Practices and beliefs as Catalysts OR deterrents in the use of preventive prophylactics for at-risk populations: Unlocking potential for use of the rectal Microbicide in Uganda.

*Muyunga Thomas, Sebulime Gerald, Grace Kabayaga, Nabaggala Deborah

BACKGROUND: Sexual reproductive practices and beliefs around sexual intercourse can influence risky sexual behaviours. 320 settings in Uganda were identified to describe this association from July 2010 to August 2011.

OBJECTIVE: To show effect of practices and beliefs on use of prophylactics, their demand and provision.

DESIGN:  Literature review into cultural practices and perceptions around sexual intercourse, anecdotal recollections on use of prophylactics, Qualitative information using a short structured questionnaire and focus group discussions inquiring into sexual intercourse practices, use of condoms in sex-work, use of condoms for those in long term relations, checking registers where condoms/lubricant are sourced and what the unique characteristics attributed to anal sex were, formed our design.

SETTING: This covered suburbs of Kampala, 5 municipalities, Town Councils and 5 landing sites chosen for the big number of  groups we had mobilised and the identified female/male sex-work spots and; 15 major pharmacies/shops that stock KY jelly, female condoms and Same sex sexual reproductive health commodities. 

RESPONDENTS: The respondents included 100 male sex-workers (17 years to 38 years), 100 female sex-workers, 54 male pimps/escorts (22 were 25-33 years: 32 were 42-52 years), 20 gay-friendly organisation heads, 13 young positives, 100 couples in a heterosexual relation, 45 substance users (20-35 years), 15 pharmacists, 73 condom distributors and 23 regular clients of male sex-workers (27-47 years) as key informants.

INTERVENTION: All discussions and conversations were conducted in safe spaces and confidentiality was assured for all. Names of respondents except for venues were struck off all lists.

MAIN OUTCOME MEASUREMENT:  The extent and scale of use of condoms and right lubrication among male sex-workers, sexual minorities and substance users is affected by beliefs, regard of providers, the price and branding of SRH materials.

RESULTS: 300 had experiences of having not used condoms in the last 3 months: 110 reasoned they knew their sexual partners for more than 1 year; 70 females said condoms after sex are cumbersome as they do the cleaning of the penis; 25 males said anal sex was enjoyable even without condoms and expressed no risk of transmission of any infections; 20 sex-workers said that they charged higher fees for un protected anal sex; 30 males and 45 female respondents in long term heterosexual relations had never used condoms; 15 females were living in relations as co-wives. 20 gay leaders said it was difficult to provide water based lubricants in Uganda because it was expensive, this also meant there was incorrect use of condoms as most gay people use saliva, Vaseline or lotion during most anal sexual acts. 15 pharmacists said they ordered for KY-Jelly and the product was popular mostly among female clients. 13 young positives reported stigma at schools and communities of residence and it is hard for them to be provided opportunity to access sex-education while positive.

In depth interviews revealed:

 “During my adolescent years as a girl I was trained by my auntie to pull my labia so that in the event of marriage I give my husband more pleasure, I was also instructed on how to clean his penis after a sex-act. I was never taught how to do this when the condom is on. The condom gets in the way of this ritual. ” – Female respondent

“I enjoy the feel of a wet vagina; I feel bathed in warm slippery fluids.  I also enjoy it when a man enters my tight arse in an anal sexual act.” –A receptive bisexual man

“My husband refused to use condoms in our marriage saying ‘can you use condoms in a marriage?’. So I left it to be a single mother”- Female respondent

CONCLUSIONS: Demand and supply of preventive prophylactics is disproportionately due to beliefs, cultural practices, stigma, price and branding. This impacts on use and is a risk factor for HIV/AIDS/STIs/TB. This association must be recognized and must be part of health education, branding and social marketing around the New Prevention Technologies (NPT) such as Microbicides to be effectively used in protection. Such prophylactics provide the user an opportunity to negotiate for safer non-infectious sexual intercourse.

·         All authors from MARPS IN UGANDA