Table 1 Characteristics of PLWHA having reported sexual intercourse with a steady partner either HIV-negative or of unknown serostatus in the
previous 3 months (n907): data from the EVAL Survey in Cameroon (ANRS 12-116)
a. Sociodemographic/economic characteristics and characteristics related to living in a couple, sexual activity and parenthood
Inconsistent condom use
All patients
(n[907) No (n[587) Yes (n[320)
Characteristics n (%), mean (SD) or median (IQR) Crude OR 95% CI p Value
Sociodemographic and economic characteristics
Age* (years) 36 (8) 36 (9) 35 (8) 0.89 0.75 to 1.05 0.16
Gender and social condition*
Men (ref.) 299 (33.0) 198 (33.7) 101 (31.6) 1 <0.0001
Women not heads of their household 423 (46.6) 246 (41.9) 177 (53.3) 1.41 1.04 to 1.92
Women heads of their household 185 (20.4) 143 (24.4) 42 (13.1) 0.58 0.38 to 0.88
Area of habitation*
Urban or semiurban (ref.) 758 (83.6) 501 (85.3) 257 (80.3) 1 0.05
Rural 149 (16.4) 86 (14.7) 63 (19.7) 1.43 1.00 to 2.04
Educational level*
Primary school 330 (36.4) 191 (32.5) 139 (43.4) 1.59 1.20 to 2.11
High school or university (ref.) 577 (63.6) 396 (67.5) 181 (56.6) 1 0.001
Monthly household income per adult 13 (7; 25) 13 (7; 27) 12 (6; 22) 0.79 0.59 to 1.04 0.09
equivalent*31000 F CFA
Being a member of an association of PLWHA*
No (ref.) 779 (85.9) 490 (83.5) 289 (90.3) 1 0.005
Yes 128 (14.1) 97 (16.5) 31 (9.7) 0.54 0.35 to 0.83
Binge drinking*
No (ref.) 803 (88.5) 527 (89.8) 276 (86.3) 1 0.11
Yes 104 (11.5) 60 (10.2) 44 (13.8) 1.40 0.92 to 2.12
Characteristics related to living in a couple, sexual activity and parenthood
Living in a couple*
No (ref.) 212 (23.4) 157 (26.7) 55 (17.2) 1 0.001
Yes 695 (76.6) 430 (73.2) 265 (82.8) 1.76 1.25 to 2.48
HIV serostatus disclosure to main partnery
Serostatus concealed (ref.) 128 (14.1) 69 (11.8) 59 (18.4) 1 0.001
Not living in a couple 212 (23.4) 157 (26.7) 55 (17.2) 0.41 0.26 to 0.65
Serostatus disclosed 567 (62.5) 361 (61.5) 206 (64.4) 0.67 0.45 to 0.98
Frequency of sexual relationships*
Less than once a month (ref.) 200 (22.0) 135 (23.0) 65 (20.3) 1 0.54
Once a month 198 (21.8) 129 (22.0) 69 (21.6) 1.11 0.73 to 1.68
More than once a month 417 (46.0) 269 (45.8) 148 (46.2) 1.14 0.80 to 1.63
Several times a week or everyday 92 (10.1) 54 (9.2) 38 (11.9) 1.46 0.88 to 2.43
Having a casual partner*
No (ref.) 617 (68.0) 424 (72.2) 193 (60.3) 1 <0.0001
Yes 290 (32.0) 163 (27.8) 127 (39.7) 1.71 1.28 to 2.28
Presence of children in the household*
No (ref.) 171 (18.9) 103 (17.5) 68 (21.3) 1 0.17
Yes 736 (81.1) 484 (82.5) 252 (78.8) 0.79 0.56 to 1.11
At least one biological child
No (ref.) 158 (17.4) 100 (17.0) 58 (18.1) 1 0.68
Yes 749 (82.6) 487 (83.0) 262 (81.9) 0.93 0.65 to 1.32
Desire to have a(nother) child*
Do not want a(nother) child (ref.) 279 (30.8) 199 (33.9) 80 (25.0) 1 0.02
Cannot have a(nother) child 48 (5.3) 28 (4.8) 20 (6.3) 1.78 0.95 to 3.33
Want a(nother) child 580 (63.9) 360 (61.3) 220 (68.8) 1.52 1.12 to 2.07
History of forced sexual relationships
No (ref.) 814 (89.7) 528 (89.9) 286 (89.4) 1 0.78
Yes 93 (10.3) 59 (10.1) 34 (10.6) 1.06 0.68 to 1.66
b. Clinical characteristics, health-related quality of life and self-reported symptoms
