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Awareness of AIDS is widespread among both men and women, international survey programs find. Some people, however, continue risky sexual practices-for example, having multiple partners and not using condoms consistently and correctly-even though they know that such behavior puts them and others at risk for HIV/AIDS.
Since 1990, 58 countries surveyed in the Demographic and Health Surveys (DHS) and Reproductive Health Surveys (RHS) programs have asked women, and 44 countries have asked men, questions about their awareness and perceptions of AIDS, and also about their behavior in response to the AIDS crisis. Most surveys about HIV/AIDS have been conducted in sub-Saharan Africa and Latin America and the Caribbean (see Table 1).
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In Pakistan a field worker interviews a group of men on reproductive health. Nationally representative surveys increasingly include men, recognizing their importance to good reproductive health. |
Survey programs have paid increasing attention to HIV/AIDS as it has reached epidemic proportions in some parts of the world. An estimated 40 million people around the world are living with HIV/AIDS. In 2003, 3 million people died of AIDS (5). In some countries AIDS mortality will overwhelm the progress made in life expectancy achieved through control of other infectious diseases during the last half century (14).
The HIV/AIDS crisis is to a large extent a crisis of sexual behavior. Unsafe sex is responsible for the large majority of HIV infections in sub-Saharan Africa and in Latin America and the Caribbean (10, 17). In Eastern Europe and Central Asia, HIV infections are primarily transmitted through injecting drug use, but sexual transmission is becoming more prominent in some countries of the region (5). The AIDS epidemic will not subside until most people around the world know how HIV is transmitted, how to prevent infection and, if they or their partners are at risk, substantially change their sexual behavior (8, 16).
This report is a supplement to Population Reports, Men's Surveys: New Findings, Series M, Number 18, Spring 2004 and presents survey findings on HIV/AIDS awareness and behavior, in a format of questions and answers. International donors, national governments, and policy-makers often have questions about how to address the AIDS crisis and whether AIDS prevention programs are making a difference (4, 7). Survey data can help address these questions by reporting the extent to which people:
Answers to survey questions about HIV/AIDS awareness and behavior can help guide program responses by identifying groups of people who are at risk of infection, whether they lack information or behave in risky ways despite knowing the risks. The questions and answers provided in this report can be adapted for use in newsletters, training, and other ways.
The DHS and RHS ask men and women if they have heard of AIDS. Surveys find that awareness of AIDS is widespread among both men and women in most surveyed countries. In most surveyed countries, however, more men than women have heard of AIDS.
Awareness of AIDS is widespread in surveyed countries. In 36 of 44 countries with survey data on men, at least 90% of men have heard of AIDS. Only in Bangladesh, at 50%, and in Nepal, at 72%, does men's awareness of AIDS fall below 85% (see Table 2).
In 41 of 59 countries with survey data for women, at least 90% of women have heard of AIDS. In four countries, however—Bangladesh, Haiti, India, and Nepal—no more than half of women have heard of AIDS (see Table 3).
In 33 of the 44 countries with data on both men and women, more men than women have heard of AIDS—by at least 20 percentage points in Chad, Haiti, Niger, and Nepal. In the other 11 countries men and women have similarly high levels of awareness of AIDS.
Where knowledge of AIDS is relatively low, differences in awareness among groups of men and women are occasionally large (see Tables 2 and 3). Knowledge of AIDS is generally somewhat lower among men and women in rural areas than among urban men and women. Knowledge of AIDS is lower among men and women with little or no schooling than those with more schooling.
Differences between groups of women are often more substantial than between groups of men. In Niger, for example, 98% of urban men have heard of AIDS compared to 86% of rural men, a difference of 12 percentage points (see Table 2). In contrast, 94% of urban women but only 45% of rural women in Niger have heard of AIDS, a difference of 49 percentage points (see Table 3).
In order for people to avoid HIV/AIDS, they must have accurate perceptions of it and of their own risk of infection (1, 16). The DHS and RHS ask respondents who have heard of AIDS three additional questions to measure how much they know about it: (1) "Can a healthy-looking person have the AIDS virus?" (2) "Is AIDS a fatal disease?" and (3) "What are your chances of getting the AIDS virus?"
In most countries the vast majority of men and women have heard of AIDS. Far fewer, however, know that people with AIDS may lack obvious symptoms. In 38 of 42 countries with men's surveys, more than half of the respondents know that a healthy-looking person can have AIDS. Nevertheless, in 18 of 37 countries at least one-quarter of men answered "no" or "don't know" to this question (see Table 4).
Similarly, in 44 of 56 countries with survey data on women, the majority of women know that healthy-looking people can have AIDS. In 32 of 45 countries, however, at least one-quarter of women answered "no" or "don't know" to this question (see Table 5). In general, more women than men do not know that a person can appear healthy but have AIDS.
In 21 of 23 countries with surveys of men, and 26 of 28 countries with surveys of women, most respondents know that AIDS is usually fatal (see Tables 4 and 5). In Bolivia, Côte d'Ivoire, Gabon, and Mozambique, however, at least one man in every five surveyed thinks that AIDS is almost never fatal, or is fatal only in some cases (see Table 4). Among women in Bangladesh, Côte d'Ivoire, Jordan, Mozambique, and Turkey, at least one in every five thinks AIDS can be a nonfatal disease (see Table 5).
In most surveyed countries the large majority of men and women believe they have only a small risk of getting AIDS, or have no risk at all. In 20 of 25 men's surveys, over three-quarters of respondents say they face no risk of getting AIDS, or only a small risk (see Table 4). The same is true in 20 of 34 women's surveys (see Table 5). In general, men are more likely than women to believe they face little risk of HIV infection.
