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 Tuesday 26 February 2008
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Beyond ABC: The challenge of Prevention

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SOUTH AFRICA: Trust, Lust and Latex

Photo: LoveLife
Is trust overrated?
Sexual relationships are complicated enough as it is, and become even more so when a piece of latex is added to the equation, but when love appears things tend to become even more difficult.

Just ask a group of 15 young professional women gathered at a party in a stylishly decorated lounge in Sunninghill, an affluent suburb in Johannesburg, South Africa's economic hub.

A "Naughty Knickers" party - a private affair where women can purchase sexy underwear and sex toys, and swap sex stories - seemed to be the perfect place to broach the topic of condom use in relationships.

However, after the women had oohed and aahed over the colourful wares, and regaled each other with their sexual triumphs and disasters, the humble condom had yet to make an appearance in conversation or during the saleswoman's exhibition.

Hardly surprising, noted business analyst Mpho, 26, (last name withheld) as many of the women were in love, trusted their partners, and thought that it no longer necessary to use condoms.

"It's fine [to use condoms] when you're in a fling and you don't know where it's going. But once it starts getting serious, you always associate condoms with suspicious behaviour and all sorts of questions arise," she told PlusNews.

Dr Catherine MacPhail, of the adolescent programme at the University of Witwatersrand's Reproductive Health Research Unit (RHRU), admitted that this was a "huge issue" when addressing HIV/AIDS prevention and behaviour change, particularly among young people.

Although condom use in South Africa has increased over the past few years, getting people to use this method of protection regularly is still a major challenge.

In 2004, the largest representative survey of South African youth aged between 15 and 24 conducted by RHRU found that although 33 percent of youth who had sex in the past 12 months reported always using a condom, double that number - 67 percent - were still not using condoms consistently.

In a country where an estimated 5.3 million people are living with HIV/AIDS, can people still afford to attach negative connotations to regular condom use?

However, MacPhail said HIV/AIDS prevention campaigns were starting to realise the importance of contextual factors feeding people's vulnerability to HIV/AIDS and were no longer conveying messages such as 'you're stupid if you don't use a condom'.

Angela Stewart-Buchanan, media manager for LoveLife - South Africa's largest youth HIV/AIDS awareness campaign - warned that prevention efforts could no longer ignore these factors.

"It's not as easy to pinpoint why people are engaging in unsafe sex, it's multi-faceted, and this must be taken into account. Self-esteem, lifestyle, values and trust - they all play a role," she told PlusNews.


In her previous relationship, Mpho and her boyfriend did not consciously make a decision to stop using condoms, "it just happened".

"I loved him and I wanted to show him that I trusted him absolutely. We knew each other quite well, we were exclusive but we never tested [for HIV]," she admitted, despite the fact that he was a doctor.

Which is one of the reasons the government's awareness campaign, Khomanani, has launched a series of print, radio and TV advertisements urging young couples to get tested together. All the young women in Sunninghill agreed that the idea of couple-testing had merit, and they would definitely do it before they got married - but not now.

"They make it look so easy and it's not, especially when you supposedly trust someone enough not to use a condom. It's difficult to revert to all of that mistrust," said Mpho, who is preparing herself to bring up the issue in her latest relationship.

MacPhail remarked on how young people often mentioned the notion of trust, which made "absolutely no sense", as it had very little to do with how their partner behaved.

"It's a complete mismatch ... saying you trust someone but at the same time you admit your partner has other sexual partners," she added.

Goretta, 27, (not her real name) is aware of the tension that arises when emotions and condoms mix. Her sister has been in a relationship for five years and does not use condoms, even though she is aware that her partner has been cheating on her.

"After five years she needs to trust him [because] she needs to hold on to him," she observed. But the ambitious IT analyst is not taking any chances - with two of her family members living with HIV/AIDS, she has learnt to be more careful.

"I've never reached a point where I trust, or even love, someone enough not to use a condom," Goretta stressed.

For young women who are empowering themselves economically, the bedroom remains the final frontier.

