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. Author manuscript; available in PMC: 2011 Feb 6.
Published in final edited form as: J Multicult Nurs Health. 2004 Jan 1;10(1):24–31.

A Sexual Barrier Intervention for HIV+/− Zambian Women

Acceptability and Use of Vaginal Chemical Barriers

Deborah L Jones 1, Stephen M Weiss 2, Ganapati J Bhat 3, Douglas Feldman 4, Violet Bwalya 5, Danielle Budash 6
PMCID: PMC3034147  NIHMSID: NIHMS7960  PMID: 21304832

Abstract

OBJECTIVES

The purposes of this study were to (a) assess the efficacy of a culturally tailored behavioral intervention to increase use and acceptability of sexual barrier products among HIV+ and HIV− Zambian women, (b) compare group versus individual interventions to increase barrier use and acceptability, and (c) validate the role of cultural factors as facilitators or impediments to sexual risk reduction.

METHODS

A sample of 150 HIV+ and HIV− Zambian women was recruited from the University Teaching Hospital HIV Voluntary Counseling and Testing Centre, randomized into one of three conditions, and assessed at baseline and 6 months. Group and individual intervention participants attended a 3-session intervention plus pre- and post-HIV test counseling; control participants received pre- and post-test counseling only.

RESULTS

Group intervention participants increased use of sexual barriers and had higher levels of acceptability than did individual intervention participants. HIV− group participants increased use of chemical barriers and female condoms.

CONCLUSIONS

Results support the use of group interventions to increase sexual barrier use and acceptability and decrease sexual risk behavior in both HIV+ and HIV− women.

Keywords: Culture, HIV Intervention, Sexual Barriers, Sexual Behavior, Women

More than 70% of the 43 million persons now infected with human immunodeficiency virus (HIV) live in sub-Saharan Africa (UNAIDS/WHO, 2002). The majority of HIV infection in this region occurs in marital and cohabiting relationships as a result of sexual transmission (Hira et al., 1997; McKenna et al., 1997). Zambia, with a population of 10.2 million, has been particularly hard hit by the HIV/AIDS pandemic. Adult (i.e., ages 15–49) infection rates approach 20% in the general population, with an estimated 10 to 15% of rural and 30% of urban populations already HIV-infected. The total number of infections include 923,000 adults and 87,000 children (UNAIDS/WHO, 2002). AIDS has reduced life expectancy for Zambians from 54 to 43 years in the past decade, and life expectancy is projected to be reduced to 34 by 2010 (UNAIDS, 2001). HIV infection is also predicted to reduce national productivity, decrease access to education, and increase infant mortality to 82 per 1,000 live births (HIV/AIDS in Zambia, 1999; Zambian Demographic Health Survey [ZDHS], 2002).

In addition to HIV, other sexually transmitted diseases (STDs) represent the third most frequent reason for adult outpatient visits, with an estimated 300,000 new cases per year (Faxelid, Ahlberg, Ndulo, & Krantz, 1998). Following diagnosis, STD treatment may be unavailable due to limited supplies. Additionally, HIV treatment may be financially prohibitive for the majority of Zambians, and even protective measures (e.g., condoms) may be in short supply. In a survey of sexual behavior, only 39.9% of males and 18.6% of females had ever used a male condom among unmarried Zambians, and only 29.1% of males and 18.0% of females had used a condom during their last sexual act. Only 2.1% of males and 0.5% of females reported that they had ever used a female condom (Zambia Sexual Behaviour Survey [ZSBS], 1999). Since sexual transmission is the primary mode of HIV/STD infection in this population, increasing safer sex practices is essential to containing the spread of the virus. Women are disproportionately affected by the HIV epidemic and STDs due, in part, to genital vulnerability (HIV/AIDS in Zambia, 1999). Of those Lusakan women who agreed to be tested for HIV during pregnancy, 27% were found to be HIV seropositive (Fylkesnes et al., 1997; UNAIDS/WHO, 2000). Gender-based power dynamics including subordinate social and economic status, multiple sexual partners, polygamy, financial dependence, and sexual practices engaged in to satisfy husbands and prevent marital infidelity (e.g., dry sex) (Chikumbi, 1999; HIV/AIDS in Zambia, 1999; ZSBS, 1999) profoundly affect women’s ability to protect themselves from HIV/STDs (Campbell & Kelly, 1995).

