Wealth and sexual behaviour among men in Cameroon

BACKGROUND: The 2004 Demographic and Health Survey (DHS) in Cameroon revealed a higher prevalence of HIV in richest and most educated people than their poorest and least educated compatriots. It is not certain whether the higher prevalence results partly or wholly from wealthier people adopting more unsafe sexual behaviours, surviving longer due to greater access to treatment and care, or being exposed to unsafe injections or other HIV risk factors. As unsafe sex is currently believed to be the main driver of the HIV epidemic in sub-Saharan Africa, we designed this study to examine the association between wealth and sexual behaviour in Cameroon. METHODS: We analysed data from 4409 sexually active men aged 15–59 years who participated in the Cameroon DHS using logistic regression models, and have reported odds ratios (OR) with confidence intervals (CI). RESULTS: When we controlled for the potential confounding effects of marital status, place of residence, religion and age, men in the richest third of the population were less likely to have used a condom in the last sex with a non-spousal non-cohabiting partner (OR 0.43, 95% CI 0.32–0.56) and more likely to have had at least two concurrent sex partners in the last 12 months (OR 1.38, 95% CI 1.12–1.19) and more than five lifetime sex partners (OR 1.97, 95% CI 1.60–2.43). However, there was no difference between the richest and poorest men in the purchase of sexual services. Regarding education, men with secondary or higher education were less likely to have used a condom in the last sex with a non-spousal non-cohabiting partner (OR 0.24, 95% CI 0.16–0.38) and more likely to have started sexual activity at age 17 years or less (OR 2.73, 95% CI 2.10–3.56) and had more than five lifetime sexual partners (OR 2.59, 95% CI 2.02–3.31). There was no significant association between education and multiple concurrent sexual partnerships in the last 12 months or purchase of sexual services. CONCLUSION: Wealthy men in Cameroon are more likely to start sexual activity early and have both multiple concurrent and lifetime sex partners, and are less likely to (consistently) use a condom in sex with a non-spousal non-cohabiting partner. These unsafe sexual behaviours may explain the higher HIV prevalence among wealthier men in the country. While these findings do not suggest a redirection of HIV prevention efforts from the poor to the wealthy, they do call for efforts to ensure that HIV prevention messages get across all strata of society

Changing association between schooling levels and HIV-1 infection over 11 years in a rural population cohort in south-west Uganda.

BACKGROUND: Previous studies have found that in Africa, a greater risk of HIV infection is often found in groups with higher educational attainment. However, some serial cross-sectional studies have found greater reductions in HIV prevalence among more educated groups, especially in cohorts of young adults. More recent studies have found some instances where higher schooling levels are associated with lower HIV prevalence. METHODS: We describe changes in the association between schooling levels, HIV prevalence and condom use in a rural population-based cohort between 1989/1990 and 1999/2000, in Masaka District, Uganda. RESULTS: In 1989-1990, higher educational attainment was associated with higher risk of HIV-1 infection, especially among males, but once odds ratios are adjusted for age, no significant relation between schooling and HIV infection remains. In 1999-2000, there is, for females aged 18-29 years, a significant relationship between higher educational attainment and lower HIV prevalence, even after adjustment for age, gender, marital status and wealth (P for trend 0.01). Tests for interaction, significant for males and both genders combined, show that more schooling has been shifting towards an association with less HIV infection between 1989-1990 and 1999-2000, especially for young individuals. Condom use increased during the study period and this increase has been concentrated among more educated individuals. CONCLUSIONS: These findings suggest that over a decade more educated young adults, especially females, have become more likely to respond to HIV/AIDS information and prevention campaigns by effectively reducing their sexual risk behaviour

Does increased general schooling protect against HIV infection? A study in four African cities.

BACKGROUND: The association between educational attainment and risk of HIV infection varies between populations and over time. Earlier studies in sub-Saharan Africa have found that those with more education are at increased risk of HIV infection. METHODS: We investigated the associations between general schooling and both HIV and herpes simplex-2 (HSV-2) infection using data from the multicentre study on factors determining the differential spread of HIV in four African cities. Cross-sectional general population studies were conducted in 1997-1998 in Cotonou (Benin), Yaoundé (Cameroon), Kisumu (Kenya), and Ndola (Zambia), including about 2000 adults in each city. RESULTS: There was no association between schooling and HIV infection in men or women in Kisumu or Ndola. Women in Yaoundé and men in Cotonou, with more schooling, were less likely to be HIV positive. These associations persisted after adjusting for sociodemographic factors. Similar trends in men in Yaoundé and women in Cotonou were not statistically significant. Increased schooling was associated with significantly decreased risk of HSV-2 infection in women in Kisumu and Ndola and men in Cotonou. In all the cities those with more education tended to report less risky sexual behaviour. CONCLUSIONS: There was no evidence of an increased risk of HIV infection associated with education as seen in earlier studies. In each city there was some evidence of lower HIV or HSV-2 infection rates and less risky sexual behaviour associated with increased education levels. The most educated may be responding more readily to health education programmes. The challenge is to extend this to the rest of the population

Educational attainment and HIV-1 infection in developing countries: a systematic review.

OBJECTIVES: To assess whether educational status is associated with HIV-1 infection in developing countries by conducting a systematic review of published literature. METHODS: Articles were identified through electronic databases and hand searching key journals. Studies containing appropriately analysed individual level data on the association between educational attainment and HIV-1 status in general population groups were included. RESULTS: Twenty-seven articles with appropriately analysed results from general population groups in developing countries were identified, providing information on only six countries. Large studies in four areas in Africa showed an increased risk of HIV-1 infection among the more educated, whilst among 21-year-old Thai army conscripts, longer duration of schooling was strongly protective against HIV infection. The association between education and schooling in Africa was stronger in rural areas and in older cohorts, but was similar in men and women. Serial prevalence studies showed little change in the association between schooling and HIV over time in Tanzania, but greater decreases in HIV prevalence among the more educated in Uganda, Zambia and Thailand. CONCLUSIONS: In Africa, higher educational attainment is often associated with a greater risk of HIV infection. However, the pattern of new HIV infections may be changing towards a greater burden among less educated groups. In Thailand those with more schooling remain at lower risk of HIV infection