Association of negotiation strategies with consistent use of male condoms by women receiving an HIV prevention intervention in Zimbabwe

One of the fundamental aspects of HIV counselling for women is condom negotiation strategy development. The present research sought to identify condom request strategies used by Zimbabwean women and to determine which were most effective in persuading male partners to use condoms. Of six types of strategies used by women after a prevention intervention, one was significantly associated with consistent condom use 2 months later. Implications for the development of counselling and testing protocols are discussed. Voluntary HIV counselling and testing is currently being implemented throughout the world, particularly among pregnant women. Research has shown that voluntary counselling and testing can profoundly reduce risky sexual behavior among those who test positive or are in serodiscordant relationships 1,2. Because men, not women, wear male condoms (or must cooperate in the use of the female condom), the development of condom request strategies should be an integral part of the counselling session. Negotiating condom use with male partners, however, is often difficult for women 3. Although prevention programmes that provide skills-building in this domain tend to be more effective, little is known about what strategies are used, nor the differential effectiveness of specific strategies in persuading male partners to use condoms. Whereas a small amount of research on this topic has been conducted in the United States 4, even less has been carried out in the developing world. The present study was designed to identify condom negotiation strategies used by HIV-seronegative Zimbabwean women after a prevention intervention. We further wished to explore the effectiveness of specific strategies in achieving consistent condom use (CCU) with male partners. Participants were women recruited from family planning clinics serving low-income women from high-density residential areas in Harare, Zimbabwe. Inclusion criteria were: (i) aged 18 years or older; (ii) sexually active with men, at least 10 times during the previous 3 months; (iii) using contraception or otherwise not able to become pregnant; and (iv) willing to be tested for HIV and receive the result. Women were excluded if they reported condom use at more than 50% of all sexual episodes in the previous 3 months; were HIV-seropositive; or were unable to speak English or Shona. Women were recruited using active outreach by clinic nurses. Altogether 359 women were eligible to participate and 339 were enrolled. Of these, 260 women completed all four study visits, yielding a retention rate of 77%. The average age of participants was 29 years. Most women (96%) were married and had at least one child (99%). Each of the four study visits occurred at the clinic. At the first visit, all women were screened for eligibility (excluding HIV status); those who were eligible gave informed consent then received a medical examination and enhanced pre-test counselling (the first component of the intervention). Serum was drawn to test for HIV-1. Two weeks later, the participants returned for their HIV-1 test results. HIV-seronegative women were enrolled and underwent a face-to-face interview assessment of their sexual behavior and other reproductive health factors. After the interview they received the second counselling session of the intervention and an ample supply of condoms in a plain cloth package. One month after the second visit, women underwent interview assessment again and received a third ‘booster’ counselling session (an abbreviated version of the earlier session) and again received condoms. At this visit, women reported which negotiation strategies they had used with their partners in an open-ended format. Two months after the ‘booster’ session, women underwent their final interview assessment, which focused on sexual behavior in the previous 2 weeks. Raters developed a codebook for identified themes in the open-ended responses on negotiation strategies. This iterative process involved using previous coding disagreements to improve and modify the codebook. The raters used the final codebook to code negotiation strategies and achieved high inter-coder reliability (kappas between 0.84 and 1.0). The intervention achieved impressive levels of self-reported CCU. CCU increased from 0 pre-HIV test to 42% post-test and intervention to 63% at the booster intervention and 55% at the 2-month follow-up. CCU was significantly higher at all follow-up timepoints relative to the first (McNemar test chi-squares between 136.0 and 140.0, all P < 0.0001) and the drop-off at 2-month follow-up was non-significant (chi-square 2.36, P = 0.12). Six strategies were identified and used by at least 10% of women (see Table 1). The sample in Table 1 excluded five women who did not report negotiation strategies. One strategy, reported by 47% of the participants, involved simply remarking that condoms prevent HIV/AIDS. Twenty-five per cent of the women mentioned participation in the study specifically, e.g. ‘We are encouraged to use condoms by the people at the study'. Another, alluding to her own HIV-negative test result, was used by 15% of respondents. Twelve per cent of the women reported strategies involving efforts to exonerate their partners of blame, e.g. ‘Using condoms does not mean you are promiscuous'. A fifth strategy, reported by 11% of women, based the request on the high prevalence of HIV/AIDS in their community. Finally, 11% of women mentioned her partner's earlier infidelities or her own lack of trust in him.Table 1: Logistic regression models for negotiation strategies reported at intervention booster predicting consistent condom use at 2-month follow-up (n = 255).Of the six types of negotiation strategies used by the women, one was significantly predictive of CCU at follow-up (see Table 1): the strategy that focused on the prevalence of HIV in the surrounding community. The other strategies were not significantly related to CCU, although mentioning participation in the study – the only other strategy not focusing on the couple – conferred a non-significant protective effect. The present study attempted to document and evaluate for effectiveness specific condom negotiation strategies used by Zimbabwean women after a prevention intervention. Of six classes of negotiation strategies identified, only one, mentioning the prevalence of AIDS in the surrounding community, was significantly associated with CCU use 2 months after the intervention ended. It may be that focusing on the virus, or on the community at large, creates less resistance and greater cooperation than using strategies that focus on either or both members of the couple. In Zimbabwe, as in other cultures where group identity is more salient than individual identity 5, these indirect and non-threatening appeals may be more effective than appealing to individual behaviors. Because testing and counselling are becoming the mainstays of prevention efforts around the world, the identification of the most effective counselling strategies is critical. One of the fundamental aspects of counselling for women is condom negotiation skill-building. The present research represents a preliminary attempt to differentiate effective from ineffective strategies.