HIV prevention efforts in sub-Saharan Africa have focused principally on encouraging the use of male condoms through voluntary counseling and testing (VCT) programs (Allen et al., 1992). VCT has been shown to be most successful in reducing transmission among serodiscordant couples (Allen et al., 1999). Although male condoms have high efficacy (i.e., 93–95%) in reducing transmission of HIV and other STDs (Kamb et al., 1998); the impact of condoms on disease prevention has been minimal due, in large part, to low acceptability as well as to culture-specific sexual practices (e.g., dry sex) and lack of knowledge (Lagarde et al., 2001), highlighting the need for multiple sexual barrier options (Musaba, Morrison, Sunkutu & Wong, 1998; Ndoye, 1999). For women whose partners refuse to use male or female condoms, alternative female controlled strategies (e.g., vaginal chemical barriers, microbicides) for protection against pregnancy, STDs and HIV transmission are needed (Steyn, 1995). Although there are several products currently in Phase II or Phase III testing, there are presently no approved vaginal chemical barriers for prevention of HIV/STD transmission. Acceptability studies have been conducted to assess women’s (Elias et al., 1996; Hira et al., 1995; Jones et al., 2001; Pool et al., 1999) and men’s (Ramgee, Gouws, Andrews, Myer, & Weber, 2001; Steiner et al., 1995) preferences regarding specific characteristics of barrier products in anticipation of the eventual availability of a safe and effective vaginally applied chemical method of protection from HIV/STD transmission.

In the United States, hierarchical interventions utilizing multiple methods have been found to increase the percentage of protected sex acts without condom drift (Jones et al., 2001; Malow, Ziskind, & Jones, 2000). HIV interventions that address sexual education, including reproductive desires, sexual negotiation skills (Sheeran, Abraham, & Orbell, 1999), and methods of transmission prevention that are under women’s control have appeared most useful in increasing sexual barrier use (Gupta & Weiss, 1993; Malow et al., 2000; Musaba et al., 1998). In addition, safer sex interventions that allowed a choice from a variety of sexual barriers enabled women to make informed choices based on their perceived risk, desire for children, socioeconomic circumstances, and role as defined by their culture (Fleming & Wasserheit, 1999).

In Zambia, interventions that have been proposed to control the spread of AIDS include reducing number of sexual partners, promoting use and availability of male and female condoms, controlling other STDs, and encouraging VCT (HIV/AIDS in Zambia, 1999). This study assessed the efficacy of a culturally tailored sexual behavior intervention utilizing Cognitive/Behavioral therapeutic strategies, negotiation skills, and experiential/interactive skill training. We assessed the acceptability and use of sexual barriers (i.e., male and female condoms, vaginal chemical barriers) among HIV+ and HIV− Zambian women, the role of cultural considerations and sexual concerns as facilitators or impediments to use, and the efficacy of group and individual interventions to increase barrier use and skill mastery. Endpoints for the study included acceptability and use of sexual barriers and decreased sexual risk behaviors.

METHODS

Recruitment and Eligibility

Institutional Review Board (IRB-US) and Research Ethics Committee (REC- Zambia) approvals were obtained prior to the onset of the study. Study candidates were recruited from the VCT sites at the University Teaching Hospital (UTH), the KARA Counseling Center, and community health clinics as well as from among the membership of the Network of Zambian People Living Positive (NZP +). Participants were 150 women (i.e., 75 HIV+ and 75 HIV−) who were 18 years of age or older, sexually active, and living in the Lusaka Metropolitan Area.

Interested candidates were initially screened to determine potential eligibility; women who were deemed eligible completed an informed consent and were administered a baseline assessment (i.e., psychosocial and behavioral). Assessments and interventions were primarily conducted in English. Recruiters, assessors, and interventionists translated any information that required clarification for those experiencing difficulty with English comprehension into participant dialect/language (i.e., Bemba, Nyanja, or Lozi).

Participants were randomly assigned to one of three conditions: group, individual, or usual care control. Group and individual participants received pre-and post-HIV test counseling and completed three monthly sessions, while usual care control participants received pre-and post test counseling only. Stratification was employed to ensure equal numbers in each condition by serostatus. Groups were not segregated by serostatus, and both HIV+ and HIV− women participated in the same groups. All participants were followed over a 6 month period including individual baseline assessment; sessions 1, 2 and 3; brief assessments at 3 and 4 months; and a 6 month post-baseline assessment. Study assessors and investigators were blind to participant assignment, and participants were asked not to reveal their condition assignment. All participants received monetary compensation for their time and travel expenses.

