracted related to the HIV screening results and the bio-data of the couples tested. The lack of reliable data on the educational and occupational status of the individuals was a limitation in the study. Univariate analysis was carried out and frequency tables constructed. The chi-square test was employed to determine significance, at a p-value of less than 0.05. Results Through the period under review (2000-2004) 858 individuals (429 couples) were screened for HIV infection. Of these, 52 individuals were HIV-positive, amounting to 6.1% prevalence (Table 1). This affected 49 couples (approximately 1 in 9 couples). In 46 couples only one partner was HIV-positive; in 3 couples both partners were positive. Of the total tested over 5 years, 23 males were positive (5.4%) and 29 females (6.8%) were positive (Table 2), but the difference in sex distribution was not statistically significant (P = 0.39). The youngest age group of both females and males (i.e., females age 19 years and under, and males aged 20-29 years) had the highest age-specific prevalence, at 10.7% and 10.8%, respectively. The mean ages of the study population were 32.9 ± 5.0 years for males and 26.1 ± 4.5 years for females. The majority of individuals (47.6%) were within the 20–29-year-old age group (Table 3) and contributed the majority (57.7%) of HIVpositive cases. Adolescents (age 19 years and under, but only females tested) had the highest age-specific prevalence (10.7%), constituted the least portion (3.3%) of the study population, and contributed the least (5.8%) to the total number of HIV-positive cases. The 30–39-year-old age group made up 46.4% of the study population, had the lowest age-specific prevalence (4.8%), and contributed 36.5% of the total positive cases. Of the screened population, 437 were rural dwellers, with 27 (6.2%) returning positive tests, while 25 (5.9%) of 421 urban dwellers tested HIV-positive; however, the difference in locality was not statistically significant (χ2 = 0.02; P = 0.88) (Table 4). Most men screened (66.4%) resided in an urban area, and most females (68.3%) lived in a rural area. HIV prevalence was marginally higher among females from rural areas (6.8%, n = 20) than among females from urban areas (6.6%, n = 9), but this was not statistically significant (χ 2 = 0.01, df = 1; P = 0.94). More HIV-positive cases occurred among males from urban areas (5.6%, n = 16)
Umeora and Esike
Table 1: HIV prevalence in the study population Year 2000 2001 2002 2003 2004 5-yr total
No. tested
HIV+ (n)
Prevalence (%)
108 164 170 204 212 858
5 6 11 19 11 52
4.6 3.7 6.5 9.3 5.2 6.1
Table 2: Sex distribution and age-specific HIV prevalence among 429 couples tested (2000-2004) Age (years) Males ≤19 20–29 30–39 40–49 Females ≤19 20–29 30–39 40–49 Total
No. tested
HIV+ (n)
Age-specific prevalence (%)
– 93 312 24 429
– 10 13 – 23
– 10.8 4.2 – 5.4
28 315 86 – 429
3 20 6 – 29
10.7 6.3 7.0 – 6.8
χ2 (for general sex distribution) = 0.74 (df = 1), P = 0.39 than those who were rural dwellers (4.9%, n = 7), but the difference also was not statistically significant (P = 0.74). No statistical difference was demonstrated in prevalence among rural women vs rural men (P = 0.68), nor among urban females vs urban males (P = 0.42). We noted that many men living in urban centres had become engaged to rural-dwelling women. Nineteen of such couples were affected by positive test results and made a 38.8% contribution to the total number of positive cases. Only in 19 instances had a man from a rural area become engaged to a woman living in an urban centre. Two of these men were HIV-positive, contributing 4.1% to the total number of positive cases. In terms of locality, HIV prevalence was highest (at 13.6%) in situations where both partners lived in a rural village (125 couples), and partners in such couples made a high contribution to the total number of positive cases (34.7%). One hundred and seventeen couples had partners who both lived in an urban area, and 11 of these persons tested positive. There was a statistically significant difference between the number of HIVpositive cases occurring among 627 individuals who admitted to having had premarital sex (75.7%), and the number of HIV-positive cases among those who claimed (during the post-test counselling session) to have not had premarital sex. Forty-six individuals (73.4%) who’d had premarital sex tested HIV-positive. Of these, 67.2% admitted multiple partners. Six persons (3%) of the 201 individuals who claimed to have not had premarital sex were HIV-positive. This difference in the number of HIV-positive cases between those who claimed to have had premarital sex and those
