Introduction

In the past decade, the international public health response to the human immunodeficiency virus (HIV) epidemic has been strengthened. This is partly due to biomedical advances, such as the introduction of male circumcision as a viable prevention measure [1] and the expansion of antiretroviral (ARV) treatment options [2]. Despite the potential of these interventions to reduce rates of HIV transmission, they offer only partial protection from the sexual transmission of HIV, the main mode of transmission in Sub-Saharan Africa [3], where HIV persists as a major public health and development challenge. If used correctly and consistently, the male latex condom remains an important method available to individuals that can offer up to 95% protection from the sexual transmission of HIV [4]. Consistent use of condoms can also protect against most other sexually transmitted infections (STIs) [5] and offer protection from unwanted pregnancies. However, UNAIDS raised concerns about the low rates of condom use in African countries, particularly by youths, a population group especially vulnerable to HIV [3], [6].

Uganda was the first country in sub-Saharan Africa to reverse the adult prevalence of HIV in the 1990s [7]. However, the impressive initial reversal in the trend of HIV prevalence plateaued in Uganda. In 2009, HIV prevalence in Uganda was 7.3% [8] marking a slight increase from previous estimates. Many HIV experts are reluctant to credit the early reduction in HIV prevalence to one key message or intervention. Nevertheless, condom distribution and promotion of their use is critical component of Uganda’s HIV prevention strategy.

Recent investigations of the predictors of condom use have produced diverse findings [9]–[14]. Education level, economic status, and age were all positively correlated with condom use [11], [15]–[17]. Exposure to prevention messages, while positively associated with condom use, is substantially influenced by sex, economic status, age difference between partners, and the length of the relationship [6], [12], [18]–[20]. Knowledge that you yourself may be at risk of HIV, does not necessarily lead to using a condom [19].

Given that contextual and demographic factors may not easily be targeted through shorter-term public health interventions, researchers have analysed the experience of condom use in early sexual encounters. A recent study reports that people who use condoms in early sexual encounters are more likely to use condoms in later sexual encounters, and that a positive experience of condom use is a strong predictor of subsequent use [21]. This finding is pertinent to Uganda, as in many other countries [22], a person’s sexual debut frequently occurs before the age of 18 [23], [24]. If condom use is established at the earliest sexual encounter, individuals may be more likely to use a condom at their most recent sexual encounter and more likely to use condoms consistently with both regular and non-regular partners [10], [25]–[28]. Despite concerns that promoting condom use in young adults encourages sexual promiscuity, more recent evidence indicates the contrary. A multi-country study suggests there is no increase in the number of sexual partners between those who were exposed to condom promotion programs at a younger or an older age [29].

Our current study contributes to this literature through investigation of a unique database. We consider the effects of condom use by youths at their sexual debut over time using retrospective cross-sectional data. The data were collected over multiple time points, using multiple independent surveys carried out each year in a large number of different districts at each time point. This study analysed factors associated with several condom use measures in Ugandan youth aged 15–24 years old (n = 4493) over a 7-year period (2003–2010). We assess whether condom use at sexual debut was associated with recent condom use, adjusting for time, age, sex, education and Ugandan region. We cannot include economic status in this assessment, because household assets questions were not included in the questionnaires. The questions on condom use and sexual behaviour remained unchanged across the study time period. We carried out this epidemiological study with the aim of understanding determinants of condom use in Ugandan youth, over time, in order to inform future prevention programs. We hypothesised that those youth using a condom at sexual debut would be more likely to use a condom consistently and at future sexual encounters, adjusting for a number of demographic factors, such as age and educational level, in addition to time and space. We also expected that this relationship would exist regardless of the type of partner (regular or non-regular) and perceived risk of HIV. If messages and experiences learned in early sexual encounters play a consistently strong role in shaping future behaviours related to safer sex, our results could offer important evidence to guide social policy towards more focused and targeted behavioural interventions to successfully promote condom and safer sexual behaviour by youths.