Due to the provision of vaginal chemical products, all participants were screened for STDs and vaginal abnormalities that were contraindications for use. Women were notified of their STD results, advised regarding appropriate treatment, and referred for follow-up prior to beginning the study. If contraindications for use were identified (i.e., discharge, burning, itching, lesions), participants were referred for treatment prior to receiving study products.

Intervention Format and Content

Group condition

This group intervention was manualized and developed with feedback from previous pilot projects (Jones et al., 2001; Malow et al., 2000) as well as focus groups conducted in the US and Zambia. Facilitators were registered nurses (RNs), licensed practical nurses (LPNs), and health care staff trained in the administration of each condition.

The group condition employed a closed, structured intervention limited to 10 women. Each of the three monthly 2-hour sessions emphasized group participation and experimentation and provided an opportunity for practice, feedback, and reinforcement of sexual risk reduction strategies. Special consideration was given to group cohesion and skill building in a supportive environment. Participants in the group condition received information about HIV/STDs, counseling on the use of sexual barrier methods, reproductive choice information, and cognitive behavioral skill training to increase use of and adherence to sexual barriers. Discussion focused on reactions to barriers, cognitive reframing, and sexual negotiation. Information was presented through multiple modalities (i.e., visual, auditory, experiential) with ample opportunities for practice, feedback, and reinforcement (e.g., discussion of methods of reproductive choice, sharing experiences with products, questions on product use, opportunity to handle and examine products).

The intervention and accompanying videos were developed in English and translated into Nyanja, Bemba, and Lozi as required during the intervention. Videos illustrated the correct methods of barrier use and discussed commonly asked questions. After each session, participants were provided with a 1 month supply of male and female condoms during sessions 1 through 3 and visits 4 and 5; vaginal chemical products (i.e., gels, suppositories and films) were also provided during sessions 2 and 3 and visits 4 and 5. Participants were strongly encouraged to use condoms in conjunction with the vaginal chemical products at all times.

Individual condition

The individual condition provided participants with a time matched intervention in an individual format, which included information on HIV/STD transmission, hierarchical counseling and skill training to facilitate product use, videos, written materials on instructions for use, and supplies of male and female condoms and vaginal chemical products.

Usual care

The control condition provided participants with standard care that included pre-and post HIV test counseling. Participants were also given and female condoms.

Outcome Measures

All measures were administered at baseline and 6 months post-baseline.

Sexual Activities Questionnaire

A 55-item scale was adapted from the widely-used Sexual Risk Behavior Assessment Schedule (SERBAS)(Meyer-Bahlberg, Dugan, Exner,& Gruen, 1992). Responses indicated the frequency of heterosexual sexual intercourse (i.e., vaginal, oral, anal) in the past 3 months with both primary partners (i.e., most frequent sexual relations) and non-primary partners (i.e., any other male partners). The questionnaire also assessed sexual barrier use, HIV status of the partner(s), known sexual practices of the partner, and alcohol or drug use prior to the initiation of sexual activity. The SERBAS is a structured interview that identifies frequency as 9 times out of 10 (all the time), 7 times out of 10 (most times), 5 times out of 10 (half of the time), 3 times out of 10 (sometimes), or never. The measure identified the percentage of women who were sexually active, number of sexual partners, and percentage of women who used condoms (i.e., male and/or female).

Barrier Questionnaire

This scale was adapted from the University of California at San Francisco Center for AIDS Prevention Studies Barrier Questionnaire and measures current and previous use of and willingness to use sexual barriers. Likert-scale items on acceptability of use are rated as never used, strongly dislike, dislike somewhat, neutral, like somewhat, and like very much. Likert -scale items for willingness to use are rated as not at all willing to use, slightly willing, moderately willing, and very willing. The measure identified the percentage of women who currently used barriers, previously used vaginal chemical barriers, acceptability of use, and willingness to use.

Demographic Questionnaire

This questionnaire included items on age, religion, nationality, ethnicity, educational level, employment status, residential status, HIV serostatus (i.e., date of HIV infection, if known; mode of infection with HIV), current or previous drug use/abuse, participation in drug treatment programs, marital status/current partner status, living situation, number of children, and children’s serostatus (if known).