African Journal of AIDS Research 2005, 4(2): 99–102
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Table 3: Age-specific HIV prevalence among the study population Age (years)
No. screened n (%)
≤19* 20–29 30–39 40–49 Total
28 (3.3) 408 (47.6) 398 (46.4) 24 (2.8) 858 (100)
HIV+ (n) 3 30 19 0 52
Age-specific prevalence (%)
% Contribution (n = 52 HIV+)
10.7 7.4 4.8 0 6.1
5.8 57.7 36.5 0
* Only females tested
Table 4: Distribution of HIV-positive respondents and their locality Locality Rural Urban Total
Males (n)
HIV+ (%)
(n)
144 285 429
7 (4.9) 16 (5.6) 23 (5.4)
293 136 429
who did not, achieved statistical significance (χ2 = 4.89, df = 1; P = 0.027). Although 22 of the respondents had had some form of surgery in the past (mainly appendectomies, 68.2%, and herniorrhaphies, 22.7%), none had ever had a blood transfusion. Discussion The estimated 6.1% HIV prevalence in the study population is marginally higher than, yet comparable to, Nigeria’s national average. Estimates by UNAIDS (2004) showed 5.4% HIV prevalence in adults aged 15 to 49 years in 2003 — the same age bracket considered here. The implications of these figures should not be lost: the ratio of 1 in 9 couples in the study population affected by HIV is alarming. In traditional African society, premarital chastity was encouraged; however, with modernisation and Western cultural influence, much of Africa’s population now adopts a more liberal attitude to sex, with a consequent increase in sexual activity (Fawole, Asuzu & Oduntan, 1999). Premarital sex is on the increase (Gage, 1999) and a multiplicity of partners is common (Fawole et al., 1999; Gage, 1999). More than 88% of the HIV-positive respondents in the study admitted to having had premarital sex, and in some cases with more than one partner. The health implications include potential HIV infection. In Nigeria, unprotected heterosexual sex accounts for about 85% of HIV transmission (FMOH, 2003). Such risk is increased in the presence of other sexually transmitted infections and a multiplicity of partners (FMOH, 2003). It is likely that our HIV-positive subjects had contracted their infection through premarital sex as none ever had a blood transfusion, and, except for using public barbers, no other obvious risk factors were observed among them. Similar to findings by Ekweozor, Olaleye, Tomori, Salia & Essien (1994), there was a slight preponderance of HIV-positive females compared with males, although prevalence was nearly the same among men and women, and the difference was not statistically significant (χ 2 = 0.74, df = 1; P = 0.39).
Females HIV+ (%) 20 (6.8) 9 (6.6) 29 (6.8)
Total (n)
HIV+ (%)
437 421 858
27 (6.2) 25 (5.9) 52 (6.1)
However, it has been shown that females can be biologically, physiologically, socially and economically more vulnerable to HIV infection, especially in the face of their limited power in negotiating sexual relations and condom use (WHO, 1996; Fawole et al., 1999). The HIV infection and deaths of women under these circumstances has grave implication in developing countries, where women are often affected during their economic prime (Royal College of Obstetricians and Gynaecologists, 1996). The majority of the couples fell within the 20–29-year-old age bracket, which made the largest contribution to the number of HIV-positive cases. It is noteworthy that adolescent females had a relatively high age-specific prevalence at 10.7%, and that the youngest group of males tested (age 20–29 years) had a similarly high prevalence at 10.8%. The vulnerability of adolescents and young adults has been documented in several studies (see Shulkin, Mayer, Wessel, De Moor, Elder & Franzini, 1991; Fawole et al., 1999; Gage, 1999). In adolescents, this arises from their growing personal conflict, sexual maturation and experimentation against a background of poor knowledge, skills and low contraceptive usage. Ekweozor et al. (1994) also found higher HIV prevalence among urban dwellers than rural dwellers in Nigeria. Our estimate was similar, but not statistically significant. It may be that the aggressive HIV/AIDS