The purpose of this study is to provide strategic information on key HIV-related indicators for program managers and policymakers to monitor and evaluate prevention programs and to design new strategies. The report summarizes levels and recent changes in 69 indicators of HIV-related knowledge, attitudes, and behaviors of women and men age 15–49 in 23 countries in sub-Saharan Africa. Data come from the two most recent rounds of population-based, nationally representative Demographic and Health Surveys (DHS) conducted between 1992 and 2006.
The results show that in most countries in the region education levels and exposure to the mass media have improved in recent years, yet men remain better educated than women and continue to have more exposure to the media. Overall, there have been improvements in women’s participation in household decision-making, and women report greater ability to negotiate safer sex. Men are more likely than women themselves to report that women can negotiate safer sex.
In most sub-Saharan countries knowledge about HIV prevention methods has increased. However, considerable proportions of men and women still lack knowledge of specific prevention methods: abstinence, partner faithfulness, and condom use. Comprehensive knowledge about HIV/AIDS has increased, but in most countries, especially in west Africa, levels of such knowledge remain unacceptably low.
Although men generally are more knowledgeable than women about HIV prevention methods, higher percentages of women than men know that HIV can spread from mother to child through breast milk. Few adults know about drugs that can prevent mother-to-child HIV transmission.
The results suggest that considerable proportions of people continue to have discriminatory attitudes toward people living with HIV (PLHIV). While a majority of adults indicate that they would care for an infected family member, fewer would want others to know if someone in their own family were infected. Levels of acceptance of HIV-infected female teachers or vegetable vendors are also low, though improving.
An overwhelming majority of adults agree that children age 12–14 should be taught to abstain from sex until they get married. However, in most sub-Saharan countries only about half of women and a slightly higher percentage of men would want children age 12–14 to be taught about condom use.
In all countries a large majority of people perceive themselves to be at no risk or low risk of becoming infected with HIV. Nonetheless, many adults, particularly men, report being at no risk or low risk of HIV infection, even though they have had multiple lifetime sexual partners. The proportion of people who consider themselves to be at high risk or who already have HIV shows no correlation to HIV prevalence in the country.
A high percentage of men and women initiate sex before age 15. Median age at first sex is much lower among women than among men. In recent years, the median age at first sex has remained generally unchanged for both men and women in most countries.
Men are much more likely than women to report having multiple sexual partners in their lifetime, as well as in the year before the survey. Men also are much more likely than women to report non-spousal sex. In most countries women have become less likely to report multiple partners, but among men there is no clear pattern of change. The highest levels of paid sex among men are in southern Africa, where the prevalence of HIV is higher than in east Africa or west Africa.
Among never-married youth age 15–24, no clear pattern of change appears across countries in the practice of primary abstinence, but secondary abstinence has increased in most countries. Over time, fewer youth are having multiple sex partners, comparing the two rounds of surveys. Considerable proportions of young women report that their first sex was forced and that they have had sex with non-spousal partners who were 10 years or older than themselves. Women in west Africa are more likely to have older non-spousal partners than women in east Africa or southern Africa.
Overall, condom use has increased somewhat but remains very low in most sub-Saharan countries. Less than one woman in every six and one man in every three report using a condom at last sex in the year before the survey. Levels of consistent condom use are even lower.
Although in east Africa and southern Africa the percentages of respondents who know where to get tested for HIV are substantial, the percentages of respondents who have ever been tested for HIV and received test results are quite low in most sub-Saharan countries, at less than 25 percent of men and women. For countries with data from two time points, the study finds sizeable increases among both women and men in knowledge of where to get tested for HIV.
In sum, the study provides a comprehensive look at the levels and direction of many important HIV/AIDS-related indicators in sub-Saharan countries. Notably, the study finds evidence of improvements in HIV/AIDS-related knowledge and attitudes but also highlights persistent high levels of sexual risk-taking and very low levels of voluntary counseling and testing coverage and condom use. These findings make a case for strengthening prevention programs in sub-Saharan Africa with a range of efforts to promote safer sexual behavior.
The study also highlights large differentials between women and men in a number of HIV-related indicators, and wide variations among the 23 countries studied in the levels of and recent changes in HIV-related knowledge, attitudes, and behaviors. These differences suggest the need for HIV prevention, treatment, and care policies and programs to be gender and context specific.