Predictors of unprotected sexual intercourse among HIV-infected patients receiving antiretroviral drugs in the Niger Delta Region of Nigeria

ABSTRACT

This study aims to evaluate the predictor of unprotected sexual intercourse among HIV-infected adults receiving antiretroviral therapy (ART) in a tertiary facility in the Niger Delta Region of Nigeria. A cross sectional study was undertaken in a 200 bed tertiary hospital in Bayelsa state, south-south Nigeria. A standardized pre-tested interviewer administered questionnaire was used to collect demographic, clinical and sexual history from consecutive HIV-1 infected adults receiving ART for at least 6 months. Independent predictors of unprotected sexual intercourse (defined as irregular condom use or unprotected sex in previous 6months) were determined using an unconditional logistic regression model. Out of 241 patients studied, 71.8% were females, 48.5% were married, and 20.7% had a sexual partner that is HIV-1 infected. Sixty (24.9%) patients engaged in unprotected sex, 86 (35.7%) used condom consistently and 95 (39.4%) abstained. Female sex, being currently married, age18–35years, partner being HIV-positive and living with sexual partner were significant associated with risky sex. Female sex, age18–35years and being currently married were the only independent predictors of unprotected sex. HIV-infected adults receiving ART in resource limited settings are potential sources of secondary transmission of HIV. Condom use in the prevention of secondary transmission of HIV in study area should target females, young adults and married couples.

KEYWORDS:

• Predictors
• unprotected sexual intercourse
• risky sex
• HIV/AIDS
• condom

Introduction

Although, antiretroviral therapy has significantly contributed to the declining prevalence and burden of HIV globally (World Health Organization, 2013), the growing challenge of ART failure as well as the practice of unprotected sexual intercourse among HIV-infected patients receiving ART is fuelling the emergence of new HIV-infections (UNAIDS, 2016). The prevalence of unprotected sexual intercourse among HIV-infected receiving ART has been reported to range from 30% to 40% in the United States, (Reilly, Woodruff, Smith, Clapp, & Cade, 2010) 20% in Argentina (Harding et al., 2013) and 36.9% (Dessie, Gerbaba, Bedru, & Davey, 2011) in Ethiopia. A multi-clinic study in South Africa recorded an unprotected sexual intercourse rate of 48.6% and 56.3% for men and women respectively (Shuper et al., 2010).

Most of the aforementioned studies reported poor knowledge of condom use, fertility desires, lower perceived power to insist on condom usage and lack of sexual pleasure when using condoms as reasons for the practice of unprotected sexual intercourse.

Nigeria has the second-largest population of people living with HIV in the world, with an estimated adult HIV prevalence of 3.1% (World Health Organization, 2013). In Nigeria, unprotected sexual intercourse remains the major route of HIV transmission, contributing to about 89.4% of all new HIV infections (NACA, 2014). A multisite study in Nigeria recorded an unprotected sexual intercourse rate of 58% among HIV patients enrolled in ART clinics (Olley, Adebayo, Ogunde, & Odeigah, 2016). In Ibadan, South West Nigeria, being unmarried and the female gender were the predictors of unprotected sex among HIV-infected patients on ART (Adebiyi & Ajuwon, 2015). A study in Kano, Northern Nigeria reported primary or lower education, HIV status nondisclosure and female gender as predictors of unprotected sexual intercourse in HIV patients (Ara, Solomon, Onyemocho, & Olabisi, 2014).

There have been no previous studies on the prevalence and predictors of unprotected sexual behaviour among HIV-infected patients receiving ART in Bayelsa state situated in the Niger Delta Region of Nigeria. A prior study from this region revealed high rates of HIV non-disclosure among HIV infected patients (Ebuenyi et al., 2014). In this study, we aim to report the prevalence and predictors of unprotected sexual intercourse among HIV-infected adults receiving ART. We hope our study findings will be useful in identifying ART-experienced individuals at high risk of unprotected sex as well as to devise strategies to foster safer sex practises among HIV-infected patients receiving ART in our region and other limited-resource settings.

Materials and methods

This cross-sectional survey was carried out among HIV-positive patients attending the Anti-Retroviral Therapy Clinic of Niger Delta University Teaching Hospital (NDUTH) Okolobiri, Bayelsa State. The hospital is a 200 bed state-owned tertiary hospital situated in Okolobiri, Bayelsa state and provides comprehensive ART services in South-South Nigeria. Ethical approval for the study was obtained from the hospital’s ethical committee.

