Journal of Clinical Research in HIV AIDS and Prevention
ISSN: 2324-7339
Current Issue
Volume No: 2 Issue No: 2
share this page

Research Article | Open Access
  • Available online freely | Peer Reviewed
  • | Provisional

    Determinants of Consistent Condom Use among HIV-Positive Women in Abia State, South-East Nigeria.

    Ijeoma Nduka 1     Ezinna Ezinne Enwereji 2       Enyinnaya C Nduka 3     Eke Reginald Ahuizi 2    

    1 Department of Community Medicine, Niger Delta University Wilberforce Island, Amassoma Bayelsa state, Nigeria.

    2 College of Medicine, University Teaching Hospital, Abia State University Uturu, Aba, Abia State, Nigeria.

    3 Department of Obstetrics and Gynecology, Federal Medical Center, Umuahia, Abia State.

    Abstract

    Background:

    The use of condoms in marriages is a complex decision. It however plays a role in prevention of HIV and other sexually transmitted infections (STIs). The problem is, what factors and conditions determine consistent condom use among HIV positive women? This study aimed at identifying determinants of consistent condom use among HIV positive women cohabiting with their partners and attending ‘Heart to Heart’ treatment centre in Abia State University Teaching Hospital.

    Materials and Method:

    This longitudinal descriptive study was conducted among 248 married HIV positive women who attended ‘Heart to Heart’ treatment centre in the Abia State University Teaching Hospital from December 2012 to February 2013 and are cohabiting with their partners. Interviewer administered semi-structured questionnaire was used to obtain data from the respondents. Data were analysed using SPSS version 17 software.

    Results:

    A total of 73(29.4%) of the respondents used condom consistently. Age, level of education, and desire for more children influenced condom use (OR 7.023., CI 2.050 – 24.047, P<0.001). The older the respondents, the more condom they used (OR 164.474, CI 21.477 – 1260.2, P<0.001). Also the more educated the respondents were, (tertiary, secondary) the more likely they used condom. Women who did not desire more children used condom more than those who desired more children (OR 13.612, CI 0.043-26.311, P<0.001). Women who had disclosed their HIV status to their spouses, used condom more than those who had not (OR 13.072, CI 5.836 – 29.253, P<0.001).

    Conclusion

    The fact thatonly 29.4% of the respondents used condom consistently with their spouses shows lack of awareness of the benefits of condom use. Health education which will stress the importance of using condom in preventing HIV transmission and other sexually transmitted infections (STIs) is recommended for HIV positive women and their spouses.

    Received 10 Oct 2013; Accepted 27 Jun 2014; Published 19 Jul 2014;

    Academic Editor:Christophe Marchand, National Cancer Institute, NIH, Bethesda, MD 20892

    Checked for plagiarism: Yes

    Review by: Single-blind

    Copyright©  2014 Ijeoma Nduka, et al.

    License
    Creative Commons License    This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

    Competing interests

    The authors have declared that no competing interests exist.

    Citation:

    Ijeoma Nduka, Ezinna Ezinne Enwereji, Enyinnaya C Nduka, Eke Reginald Ahuizi (2014) Determinants of Consistent Condom Use among HIV-Positive Women in Abia State, South-East Nigeria.. Journal of Clinical Research In HIV AIDS And Prevention - 2(2):1-12.
    Download as RIS, BibTeX, Text (Include abstract )
    DOI10.14302/issn.2324-7339.jcrhap-13-321

    Introduction

    Nigeria is the most populated country in Africa with an estimated population of 163 million and an annual growth rate of 2.6%. The prevalence of HIV among the general population is 3.6% with a national median prevalence of 4.1% among pregnant women 1, 2, 3, 4, 5. In sub-Saharan Africa, 60% of the people living with HIV are females. These African women make up 50% of the global epidemic 6. In Nigeria, females constitute 58% (about 1.62 million) of persons living with HIV 7. About 55% of AIDS deaths that occur in Nigeria each year, are among females within 15-49 years of age. This shows that the number of women infected with HIV is on the increase. 8, 9.

