Condom and sexual abstinence talk in the Malawi National Assembly

Summary

Background

Correct and consistent use of condoms has been reported as effective in the prevention of transmission of HIV. There have been many studies reporting on attitudes (perceptions) of communities on condoms and other aspects of HIV and AIDS and yet there is paucity of data on the perception towards condoms and abstinence by law makers.

Objective

To determine perceptions of Members of Parliament in Malawi towards condoms.

Methods

A qualitative study utilising parliamentary Hansards to describe the discussions about condoms and abstinence in the National Assembly 1999–2004. Content and discourse analyses were used.

Results

In general, Members of Parliament had negative attitudes towards extra- and/or pre-marital sexual intercourse, condom promotion and use. Sexual abstinence amongst non-married persons was preferred as opposed to condom use. Condom use was not perceived as an effective way of controlling the spread of HIV. Some MPs though called for a change in mind-set so as to allow use of condoms in prisons, in order to prevent transmission of infection from prisoners to the general community once the prisoners were released.

Conclusion

This study confirms that health interventions such as condoms are not perceived neutrally and may be construed as the enemy of society.

Introduction

Malawi is among the countries heavily affected by the HIV and AIDS scourge. About 14 percent of the adult population 19–49 years is infected with the virus.¹ Like many African countries, heterosexual spread is the commonest mode of transmission followed by vertical transmission. Most hospitalized patients in the adult medical wards are HIV infected. HIV infection rates in pediatric patients and adult surgical patients are also high. ^2–4

The spread of HIV has been blamed on many factors which include: poverty, low social status of women, multiple sexual partners, low education status, high occurrence of sexually transmitted infections (STIs) and their poor management and lack of condom use. The male condom, if correctly and consistently used, has been demonstrated as an effective tool in the fight against sexually transmitted diseases including HIV. ⁵ The female condom is as yet not readily available in Malawi. A study by Zachariah et al ⁶ however, demonstrated a high acceptance of the female condom among female commercial sex workers in Thyolo district, southern Malawi. Some problems identified with the female condom were that; it was noisy, reduced sexual pleasure as a result of increased lubrication and there was likelihood of re-use.

In a study from Zambia Benefo ⁷ reported that within male-reported relationships, having a sexual partner from the same community was associated with a reduced likelihood of condom use while within female-reported relationships, condom use was likely if sexual intercourse occurred only once. Condom use within marriage continues to be resisted among most communities in Africa.⁸ There have been increased social marketing of condoms in Eastern and Southern Africa.⁹

The Ugandan experience of reduction in incidence and prevalence of HIV is partly explained by the ABC approach.¹⁰ Other authors however suggest that the drop in HIV incidence in Uganda has more to do with reduction in unsafe injections than ABC approach.¹¹ One thing that is clear though is that Uganda has made important strides in ensuring increased abstinence, monogamy, condom use, care and support of the HIV infected and safe injection practice, all of which would contribute to reduction in HIV incidence.

There have been several studies on attitudes towards specific aspects of STIs, condoms and HIV among the general population in Malawi.^12–14 I am unaware of any such studies amongst members of parliament who are responsible for policy, national budget and legislative formulation in a country. This study was conducted in order to describe the discussions on condoms and sexual abstinence occurring within the Malawi National Assembly between 1999 to 2004. Knowledge and analysis of such parliamentary discourse would better inform researchers and other policy makers the background and basis of decisions the Malawi National Assembly makes on condoms and HIV/AIDS.

Materials and Methods

This was a qualitative study utilizing all the Malawi National Assembly's Hansards for the period 1999–2004 as sources of data. The Hansard is the official published verbatim report of the proceedings of a parliamentary body. Copies of the Hansards were obtained from the National Assembly and were manually read to identify sections where discussions on HIV and AIDS, reproductive health and condoms were made. The speeches were later analysed using thematic content and discourse analysis to identify themes under the following key words (effectiveness of condoms, perceptions on condoms, sexual abstinence and sexual intercourse, perceptions toward pre-marital sex, ways of preventing HIV transmission, suggestions for change) and patterns of thought. ^15–18 The analytic approach is within the domain of social psychology operating an the interface between ethnomethodology and conversation analysis. The limitations of using Members of Parliament as study subjects include the fact that it may not be possible to strictly determine whether what was said were their own thought or they were speaking on behalf of others, e.g. their constituents. However, as these speeches are being made in the National Assembly, such may have far reaching consequences in terms of policy, although not necessarily practice.