Deep-rooted gender inequalities and social norms that require them to be passive about sex, and submissive to the will of men in determining the terms of sexual relationships, remain prevalent - more so with poorer women.

Although Dinga Makohliso (not his real name) pointed out that his current motto was "trust no-one" and that condoms were a necessity in his sexual relationships, he admitted that this was not always the case.

"With guys my age ... once you've been out with a girl for at least six months, that's when you decide to stop using condoms. You trust her to stay on the pill and leave it up to her. If she insists on using condoms, your initial reaction would be: 'Why, who've you been sleeping around with?'" the 20-year-old student commented.


Men are frequently criticised for being in denial about the disease, and blaming women for "bringing the virus into the home". They are also accused of refusing to take responsibility for their health, and failing to practice safer sex.

Women bear the brunt of the epidemic, and for physiological, economic and social reasons find it extremely difficult to negotiate condom use in their relationships.

With the odds stacked against them - including poverty, abuse and violence, lack of information and coercion by older men - many mainstream prevention strategies are untenable, for example, those based exclusively on the 'ABC' approach - "abstain, be faithful, use a condom".

Where sexual violence is widespread, abstinence or insisting on condom use is not a realistic option for women and girls, nor does marriage always provide the answer. In many parts of the developing world, married women have higher rates of HIV than their unmarried, sexually active peers, usually because their husbands have several partners.

But women are not entirely blameless. In her book, 'Letting them die: How HIV/AIDS prevention programmes often fail' researcher Catherine Campbell found that young women "argued particularly strongly that if a steady partner were to insist on condom use, this would indicate a lack of respect".

"If a boy wants to use a condom, a girl will say this is because he disrespects her - because he wants to use 'a plastic'," a teenage girl was reported was saying.

According to Campbell's findings, based on the evaluation of a pilot project on community-based HIV/AIDS prevention in a South African mining town, young people believed that condoms were unnecessary when having sex with their "steady" partner, and should only be used for casual sexual partners.

Young women told the study researchers it was important to appear unavailable for sex by not carrying condoms, to protect their reputations.

MacPhail agreed: "Often many young women don't want to use condoms and be associated with connotations surrounding condoms."

Until a few months ago, before she became involved with "a 24/7 condom user", Mpho would "never be caught dead" buying condoms or carrying them in her bag. "I wouldn't mind someone finding a tampon in my bag but I would be mortified if they found a condom ... it would have looked like I was asking for it," she said.

Mpho was not alone - a chorus of agreement greeted her comments. "I always get shocked when I hear my friends - all well-educated people - say they would rather use the morning-after pill than the condom because they don't enjoy them," Goretta said.

"By the time you put on the condom it can be a passion killer," acknowledged Goretta, "but at what price?"

While condoms admittedly robbed people of a "heightened sense of closeness", there was no reason not to enjoy practising safer sex. "I enjoy sex but I don't want to be thinking about all the risks when I'm doing it. That's why I've learned how to put them on and even have my own," she added.


Apart from condoms, there is another way to curb the spread of HIV once people become sexually active: reducing casual sex and multiple sexual partnerships - the B in the ABC - which has so far been an afterthought.

"While most of the often polarised discussion surrounding AIDS prevention has focused on promoting abstinence or use of condoms, partner reduction has been the neglected middle child of the ABC approach," Daniel Halperin, prevention expert at the United States Agency for International Development, and his fellow researchers noted in the British Medical Journal (BMJ) in 2004.

The BMJ article went on to point out that in Zambia, HIV prevalence reportedly fell among urban young women during the 1990s. At about that time, there was a large reduction in casual sex and having multiple sexual partners as a result of faith-based and other grassroots efforts to promote the delay of sexual debut among young people and monogamy for those who were sexually active.

However, Mpho and the rest of the partygoers were not entirely convinced. "I guess that's the ideal," she said, "but I'm not sure if that can work in real life."


Trusted Partner Campaign - East and Southern Africa
LOVELIFE - South Africa

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