    According to the UNAIDS 2011 report, young women (15-24years) have a three times higher infection rate than young men of same age. The problem is that these females, who are in their reproductive ages, can have sex without condom. Having sex without condom can expose the females and their sex partners to the risk of HIV infection. Also if they get pregnant, there are chances of increasing the number of children they will have living with HIV and AIDS. This is possible because less than 30% of pregnant women in Nigeria have access to prevention of mother to child transmission (PMTCT) services 10, 11, 12, 13. There is need to increase PMTCT because according to the UNAIDS report of 2013, Nigeria has the highest number of children living with HIV and AIDS.

    Vulnerability of females to HIV in Nigeria has been linked to various factors including non-insistence on use of condom during sexual intercourse. In Nigeria, culture prohibits women from negotiating condom use during sex. As a result, most women, especially those whose spouses engage in multiple sex partners are exposed to sexually transmitted infections (STIs) including HIV 14. Some researchers have estimated that 33% of marriages in Nigeria are polygamous in nature and have recommended that women should be encouraged to negotiate condom use during sex so as to prevent sexually transmitted infections including HIV 15, 16, 17. Therefore the need to emphasize condom use among females especially those living positively with HIV and AIDS should not be underestimated.

    Studies have shown that for condom use to provide 69-94% effectiveness in preventing sexually transmitted diseases including HIV, it must be used consistently during sexual intercourse 18. However, consistent condom use in stable marriages is doubtful. The fear of being accused of infidelity prevent couples especially women from negotiating condom use during sex 19, 20, 21. In a study of five African countries, it was found that two-thirds of HIV infected couples with sero-discordant families use condom but irregularly. The main reason identified for the irregular condom use was the desire to have children. It is estimated that over half of new infections that occur in marriages are as a result of infrequent condom use 22, 23, 24. It is thought that with the increasing availability and accessibility of antiretroviral treatment and improved health care services, that the prevalence of HIV and AIDS among females will be reduced if condom is consistently used during sex. Studies have shown that inconsistent condom use has exposed spouses especially females to infections and re-infection of sexually transmitted diseases including HIV 25, 26.

    However, promotion of condom use among couples should be done with caution to prevent violence occasioned by couples suspecting each other of sexual promiscuity. In such families, the indirect benefits of condom as a contraceptive rather than as a stand-alone method for preventing STIs should be emphasized. In this case, the risk of HIV transmission in marriages could be reduced by encouraging partners to disclose their sero-status as well as use condom for sexual intercourse. 27, 28, 29, 30.

    Studies on the use of condoms among HIV positive women in stable marriages are limited in developing countries including Nigeria. The purpose of this study was to assess the factors that encourage individuals living with HIV and AIDS to consistently use condom during sexual relations so as to protect themselves against infections and re-infections. The researchers were motivated to carry out this study by the recent call on the need to reduce HIV infection and re-infection among couples so as to guarantee increased PMTCT. By this study, the researchers intend to contribute a quota in the reduction of HIV and AIDS prevalence in Nigeria. The result of the study will help to increase the chances of clients benefiting from the services offered to them in the clinic.

    Materials and Methods

    The study was conducted among 248 married HIV positive women between the ages of 15-49 years who are cohabiting with their husbands and attending the ‘Heart to Heart’ clinic in the Abia State University Teaching Hospital between December 2012 and February, 2013. The study took place in the Abia State University Teaching Hospital. This hospital is the only tertiary and referral health center that serves HIV positive individuals in Abia State and its environs. The antiretroviral treatment [ART) offered in this center is jointly supported by the Government and the Family Health International. The ART services are offered free to clients. The services in this center especially ART are highly patronized. An average of 30 HIV positive patients access ART services daily and over 50% of those who access the ART services are married females.

