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To explore whether differences in sexual behaviour could explain differences in the rate of spread of HIV in four urban populations in Africa.A cross-sectional, population-based study was conducted in two cities where the prevalence of HIV among adults exceeded 20% (Kisumu, Kenya and Ndola, Zambia) and two cities with a much lower HIV prevalence among adults (Cotonou, Benin and Yaoundé, Cameroon). In each of these cities, approximately 1000 men and 1000 women, aged 15-49 years, were randomly selected from the general population. Consenting men and women were interviewed about their sociodemographic characteristics and sexual behaviour, including characteristics of spouses and of non-spousal partners. Key parameters of sexual behaviour were compared between the four cities.On average, women in the high HIV prevalence cities had their sexual debut earlier than in the other cities. Men and women in Kisumu and Ndola got married earlier than men and women in Cotonou and Yaoundé. High rates of partner change, contacts with sex workers, concurrent partnerships and large age differences between partners were no more common in the two high HIV prevalence cities than in the two low HIV prevalence cities.In these four African populations, differences in reported sexual behaviour could not explain the differences in rate of spread of HIV. In all four cities, high-risk sexual behaviour patterns were identified.

Objectives: To estimate rates of condom use in four urban populations in sub-Saharan Africa and to assess their association with levels of HIV infection and other sexually transmitted diseases (STDs). Methods: Data were obtained from a multicentre study of factors that determine the differences in rate of spread of HIV in four African cities. Consenting participants were interviewed on sexual behaviour, and also provided blood and urine samples for testing for HIV infection and other STDs. Data on sexual behaviour included information on condom use during all reported spousal and non-spousal partnerships in the past 12 months. Results: A total of 2116 adults aged 15-49 years were interviewed in Cotonou (Benin), 2089 in Yaounde (Cameroon), 1889 in Kisumu (Kenya) and 1730 in Ndola (Zambia). Prevalence rates of HIV infection were 3.4% in Cotonou, 5.9% in Yaounde, 25.9% in Kisumu and 28.4% in Ndola. Reported condom use was low, with the proportions of men and women who reported frequent condom use with all non-spousal partners being 21-25% for men and 11-24% for women. A higher level of condom use by city was not associated with lower aggregate level of HIV infection. The proportions of men reporting genital pain or discharge during the past 12 months were significantly lower among those reporting frequent condom use in all sites except Yaounde: in Cotonou, adjusted odds ratio (OR) = 0.28, 95% confidence interval (Cl) = 0.09-0.94; in Kisumu, adjusted OR = 0.34, 95% Cl = 0.14-0.83; and in Ndola, adjusted OR = 0.33, 95% Cl = 0.12-0.90. The same association was found for reported genital ulcers in two sites only: in Cotonou, adjusted OR = 0.14, 95% Cl = 0.02-1.02; and in Kisumu, adjusted OR = 0.18, 95% Cl = 0.04-0.75. There were few statistically significant associations between condom use and biological indicators of HIV infection or other STDs in any of the cities. Conclusion: Similar levels of condom use were found in all four populations, and aggregate levels of condom use by city could not discriminate between cities with high and low level of HIV infection. It seems that rates of condom use may not have been high enough to have a strong impact on HIV/STD levels in the four cities. At an individual level, only a male history of reported STD symptoms was found to be consistently associated with lower rates of reported condom use.