prevention campaign, mainly via the print and electronic media, is mostly urbanbased and hardly filters to the rural areas. The destruction of cultural and traditional African family values in the face of poverty might mean an increase in unprotected premarital sex for financial gain (Gorgen, Birga & Hans Jochen, 1993; Gage 1999). In fact, we found that the couples who lived in rural villages were the larger portion of couples affected by HIV (13.6%). Where both partners were urban residents, 9.4% of those couples were affected by HIV. However, locality (urban or rural) had no statistical influence on predicting HIV prevalence (χ2 = 0.02, df = 1; P = 0.88), and neither did couples’ various residential combinations. Nonetheless, it was clear that many urban-based men
102
preferred engagement to rural women, whom they considered more ‘sexually decent’ than urban women. Our study hardly substantiated such a belief: partners in a couple comprising an urban male and a rural female made the highest contribution to the total number of positive cases (38.8%) as well as the total portion of couples affected (11.3%). Ekweozor et al. (1994) noted that such urbanbased men engaged in occupations like driving, salesmanship and trading — groups understood as at higher risk of HIV infection. Conclusions Premarital HIV screening of a population thought not to be at risk has revealed relatively high prevalence among partners preparing for marriage. Most cases were of serodiscordant couples (only one partner infected). In Nigeria, the primary mode of HIV transmission is heterosexual sexual contact. Premarital HIV screening among couples, as offered by the Catholic Church in Nigeria, seems a compelling means to identify cases of HIV infection, especially in a country where doctors may lack knowledge of counselling to accompany HIV testing and where other opportunities to screen a population may be missed (Umezulike & Etefie, 2002). Acknowledgments — The authors are grateful to staff in the records department of both hospitals for their cooperation with data retrieval. The authors — OUJ Umeora is a lecturer in obstetrics and gynaecology at Ebonyi State University, and an honorary consultant obstetrician and gynaecologist at Ebonyi State University Teaching Hospital. His research interests are maternal mortality, adolescent reproductive health and HIV/AIDS. COU Esike is a registrar for obstetrics and gynaecology at Ebonyi State University Teaching Hospital. His research interests are maternal mortality and HIV/AIDS.
References American College of Obstetricians and Gynecologists (1999) American Academy of Pediatrics and American College of Obstetricians and Gynecologists, joint statement on human immunodeficiency virus screening. Washington D.C. Apodaca, C.C. & Maslow, A.S. (2001) Acquired immunodeficiency syndrome in gynecology. Chapter 46. In: Sciarra, J.J. (ed.)
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Gynecology and Obstetrics 2001 on CD-ROM, Vol. 1. Philadelphia, Lippincott Williams & Wilkins. Center for Disease Control (1995) USPHS recommendations for human immunodeficiency virus counseling and voluntary testing for pregnant women. Morbidity and Mortality Weekly Review 44, pp. 1–15. Ekweozor, C.C., Olaleye, O.D., Tomori, O., Salia, I. & Essien, E.M. (1994) Sexually transmitted diseases in Ibadan in the 1990s: HIV an additional dimension. African Journal of Medical Sciences 23, pp. 363-367. Fawole, O.I., Asuzu, M.C. & Oduntan, S.O. (1999) Survey of knowledge, attitudes and sexual practices relating to HIV infection/AIDS among Nigerian secondary school students. African Journal of Reproductive Health 3(2), pp. 15-24. Federal Ministry of Health (FMOH) (2003) Training Manual on HIV/AIDS Voluntary Counselling and Testing Services in Nigeria. Abuja, Nigeria, The Federal Ministry of Health. Gage, A.J. (1999) Sexual activity and contraceptive use: the components of the decision-making process. Studies in Family Planning 29(2), pp. 154-166. Germain, A. & Kidwell, J. (2005) The unfinished agenda for reproductive health: priorities for the next 10 years. International Family Planning Perspectives 31(2), pp. 90-93. Gorgen, R., Birga, M. & Hans Jochen, D. (1993) Problems related to schoolgirl pregnancies in Burkina Faso. Studies in Family Planning 24(5), pp. 283-294. Lindan, C., Allen, S. & Serufilira, A. (1992) Predictors