    Culturally, the decision to use condom during sex is usually the prerogative of the male partner. In this circumstance, females only adhere to the wishes of the male partner. In this study, the researchers are of the view that if women who are disadvantaged by culture to negotiate for condom use are sufficiently equipped with the information on benefits of consistent condom use during sex, that the possibility of the women to negotiate for condom use during sex may be increased. Consistent condom use for this study refers to the ability of HIV positive women to use condom for every sexual intercourse. From clinic observations, women seem to attend ART treatment more regularly than the men do. Therefore using women who were easily accessible in the clinic afforded enough sample for the study. Also the researchers chose women for this study because of the need to encourage them to increase condom negotiation during sex so as to advance prevention of mother to child transmission (PMTCT).

    This longitudinal descriptive study adopted systematic sampling technique. In this study, every third female client within the age range of 15-49 years who came for Heart to Heart treatment in the Abia State University Teaching Hospital within the period under study (December 2012 to February 2013) was selected. A sample of 248 married females who are cohabiting with their partners was selected for study. Semi-structured questionnaire which lasted for 25 minutes was used for data collection. The questionnaire was administered using the local language so as to ensure uniformity in the data collected. The sample constituted mainly of women in the low educational background and therefore they may not be competent to complete the questionnaire correctly on their own.

    Data were analyzed with the aid of SPSS version 17 software using descriptive and inferential statistics. Frequencies and proportions were presented in Tables, while Chi square (X2) test was used to determine associations between categorical variables. Logistic regression analysis was used to identify predictor factors for consistent condom use. Triangulation was used to adjust predictor variables that were significantly related to the outcome variable at the bivariate level.

    Quality Control:

    The questionnaire was pre-tested and administered by well trained female research assistants. Female research assistants were used to encourage frank and open-minded discussions with the respondents. This encouraged the female respondents to discuss very freely with the female research assistants. This strategy helped to ensure the collection of acceptable and quality information from the respondents. To minimize error, the interviewers used both English and local language to administer the questions to the sample. Also all unclear questions were explained to the sample in the local language. The research assistants collected the completed questionnaire at the end of each exercise. As part of the respondents’ motivation, they were entertained with some drinks and snacks. Thereafter, data were checked for completeness and accuracy before analysis.

    Ethical Considerations

    Informed consent was obtained verbally from the respondents after explaining the objectives of the study. As a result, all the respondents positively consented to participate in the study and they were included. Ethical clearance was obtained from the Ethical Review committee of the Abia State University Teaching Hospital.

    Results

    Socio – Demographic Characteristics:

    The ages of the respondents were varied, with the mean age of 35.04 + 7.2 years. Half of the respondents 124(50%) were within the age range of 30-39 years. For education, a good number of the respondents, 127 ( 51.2% ) had Secondary education, while for occupation, a good number of them 130 ( 52.4% ), were trading Table 1.

    Table 1. Socio-demographic characteristics of respondents
    Variable Frequency %
    Age ( Years )  
    <25 28 ( 11.3 )
    25 - 29 34 ( 13.7 )
    30 – 34 73 ( 29.4 )
    35 – 39 51 ( 20.6 )
    40 – 44 35 ( 14.1 )
    >45 27 ( 10.9 )
    Total 248 ( 100.0 )
    Level of Education  
    No formal education 27 ( 10.9 )
    Primary 40 ( 16.1 )
    Secondary 127 ( 51.2 )
    Tertiary 54 ( 21.8 )
    Total 248 ( 100.0 )
    Occupation  
    Housewife 71 ( 28.6 )
    trading 130 ( 52.4 )
    Civil service 35 ( 14.1 )
    Teaching 7 (2.9 )
    Farming 5 ( 2.0 )
    Total 248 ( 100.0)
    Total number of living children  
    None 64 ( 25.8 )
    1 38 ( 15.3 )
    2 40 ( 16.1 )
    3 42 ( 17.0 )
    4 33 ( 13.3 )
    >4 31 ( 12.5 )
    Total 248 ( 100.0)

    From Table 2, age, education and occupation were important determinants of condom use p<.001. Findings show that the older the respondents, 44 years and above, the more likely they used condom. Also the less educated the respondents, (no formal education and primary), the less likely they used condom.