RESULTS

This study used a repeated measures design with experimental condition (i.e., group, individual, control) as the between-subjects factor and time (i.e., baseline and post-intervention) as the within-subjects factors. The significance level for all analyses was set at an alpha (2-tailed) of 0.05.

Participant Characteristics

The mean age of sample participants (N = 150) was 27; most women (n = 131, 87%) were unemployed. Ethnic groups included Bemba (n = 37, 25%,), Nsenga (n = 37, 25%), Ngoni/Chewa (n = 40, 27%), Tonga (n = 10, 7%), Lozi (n = 7, 5%), Lunda/Kaonde (n = 7, 5%), and other tribes (n = 9, 6%). Most women (n = 133, 89%) reported that they actively attended religious services. The average level of educational completion was 8th grade, ranging from no formal education to some post-secondary education. Most women were married or had a steady partner (n = 117, 78%) and lived with their partner or spouse (n = 66, 44%) or family members (n = 34, 23%). Eleven percent (n = 17) of participants had children living with HIV. There were no significant differences in demographic characteristics between HIV+ (n = 73, 49%) and HIV− (n = 77, 51%) participants or between group, individual, and control condition participants.

Baseline Sexual Behavior

Most women had been sexually active in the last month (n = 101, 67%). A majority of women practiced unprotected sex (n = 112, 75%), and 37 (25%) reported never using condoms. Only 25 women (17%) reported consistent condom use. There were no significant differences in sexual behavior between conditions or by HIV status. Only seven (5%) of the participants had ever used female condoms, and only three (2%) had tried vaginal chemical barriers, which were available in Zambia as contraceptive suppositories. Eight percent (n =12) of the sample reported engaging in dry sex practices, and few women reported oral (n = 10, 7%) or anal (n = 4, 3%) intercourse. Eighty one (54%) of the women reported that their partners were HIV+, 12 (8 %) reported that their partners were HIV−, and 57 (38%) did not know their partners’ HIV status. Only 4 (3% ) of women had more than one partner, while 37 (25%) believed that their partners were sexually active outside the relationship. Overall, participants were unanimous in their unwillingness to use products requiring an applicator or those that would have some degree of leakage or cause irritation. Participants were slightly willing to use products that were slippery or wet and were moderately or very willing to use products that would not be detected by their partner. There were no differences in sexual behavior between intervention conditions or by HIV status at baseline.

Sexual Behavior and Barrier Acceptability at Six Months Post-Baseline

At 6 month post-baseline, group participants showed a proportionately greater increase in overall practice of protected sex, χ2(2, N = 150) = 9.5, p < .001 and use of male condoms, χ2(2, N = 150) = 7.3, p < .001 than did individual and control group participants. Group participants also had significantly higher ratings of female condoms than did women in the other conditions, F(1, 59) = 3.7, p < .05. In addition, willingness to use male condoms increased more among participants in the group condition than among participants in both individual and control conditions, F(1, 59) = 4.2, p < .05. Reported trial use of all types of vaginal chemical barriers increased significantly among women in both group and individual conditions from no experience to 48% who have tried any product, F(1, 59) = 2.4, p < .001; 31% for gels, F(1, 59) = 4.2, p < .001); 20% for suppositories, F(1, 59) = 2.4, p < .001; and 25% for film F(1, 59) = 5.4, p < .001.

In comparison to the group intervention participants who were moderately willing to use products, participants in the individual condition were less willing to use vaginal chemical barriers following exposure, χ2(2, N = 150) = 3.2, p < .05. The experience of exposure to products did not significantly affect participants’ attitudes regarding willingness to use vaginal chemical barriers based on specific characteristics (e.g., application method, viscosity, taste, protection), although there was a nonsignificant trend toward more positive attitudes following exposure. One interesting finding was that following exposure, there was a dramatic positive shift in both group and individual participants’ willingness to use products requiring an applicator, F(1, 59) = −5.6, p < .001. In addition, participants became more willing to use products with a small amount of leakage but remained unwilling to tolerate products with large amounts of leakage.

Barrier Acceptability By HIV Status

In the group condition post-baseline, there was a significant increase in the use of vaginal chemical barriers, F(1, 35) = −2.9, p < .001); chemical barriers in combination with condoms, F(1, 35) = −4.6, p < .001; and in female condom use, F(1, 35) = −2.8, p < .05) among HIV− participants than among HIV+ participants, with a corresponding decrease in the use of other, more traditional products (e.g., herbs), F(1, 35) = 2.6, p < .001). There were no significant differences between HIV+ and HIV− participants in the other two conditions.