of mortality among HIV-infected women in Kigali, Rwanda. American Journal of Internal Medicine 116, pp. 320-328. Royal College of Obstetricians and Gynaecologists (1996) HIV and pregnancy. British Journal of Obstetrics & Gynaecology 103, pp. 1184–1190. Shulkin, J.J., Mayer, J.A., Wessel, L.G., deMoor, C., Elder, J.P. & Franzini, L.R. (1991) Effects of a peer-led intervention with university students. Journal of American College Health 40(2), pp. 75-79. World Health Organization/Family and Reproductive Health (1996) Safe Motherhood: A newsletter of worldwide activity 22(3), p. 4. World Health Organization (1999) Reduction of Maternal Mortality. A joint statement by WHO, UNFPA, UNICEF and the World Bank. Geneva, WHO. Wallace, S. (2004) HIV in obstetrics and gynaecology. In: Arulkumaran, S., Symonds, I.M. & Fowlie, A. (eds.) Oxford Handbook of Obstetrics and Gynaecology. New Delhi, India, Oxford University Press. Umezulike, A.C. & Etefie, E.R. (2002) Lack of HIV knowledge and counselling. International Journal of Obstetrics & Gynaecology 76, pp. 89-90. UNAIDS (2004) Report on the Global HIV/AIDS Epidemic. Geneva.
Copyright © NISC Pty Ltd
AJAR EISSN 1727–9445
Prevalence of HIV infection among premarital couples in southeast Nigeria Odie Ugochukwa Umeora* and Chidi Esike Department of Obstetrics & Gynaecology, Ebonyi State University Teaching Hospital, PO Box 980, Abakaliki 480001, Ebonyi State, Nigeria * Corresponding author, e-mail: [email protected]
The Catholic Church in Nigeria offers premarital HIV screening to couples, yet instances of voluntary screening are rare in southeast Nigeria. This study examines the contribution of such tests to HIV detection, and evaluates the prevalence of HIV infection in southeast Nigeria among couples who are planning to marry. Out of 858 individuals (or 429 couples) tested for HIV, 52 individuals were found to be HIV-positive (overall prevalence 6.1%), and females were marginally more affected than males. In both sexes, prevalence was higher in younger age groups. Prevalence among adolescent females was 10.7%. Although no male adolescents were screened, prevalence for the group aged 20 to 29 years was 6.3% for females and 10.8% for males. The prevalence estimate was slightly higher for rural dwellers (6.2%) than for urban residents (5.9%), but this was not statistically significant. We propose that screening apparently healthy individuals, such as couples intending to marry, and who are otherwise not members of a group considered at high risk for HIV infection, can serve an important role in HIV detection in the general population. Keywords: Africa, church, counselling, testing and screening, seropositive partners
Introduction
Methodology
Since the 1980s, HIV-related illnesses have been the leading cause of death among young women in Africa (Lindan, Allen & Serufilira, 1992). This trend has grave implications to African society where women are often the primary earners, the custodians of family values, and the primary educators and caregivers of young and old alike (WHO, 1999). A delay in the detection and management of HIV infection is directly linked to such deaths, as many individuals, and their health-care providers, do not perceive themselves as at-risk (Apodaca & Maslow, 2001). Over the years, recommendations for HIV testing among women have evolved from initial testing offered especially to those identified as high risk, to broader voluntary counselling and testing (VCT). In an effort to de-stigmatize HIV testing and increase the rate of testing and identification of HIV-positive women, the American Institute of Medicine recommended a shift from counselling and VCT to universal HIV testing with patient notification as a routine component of prenatal care (Center for Disease Control, 1995). This recommendation was endorsed by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists (1999) and has been in practice in the United Kingdom since 2000 (Wallace, 2004). More recently, there appear to be increasing rates of premarital sexual activity in developing countries (Gage, 1999). The Roman Catholic Church in Nigeria offers HIV screening to all premarital couples. This has provided an opportunity to screen an apparently healthy component of the population, who are considered not at risk of HIV infection. This study aimed to assess HIV prevalence among couples so screened.