    Table 2. Respondents’ demographic characteristics and condom use.
    Variable Used No condom X 2 /p-value
    Age ( in years ): Condom (%) Used ( %)  
    < 25 2 ( 2.7 ) 26 ( 14.9 ) X2=87.6
    25 – 29 1 ( 1.4 ) 33 ( 18.9 )  
    30 – 34 11 ( 15.1 ) 62 ( 35.4 ) p<0.001
    35 – 39 15 ( 20.5 ) 36 ( 20.0 )  
    40 – 44 19 ( 26.0 ) 16 ( 9.1 )  
    >44 25 ( 34.3 ) 2 ( 1.1 )  
    Total 73 ( 100.0 ) 175 ( 100.0)  
     Level of Education:      
    No formal education 4 ( 5.5 ) 23 ( 13.1 ) X2= 19.4
    Primary 22 ( 30.1 ) 18 ( 10.3 ) P<0.001
    Secondary 28 ( 38.4 ) 99 ( 56.6 )  
    Tertiary 19 ( 26.0 ) 35 ( 20.0 )  
    Total 73 ( 100.0 ) 175 ( 100.0)  
    Occupation:      
    House wife 21 ( 28.8 ) 50 ( 28.6 ) X2 =2.9
    trading 35 ( 48.0 ) 95 ( 54.3 ) p > 0.50
    Civil service 12 ( 16.4 ) 23 ( 13.1 )   
    Teaching 2 ( 2.7 ) 5 ( 2.9 )  
    Farming 3 (14.1 ) 2 ( 1.1 )  
    Total 73 (100.0 ) 175 (100.0)  

    The respondents were later examined to find out the factors that encouraged condom use. Table 3 contains the details. From this Table, respondents on regular ARV 63 (86.3%) used condom more than those that are not on regular ARV 10 (13.7 %). This is not significant p = 0.20. Those who disclosed their status to their spouses 50 (68.5%) used condom more than those who did not disclosed their status 23(31.5%). This is highly significant p<0.001.

    Table 3. Factors that encouraged condom use
    Factors Frequency of condom use X 2 /P-value
      Used condom Did not use condom  
    On regular ARV X2= 2
    Not on regular ARV 63 ( 86.3 ) 137 (78.3) P = 0.20
      10 (13.7 ) 38 (21.7)  
    Total 73 ( 100.0 ) 175 (100.0)  
    Desire more children 17 (23.3) 141 (80.6) X2 = 72.9
    Do not desire 56 (76.7) 34 (19.4) P < 0.001
    Total 73 ( 100.0 ) 175 (100.0)  
    Did not disclose status to spouse 23 ( 31.5 ) 150 (85.7) X2 = 71.6
    Disclosed status 50 ( 68.5 ) 25 (14.3) P < 0.001
    Total 73 ( 100.0 ) 175 (100.0)  
    Both are positive 23 ( 31.5 ) 77 (31.9) X2 = 0.50
    Both not positive 26 ( 35.6 ) 70 (40.0) P > 0.50
    Don’t know spouse’s status 24 ( 32.9 ) 51 (29.1)  
    Total 73 ( 100.0 ) 175 (100.0)  

    The respondents with discordant families who did not disclose their status to their partners, used condom more than those who are both positive. This is not significant p>0.50 Table 4shows the views of the respondents on how they contracted HIV. From this Table, it is obvious that the respondents contracted HIV from different ways. A good proportion of the respondents 121(48.8%) did not know how they contracted HIV while 109(43.9%) said they contracted HIV through sexual route. There was need to find out the reasons the respondents had for not using condom consistently. Table 5contains the reasons the respondents gave.