Over a period of three months (January–March 2013), a total of 241 adult HIV-infected patients on ART for at least six months who gave consent were enrolled for the study. Study data were collected using a pre-tested standardized questionnaire administered face to face and confidentially by 5 trained medical doctors. The questionnaire covered sociodemographic history, clinical data and sexual history including use of condom. In this study, unprotected sex refers to sexual intercourse without a barrier contraceptive(condom) in the last six months before presentation. All patients who have abstained from sex in the last six months before presentation and those who used condoms consistently and correctly in the prior six months were categorized as practicing ‘non-risky sex’.

All study participants gave consent for the study and confidentiality was assured in data collection.

The data was analyzed using Statistical Package of Social Sciences (SPSS) version 20. Sociodemographic, clinic and sexual history were reported using percentages and Chi square. Independent predictors of unprotected sexual intercourse were ascertained using logistic regression model. P < 0.05 was considered statistically significant for all analysis.

Results

Sociodemographic data

A total of 241 individuals, consisting of 173 females and 68 males were enrolled for the study. The median age and interquartile range (IQR) of the study population was 37 years (31, 43). Majority (78.4%) of the study population had less than tertiary level of education. Other details of the socio-demographic data of the study participants are summarized in Table 1.

Table 1. Socio-demographic characteristics of study participants.

S/N	Variables	Unprotected Sexual Intercourse		Total Population	P value for differences
		Yes	No
1.	Age (years)-Median(IQR) Age group 18–35 years N (%) ≥36 years N (%)	34 (30,40) 35 (35.5) 25 (19.2)	38 (32,44) 76 (68.5) 105 (80.8)	37 (31,43) 111 (100) 130 (100)	P = 0.03 P = 0.03 X^2=4.85
2.	Sex Male N (%) Female N (%)	11 (16.2) 49 (28.3)	57 (83.8) 124 (71.7)	68 (28.2) 173 (71.8)	P = 0.05 X^2 = 3.85
3.	Marital Status Currently Married N (%) Not Currently Married N (%)	45 (38.5) 15 (12.1)	72 (61.5) 64 (68.1)	117 (48.5) 124 (51.5)	P = 0.00 X^2 = 22.4
4.	Educational Status Less than tertiary level Tertiary level	50 (26.5) 10 (19.2)	139 (73.5) 42 (80.8)	189 (78.4) 52 (21.6)	P = 0.29 X^2 = 1.14
6.	Household Status Living with sexual Partner N (%) Not Living with sexual Partner N (%)	38 (39.2) 22 (15.3)	59 (60.8) 122 (84.7)	97 (40.2) 144 (59.8)	P = 0.00 X^2 =  = 17.7
7.	HIV status of Partner Positive Negative/Unknown	18 (36.0) 42 (22.0)	32 (64.0) 149 (78.0)	50 (20.7) 191 (79.3)	P = 0.04 X^2 = 4.16
9.	Partner Receiving ART Yes N (%) Others N (%)	15 (36.6) 45 (22.5)	26 (63.4) 155 (77.5)	41 (17.0) 200 (83.0)	P = 0.05 X^2 = 3.61
10	Disclosure Yes No	33 (38.4) 16 (35.6)	53 (61.6) 29 (64.4)	86 (65.6) 45 (34.4)	P = 0.75 X^2 = 0.1

Prevalence and predictors of unprotected sexual intercourse

The prevalence of unprotected sex in the study is 24.9%. Of the 241 study participants, 95 (39.4%) practiced abstinence, 86 (35.7%) used condom consistently and correctly and 60 (24.9%) did not use condom during sexual intercourse or used them inconsistently. All study participants claimed to have been in heterosexual relationships.

On univariate analysis, age of 18–35 years, female gender, being currently married, living with partner, partner being HIV-positive and partner on ART were associated with unprotected sex at P < 0.05 (Table 1). On logistic regression, the independent predictors of unprotected sexual intercourse were being female, age group 18–35 years and being currently married. Other details of the predictors of unprotected sexual intercourse are as shown in Table 2.

Table 2. Logistic regression showing independent predictors of unprotected sexual intercourse among study participants.