Background to the study Preparatory to marriage Catholic couples are required to attend premarital classes on family life. Included in such a course is haematological screening for blood group and genotype. Couples are also taught about HIV/AIDS; following pre-test counselling they are sent for HIV screening at one of the Catholic or recognised government hospitals in their locality. The Mater Misericordiae Hospital in Afikpo and St. Vincent’s Hospital in Ndubia are Catholic hospitals in Ebonyi State, southeast Nigeria. The former is accredited by both the Nigerian National and West African postgraduate medical colleges for training in obstetrics and gynaecology, while the latter serves as a training centre for community healthextension workers. Both run efficient laboratory services with facilities for HIV testing for clients originating within or outside the hospitals. Patients attend these hospitals from areas throughout Ebonyi State as well as from parts of the neighbouring Abia and Cross River states. Study population This is a review of retrospective data relating to all premarital couples who underwent HIV testing at the two hospitals over a five-year period (2000–2004). The couples usually arrived together, with a letter from the Catholic parish requesting screening. The couples were counselled earlier as part of the mandatory marriage course organised by their parish. On arrival, they obtained a hospital folder where their bio-data, including age and place of residence, were recorded. Other pre-test counselling was not mandatory at this stage.
100
HIV testing procedure A 5ml sample of blood was collected from each client and sent to the laboratory for screening by the ELISA technique. Reactive tests were repeated in duplicate, and any one that turned reactive again was declared positive. Post-test counselling was undertaken by the medical officer on duty before disclosure of the result to the couple, individually and confidentially. Individuals testing HIV-positive were encouraged to go for confirmatory tests. Results of the screening were documented and kept in the hospital’s central records department. Statistics We retrieved case records from the central records department of the two hospitals. Data extracted related to the HIV screening results and the bio-data of the couples tested. The lack of reliable data on the educational and occupational status of the individuals was a limitation in the study. Univariate analysis was carried out and frequency tables constructed. The chi-square test was employed to determine significance, at a p-value of less than 0.05. Results Through the period under review (2000-2004) 858 individuals (429 couples) were screened for HIV infection. Of these, 52 individuals were HIV-positive, amounting to 6.1% prevalence (Table 1). This affected 49 couples (approximately 1 in 9 couples). In 46 couples only one partner was HIV-positive; in 3 couples both partners were positive. Of the total tested over 5 years, 23 males were positive (5.4%) and 29 females (6.8%) were positive (Table 2), but the difference in sex distribution was not statistically significant (P = 0.39). The youngest age group of both females and males (i.e., females age 19 years and under, and males aged 20-29 years) had the highest age-specific prevalence, at 10.7% and 10.8%, respectively. The mean ages of the study population were 32.9 ± 5.0 years for males and 26.1 ± 4.5 years for females. The majority of individuals (47.6%) were within the 20–29-year-old age group (Table 3) and contributed the majority (57.7%) of HIVpositive cases. Adolescents (age 19 years and under, but only females tested) had the highest age-specific prevalence (10.7%), constituted the least portion (3.3%) of the study population, and contributed the least (5.8%) to the total number of HIV-positive cases. The 30–39-year-old age group made up 46.4% of the study population, had the lowest age-specific prevalence (4.8%), and contributed 36.5% of the total positive cases. Of the screened population, 437 were rural dwellers, with 27 (6.2%) returning positive tests, while 25 (5.9%) of 421 urban dwellers tested HIV-positive; however, the difference in locality was not statistically significant (χ2 = 0.02; P = 0.88) (Table 4). Most men screened (66.4%) resided in an urban area, and most females (68.3%) lived in a rural area. HIV prevalence was marginally higher among females from rural areas (6.8%, n = 20) than among females from urban areas (6.6%, n = 9), but this was not statistically significant (χ 2 = 0.01, df = 1; P = 0.94). More HIV-positive cases occurred among males from urban areas (5.6%, n = 16)
Umeora and Esike
Table 1: HIV prevalence in the study population Year 2000 2001 2002 2003 2004 5-yr total