    Table 4. Respondents’ views on how they contracted HIV
    * Views Frequency (%)
    Sexual route 109 (43.9)
    Blood transfusion 35 (14.1)
    Injection got when sick 22 (8.9)
    During child birth 19 (7.7)
    Do not know 121 (48.8)

    * Multiple response
    Table 5. Respondents’ reasons for not using condom consistently during sex
    *Reasons Frequency (%)
    Desire to have more children 158 (63.7)
    Fear of being suspected for infidelity 75 (30.2)
    Husband dislikes condom 112 (45.2)
    Both of us are positive 47 (18.9)

    * Multiple responses

    From this Table, the commonest reason 158 (63.7%) of the respondents had for not using condom consistently was the desire to have more children. There was need to find out the number of the respondents who actually used condom consistently (for every sexual intercourse). Table 6contains this.The respondents were asked the extent to which they always use condom during sex. From the responses in Table 6, only 73(29.4%) of them agreed that they use condom during each sex.

    Table 6. Respondents who consistently used condom during sex
    Using condom for every sex (consistent) Response category
     Always use condom during sex  73(29.4%)
     Do not always use condom during sex  175(70.6%)
     Total  248(100%)

    Following the logistic regression in Table 7, levels of education were associated with high condom use. For instance, the higher the respondent’s education (tertiary and Secondary) the more consistently condom was used (OR 7.023., CI 2.050 – 24.047, P<0.001). Also the older the respondents 40 years and above, the more consistently they used condom (OR 164.474, CI 21.477 – 1260.2, P<0.001) while the younger the respondents 25-29 years, the less consistently condom was used (OR. 0.395, CI 0.034- 4.604, P = 0.20)

    Table 7. Respondents and predictors for consistent condom use
    Age OR S.E C.I Z P
    *< 25          
    25 – 29 0.395 1.253 0.034-4.604 0.74 0.2
    30 -34 2.329 0.804 0.481-11.257 1.05 0.1
    35 – 39 5.487 0.797 1.150-26.154 2.136 0.01
    40 – 44 15.631 5.487 3.199-76.325 3.39 <0.001
    >44 164.474 1.039 21.477-1260.2 4.91 <0.001
    Level of Education          
    *No formal education          
    Primary 7.023 0.628 2.050-24.047 3.1 <0.001
    Secondary 1.626 0.582 0.519-5.089 0.84 0.2
    Tertiary  3.121  0.612  0.941-10.350  1.85  0.04 
    Desire for more children  13.612  0.336  0.043-26.311  7.70  <0.001
    Disclosed status to spouse  13.072   0.412   5.836-29.253 6.238  <0.001

    * Reference category

    Also women who did not desire more children used condom more consistently than those who desired more children (OR 13.612, CI 0.043-26.311, P<0.001). Women who disclosed their HIV status to their spouses used condom more consistently than those who did not disclose (OR 13.072, CI 5.836 – 29.253, P<0.001).

    Discussion

    The result of this study showed that only 29.4% of the respondents used condoms consistently during sex. This might not be unrelated to the cultures and traditions behind the marriage institution where condom use among couples is regarded as a taboo. The effect of regarding condom use among couples as a taboo is that most couples may not consider it necessary to use condom during sex. This could make such couples unaware of the full benefits of using condom during sex. The few proportion of respondents who stated that they used condom consistently may be those who have good knowledge of the benefits of using condom during sex. The finding that the respondents who used condom consistently may be those with good knowledge of the benefits of condom use agrees with that of 3, 12, 16 where couples used condom consistently only when they were informed that condom use was not associated with infidelity .

    The desire for more children was a panacea for irregular condom use among the respondents. This finding is in conformity with the findings of 13, 14 at Guatemala where a good proportion of the sample studied did not use condom during sex because of the desire to have more babies. The desire to have children is common in every African marriage and in Nigeria in particular. Married women, irrespective of their health status, will desire to have children to maintain the marriage. This might explain why most of the women in this study desired more children despite their HIV status.

    The result that the respondents on regular ART used condom more than those on irregular ART is a strength to this study. For this group of women, it is possible that the routine health education clinicians provide clients during services might have influenced their decision to use condom during sex. It is also likely that they might have been counseled on the benefits of using condom during sex. With this information, it is likely that these group of clients might sustain condom negotiation during sex.