Methods

Data

The data were collected using multiple cross-sectional district level community surveys during 2003–2010. In 2003, the Uganda AIDS Commission (UAC), with the support of The World Bank, introduced Lot Quality Assurance Sampling (LQAS) methodology to monitor HIV-related indicators, including condom use, at the district and sub-district level. It was introduced during 2003 into 19 (of the then 56) districts comprising the country, and expanded to 11 more in 2004 [30], [31]. In 2009, USAID provided funding to support the roll out of LQAS as a national health sector monitoring system (http://www.starelqas.ug). This same funding will make the dataset available for wider use by the public during 2014 through an as yet unidentified Ugandan institution. By 2011, LQAS surveys had been completed in 53 of the current 112 districts comprising the country. Many of the districts implemented surveys at one or more time points from 2003–2011. During this period Uganda had sub-divided its districts leading to an increase from 56 (2003) to 112 (2011). Between 2003 and 2010 five multi-district surveys were completed and included in this study (Table 1). Areas surveyed during the first three time points were distributed across the four Uganda regions (Central, Eastern, Northern and Western), while recent time points focus on districts in the Eastern (2009, 2010) and South Western (2010) regions. All districts supported by donors were included in the study. They include The World Bank (2003–2006) and USAID (2009-present). Donors tended to select the districts they worked in, choosing those with the lowest health indicators. All data used in this study are representative of these districts, and are not intended to be representative of the country as a whole. At each time point, teams interviewed up to six respondent groups: youths 15–24 years, women 15–49 years, men 15–54 years, mothers with infants 0–11 months, mothers with children 12–23 months, and orphans and other vulnerable children. This study focuses on the analysis of data collected among youth aged 15–24 interviewed between 2003 and 2010 for which the measures of condom usage and sexual behaviour remained unchanged.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 1. Overview of samples of youths included in this study across time and region in Uganda during 2003 to 2010.

https://doi.org/10.1371/journal.pone.0093083.t001

Results

Of the 7187 youths included in the study across the five time points, 63% (n = 4518) reported a history of sexual activity. This corresponds with the 2011 DHS, which found 64% of Ugandan youths to be sexually active (UDHS, 2011). This subset was used for the analysis; their descriptive data are shown in Table 2. Sexually active youths were almost equally divided between females (50.3%) and males (49.7%). Their average age was 20.2 years within a range of 15–24 years. Most individuals (74.8%) had their first sexual intercourse between the age of 15 and 19 years, mean 16.5, median 17.0. Approximately 45% were married or lived with their partner. Almost 35% had attended secondary or post-secondary level education. A third (33.1%) of the participants perceived themselves as being at high risk of acquiring HIV. Almost 60% of participants reported having ever used a condom; however, only 34% and 30% reported using a condom at sexual debut and during their most recent sexual intercourse, respectively. More than 45% of the participants who reported having intercourse with a NR partner in the previous year used a condom at last intercourse. Nearly 19% of sexually active youths reported always using a condom during intercourse, while, alarmingly, almost 49% reported never using one.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 2. Characteristics of sexually active youths participating in LQAS surveys across Uganda between 2003 and 2010 (n = 4518).

https://doi.org/10.1371/journal.pone.0093083.t002

Logistic Regression Models

Table 3 shows the univariate regression of condom use behaviour outcomes on selected independent variables. The main behaviour outcomes of interest include: condom use at sexual debut, condom use at most recent sexual intercourse, condom use at last intercourse with a NR partner and frequency of condom use.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 3. Odds ratios of the effects of socio-demographic and behavioural characteristics on condom use and sexual practice.

https://doi.org/10.1371/journal.pone.0093083.t003

For all four outcomes, condom usage increased from 2003 to 2006. We observed geographic disparities. For all four outcomes, condom use was significantly higher in the Central region. The odds of condom use at sexual debut, at last intercourse and consistent condom use were respectively, 48%, 18% and 18% higher in the Eastern than in the Northern region. The odds of condom use at last intercourse with a NR partner were 50% lower in the Northern than in the Western region. The odds of condom use at first intercourse were 66% higher in the Eastern than in the Western region. These results should be interpreted with caution, since the surveyed geographical area varies between time points. In particular the 4 districts surveyed in 2009 were located in the Eastern region, while the 2010 survey included 9 additional districts in the Western region.