No. tested
HIV+ (n)
Prevalence (%)
108 164 170 204 212 858
5 6 11 19 11 52
4.6 3.7 6.5 9.3 5.2 6.1
Table 2: Sex distribution and age-specific HIV prevalence among 429 couples tested (2000-2004) Age (years) Males ≤19 20–29 30–39 40–49 Females ≤19 20–29 30–39 40–49 Total
No. tested
HIV+ (n)
Age-specific prevalence (%)
– 93 312 24 429
– 10 13 – 23
– 10.8 4.2 – 5.4
28 315 86 – 429
3 20 6 – 29
10.7 6.3 7.0 – 6.8
χ2 (for general sex distribution) = 0.74 (df = 1), P = 0.39 than those who were rural dwellers (4.9%, n = 7), but the difference also was not statistically significant (P = 0.74). No statistical difference was demonstrated in prevalence among rural women vs rural men (P = 0.68), nor among urban females vs urban males (P = 0.42). We noted that many men living in urban centres had become engaged to rural-dwelling women. Nineteen of such couples were affected by positive test results and made a 38.8% contribution to the total number of positive cases. Only in 19 instances had a man from a rural area become engaged to a woman living in an urban centre. Two of these men were HIV-positive, contributing 4.1% to the total number of positive cases. In terms of locality, HIV prevalence was highest (at 13.6%) in situations where both partners lived in a rural village (125 couples), and partners in such couples made a high contribution to the total number of positive cases (34.7%). One hundred and seventeen couples had partners who both lived in an urban area, and 11 of these persons tested positive. There was a statistically significant difference between the number of HIVpositive cases occurring among 627 individuals who admitted to having had premarital sex (75.7%), and the number of HIV-positive cases among those who claimed (during the post-test counselling session) to have not had premarital sex. Forty-six individuals (73.4%) who’d had premarital sex tested HIV-positive. Of these, 67.2% admitted multiple partners. Six persons (3%) of the 201 individuals who claimed to have not had premarital sex were HIV-positive. This difference in the number of HIV-positive cases between those who claimed to have had premarital sex and those
African Journal of AIDS Research 2005, 4(2): 99–102
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Table 3: Age-specific HIV prevalence among the study population Age (years)
No. screened n (%)
≤19* 20–29 30–39 40–49 Total
28 (3.3) 408 (47.6) 398 (46.4) 24 (2.8) 858 (100)
HIV+ (n) 3 30 19 0 52
Age-specific prevalence (%)
% Contribution (n = 52 HIV+)
10.7 7.4 4.8 0 6.1
5.8 57.7 36.5 0
* Only females tested
Table 4: Distribution of HIV-positive respondents and their locality Locality Rural Urban Total
Males (n)
HIV+ (%)
(n)
144 285 429
7 (4.9) 16 (5.6) 23 (5.4)
293 136 429
who did not, achieved statistical significance (χ2 = 4.89, df = 1; P = 0.027). Although 22 of the respondents had had some form of surgery in the past (mainly appendectomies, 68.2%, and herniorrhaphies, 22.7%), none had ever had a blood transfusion. Discussion The estimated 6.1% HIV prevalence in the study population is marginally higher than, yet comparable to, Nigeria’s national average. Estimates by UNAIDS (2004) showed 5.4% HIV prevalence in adults aged 15 to 49 years in 2003 — the same age bracket considered here. The implications of these figures should not be lost: the ratio of 1 in 9 couples in the study population affected by HIV is alarming. In traditional African society, premarital chastity was encouraged; however, with modernisation and Western cultural influence, much of Africa’s population now adopts a more liberal attitude to sex, with a consequent increase in sexual activity (Fawole, Asuzu & Oduntan, 1999). Premarital sex is on the increase (Gage, 1999) and a multiplicity of partners is common (Fawole et al., 1999; Gage, 1999). More than 88% of the HIV-positive respondents in the study admitted to having had premarital sex, and in some cases with more than one partner. The health implications include potential HIV infection. In Nigeria, unprotected heterosexual sex accounts for about 85% of HIV transmission (FMOH, 2003). Such risk is increased in the presence of other sexually transmitted infections and a multiplicity of partners (FMOH, 2003). It is likely that our HIV-positive subjects had contracted their infection through premarital sex as none ever had a blood transfusion, and, except for using public barbers, no other obvious risk factors were observed among them. Similar to findings by Ekweozor, Olaleye, Tomori, Salia & Essien (1994), there was a slight preponderance of HIV-positive females compared with males, although prevalence was nearly the same among men and women, and the difference was not statistically significant (χ 2 = 0.74, df = 1; P = 0.39).