    The finding that some of the respondents indicated that they did not use condom for sex because their partners dislike its use further explains the inequality women experience in their marriages. This finding supports the need for aggressive health education on the benefits of condom use during health and marriage counseling sessions. This is important because couples should be well educated on the benefits of condom use early in the marriage irrespective of the cultural barriers on condom use.

    The fact that only (29.4%) of the respondents disclosed their sero-status to their partners revealed the extent to which couples are at risk of HIV infection and re-infection. This finding is at variance with that of 15 in Uganda, where 54% of the respondents disclosed their status to their spouses so as to protect other family members from infection. The difference between our study and that of Ugandan might be related to geographical location and not cultural differences. The main reason for non- disclosure as documented in the Ugandan study was fear of spouse abandonment. The same reason for non-disclosure in Ugandan study is also the reason for non-disclosure in the present study but of a more severe consequence as a result of the low proportion of those who disclosed.

    The fact that older women 40 years and above used condoms more regularly than the younger ones could be explained that at this age, majority of the women must have had their desired number of children and as such, their prerogative is to avoid infection and prevent pregnancy at any material time of their sexual activity.

    Level of education played a positive role in the use of condoms in the study. Women with higher level of education (tertiary and secondary), used condom more consistently than others in the study. This finding is consistent with studies by 17, 18, 22, 24. The finding could be explained by the fact that the higher the education of an individual, the more likely the individual will be exposed to correct information on HIV/AIDS transmission. Correct information on HIV and AIDs prevention will empower the individual to use relevant strategies to protect self from infection.

    Conclusion

    The study noted low awareness of benefits of condom use, hence only an insignificant proportion 29.4% of the respondents used condom consistently. The desire for more children played a negative role in the consistent use of condom among the respondents. Since child bearing is important in African culture especially that of Nigeria, it is therefore necessary to organize a planned and consistent health education and marriage counseling sessions for HIV positive individuals irrespective of their ages and sex. This can be achieved through guarantying proper HIV testing and counseling, as well as regular and subsidized HIV treatment services.

    Limitations:

    Although this study has identified some variables that significantly affected consistent condom use among the respondents, it has some limitations. The short period of the study could not afford the researchers a full understanding of the factors associated with consistent condom use among HIV positive women. Also the fact that only married females cohabiting with their spouses were studied could not allow for wider and diverse understanding of how condom is used among other females who are HIV positive. Studies of this type may not allow for full assessment and evaluation of condom use among the HIV positive individuals. This may affect awareness and sustainability of consistent condom use.

    Also the self-reporting of condom use by the respondents as well as the administered method of data collection could be affected by interviewer bias. Nevertheless, the study is relevant in understanding the main predictors of consistent condom use among married women living with HIV and AIDS. This knowledge is important in the control of HIV and AIDS and the development of strategies for HIV prevention among married couples.