DISCUSSION

The overall response to this sexual barrier intervention adapted to a Zambian context was quite favorable. We found that use of vaginal chemical barriers and female condoms increased in those participating in the group sexual barrier intervention with an accompanying decrease in male condom use. Group intervention formats have been shown to facilitate communication and sharing of experiences (Jones et al., 2001; Malow et al., 2000). As a result of the group intervention, HIV− participants, in particular, demonstrated a significant increase in chemical barriers and female condom use. This finding suggests that group intervention may have a more powerful primary prevention message for HIV− women than for HIV+ women. In addition, the presence of HIV+ women in the group may have served as a potent reminder of the consequences of unprotected sex.

Results support findings from other behavioral intervention research involving sexual education (Sheeran et al., 1999), sexual negotiation skills, female controlled methods, and hierarchical counseling (Ehrhardt et al, 1992; Fleming & Wasserheit, 1999; Gupta & Weiss, 1992; Malow et al., 2000; Musaba et al., 1998). While improving among the elite, the status of Zambian women remains unequal, and most women do not have the ability to negotiate safer sex in their households unless taught the type of sexual negotiation skills developed for the group intervention. Participants in the group intervention reported that once introduced to the new products, their partners were willing and often enthusiastic about the use of such products as the female condom.

Although trial basis use of vaginal chemical barriers did not result in a more favorable evaluation of specific products, the trend toward more positive attitudes found in the post-intervention evaluations suggests that results may be limited by the size of the sample. As previously found in U.S. studies (Jones et al., 2001; Malow et al, 2000), Zambian participants increased their use of chemical barrier products. These results suggest that expressed willingness to use specific barrier products may not be related to participants’ product acceptability ratings.

In comparison with previous research with multiethnic women in the U.S. (i.e., African Americans and Hispanics) (Jones, et al., 2001), Zambian women preferred less lubricated sex [NB: a preference shared with Haitian women (Jones et al, 2001)]. However, our data demonstrated that ethnic and cultural preferences for drier sex can be influenced by behavioral interventions. The necessity for an effective vaginal chemical barrier method has highlighted concern about the relative lack of information regarding acceptability among diverse populations. These findings can guide the development of culturally sensitive sexual behavior interventions to accompany the eventual introduction of microbicidal products.

The primary limitation of this study was its small sample size given its multicultural composition (i.e., 73 local and 3 primary regional languages and at least 5 distinct cultural groups) which precluded analyses by specific cultural group. In addition, approximately one third of the women in the study were not currently sexually active, which reduced the number of women who used sexual barriers. Finally, results suggest that exposure to products influenced actual use; however, the limited sample size restricted predictive analyses between exposure to and actual use of vaginal chemical barriers.

Prevention of HIV sexual transmission does not occur in a vacuum. As new products become available, research on cultural factors that may influence acceptability and the development of culturally relevant interventions to promote use are essential. Female-controlled methods of protection will allow women to assume a more prominent role in reducing risk of sexual transmission while ensuring their own protection, an idea whose time has finally come.

Acknowledgments

This research was made possible by a grant from the National Institute of Mental Health RO1MH55463.

Contributor Information

Deborah L Jones, Department of Psychology, Barry University, Miami Shores, FL.

Stephen M. Weiss, University of Miami School of Medicine, Miami, FL.

Ganapati J. Bhat, University of Zambia School of Medicine.

Douglas Feldman, State University of New York at Brockport, NY.

Violet Bwalya, University of Zambia.

Danielle Budash, Barry University Department of Psychology, Miami Shores, FL.