Inconsistent condom use
All patients
(n[907) no (n[587) yes (n[320)
Characteristics n (%), mean (SD) or median (IQR) Crude OR 95% CI p Value
Clinical characteristics
Time since HIV diagnosis*din months 27 (23) 29 (23) 24 (21) 0.99 0.98 to 0.99 0.003
Initiative for diagnosis test*
Medical team (ref.) 574 (63.3) 362 (61.7) 212 (66.3) 1 0.17
Patients personal initiative 333 (36.7) 225 (38.3) 108 (33.8) 0.82 0.62 to 1.09
Table 1 Continued
b. Clinical characteristics, health-related quality of life and self-reported symptoms
Inconsistent condom use
All patients
(n[907) no (n[587) yes (n[320)
Characteristics n (%), mean (SD) or median (IQR) Crude OR 95% CI p Value
Receiving ART*
No 216 (23.8) 105 (17.9) 111 (34.7) 2.44 1.78 to 3.33
Yes (ref.) 691 (76.2) 482 (82.1) 209 (65.3) 1 <0.0001
Self-report of ART interruption for more than 2 days in the previous 4 weeksz
No (ref.) 618 (68.1) 435 (74.1) 183 (57.2) 1 <0.0001
Yes 73 (8.0) 47 (8.0) 26 (8.1) 1.31 0.79 to 2.19
Not treated 216 (23.8) 105 (17.9) 111 (34.7) 2.51 1.83 to 3.45
CDC C clinical stage
No (ref.) 637 (70.2) 404 (68.8) 233 (72.8) 1 0.21
Yes 270 (29.8) 183 (31.2) 87 (27.2) 0.82 0.61 to 1.11
CD4 count at last assessment*- in cells/mm3 321 (213; 470) 321 (216; 484) 320 (195; 456) 0.97 0.94 to 1.00 0.079
<200 cells/mm3 213 (23.5) 132 (22.5) 81 (25.3) 1 <0.0001
$200 cells/mm3 694 (76.5) 455 (77.5) 239 (74.7) 0.61 0.46 to 0.80
Frequency of hospital visits*
#1 visit every 2 months 360 (39.7) 208 (35.4) 152 (47.5) 1
>1 visit every 2 months 547 (60.3) 379 (64.6) 168 (52.5) 0.61 0.46 to 0.80
Health-related quality of life (HRQL) and self-reported symptoms
Physical HRQL score* 52 (45; 56) 52 (46; 56) 51 (43; 55) 0.98 0.96 to 0.99 0.008
Mental HRQL score 45 (38; 51) 45 (38; 51) 44 (37; 50) 0.99 0.98 to 1.01 0.40
No of general symptoms* 5 (2; 7) 4 (2; 7) 5 (3; 8) 1.05 1.01 to 1.09 0.01
No of symptoms related to changes in body 0 (0; 2) 0 (0; 2) 1 (0; 3) 1.04 0.97 to 1.12 0.30
shape
c. ART knowledge
Inconsistent condom use
All patients No (n[587)
Characteristics (n[907) n (%) Yes (n[320) Crude OR 95% CI p Value
HIV can be cured by ARVs (the virus disappears)*
No, I do not agreex (ref.) 406 (44.8) 273 (46.5) 133 (41.6) 1 0.15
Yes, I agree/I do not know 501 (55.2) 314 (53.5) 187 (58.4) 1.22 0.93 to 1.61
ARVs stabilise the development of the illness and can enable the person to live normally*
No, I do not agree/I do not know (ref.) 88 (9.7) 47 (8.0) 41 (12.8) 1 0.02
Yes, I agreex 819 (90.3) 540 (92.0) 279 (87.2) 0.59 0.38 to 0.92
Risk of falling ill is reduced with ARVs*
No, I do not agree/I do not know (ref.) 180 (19.8) 106 (18.1) 74 (23.1) 1 0.07
Yes, I agreex 727 (80.1) 481 (81.9) 246 (76.9) 0.73 0.52 to 1.02
Someone who takes ARVs cannot transmit the virus*
No, I do not agreex (ref.) 613 (67.6) 425 (72.4) 188 (58.8) 1 <0.0001
Yes, I agree/I do not know 294 (32.4) 162 (27.6) 132 (41.3) 1.84 1.38 to 2.45
When someone who takes ARVs feels better, there is no further need to take the medicine*
No, I do not agreex (ref.) 779 (85.9) 521 (88.8) 258 (80.6) 1 0.0009
Yes, I agree/I do not know 128 (14.1) 66 (11.2) 62 (19.4) 1.90 1.30 to 2.77