The results also show that the odds of using a male condom at last intercourse or consistently during sexual intercourse are, respectively, 47% and 53% lower for women than for men. However there is no significant difference in the odds of condom use at first sex between males or females. The odds of condom use at sexual debut, most recent intercourse or consistent condom use during sexual intercourse decrease by about 5% for every year increase in the respondent’s age.

Additionally, for every one-year older a youth is when they first have intercourse, the odds using a condom at their sexual debut increases by almost 10%. Compared to their single counterparts, the odds of using a condom at last intercourse or at sexual debut are respectively 85% and 53% higher among youth who are married or living with their partner. Furthermore, youth who are married or living with their partner have a 91% increase in the odds of consistently using a condom compared to those who do not live with a partner or a spouse. Among those who had sexual intercourse with a NR partner in the last 12-months, the odds of using a condom at last intercourse are 34% lower among youth who are married or living with their partner compared to their single counterparts.

Higher education level is strongly associated with increased condom usage. Among youths with post-secondary level schooling compared with no schooling, the odds of using a condom at sexual debut are 4 times higher, the odds of condom use at last intercourse are 6 times higher, the odds of condom use at last intercourse with a NR partner are almost 4 times higher while the odds of using a condom every time they have sex are over 8 times higher. Additionally, the odds of having used a condom at first intercourse, last intercourse and consistently are, respectively, 26%, 31% and 43% lower among youths who do not know their risk of acquiring HIV, compared to those who perceive no risk of acquiring HIV.

In line with previous studies, this study shows that condom use at sexual debut is highly associated with condom use at most recent sexual encounter. When controlling for sex, age, education, marital status, age at first intercourse, region, survey year, perceived risk for HIV and ever tested for HIV, the odds of condom use at last intercourse are almost ten times higher if a condom was used at sexual debut. Using a condom at first sex also increases by more than three the odds of condom use with a NR partner and by more than eleven the odds of consistent condom use (Table 3 and Tables S1, S2, S3 in File S1). The associations are also high when measured for males and females separately.

Discussion

We studied the association between using a condom during first sexual intercourse and subsequent condom use in Ugandan youth in a multiple logistic regression model. Our findings show that condom usage at sexual debut is strongly correlated with condom use at most recent intercourse and with consistent condom use with both regular and NR partners. These relationships persist when adjusting for geographic region, educational level, sex, marital status, perceived risk of HIV and having ever taken an HIV test. These findings substantiate the need for youth HIV prevention and sexual health programmes introduced prior to the initiation of sexual intercourse. Encouraging youth to use condoms at first sexual encounter may help to promote and reinforce healthy sexual behaviour that lasts into later life.

In our study, we found that youth in Uganda who used a condom the first time they have sexual intercourse were nearly ten times as likely to use a condom at their most recent sexual encounter and nearly five times as likely to use a condom at last intercourse with a NR partner. This finding is consistent with studies in the United States [26], [38], Latin America [39], sub-Saharan Africa [10], [28], and Europe [40] showing that early use is associated with subsequent use. To the best of our knowledge, the current study is the first to isolate the important positive association of condom use at sexual debut even with high-risk sexual behaviours (such as sex with non-regular partners), and to demonstrate that this relationship is consistent across multiple time points and over multiple geographical locations.

One theory potentially explaining this association is that when youth understand the benefit of condom use early enough to embrace protective behaviour at the first sexual encounter, this keystone event may have a lasting impact on subsequent encounters, regardless of their type of partner. However, it may simply be the case that a certain portion of individuals have a tendency towards more healthy or protective behaviours and others may be risk takers, explaining why the same individuals maintain the health protective behaviours from the outset. Nonetheless, the multiple independent variables included in the Multivariate Model (Table 2) suggest that reality is complex and that controlling for variables such as education, age, and marital status is relevant to understanding this behaviour. Future studies will have to consider the motivations behind condom use at first and subsequent sexual acts; and need to take into account that not all sexual encounters are consensual [41].

