Students’ low condom use continues to drive HIV infections

Are sexual relationships with older partners, who are more likely to insist on having sex without the use of condoms, one of the high-risk drivers that promote and encourage the transmission of human immunodeficiency virus, or HIV, among university students across Sub-Saharan Africa?

This was one of the questions raised by public health researchers in a study, ‘Low condom use at the last sexual intercourse among university students in Sub-Saharan Africa: Evidence from a systematic review and meta-analysis’, that looked into the persistent low and inconsistent use of condoms by university students in the sub-region during the past two decades.

According to Dr Jonathan Izudi, a research fellow in global health at the University of California, and his associates from Uganda’s Makerere University and Mbarara University of Science and Technology, condom use by university students in the region stands at 52.9%.

The researchers found that, although knowledge and awareness of HIV was extremely high – measured at about 97% among university students – there was significant prevalence of risky sexual behaviours that included low condom use, multiple sexual partnerships and high use of alcohol.

“We found condom use among sexually active university students to be lowest in Eastern Africa at 40.5%, and central Africa at 43.9%, and highest in Western and Southern Africa at 58.6% and 50.5% respectively,” Izudi told University World News.

Factors influencing condom use

Using the last sexual intercourse indicator that measures progress towards preventing exposure to HIV through unprotected sex among people with multiple sexual partners, researchers analysed studies on condom use among university students that were included in the Web of Science, Google Scholar and other public health platforms for the period between 2000 and 2019.

Admitting that there was little data to explain the regional differences in condom use in Sub-Saharan Africa, Izudi implied the differences could be explained by socio-cultural, religious and differences in HIV/AIDS control and prevention approaches in each country.

He explained that findings of a higher use of condoms in Western and Southern Africa, in comparison with Eastern and Central Africa, might have been due to differences in HIV prevalence.

“Our submission is that, in high HIV-prevalence settings, the majority of students are potentially influenced to use condoms due to the increased risk of HIV acquisition,” Izudi told University World News in an interview in November.

But, in this regard, the study noted that what was not in doubt was that the university environment in Sub-Saharan Africa was creating a setting for high-risk sexual behaviours through condomless sexual intercourse and multiple sexual partnerships.

Based on data from individual studies, Izudi said countries with low condom use of less than 20% among university students included Madagascar, Ethiopia and Rwanda.

Students and high-risk sex

Most researchers appear to be in agreement that persons aged between 15 and 29, an age bracket that includes most university students, bear the burden of most of the new HIV infections in Sub-Saharan Africa as a result of high-risk sexual behaviours that include transactional sex, concurrent sexual partnering and inconsistent use of condoms.

According to Dr Ayesha Kharsany, a senior scientist at the Centre for the AIDS Programme of Research in South Africa, or CAPRISA, and an honorary associate professor at the University of KwaZulu-Natal, of the estimated 6,000 new infections that occur globally each day, two out of three are in Sub-Saharan Africa, with young women continuing to bear the greater burden.

The issue is that, unlike their male peers, most young women, including female university students, are unable to negotiate properly with older men on HIV prevention options, such as abstinence, behaviour change, condoms and medical male circumcision.

But, beyond university students being engaged in age-disparate relationships that are commonly defined as those between younger women and men who are at least five years older, researchers have identified a wide range of factors that are contributing to risky sexual behaviours.

Dr Mark Mohan Kaggwa of the School of Medicine at Mbarara and his colleagues from Makerere University and Nottingham Trent University in the United Kingdom have identified poverty, the use of illicit drugs and excessive drinking of alcohol as well as the watching of pornographic content as some of the factors contributing to risky sexual behaviours in most countries globally.

But, even more critical for university students in Sub-Saharan Africa, Kaggwa argues that peer pressure, living alone in urban settings, lack of parental control, low family connectedness, poor academic performance and having multiple concurrent sexual partners have become new pathways for HIV and other sexually transmitted infections (STI) in student communities.

In reference to university students in Uganda in the study, ‘Risky sexual behaviours among Ugandan university students: A pilot study exploring the role of adverse childhood experiences, substance use history, and family environment’, that was published in the PLOS ONE edition of 16 November, Kaggwa and his associates noted that the combination of social and demographic factors, family environment and adverse childhood experiences appear to play a huge role in risky sexual behaviours among university students.

First-year students and multiple sexual partners

Even more vulnerable are first-year university students, according to Dr Godswill Osuafor, a senior lecturer in population studies at North-West University in South Africa, and Chinwe Okoli of the Federal Medical Centre. In an article they argued that factors associated with multiple sexual partners among first-year students are not properly characterised in South African universities.

But, according to Izudi, the newly found freedom of living on their own and, too often, sharing rental rooms in informal settlements could be exposing such students to unsafe sex practices.

Dr Vikas Choudhry, the vice president of public health and nutrition at Sambodhi Research and Communications and a former public health researcher at Lund University in Sweden, has also suggested that the systematic withdrawal of public resources in higher education in the past two decades appears to have put many students from poor family backgrounds in Africa at risk of contracting HIV infections as they try to meet their living and learning expenses.

In a recent study that investigated campus relationships at Mbarara, Choudhry and his co-researchers found that multiple concurrent sexual relationships, inconsistent condom use and the exchange of sex for money, gifts and other favours, are drivers of the HIV epidemic among students in Uganda.

Assuming that what is occurring in Ugandan universities, is also happening in other countries in the sub-region, then all is not well as, according to Choudhry and co-researchers, higher rates of HIV infections in this East African country were recorded among young girls in university.

Besides, although there is compelling evidence of increasing sexual activity among university students in Sub-Saharan Africa, the researchers pointed out that very little is known about how students view their sexual relationships in terms of avoiding HIV infections.

Even then, there are indicators that some rich and middle-class parents have started taking their children, especially daughters, to private universities or renting them better accommodation away from the overcrowded public university hostels.

According to Izudi, private and public university students have inherent differences in social and economic status, with the former category being from settings with higher income and social status.

“Students from private universities are better catered for by their parents and, according to our research, the majority of such students are better placed to avoid risky transactional sexual behaviours, or have money to buy and use condoms in contrast to their peers in public universities,” Izudi told University World News.

Insufficient data

The overall picture of HIV among university students in Sub-Saharan Africa is partially masked by insufficient data across the region, for instance, in the attempt to understand the situation, Izudi and his co-researchers managed to retrieve only 44 studies. Of those studies, 23 were from East Africa, 12 from West Africa, eight from Southern Africa and one from Central Africa.

But scarcity of data on the issue is not enough reason to disregard the problem as, according to Winnie Byanyima, the executive director of the Joint United Nations Programme on HIV/AIDS, economic shocks in most countries in Sub-Saharan Africa are fuelling transactional sexual relationships that are driven by a need for support.

What this means is that, with the expansion of university education in the sub-region through the adoption of marketisation policies, many poor students who have not been sponsored by governments or just get meagre public higher education subsidies might have been cast into a web of dependency and forced into trading sex in their quest to acquire a degree or a diploma.