*Variables included in the multivariate analysis.
yThis variable was not included in the multivariate analysis due to its correlation with the variable Living in a couple.
zThis variable was not included in the multivariate analysis due to its correlation with the variable Receiving ART.
xCorrect answer.
ART, antiretroviral therapy; ARVs, antiretrovirals; IQR, interquartile range (25%; 75%); PLWHA, people living with HIV and AIDS.
OR, odds ratio; CI, confidence interval.
partner (either HIV-negative or of unknown HIV status) during Characteristics related to living in a couple, sexual activity
the previous 3 months. and parenthood
Living in a couple was dened as marriage or free union, and
Variables sharing or not the same home. Disclosure of seropositivity to the
Socio-demographic and economic characteristics main partner, frequency of sexual relationships, casual partner-
Patients gender, social conditions, age, area of habitation and ship, history of forced sexual relationships, parenthood (having at
level of education were included in the analyses. Participation in least one biological child, the desire to have a/another child) and
an association of PLWHA was also considered, as well as alcohol the presence of children in the household were also considered.
abuse (binge drinking), characterised by having drunk more than
three large bottles of beer and/or more than six glasses of other Health-related quality of life and self-reported symptoms
alcohol drinks on one occasion. Monthly household income per Physical and mental health-related quality of life (HRQL) of
adult equivalent calculated from patients reports was taken as patients was evaluated using two scores ranging from 0 to 100,
an economic indicator of their standard of living. with higher values denoting better HRQL. These scores were
calculated from patients answers to the Medical Outcome Study of the remaining 907 patients (63.6%). Socio-demographic,
12-Item Short Form Health Survey.11 Patients were also asked if, economic, clinical and psychosocial characteristics of these
during the previous 4 weeks, they had experienced any symp- patients are described in table 1.
toms from a specic list derived from the self-completed HIV
symptom index developed by Justice et al12 and which comprised Factors associated with inconsistent condom use with ones
both general symptoms and symptoms related to changes in steady partner either HIV-negative or of unknown HIV status
body shape. A total of 320 patients (35.3%) engaged in inconsistent condom
use with a steady partner either HIV-negative or of unknown
Knowledge concerning antiretrovirals HIV status in the previous 3 months. The percentages of
Patients were asked a series of ve questions about their patients who reported inconsistent condom use were not
knowledge concerning antiretrovirals (ARVs) action on HIV and signicantly different between men and women (33.8% and
the need for pursuing these treatments on the long-term 36.0%, respectively, p0.50). Characteristics of the study popu-
(table 1). lation according to patients report of inconsistent condom use
are presented in table 1.