Variable		Adjusted OR	95% CI	P value for differences
1.	Gender Female Male	3.79	1.616–8.907	0.002
2.	Age 18–35 years ≥36 years	2.14	1.084–4.320	0.028
3.	Marital Status Currently Married Not currently Married	4.73	1.790–12.490	0.002
4.	Household Status Living with sexual Partner Not Living with sexual Partner	1.68	0.77–9.51	0.266
5.	Partner is Positive Yes No	0.92	0.215–3.958	0.913
6.	Partner on ART Yes No	1.67	0.360–7.710	0.514

Discussion

Our study results reveal that 24.9% of adult HIV-infected patients receiving ART in the centre engaged in unprotected sexual intercourse. This prevalence rate although slightly higher than the 20% reported in Argentina (Harding et al., 2013), is lower than the 56.3% reported in South Africa (Shuper et al., 2010) and 58% recorded in a multisite study in Nigeria (Olley et al., 2016).

The study data also indicate that female gender, being currently married and age group 18–35years were independent predictors of unprotected sexual intercourse among our study participants. Higher rates of unprotected sexual intercourse amongst female HIV patients on ART have been previously reported in studies from Ethiopia (Dessie et al., 2011) and South Africa (Shuper et al., 2010). In Nigeria, two studies in Ibadan (Adebiyi & Ajuwon, 2015) and Kano (Ara et al., 2014) have identified the female gender as a predictor of unprotected sexual intercourse as reported in our study. Socially construed gender role, male dominance and the lack of skills and power to negotiate safe sex among females have been identified as possible promoters of higher rates of unprotected sex amongst female HIV patients (Shuper et al., 2010) In addition, it is also possible that lack of female condoms and poor uptake of its use may be responsible for higher rates of unprotected sex amongst HIV patients (UNAIDS, 2016).

Our study also showed that being currently married was an independent predictor of unprotected sex amongst the study participants. This is supported by the multi-clinic study in South Africa (Shuper et al., 2010) and the multisite study conducted in Nigeria (Olley et al., 2016). Conversely, two Nigerian studies (Adebiyi & Ajuwon, 2015; Akinyemi, Awolude, Adewole, & Kanki, 2010) identified being unmarried as a predictor of unprotected sexual intercourse. Studies suggest that among married couples, the overwhelming need to procreate and fulfil marital obligations is linked with unprotected sexual intercourse amongst HIV patients (Shuper et al., 2010).

The youth age group of 18–35 years was found to be an independent predictor of unprotected sexual intercourse. Globally, high rates of unprotected sexual intercourse have been reported in young people (UNAIDS, 2016) and obviously young HIV-infected individuals exhibit similar behavioural patterns. Studies indicate that increased rates of casual sex and HIV non-disclosure in young people may be an explanation for the increased rates of unprotected sexual intercourse amongst them (Ebuenyi et al., 2014; World Health Organization, 2013).

This study did not observe any association between educational status and unprotected sexual intercourse. In contrast, two Nigerian studies in Ibadan and Kano reported lower educational status as a predictor of unprotected sexual intercourse (Akinyemi et al., 2010; Ara et al., 2014), while a multisite study also in Nigeria reported higher education as a predictor of unprotected sexual intercourse among HIV-infected adults on ART (Olley et al., 2016). These differences in associations between educational status and unprotected sexual behaviour may be attributed to differences in study population and study design.

In view of prevailing challenges of ART non-adherence and resistance (Etiebet et al., 2013), our findings have significant implications for HIV transmission and treatment in our setting. The practice of unprotected sexual intercourse among patients receiving ART could lead to emergence of new HIV infections or transmission of resistance strains to their sexual partners, especially if HIV-viral replication remains unsuppressed while on ART.

Our study is not without limitations. Since viral load assessment was not done due to resource constraints, we could not estimate the differences in prevalence of unprotected sexual intercourse between viral suppressed and unsuppressed patients. We also could not confirm same sex relationships and it was possible that study participants were unwilling to fully disclose their sexual orientation due an existing legislation against same sex marriage in Nigeria (National Assembly Nigeria, 2013) Although, our study was conducted in a resource limited setting in Africa, the findings may not necessarily be generalizable to other resource limited settings due to differences in culture and sexual behaviour. Furthermore, we cannot exclude recall bias among our study participants since we elicited information based on subjective recall of their previous sexual behaviour.

Conclusion

Our results reveal that 24.9% of our study population engaged in unprotected sexual intercourse. Females, young adults and married couples were independent predictors of unprotected sexual intercourse. In our setting, strategies to prevent risky sex, including behaviour change communication, provision of condom and couple counselling, should target females, young adults and married couples.

Acknowledgements

The authors are grateful to the patients who participated in the study and all the staff of the Antiretroviral Therapy Clinic of Niger Delta University Teaching Hospital.

Disclosure statement

No potential conflict of interest was reported by the authors.