Table 3.

Barriers and strengths related to HIV prevention behaviours by Informational-Motivational-Behavioral Skill (IMB) model of prevention behavior

	Information	Motivation	Behavioural Skills	Structural/Community-level/Other
Barriers to HIV prevention behaviours	Misinformation about discordant couples “It is impossible for one partner to be HIV positive and another partner HIV negative” (38 year old male). Misconceptions regarding condom use Condoms cause discomfort and pain (women) Condoms cause cancer Condoms can be left inside women after intercourse Misconceptions regarding circumcision People who are circumcised engage in more sexual risk, “thinking that they will not get HIV because they are circumcised” (40 year old male). People living with HIV purposely engage in unsafe sex because they want to, “make sure they spread the virus to other people intentionally” (26 year old female).	Negative attitudes towards condom use Reduced sexual pleasure (men) Condom use is like “eating a sweet with its wrapper” or “eating a banana with its peel” (47 year old male). Discomfort and pain and decreased sexual pleasure (women) More acceptable for use with extramarital partners Difficulty using long-term Desire for children	Lack of objective condom use skills Female condoms Remarks on reduced sexual pleasure, pain, and discomfort suggestive of deficits in proper male condom use. Difficulty buying condoms in public People feel “shy to ask for them” (21 year old female). Partner communication deficits (especially women) Regarding condom use, women’s ability to refuse sex with her husband, disclosing one’s status, making a prevention plan, and going for couples HIV-testing. Difficulty resisting social norms regarding sexual behaviour and gender roles Difficulty resisting peer pressure (men) Peers can influence one “to get a partner or more partners” (68 year old married male). Difficulty resisting sexual urges (men)	Drinking alcohol during sex Lack of access to female condoms HIV-stigma Differences in prevention behaviours by age Men’s mobility as a barrier to monogamy Gender inequity Male control over condom use Financial dependence on men Women are unable to refuse sex with husband for fear of losing support Women engage in transactional sex for economic support Even less control over condom use when men have paid. Social norms prohibiting women to refuse sex with her husband Cultural and social norms about sexual behaviour Multiple partners and barriers to abstinence (men) It is men’s nature to desire many women It is “prestigious to have more than one woman” (18 year old single female) Stigma-related to unmarried women and women without children Religion as a prevention barrier Religious groups’ opposition to condoms Circumcision viewed as a religious practice Many do “not want to be circumcised thinking that they are promoting [the] Muslim religion” (30 year old male). Risky tribal practices Women getting married expected to have sex with father- in-law A woman can be “free to engage in sex with all my brothers because it is part of our culture” (28 year old male).
Strengths about HIV prevention behaviours	Understanding of the protective effects of prevention behaviours on HIV acquisition Condom use and being faithful most cited Women identified the delay or avoidance of marriage as a way to reduce HIV risk “If a woman decided not to get married…it can prevent her from getting HIV” (21 year old married female).	Overall positive views towards prevention behaviours “It is good when you are circumcised; you don’t easily get sexually transmitted diseases” (38 year old male). “I don’t have any problem with a condom and my partner is so much interested in using it” (21 year old female). Women interested in female condoms Ability to disassociate circumcision as a religious issue, and see that it “make [you] clean” (35 year old female).	Women’s ability to suggest condom use in ways that may be more acceptable