Association of Negotiation Strategies With Consistent Use of Male Condoms by Women Receiving an HIV Prevention Intervention in Zimbabwe

Voluntary HIV testing and counseling is currently being implemented worldwide, particularly among pregnant women, as research demonstrates it can profoundly reduce risky sexual behavior among those who test positive or those in serodiscordant relationships.

The development of condom request strategies should be an integral part of counseling. Little is known about what strategies are used, nor the differential effectiveness of specific strategies in persuading male partners to use condoms. The authors aimed to identify condom negotiation strategies used by HIV-seronegative Zimbabwean women after a prevention intervention. They further explored the effectiveness of specific strategies in achieving consistent condom use (CCU) with male partners.

Study participants were considered if they were women age 18 or older, sexually active with men at least 10 times during the previous three months, using contraception or otherwise not able to become pregnant, and willing to be tested for HIV and receive the result. Women were excluded if they reported condom use at more than 50 percent of all sexual episodes in the previous three months; were HIV-seropositive; or were unable to speak English or Shona. Altogether, 359 women were eligible for the study and 339 were enrolled. Of these, 260 women completed all four study visits, yielding a retention rate of 77 percent. The average age of participants was 29 years. Most participants (96 percent) were married and had at least one child (99 percent).

Each of the four study visits occurred at the clinic. At the first visit, all participants were screened for eligibility (excluding HIV status); those who were eligible received a medical examination and enhanced pre-test counseling (the first component of the intervention). Serum was drawn to test for HIV-1.

The participants returned two weeks later for their HIV-1 results. HIV-seronegative women were enrolled and underwent a face-to-face interview assessment of their sexual behavior and other reproductive health factors. They received the second counseling session and an ample supply of condoms in a plain cloth package.

One month after second visit, the women underwent assessment again and received a third "booster" counseling session (an abbreviated version of the earlier session) and again received condoms. At this visit, women reported which negotiation strategies they had used with their partners in an open-ended format. Two months after the "booster" session, the participants underwent their final interview assessment, which focused on sexual behavior in the previous two weeks.

The intervention achieved impressive levels of self-reported CCU, posting an increase from zero pre-HIV test to 42 percent post-test and intervention to 63 percent at booster intervention and 55 percent at the two month follow-up.

Six strategies were identified and used by at least 10 percent of women. Forty-seven percent of the participants used a strategy of remarking that condoms prevent HIV/AIDS. Twenty-five percent of the women mentioned participation in the study, e.g. "We are encouraged to use condoms by the people at the study." Another, alluding to her own negative HIV test result, was used by 15 percent of respondents. Strategies involving efforts to exonerate their partners of blame, e.g. "Using condoms does not mean you are promiscuous," were used by 12 percent. A fifth strategy, reported by 11 percent of women, based the request on the high prevalence of HIV/AIDS in their community. Finally, 11 percent of women mentioned her partner's earlier infidelities or her own lack of trust in him.

Of the six negotiation strategies identified, only one, mentioning the prevalence of AIDS in the community, was significantly associated with CCU two months after the intervention ended. Perhaps "focusing on the virus, or the community at large, creates less resistance and greater cooperation than using strategies that focus on either or both members of the couple. In Zimbabwe, as in other cultures where group identity is more salient than individual identity, these indirect and non-threatening appeals may be more effective that appealing to individual behaviors," the researchers reported.

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