    References

    1.National Population Commission.Abuja2013.
    2.National Bureau of. Statistics.http://nigerianstat.gov.ng/ accessed9/9/13
    3.. UNAIDS/NACA2011-Women, Girls and HIV in Nigeria.http://www.unaids.org/en/ (Accessed September10th,2013) .
    4.UNAIDS2013.2013 progress report on the global plan: towards the elimination of new HIV infections among children by 2015 and keeping their mothers alive.http://www.unaids.org/en/ (Accessed September10th,2013).
    5. (2004) UNAIDS.Making condoms work for HIV prevention,UNAIDS. , Best PracticeCollection.Geneva;UNAIDS
    6.Welber S, David K. (2002) Condom effectiveness in reducing heterosexual HIV transmission. Cochrane Data base of Systemic Reviews(1):CD003255.
    7.DeWalaune D. (2007) Sero-Discardant Couples in five African Countries: Implications for Prevention Strategies.” Population and Development Review. 33(3), 501-523.
    8.Addin E N, Stephenson E. (2008) New heterosexually transmitted HIV infections in married or cohabiting couples in urban Zambia and Rivanch: an analysis of survey and clinical data.”. , Lancet 371, 2183-91.
    9.Philips K A, Kanouse D E, Chenth. (2000) Fertility desires and intentions of HIV positive men and women. Family planning perspectives. 33, 144-65.
    10.World Health Organization.Joint WHO/UNAIDS/UNFPA policy statement. Dual protection against unwanted pregnancy and sexually transmitted infections, including HIV.At; www.who.int/reproductive-health/publications. , Accessed1December2000
    11.. SPSS17.0.Statistical Package for the Social Sciences,Released7.0.1(December2008).Spss Inc .
    12.Versteeg M, Murray M. (2008) Condom use as part of the wider HIV prevention strategy: experiences, from communities in the North West Province, South Africa. , SAHARA J 5, 83-93.
    13.Jwan J Delgado, Pireda Marcella.Iric Cazali, Carlon, Mejia.(2011)Knowledge of HIV transmission and condom use among HIV-positive heterosexual men and women in Guatemala. , Journals of the International AIDS society 14.
    14.Motlatso M, Petlaer Karl. (2011) HIV sero-status disclosure and sexual behavior among HIV positive patients who are on. , ART in Moumalanga, South Africa. J Hum Ecol 35(1), 29-41.
    15.Sarah N, Lynn A, Christopher T. (2010) Reasons for disclosure of HIV status by people living with HIV/AIDS and in HIV care in Uganda: An Exploratory study. AIDS patient care and STD’s. 24(10), 2-7.
    16.Ayiga Natal. (2012) Rates and predictors of consistent condom use by people living with HIV/AIDS on Antiretroviral treatment in Uganda. , J Health popul Nutri 30(3), 270-280.
    17.Maharaji P, Cleland J. (2005) Risk perception and condom use among married or co-habiting couples in Kwazulu-Natal. , South Africa. Int. fam plan perspect 31, 24-29.
    18.Gillespie S, Kadijala S, Greener R. (2007) Is poverty or wealth driving HIV transmission.AIDS21(suppl 7):S5-S16.
    19.Hargreaves J R, Glynn J R. (2002) Educational attainment and HIV-1 infection in developing countries: a systematic review. , Trop Med Int Health 7, 489-98.
    20.Mill J E, Anarfi J K. (2002) HIV risk environment for Ghanaian women: challenges to prevention. , Soc Sci Med 54(3), 325-337.
    21.Eaton L, Flishera J, Aarob L E. (2003) . Unsafe sexual behaviour in South African youths.Soc Sci Med 56(1), 149-165.
    22.Holmes K K, Levine R, Weaver M. (2004) Effectiveness of condoms in preventing sexually transmitted infections. , Bull World Health Org 82(6), 454-461.
    23. (2006) National Population Commission. Population and Housing Census of the Federal Republic of Nigeria,www.population.gov.ng.
    24.Okunlola M A, Morhason -Bello OI, Owonikoko O M, Adekunle A O. (2006) Female condom awareness, use and concern among Nigerian Female undergraduates.26(4): 353-356: 11.J Obst et Gynaecol.
    25.Francis –chizororo M, Natshalaga N R. (2003) The Female condom: Acceptability and perception among rural women in Zimbabwe . , Afr J Reprod Health 7(3), 101-116.
    26.Maharaj P. (2001) Obstacle to negotiating dual protect ion: Perspective of men and women. , Afr J Reprod Health 5(3), 150-161.
    27.Gold R, J Maskovsky, Rogers C, Gollub E. (2000) High risk adolescents and female condoms: Knowledge, attitude and use pattern. , J Adolesc Health 26(6), 392-398.
    28.Fernandez M L, Garrido J M. (2006) A qualitative study of the viability of usage of the female condom among University students. , Int J Clin Health Psychol 6(1), 189-198.
    29.l F Hatze, Feldblum P J, Homen R K, Gmech R D. (2003) The female condom:. Is “Just as Good” good enough?. Sexually transmitted Diseases 30(5), 440-442.
    30.Meekers D, Silva M, Klein M. (2003) Determinants of condom use among youth. in Madagascar.Washington,D.C.,Population Services International [PSI],18p.(PSI Research Division Working Paper No. 55) .