References

  1. Allen S, Serufilira A, Bogaerts J, Van de Perre P, Nsengumuremyi F, Lindan C, Carael M, Wolf W, Coates T, Hulley S. Confidential HIV testing and condom promotion in Africa: Impact on HIV and gonorrhea rates. Journal of the American Medical Association. 1992;268:3338–3343. [PubMed] [Google Scholar]
  2. Allen SA, Karita E, N’gandu N, Tichacek A. The evolution of voluntary testing and counseling as an HIV prevention strategy. In: Gibney L, DiClemente RJ, Vermund SH, editors. Preventing HIV in developing countries: Biomedical and behavioral approaches. New York: Kluwer; 1999. [Google Scholar]
  3. Campbell T, Kelly M. Women and AIDS in Zambia: A review of the psychosocial factors implicated in the transmission of HIV. AIDS Care. 1995;7:365–73. doi: 10.1080/09540129550126579. [DOI] [PubMed] [Google Scholar]
  4. Chikumbi B. Dry sex potentiates HIV and STD spread. Paper presented at the Eleventh International Conference on AIDS and STDs in Africa (ICASA); Lusaka, Zambia. 1999. Sep, [Summary retrieved September 9, 2003, from http://www.hivnet.ch:8000/africa/af-aids/viewR?444] [Google Scholar]
  5. Elias C, Coggins C, Atissok R, Bassett MT, Ettiegne-Traore V, Ghys PD, Jenkins-Woelk L, Thogkrajai E, VanDevanter NL. Women’s preferences regarding the formulation of over-the-counter vaginal spermicides. Paper presented at the XI International Conference on AIDS (abstract no. Th.C.322); Vancouver, Canada. 1996. Jul, [DOI] [PubMed] [Google Scholar]
  6. Ehrhardt AA, Yingling S, Zawazki R, Martinez-Remirez N. Prevention of heterosexual transmission of HIV: Barriers for women. Journal of Psychology and Human Sexuality. 1992;5:37–67. [Google Scholar]
  7. Faxelid E, Ahlberg BM, Ndulo J, Krantz I. Health-seeking behavior in patients with sexually transmitted diseases. East African Medical Journal. 1998;75:232–236. [PubMed] [Google Scholar]
  8. Fleming DT, Wasserheit JN. From epidemiological synergy to public health policy and practice: The contribution of other sexually transmitted diseases to sexual transmission of HIV infection. Sexually Transmitted Infections. 1999;75:3–17. doi: 10.1136/sti.75.1.3. [DOI] [PMC free article] [PubMed] [Google Scholar]
  9. Fylkesnes K, Musonda RM, Kasumba K, Ndhlovu Z, Mluanda F, Kaetano L, Chipaila CC. The HIV epidemic in Zambia: Socio-demographic prevalence patterns and indications of trends among childbearing women. AIDS. 1997;11:339–45. doi: 10.1097/00002030-199703110-00012. [DOI] [PubMed] [Google Scholar]
  10. Gupta GR, Weiss E. Women’s lives and sex: Implications for AIDS prevention. Culture, Medicine, and Psychiatry. 1993;17:399–412. doi: 10.1007/BF01379307. [DOI] [PubMed] [Google Scholar]
  11. Hira SK, Spruyt AB, Feldblum PJ, Sunkutu MR, Glover LH, Steiner MJ. Spermicide acceptability among patients at a sexually transmitted disease clinic in Zambia. American Journal of Public Health. 1995;85:1098–103. doi: 10.2105/ajph.85.8_pt_1.1098. [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Hira SK, Feldblum PJ, Kamanga J, Mukelabai G, Weir SS, Thomas JC. Condom and nonoxynol-9 use and the incidence of HIV infection in serodiscordant couples in Zambia. International Journal of STD AIDS. 1997;8:243–250. doi: 10.1258/0956462971919994. [DOI] [PubMed] [Google Scholar]
  13. HIV/AIDS in Zambia: Background, projections, impacts, Interventions. Republic of Zambia: Ministry of Health/Central Board of Health; 1999. [Google Scholar]
  14. Jones DL, Weiss SM, Malow R, Ishii M, Devieux J, Stanley H, Cassells A, Tobin JN, Brondolo E, LaPerriere A, Efantis-Potter J, O’Sullivan MJ, Schneiderman N. A brief sexual barrier intervention for women living with AIDS: Acceptability, use and ethnicity. Journal of Urban Health. 2001;12:593–604. doi: 10.1093/jurban/78.4.593. [DOI] [PMC free article] [PubMed] [Google Scholar]