OBJECTIVE: To identify factors that could explain differences in rate of spread of HIV between different regions in sub-Saharan Africa. DESIGN: Cross-sectional study. METHODS: The study took place in two cities with a relatively low HIV prevalence (Cotonou, Benin and Yaounde, Cameroon), and two cities with a high HIV prevalence (Kisumu, Kenya and Ndola, Zambia). In each of these cities, a representative sample was taken of about 1000 men and 1000 women aged 15-49 years. Consenting men and women were interviewed about their socio-demographic background and sexual behaviour; and were tested for HIV, herpes simplex virus type 2 (HSV-2), syphilis, Chlamydia trachomatis and Neisseria gonorrhoea infection, and (women only) Trichomonas vaginalis. Analysis of risk factors for HIV infection was carried out for each city and each sex separately. Adjusted odds ratios (aOR) were obtained by multivariate logistic regression. RESULTS: The prevalence of HIV infection in sexually active men was 3.9% in Cotonou, 4.4% in Yaounde, 21.1% in Kisumu, and 25.4% in Ndola. For women, the corresponding figures were 4.0, 8.4, 31.6 and 35.1%. High-risk sexual behaviour was not more common in the high HIV prevalence cities than in the low HIV prevalence cities, but HSV-2 infection and lack of circumcision were consistently more prevalent in the high HIV prevalence cities than in the low HIV prevalence cities. In multivariate analysis, the association between HIV infection and sexual behavioural factors was variable across the four cities. Syphilis was associated with HIV infection in Ndola in men [aOR = 2.7, 95% confidence interval (CI) = 1.5-4.91 and in women (aOR = 1.7, 95% CI = 1.1-2.6). HSV-2 infection was strongly associated with HIV infection in all four cities and in both sexes (aOR ranging between 4.4 and 8.0). Circumcision had a strong protective effect against the acquisition of HIV by men in Kisumu (aOR = 0.25, 95% CI = 0.12-0.52). In Ndola, no association was found between circumcision and HIV infection but sample sizes were too small to fully adjust for confounding. CONCLUSION: The strong association between HIV and HSV-2 and male circumcision, and the distribution of the risk factors, led us to conclude that differences in efficiency of HIV transmission as mediated by biological factors outweigh differences in sexual behaviour in explaining the variation in rate of spread of HIV between the four cities.

18 sample surveys conducted in 1989-1993 of male and female respondents aged 15-49 years reporting sex with a nonregular partner in the preceding year were analyzed. The proportion of men ranged from 4% to 47% and women from 1% to 19%. In the five Asian sites 10-20 times more men than women reported nonregular sex. Among the 18 surveys the proportion of men reporting five or more partners in the last 12 months varied from 0% in Sri Lanka and Hong Kong to 11% in Thailand; for women the level never exceeded 3%. The proportion of male respondents with more than five nonmarital partners was consistently highest among those aged 25-34 years. A significant relationship was found between the prevalence of premarital sex among 15-24 year old youths and the prevalence of nonregular sex among adults for both men and women (R2 = 0.43 for men; R2 = 0.57 for women). Prevalence of all men aged 15-49 years reporting commercial sex ranged from 1% to 25% with a median of 9.7%. Among women the corresponding figures were

We examined factors associated with perceived risk of AIDS, behavior change, and HIV infection in a representative sample of 1458 child-bearing urban women in Rwanda, central Africa. Although 68% of women reported only one lifetime partner, and the majority (87%) lived with a husband or steady partner, the prevalence of HIV antibodies was still high (32%). Before receiving their HIV test results, the women completed a questionnaire about AIDS knowledge, attitudes, and practices. Knowledge about HIV transmission was high, with 96-98% of women correctly identifying the three primary routes of infection. However, only 16% of women reported taking any action to avoid AIDS in the previous year, and most (11%) had done so merely by asking their male partners to change their behavior. Only 7% of women had ever tried condoms, and many (68%) thought they could be dangerous to use. Women who perceived themselves at risk of AIDS (57%) were more likely to report changing behavior; they were also more likely to be infected with HIV. Other factors associated with behavior change included having known someone with AIDS, having discussed AIDS with a male partner, and believing that condoms are not dangerous. Future interventions should enhance perception of risk, encourage male sexual partners to reduce risky behavior, and increase familiarity with condoms.The authors examined factors associated with perceived risk of AIDS, behavior change, and HIV infection in a representative sample of 1458 childbearing urban women in Rwanda, central Africa. Although 68% of them reported only 1 lifetime partner, and the majority (87%) lived with a husband or steady partner, the prevalence of HIV antibodies was still high (32%). Prior to receiving their HIV test results, the women completed a questionnaire about AIDS knowledge, attitudes, and practices. Knowledge about HIV transmission was high, with 96-98% of women correctly identifying the 3 primary routes of infection. However, only 16% reported taking any action to prevent AIDS in the previous year, and most (11%) had done so merely by asking their male partners to change their behavior. Only 7% of the women has ever tried condoms, and many (68%) thought they could by dangerous to use. Those women who perceived themselves at risk for AIDS (57%0 were more likely to report changing behavior; they were also more likely to be HIV-infected. Other factors associated with behavior change included having known someone with AIDS, having discussed AIDS with a male partners, and believing that condoms are not dangerous. Future interventions should enhance the perception of risk, should encourage male sexual partners to reduce risktaking behavior, and should increase familiarity with condoms.