Nigerian women and HIV transmission
Article: Olive Shisana & Alicia Davids 2004;82:812
7 December 2004 - The recent report of global HIV/AIDS trends (1) detail the dilemmas vis-à-vis addressing the rising prevalence of HIV infection in women, particularly in sub-Saharan Africa. Shisana and Davids (2) highlight such encumbrances to reducing HIV transmission among women particularly in the Southern African region.
Nigeria so far remains an unusual case with regards to African HIV transmission patterns. With a population at least 20% that of the total population of Sub-Saharan Africa, high migratory activity within and outside the country, liberal sexual attitudes - at least in the southern half of the country -, low (<10%) estimates of condom use and a thriving, unregulated, sex industry, the 14% 1990s HIV prevalence among Lagos sex workers (3), and a 2001 survey estimate reporting 5.85% HIV prevalence among women aged 15-24 (4) years is surprisingly low compared with most African countries, particularly in the so-called AIDS belt, where rates exceeding 15% among young women are not uncommon (5).
Factors which might provide partial explanation for Nigeria’s relatively low HIV prevalence include high rates of male circumcision, as well as anecdotal reports of low prevalence of intravenous drug use and anal sexual intercourse. Nevertheless, the level of high-risk sexual networking in Nigeria, be it within or outside marriage, is so high as to expose large sections of the population to the risk of HIV and other sexually transmissible diseases.
It appears that the rising global trends in female HIV prevalence is not unexpected given that the chance of one penile-vaginal sexual act in partners who are disease-free except that one is HIV-positive may be as low as one in 1000 from woman to man, compared with one in 300 from man to woman (5). The rising popularity of multi-mate mating among, in particular, urban-based women in the 15-29 years’ age group significantly increases the risk of HIV infection among women.
The following approaches are potentially useful controlling HIV transmission in Nigeria, particularly among women:
- Expansion of fee-exempt sexual health diagnostic and treatment services, integrated into family planning clinics. High levels of ulcerative genital infections in Nigeria constitute a major facilitator of HIV transmission. Currently, orthodox treatment for sexually transmissible diseases is expensive, and quackery is rampant, a scenario conducive to rapid HIV transmission.
- Regulation of the commercial sex industry, even if this implies tacit legalization of prostitution. This would enable prostitutes to be registered, and for sexual health services to be targeted at this cohort with a much higher HIV prevalence. It might also facilitate a stricter, more consistent, condom use culture among prostitutes
- Addressing the reasons for extramarital sexual relations among men and women. This is particularly important since unprotected sex among married couples is the norm, yet many married men and women engage in unprotected extramarital sexual relations, and thus risk infecting their spouses. In a 1990 study of the reasons for extramarital sex in Ekiti, South-western Nigeria, the commonest reasons given by men were enjoyment, and pregnancy/post-partum abstinence, while for women; enjoyment and economic benefits were the most common reasons. These reasons had a significant geographical bias for women, with 60% of married urban females having extramarital sex for enjoyment compared with 33% of rural married females, and with 34% of married rural women having sex as a means of securing economic benefits, compared with 14% of married urban women (6). This study has important implications in the implementation of HIV prevention programs in rural and urban settings, as the motivations for indulging in high-risk sexual behaviors in Nigeria and most developing countries vary significantly by geography and socio-economic status.
- The use of Positive Deviance techniques in promoting uncommon but health promoting attributes with respect to HIV transmission among women, such as techniques for consistent condom use with casual sexual partners, as well as unique cultural, interpersonal, legal, and religious attributes that encumber female decision making on sexual issues (7).
- Strict implementation of harsh legal sanctions for men and women who knowingly transmit HIV infection, including rapists.
- Development of effective microbicides against HIV for use by women, and provision at an affordable cost to those who most need such products.
- A whole-of government approach to facilitate major improvements in access to female education (particularly in the northern regions), female ownership of capital, and commitment to equal employment opportunities.
- AIDS epidemic update. UNAIDS/WHO – 2004. Available from: URL: http://www.unaids.org/wad2004/EPIupdate2004_html_en/epi04_00_en.htm
- Shisana O., Davids A. Correcting gender inequalities is central to controlling HIV/AIDS. Bulletin of the World Health Organization 2004;82:812.
- Mann JM, Tarantola DJM, Netter TW. (eds). AIDS in the world, Cambridge, Harvard University Press, 1992, p 896-898.
- Globalis country indicator. Available from: URL: http://globalis.gvu.unu.edu/indicator_detail.cfm?IndicatorID=131&Country=G
- Caldwell JC. Understanding the AIDS epidemic and reacting sensibly to it. Social Science and Medicine 1995;41:299-302.
- Oruboloye IO, Caldwell JC, Caldwell P, Santow G. (eds) Sexual networking and AIDS in Sub-Saharan Africa. Health Transitions Series No. 4, Health Transition Centre, The Australian National University, 1994.
- Marsh DR, Schroeder DG, Dearden KA, Sternin J, Sternin M. The power of positive deviance. BMJ 2004;329:1177-9.
Associate Professor Niyi Awofeso. New South Wales Justice Health, and School of Public Health and Community medicine, University of new South Wales, Sydney 2052 Australia. (email: Niyi.Awofeso@justicehealth.nsw.gov.au)