Older age at sexual debut is associated with condom usage, regardless of partner type [28], suggesting that delaying the age of sexual debut could be encouraged as a means to reduce the risk of youths to HIV infection and unwanted pregnancy. This situation is compounded by the known increased biological vulnerability of younger women to the HIV virus. Comprehensive risk reduction programmes can include components on delaying sexual debut alongside the promotion of other behaviours that reduce risks of pregnancy and STIs, including negotiation and communication skills and correct condom use for when sexual activity does occur. This approach differs from programmes that promote abstinence alone, which often focus exclusively on abstinence from sex until marriage [42], [43]. This distinction is important considering that our study shows two thirds of Uganda youth 15–24 are already sexually active and of those, three quarters (74.8%) had their first sexual encounter between the age of 15 and 19 years old. Our study adds to a growing body of evidence suggesting that efforts should be made to promote condom use and other health protective mechanisms prior to the earliest age that youths tend to initiate sexual activity [27], [44]. Our results also suggest that such programmes can have an enduring and beneficial effect regardless of where or with whom they are implemented.

As we found that married youths were less likely to use condoms when having sex with a NR partner, prevention programmes may need to reinforce the importance of condom use for all youths. Regardless of partner type (marital or casual), there is a strong association between educational level and condom usage. Education may affect sexual behaviour in a number of ways, including improving social opportunities and access to health promoting resources that positively influence other personal characteristics known to be associated with condom use, such as self-efficacy and ability to negotiate.

Because the efficacy of condoms in protecting from HIV and STIs drops sharply when condom use is inconsistent, consistent condom use is the desirable health behaviour. One of our strongest findings is that youth in Uganda who use a condom the first time they have sexual intercourse were nearly twelve times as likely to report always using a condom. Earlier research found that condom use is a habitual action based on a learned routine, rather than being a mediated, calculated or rational decision, or one based on social or peer influences [27]. This result suggests that consistent condom use by youths is a habit, rather than a discreet decision made at each sexual encounter based on peer pressure or their knowledge of the risks of unprotected sex. A number of related studies has found that negative experiences with condom use in early sexual experiences is negatively associated with later condom use by both sexes [6], [21], [44], [45]. The combined evidence from these studies suggests that the early sexual experiences are formative. As our results show no difference between males and females in the odds of condom use at first sex, social programs should be broadly conceived and focus equally on both genders. If condom use occurs “successfully” in the encounter, it can establish behaviour that is carried forward, regardless of other social and demographic factors. These potentials are especially important in light of recent multi-country models of HIV transmission that indicate that extra-couple relations are a principal route for HIV transmission in low resource settings [46].

Even with ARV treatment options and the increased protection male circumcision may offer, early and consistent condom use is still necessary, and accrues health benefits in addition to reduced HIV transmission, such as the prevention of other STIs, and unwanted early pregnancies. In a meta-analytic review, early exposure to condom promotion messages has not been found to increase the overall frequency of sexual activity or number of partners [29]. Furthermore, when provided to higher risk groups, it has been shown to have greater potential to reduce partners and increase treatment seeking behaviour, especially when delivered as part of a comprehensive risk reduction programme [29], [43]. In addition to our evidence of the strong habit-shaping role that early condom use may play, studies in multiple settings indicate that promoting self-efficacy and negotiation skills increases condom use, particularly in females [13], [24], [47]–[50]. As a preventive action that depends on male cooperation, negotiation and self-efficacy, promotion strategies should focus on the different needs of both sexes. Confidential gender and youth friendly outlets can link voluntary testing and counselling services with the provision of free condoms and promote condom use through existing community institutions frequented by youth, whether they be faith based organisations, schools and youth centres or through the use of innovative social media. Policies, of course, should also articulate a supportive legal frameworks, as well as protective procedures, for young women who experience sexual violence. Targeted programmes have been more effective than less client-focused condom promotion efforts [29], [51], [52] but they may need more clear targeting for vulnerable youths, such as those who are out of school or internally displaced.

Supporting Information

Acknowledgments

The authors gratefully acknowledge Nick Atkins, Charles Nkolo and Ronald Egonda for their support in developing the database, and William Vargas for his support over the years as an exceptional LQAS trainer. We also are grateful for the entire STAR-E staff who has worked in support of the LQAS data collection including Esther Sempiira and Edward Were. The authors wish to thank all of the districts staff for the collection of these data, and all those who participated in these surveys for their time and trust.