Clinical and treatment-related characteristics
The following clinical and treatment-related characteristics were Bivariate analyses
considered: time since HIV diagnosis, CDC clinical stage, In bivariate analyses, not receiving ARTat the time of the survey
treatment received, CD4 cell count at last assessment, infor- was among the characteristics most signicantly (p<0.0001) and
mation on the patients initiative to have an HIV test, ART strongly (crude OR (95% CI): 2.44 (1.78; 3.33)) associated with
history, healthcare services utilisation during the previous patient report of inconsistent condom use (table 1). In close
6 months and adherence to ART (dened as no self-report of ART relationships with access to ART, having been diagnosed HIV-
interruption for more than 2 days in the previous 4 weeks). positive more recently, doing less than 1 visit to hospital every
2 months, as well as reporting more general symptoms and
Statistical analyses impaired physical HRQL were also signicantly associated with
Logistic regression models were used to identify factors associ- reporting inconsistent condom use. In addition, believing that
ated with inconsistent condom use among patients who ARVs stabilise the development of the HIV illness was signi-
reported sexual activity in a regular partnership during the cantly associated with a lower risk of inconsistent condom use,
previous 3 months, with a steady partner either HIV-negative or while believing that ART can prevent HIV transmission or that
of unknown HIV status. All characteristics of patients were there is no further need to take the medicine for a treated person
tested, except those binary variables which concerned less than who feels better was associated with a higher risk of inconsistent
5% of the study population. Factors with a p value <0.20 in condom use. The other variables signicantly associated with
bivariate models were considered eligible for the multivariate inconsistent condom use concerned mainly patients social status
model. A forward stepwise procedure with an entry threshold and network (including: being a woman not at the head of the
xed at 0.05 was used to select statistically signicant factors in household, not being a member of an association of PLWHA,
the multivariate analysis and to determine the nal model. A living in a couple) as well as their sexual activity and couple
forward selection procedure13 involves starting from an empty relationships (including: living in a couple, having a casual sexual
model, then computing the c2 statistic for each variable not in partner, having the desire to have a child).
the model and examining the largest of these statistics. If it is Age, income level, frequency of sexual relationships, adherence
signicant at the a0.05 level, the corresponding variable is to ART, last CD4 count and mental HRQL were not signi-
added to the model. The process is repeated until none of the cantly associated with inconsistent condom use.
remaining variables meet the level for entry. With the stepwise
approach, variables included in the model do not necessarily Multivariate analysis
remain. Indeed, at each step, results of the Wald test for indi- In the nal multivariate model, not receiving ART at the time of
vidual parameters are examined, and the least signicant variable the survey was conrmed as a factor signicantly associated
that does not meet the a0.05 level for staying in the model is with patient report of inconsistent condom use (table 2).
removed. ORs estimates in the nal model were systematically However, time since HIV diagnosis, frequency of visits to
adjusted for the frequency of sexual relationships, as a marker of hospital, number of symptoms reported, physical HRQL as well
individuals exposure to HIV transmission risk. Two sensitivity as report of the desire to have a child and variables related to ART
analyses were performed after consistently grouping the do not knowledge were no longer signicant after multivariate adjust-
know answers with yes (rst sensitivity analysis) or no ment.
answers (second sensitivity analysis) for variables concerning The results of the two sensitivity analyses conrmed the
ART knowledge. Statistical analyses were performed using the stability of the multivariate model, as the pattern of factors
SPSS V.15.0 (SPSS, Chicago) and Intercooled Stata V.9 (StataCorp identied as being independently associated with inconsistent
LP, College Station, Texas) software packages. condom use was essentially the same (except for the variable
Someone who takes ARVs cannot transmit the virus, which
was no longer signicant when the do not know answers were
RESULTS grouped with the no answers).