Females HIV+ (%) 20 (6.8) 9 (6.6) 29 (6.8)
Total (n)
HIV+ (%)
437 421 858
27 (6.2) 25 (5.9) 52 (6.1)
However, it has been shown that females can be biologically, physiologically, socially and economically more vulnerable to HIV infection, especially in the face of their limited power in negotiating sexual relations and condom use (WHO, 1996; Fawole et al., 1999). The HIV infection and deaths of women under these circumstances has grave implication in developing countries, where women are often affected during their economic prime (Royal College of Obstetricians and Gynaecologists, 1996). The majority of the couples fell within the 20–29-year-old age bracket, which made the largest contribution to the number of HIV-positive cases. It is noteworthy that adolescent females had a relatively high age-specific prevalence at 10.7%, and that the youngest group of males tested (age 20–29 years) had a similarly high prevalence at 10.8%. The vulnerability of adolescents and young adults has been documented in several studies (see Shulkin, Mayer, Wessel, De Moor, Elder & Franzini, 1991; Fawole et al., 1999; Gage, 1999). In adolescents, this arises from their growing personal conflict, sexual maturation and experimentation against a background of poor knowledge, skills and low contraceptive usage. Ekweozor et al. (1994) also found higher HIV prevalence among urban dwellers than rural dwellers in Nigeria. Our estimate was similar, but not statistically significant. It may be that the aggressive HIV/AIDS prevention campaign, mainly via the print and electronic media, is mostly urbanbased and hardly filters to the rural areas. The destruction of cultural and traditional African family values in the face of poverty might mean an increase in unprotected premarital sex for financial gain (Gorgen, Birga & Hans Jochen, 1993; Gage 1999). In fact, we found that the couples who lived in rural villages were the larger portion of couples affected by HIV (13.6%). Where both partners were urban residents, 9.4% of those couples were affected by HIV. However, locality (urban or rural) had no statistical influence on predicting HIV prevalence (χ2 = 0.02, df = 1; P = 0.88), and neither did couples’ various residential combinations. Nonetheless, it was clear that many urban-based men
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preferred engagement to rural women, whom they considered more ‘sexually decent’ than urban women. Our study hardly substantiated such a belief: partners in a couple comprising an urban male and a rural female made the highest contribution to the total number of positive cases (38.8%) as well as the total portion of couples affected (11.3%). Ekweozor et al. (1994) noted that such urbanbased men engaged in occupations like driving, salesmanship and trading — groups understood as at higher risk of HIV infection. Conclusions Premarital HIV screening of a population thought not to be at risk has revealed relatively high prevalence among partners preparing for marriage. Most cases were of serodiscordant couples (only one partner infected). In Nigeria, the primary mode of HIV transmission is heterosexual sexual contact. Premarital HIV screening among couples, as offered by the Catholic Church in Nigeria, seems a compelling means to identify cases of HIV infection, especially in a country where doctors may lack knowledge of counselling to accompany HIV testing and where other opportunities to screen a population may be missed (Umezulike & Etefie, 2002). Acknowledgments — The authors are grateful to staff in the records department of both hospitals for their cooperation with data retrieval. The authors — OUJ Umeora is a lecturer in obstetrics and gynaecology at Ebonyi State University, and an honorary consultant obstetrician and gynaecologist at Ebonyi State University Teaching Hospital. His research interests are maternal mortality, adolescent reproductive health and HIV/AIDS. COU Esike is a registrar for obstetrics and gynaecology at Ebonyi State University Teaching Hospital. His research interests are maternal mortality and HIV/AIDS.
References American College of Obstetricians and Gynecologists (1999) American Academy of Pediatrics and American College of Obstetricians and Gynecologists, joint statement on human immunodeficiency virus screening. Washington D.C. Apodaca, C.C. & Maslow, A.S. (2001) Acquired immunodeficiency syndrome in gynecology. Chapter 46. In: Sciarra, J.J. (ed.)
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