Surveys aimed to study perceptions of a particular group of people suffer from the fact that the study subjects are not in the naturalistic environment i.e. they may try to conform in reporting what they think the researcher wants to hear. This study utilized normal parliamentary conversations and may not be affected by such biases. However, as MPs know that they are being watched, the temptation to impress and be controversial may play out in different individuals. Also, not all MPs contribute evenly to the discussions.

The Malawi National Assembly has 193 seats comprising members all elected by popular vote in the 193 constituencies spread throughout the country (rural and urban). The minimum age is 21 years and the individual standing for election should be able to speak and read English language well enough so as to understand and contribute to parliamentary proceedings. Diverse educational and professional backgrounds are therefore represented. Members of Parliament can represent a constituency they are currently residing in or their traditional home villages and residence in the constituency is not mandatory. Females contributed between 9% to 13% of the MPs in the National Assembly within the study period.

Results

Sexual abstinence is preferred

Sexual abstinence was reported to be the preferred way of preventing transmission of HIV among the Malawi population, especially among unmarried persons.

“We are saying that if we want to address the issue of HIV/AIDS, then there are three things we must do. The A, B, C of preventing this disease. The first one is abstinence. We must abstain from immorality and if we do this, we will be able to deal with this problem.”

While sexual abstinence seemed to have been the preferred mode of HIV prevention among the non-married groups, one MP argued that it was not of use to people already infected by HIV, to these rather, treatment was better.

“…I am referring to those that are already HIV/AIDS positive or even those that are on the beds dying. Abstinence, faithfulness and condom use is fine to those that are negative at the moment. But what is the government going to do with those who are already infected and cannot afford to buy the drugs?”

While the MP's concerns are appreciated, the speech may also have transmitted unwanted messages i.e. that sexual abstinence, being faithful to one partner and condoms were not to be advocated for those already HIV infected. If this were to occur, then it may be unfortunate as both the infected and uninfected can still benefit from the ABC of HIV prevention. Not only would it prevent the infected from getting other STIs but also other variants of HIV, it may prevent transmission of HIV to uninfected partners. I believe sexual abstinence if practicable, monogamous relationships and condom use could stem the spread of HIV regardless of the HIV positive status of one of the partners involved.

Sexual intercourse outside the matrimonial home is perceived negatively.

“People should very much understand the importance of abstinence and agree to the fact that sex should be practiced in the homes by married couples only and not by anyone else. Because married people have a reason for doing this.”

It is interesting to note that it was suggested that married people have a reason for having sex in the home. Although the reason that married people had sex for was not explicitly given, it is reasonable to suggest that procreation may be one of the reasons the MP may have meant. Another reason that some people have given for married people to have sex is for the “cementing” of the relationship. Incidentally though, non-married people could also have the same reasons for having sex.

One MP called fellow members to act as role models to society.

“Let me also ask each one of us to do what we preach on the need for abstinence as one of the best preventions of contracting HIV/AIDS”

In Malawi, behaviour change to most people means, sexual abstinence, despite the fact that condom use, reduction of multiple sexual partners and prompt treatment of STIs are also behavioural change. Talking about how the spread of HIV could be reduced, an MP said:

“We should try to address this problem mainly to the young ones of how they should resist from contracting this deadly disease. These people should be told to change their behaviour.”

The risk perceptions by adults in as far as HIV susceptibility among young people is concerned can be used to an advantage if interventions aimed at reducing HIV spread among young people are put in place. However, such a perception can result in older adults thinking they are not at risk themselves. Risk perception may be an indicator of perceived susceptibility to infection and this could influence willingness to consider behavioral changes. ²⁰Adults who perceive that it is only young people who are at risk may expose themselves to HIV infection. Most of the HIV and AIDS messages in Malawi are targeted at the youth, perhaps for good reasons realizing that infection rates among the youths are higher than older adults. Many people in this group are not married. Postponing sexual debut, consistent and correct use of condoms when sexually active and reducing the number of sexual partners is likely to result is greater gains in stemming the scourge among young people.

People engaged in extra- and/or pre-marital sex were perceived negatively. Terms such as “culprits” and “immoral” were used. It is argued such practices could be fuelling the negative stigma and discrimination that sometimes characterize people living with HIV/AIDS.

“… because most of the culprits, who are engaged in this immoral behaviour are doing that because of poverty.”

I believe there is need to influence change of language where HIV infected persons, or persons engaged in extra-or/and pre-marital sex are not referred to as “culprits” as the term “culprit” is judgmental.

Perceptions towards condoms

The condom if used consistently and correctly can be an effective tool towards the prevention of transmission of HIV and other STIs. Commenting on the use of condoms one MP said:

“…even if they see many people dying of AIDS, they seem not to care about it. Such people talk in riddles to one another by saying you cannot feel the sweetness of sweet if you consume it with the wrapper or implying that you can't enjoy sex with the use of a condom. This attitude should be stopped because it misleads many people and encourages them not to use a condom.”