Characteristics of the study population
Among the 3151 survey participants, 1725 (54.7%) reported no
sexual activity during the previous 3 months (of whom 72% had DISCUSSION
no main partner). Among the remaining 1426 patients, 91 (6.4%) The present study underlines the high frequency of inconsistent
had no main sexual partner or no sexual activity with their main condom use among sexually active HIV-infected outpatients in
partner during the previous 3 months, and 428 (30.0%) had Cameroon. Results of the multivariate analysis primarily high-
a seroconcordant main partner. The study population consisted light that not receiving ART is associated with a higher risk of
Table 2 Multivariate analysis of factors associated with inconsistent condom use among PLWHA having reported sexual intercourse with a steady
partner either HIV-negative or of unknown serostatus in the previous 3 months (n907): data from the EVAL Survey in Cameroon (ANRS 12-116)
Adjusted
Variables OR 95% CI p Value
Sociodemographic and economic characteristics
Gender and social condition
Men (ref.) 1 <0.0001
Women not heads of their household 1.71 1.22 to 2.41
Women heads of their household 0.71 0.45 to 1.12
Area of habitation
Urban or semiurban (ref.) 1 0.02
Rural 1.57 1.06 to 2.32
Educational level
High school or university (ref.) 1 0.004
Primary school 1.58 1.16 to 2.14
Being a member of an association of PLWHA
No (ref.) 1 0.03
Yes 0.60 0.38 to 0.96
Binge drinking
No (ref.) 1 0.02
Yes 1.72 1.08 to 2.72
Characteristics related to living in a couple, sexual activity and parenthood
Living in a couple
No (ref.) 1 0.004
Yes 1.75 1.20 to 2.56
Frequency of sexual relationships
Less than once a month (ref.) 1 0.78
Once a month 1.07 0.68 to 1.67
More than once a month 1.09 0.74 to 1.60
Several times a week or everyday 1.33 0.77 to 2.32
Having a casual partner
No (ref.) 1 <0.0001
Yes 1.91 1.39 to 2.62
Presence of children in the household
No (ref.) 1 0.02
Yes 0.64 0.44 to 0.94
Clinical characteristics
Receiving ART
Yes (ref.) 1 <0.0001
No 2.28 1.64 to 3.18
ART knowledge
Someone who takes ARVs cannot transmit the virus
No (ref.) 1 0.004
Yes/do not know 1.58 1.16 to 2.16
ART, antiretroviral therapy; ARVs, antiretrovirals; PLWHA, people living with HIV and AIDS.
OR, odds ratio; CI, confidence interval.
inconsistent condom use, even after controlling for socio- Nevertheless, results conrm those of previous studies
demographic and economic characteristics, characteristics conducted in Cte dIvoire1 and in South Africa,3 15 in which
related to living in a couple, sexual activity and parenthood, 30e44% of the patients included reported unprotected sex. In
clinical characteristics, HRQL and self-reported symptoms, and addition, the association found between not receiving ART and
patients knowledge concerning ARVs (whatever the coding used reporting inconsistent condom use is in accordance with the
for this latter group of variables). conclusion of the meta-analysis by Crepaz et al in developed
This study is the rst in Cameroon and, to our knowledge, in countries, which underlines that treated patients do not exhibit
Sub-Saharan Africa, to explore the association between ART and increased sexual risk behaviours.16 In resource-limited settings,
unsafe sexual behaviours among a large sample of PLWHA, most of the studies exploring this issue have also led to the same
representative of HIV-infected outpatients followed up in the conclusion.1 3 5 6 8 17 These studies focused either on patients
Cameroonian healthcare system. However, it is substantially followed-up in a given HIV centre3 6 or on patients living in
limited by its cross-sectional design, which makes it impossible specically delineated geographical areas.1 5 17 The present study
to evaluate pre- to post-ART changes in patients sexual behav- therefore reinforces these ndings on a sample of PLWHA
iours. In addition, it focuses only on clinical attenders, which are followed up in HIV care centres located in different regions of
not representative of the whole population of PLWHA, contrary Cameroon, of which some are decentralised. However, it
to population-based samples.2 Another limitation is that data on contradicts the results of the study of Diabate et al conducted in
sexual behaviours are only based on patients declarations, which Cte dIvoire7 among 312 non-treated and 303 ART-initiating
may be affected by social desirability bias.14 patients. This study shows a signicant increase in unsafe sexual
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