  15. Kamb ML, Fishbein M, Douglas JM, Rhodes F, Rogers J, Bolan G, Zenilman J, Hoxworth T, Malotte CK, Iatesta M, Kent C, Lentz A, Graziano S, Byers RH, Peterman TA. Efficacy of risk-reduction counseling to prevent human immunodeficiency virus and sexually transmitted diseases: A randomized controlled trial. Journal of the American Medical Association. 1998;280:1161–1167. doi: 10.1001/jama.280.13.1161. [DOI] [PubMed] [Google Scholar]
  16. Lagarde E, Carael M, Glynn JR, Kanhonou L, Abega SC, Kahindo M, Musonda R, Auvert B, Buve A Study Group on the Heterogeneity of HIV Epidemics in African Cities. Educational level is associated with condom use within nonspousal partnerships in four cities of sub-Saharan Africa. AIDS. 2001;15:1399–1408. doi: 10.1097/00002030-200107270-00009. [DOI] [PubMed] [Google Scholar]
  17. Malow RM, Ziskind D, Jones D. Use of female controlled microbicidal products for HIV risk reduction. AIDS Care. 2000;12:585–593. doi: 10.1080/095401200750003761. [DOI] [PubMed] [Google Scholar]
  18. McKenna SL, Muyinda GK, Roth D, Mwali M, Ng’andu N, Myrick A, Luo C, Priddy FH, Hall VM, von Lieven AA, Sabatino JR, Mark K, Allen S. Rapid HIV testing and counseling for voluntary testing centers in Africa. AIDS. 1997;11(Suppl 1):S103–S110. [PubMed] [Google Scholar]
  19. Meyer-Bahlberg HFL, Ehrhardt AA, Exner TM, Gruen RS. Sexual Risk Behavior Assessment Schedule: Adult. (SERBAS-A-DF-4) Manual. New York: Psychological Press; 1990. [Google Scholar]
  20. Musaba E, Morrison CS, Sunkutu M, Wong EL. Long-term use of the female condom among couples at high risk of human immunodeficiency virus infection in Zambia. Sexually Transmitted Diseases. 1998;25(5):260–264. doi: 10.1097/00007435-199805000-00008. [DOI] [PubMed] [Google Scholar]
  21. Ndoye I. STDs and HIV: Prospects and challenges in Africa. Paper presented at the Eleventh International Conference on AIDS and STDs in Africa (ICASA); Lusaka, Zambia. 1999. Sep, [Summary retrieved September 9, 2003, from http://www.hivnet.ch:8000/africa/af-aids/viewR?380] [Google Scholar]
  22. Pool R, Whitworth JAG, Green G, Mbonye AK, Harrison S, Wilkinson J, Hart GJ. An acceptability study of female-controlled methods of protection against HIV and STDs in south-western Uganda. International Journal of STDs and AIDS. 1999;11:162–167. doi: 10.1258/0956462001915606. [DOI] [PubMed] [Google Scholar]
  23. Ramgee G, Gouws E, Andrews A, Myer L, Weber A. The acceptability of a vaginal microbicide among South African men. International Family Planning Perspectives. 2001;12:1–2. [Google Scholar]
  24. Sheeran P, Abraham C, Orbell S. Psychosocial correlates of heterosexual condom use: A meta-analysis. Psychological Bulletin. 1999;125:90–132. doi: 10.1037/0033-2909.125.1.90. [DOI] [PubMed] [Google Scholar]
  25. Steyn Z. Every woman deserves to know every method. American Journal of Public Health. 1995;47:1487. [Google Scholar]
  26. Steiner MJ, Spruyt A, Joanis C, Glover L, Cordero M, Alvarado G, Onoka C. Acceptability of spermicidal film and foaming tablets among women in three countries. International Family Planning Perspectives. 1995;21:104–107. [Google Scholar]
  27. UNAIDS/WHO Working Group on Global HIV/AIDS and STD Surveillance. Epidemiological Fact Sheet on HIV/AIDS and sexually transmitted diseases. 2002 Retrieved September 11, 2003, from http://www.who.int/emc-hiv/
  28. UNAIDS/WHO Joint United National Programme on HIV/AIDS. AIDS epidemic update. Geneva, Switzerland: World Health Organization; 2000. [Google Scholar]
  29. UNAIDS/WHO Working Group on Global HIV/AIDS and STI Surveillance. Zambia Epidemiological Fact Sheet on HIV/AIDS and sexual transmitted infections. 2000 Update. Geneva, Switzerland: World Health Organization; 2001. [Google Scholar]
  30. Zambia Demographic and Health Survey. Lusuka, Zambia: Central Statistical Office; 2001. [Google Scholar]
  31. Zambia Sexual Behavior Survey 1998 with selected findings from the quality of STD Services Assessment. Lusuka, Zambia: Central Statistical Office, Ministry of Health, Project Concern International; 1999. [Google Scholar]

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