The MP who contributed to the debate as above seemed to be reporting on other people's attitudes towards condom use. Such perceptions are relatively common in Malawi and other southern African countries. Kaler ¹⁹ reporting on spontaneous conversation of adult Malawi reported similar attitudes where adult men boasted of “eating your girls with the bones” (having sex without a condom) and that one should not eat a “sweet” without removing the wrapper. Chirwa ¹³ also reported that men perceived sex without a condom as exciting. Whether individuals who hold such attitudes actually believe what they are saying and practice what they say is another matter altogether. People can say one thing and yet their practice may be contrary to their words. Public health program planners however, should be aware of these beliefs occurring in their communities of practice and plan on how to deal with them.

In his contribution, one MP also argued for change in mind-set so as to allow the distribution of condoms to prisoners.

“I understand there is a lot of homosexuality happening in prisons. Are those people given condoms in order not to transmit the diseases. Those people are part of us. They are citizens of Malawi and they need to be protected. If we keep quiet, it will not help us.”

This speech deviates from the conventional message where condoms are not allowed in prisons and yet it is generally understood that sexual intercourse, especially same-sex intercourse among males is acknowledged by society, prisoners and prison authorities as occurring in prisons. One reason the provision of condoms to prisoners has not be readily accepted in Malawi is the fact that homosexuality is classified a criminal act in Malawi's legal system.

Condoms are not thesolution

While some proponents advance that the wide availability, correct and consistent use of condoms is an important tool against the spread of HIV/AIDS, there were also perceptions among the study group that the promotion of condoms was misguided.

“… the government should consider carefully the fight against HIV/AIDS. The fight can never be fought with a condom, which has pornographic pictures on its covers. Take it from me…such a weapon defeats the honour, rather than the enemy”

This speech was possibly in reference to condom wrappers that have bare back or not fully-dressed females. Inserts (instructions on how to use condoms) of condoms readily available in Malawi also have pictures on how to correctly use a condom, which inevitably shows pictures on naked males (and females), with the male putting on the condom on an erect penis. Such instructions have not gone well with some sectors of the community who have argued that condoms are promoting irresponsible sexual practices.

Negative perceptions were not only made towards condoms only, but also firms that manufacture condoms.

“..I'm made to believe that if a cure for AIDS is found today, the people that can get angry with that good news are the companies that make condoms for that will mean the need of their business. So too with those people who are sellers of coffins, to see that people have stopped dying, they will say our business will go down.”

Condoms were reported to be promoting sexual intercourse. One MP said:

“I believe if we conduct a survey, we will discover with shock that instead of discouraging sexual intercourse, these condoms have promoted the rate of sexual intercourse on our land. People are saying, if I have a condom, I can go for these bad habits. By the end of the day, it is being promoted instead of being discouraged.”

There were also perceptions that the condom could not be effective to prevent the transmission of HIV.

“… learn it from me, condoms are made for business and not for protection against AIDS. A rubber cannot protect somebody's life. Never. The reason why they have made such condoms is to attract more people into their business. The pictures on these Chishango condoms are there to seduce the weak-minded people. …it is good that we abstain. That is the best solution…I have one word of warning to PSI and all condom makers and condom lovers. A person's life is very, very expensive and it cannot be put in a rubber.”

One MP also said:

“…our lives are expensive. You cannot entrust your life to a rubber, a mere rubber, No.”

The Chishango (shield) condom is the commonly available condom in Malawi marketed by Population Services International (PSI).

Although it is important to note the negative perceptions towards condoms, such perception were not universal. One MP challenged the notion suggesting that it was alright to advocate for condoms use. In his opinion, the prevailing attitudes towards condoms were not new, as they had been there for many years:

“…the question of AIDS has gone through an evolution. Up to now, we cannot talk about the distribution of condoms to prisoners in this country now. We have been to the prisons. If we think we have all the liberty, all freedoms that we are the experts of AIDS control problem, we are wrong. There are a few things we have to go through.”

The MP said:

“My position is that these condoms should be distributed freely in prisons as a way of trying to control the spread of HIV/AIDS.”

Providing condoms to prisoners was challenged by another member of parliament.

“First and foremost, when you are in prison, you are not supposed to have sex…and providing condoms to the prisoners is not the answer. Its either the prison warders become very strict with the way people are conducting themselves in prisons, they check and see which are the areas where they can sneak and have sex, homosexual or bring their wives in prison. Oh yes that's a better solution than providing them with condoms, because when you give them condoms you are telling them, “now it is every night, use these condoms among yourselves.””

The provision of condoms to prisoners was defended through the idea of protecting the general public (outside of jail) rather than providing protection to the prisoners themselves.

“Because these people at some stage get released into normal society, into their families and after uncontrolled sexual activity in prisons. They really pose a danger to the society of further affecting the community at large.”

Discussion

Members of Parliament in the Malawi National Assembly expressed diverse views on the roles and importance of condom availability, effectiveness and use in Malawi. This suggests that condoms are yet to be universally accepted by the country's political leadership. The common discourse on the possibility of failure to protect infection by condoms, the reduced pleasure that condoms are perceived to cause are noted by parliamentarians. Some parliamentarians in Malawi also advocate for sexual abstinence while others suggest condoms use where sexual abstinence is not possible. Kaler ²¹ concludes that “condoms do not arrive in communities as neutral, value-free objects” but rather they are attached within a nexus in which issues of health, disease and malevolence may be involved. This is also displayed in the present study where MPs do not always associate condoms and condom manufacturers and distributors with beneficence but rather with malevolent intent. Kaler ²¹ also reported perception of rural Malawi study participants who perceived that condoms were not introduced in Malawi as a beneficial intervention but rather with a malevolent agenda. The perception that if a cure for AIDS were found, condom manufacturers would not like it, attest to such feelings. These perceptions probably have far-reaching consequences as it would appear that Malawian law makers have unfavourable remarks towards condom use, which has been identified as an effective tool in the fights against HIV. Pinkerton and Abramson ²² reported that condoms if used correctly and consistently were 90–95 % in preventing transmission of HIV.

The MPs concerns that condoms were ineffective in preventing HIV transmission could have stemmed from the fact that despite increasing condom promotion in Malawi there is yet to be a report on any decline in the incidence of HIV infections in the country. This has been observed elsewhere as reported by Hearst and Chen ²³. These authors propose that condom promotion in Uganda has been associated with a declining HIV incidence as it has been applied in a multifaceted approach wish has also involved reduction is number of sexual partners ²³. In such a situation, it is possible people to conclude that condoms are not as effective. If researchers were able to show incidence rates with condom promotion and the estimated rates without condom use, and this showed benefits probably MPs would be supporting condoms.

Another important feature of parliamentarians is that they may ‘represent the views’ emanating from their own socialization, which is influenced by culture and religious beliefs. The National Assembly being a public arena, members may speak so as to conform to the perceived beliefs of their constituents are desist from the potential of being viewed as radical or “out of step with our culture.”

An MP suggested that a “person's life cannot be put in a rubber.” This probably meant that a persons life cannot be protected by a condom or rubber. The statement essentially means that a condom is such an inferior object as to protect a much noble thing as life. This study shows that Malawi is receiving mixed messages about condoms; one message suggesting condoms could be a valuable tool against HIV and AIDS while the other identifies condom use as the problem, not a worthwhile solution. That such talk occurs in Parliament is of particular importance in itself. There is need to strive for advocacy where for instance, it can be presented that the condom itself may not be the issue. People who oppose condoms could be convinced to focus on interventions that prevent pre-marital and/or extra-marital sexual intercourse and sex with multiple partners.

Zachariah et al ²⁴ reported high incidence of STIs in Malawi's prisons most of which are reportedly acquired within jails. This calls for review of policy on the availability or condoms and/or measures to reduce sexual activity within prisons.

The assertion that the wide availability and accessibility of condoms promote “promiscuity” or “irresponsible” sexual behaviour is common in Malawi. There is need to conduct studies that will guide in showing whether this is indeed the case or not. Where there is no evidence, everyone could say they are right when they speak on the issue. In a society where free speech is encouraged, it will not be possible for to force society to hold one view on an issue like condoms as cultural, religious and moral influences have a bearing on how one perceives condoms, sex and AIDS.

The reported perception that some people would not use a condom because “you cannot eat a sweet in its wrapper” has worldwide distribution, despite being differently expressed. Kulczycki ²⁵ in a study in Lebanon reported that men saying that when one wants to use condoms, “…Your nerves get cooler.” This suggested the reduction in spontaneity and pleasure with use of condoms. The perceived lack of sensation has been suggested as one reason Malawians may not have favourable opinions towards condoms ²⁶. Malawian MPs may not be as privileged as to have research information and data that would change their perceptions of condoms above that of the general public. This is, unlike National Assemblies in other countries, like Uganda, in Malawi there are no research officers that ill help MPs to understand research information. The interaction between the research community and MPs, is yet to develop fully in Malawi and this could contribute to members' negative perceptions towards condoms. Public health planners and implementers need to consider all these factors when effecting intervention in and with communities.