Many survey respondents, of course, may indeed face little risk of HIV infection, but others may be at risk even though they do not believe that they are. To measure the accuracy of people's perceptions of AIDS risk, data on perceptions can be matched to data on their behavior. Presumably, people who say they are not at risk of AIDS will not be acting in ways that put them at risk. A recent analysis of survey data of youth in Mozambique that examined such matched data found that 27% of the women ages 15 to 24 and 80% of the young men who reported being at no or small risk of getting HIV behaved in ways that put them at moderate to high risk (12).
Sexual abstinence, a mutually faithful sexual relationship, and correct and consistent condom use (often called the ABCs of AIDS prevention—for Abstaining, Being faithful, and Condom use) can prevent or substantially reduce the risks of sexual transmission of HIV/AIDS (11, 15).
To assess the extent to which people are adopting safer sex behaviors, some DHS and RHS ask men and women whether they used a condom the last time they had sex, and how many sex partners they have had in the past 12 months. Answers show that condom use and sexual activity vary widely by marital status and differ substantially between men and women.
Few married people report using condoms together. The highest percentage of married men who reported condom use the last time they had sex with their wives or cohabiting partners is in Gabon, at 18% (see Table 6). Among married women, the highest comparable level is 8%, also in Gabon (see Table 7).
Condom use is much higher outside marriage, among both married and unmarried men and women. Married men and women consistently report higher levels of condom use at last sex with an extramarital partner than with a spouse or cohabiting partner. Levels of extramarital condom use among married men vary from 19% in Haiti to 71% in Zimbabwe, and among married women from 5% in Ethiopia to 48% in Zimbabwe (see Tables 6 and 7). In 14 of 22 surveyed countries, at least one-third of married men report having used a condom the last time they had sex outside marriage (see Table 6).
Extramarital condom use among both married men and women is comparable to condom use among unmarried men and women. In only 5 of 22 countries with data is the difference between the two groups of men greater than 10 percentage points. Similarly, in only 9 of 20 countries with data is the difference between the two groups of women greater than 10 percentage points.
Men and women differ substantially in the number of sex partners they report having, but such survey findings may not be reliable. Differences in men's and women's reports may be due in part to men overreporting and/or women underreporting numbers of sex partners. Also, some groups of women, such as prostitutes, who have many partners, tend to be missing from the survey sample (2, 3, 9).
In all 19 countries with data on both men and women, the percentage of never-married men who report that they had sex in the past year is much higher than the percentage of never-married women who report sexual activity—by as much as 35 percentage points in Armenia. Furthermore, far more men than women who have never been married had multiple sex partners in the preceding year (see Table 8).
Many more married men than married women report having multiple sex partners. In 9 of the 24 countries with data on men, less than 80% of married men report being faithful to one sex partner—presumably their wives—or abstaining from sex in the year before the survey. In Gabon only half of married men surveyed said they were faithful to one sex partner, the lowest level among all 24 surveyed countries (see Table 8).
In contrast, among 24 surveyed countries with data on women, nearly all married women surveyed said they were faithful to one sex partner—presumably their husbands—or abstained from sex altogether. In fact, substantial proportions of married women report having no sex in the past year—as many as 23% of married women in Guinea. In some of these countries considerable proportions of married men also report having no sex.
In most surveyed countries, formerly married men and women are more likely than currently or never married men and women to report having multiple sex partners in the year before the survey. In 14 of 22 countries more formerly married than currently or never married men reported having more than one sex partner in the year preceding the survey. The same is true among women in 19 of 23 countries (see Table 8).
SURVEY DATA AVAILABLE
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Survey data can help programs focus efforts to improve AIDS knowledge and behavior, especially where they identify subgroups of people who are ill-informed or who are at risk of infection. Further information and data on HIV/AIDS can be found from the organizations and web sites listed below:
1. BERNARDI, L. Determinants of individual AIDS risk perception: Knowledge, behavioural control, and social influence. Rostock, Germany, Max Planck Institute for Demographic Research, Jul. 2002. (MPIDR Working Paper WP 2002-029) 32 p. (Available: <http://www.demogr.mpg.de/papers/working/wp-2002-029.pdf>, Accessed Aug. 24, 2003)
2. BREWER, D.D., POTTERAT, J.J., GARRETT, S.B., MUTH, S.Q., ROBERTS, J.M., KASPRZYK, D., MONTANO, D.E., and DARROW, W.W. Prostitution and the sex discrepancy in reported number of sexual partners. Proceedings of the National Acadamies of Science 97(22): 12385-12388. Oct. 24, 2000.
3. CARAËL, M. Methodologies for measuring behavioral trends. In: Rehle, T., Saidel, T., Mills, S., and Magnani, R., eds. Evaluating Programs for HIV/AIDS Prevention and Care in Developing Countries: A Handbook for Program Managers and Decision Makers. Research Triangle Park, North Carolina, Family Health International, 2003. p. 165-172. (Available: <http://www.fhi.org/NR/rdonlyres/eids2i3iqcw5qda4tdclohfgdmqvpsuvonddh3v5ptcc5xb334f56on7zdibh4umw4r6ttgpl7vhzl/31776textR1.pdf>, Accessed Feb. 6, 2004)
4. JOINT UNITED NATIONS PROGRAMME ON HIV/AIDS (UNAIDS). National AIDS programmes: A guide to monitoring and evaluation. Geneva, UNAIDS, Jun. 2000. 147 p. (Available: <http://www.cpc.unc.edu/measure/publications/unaids-00.17e/un-00.17e-en.pdf>, Accessed May 5, 2004)
5. JOINT UNITED NATIONS PROGRAMME ON HIV/AIDS (UNAIDS) and WORLD HEALTH ORGANIZATION (WHO). AIDS epidemic update: December 2003. Geneva, UNAIDS and WHO, Dec. 2003. 48 p. (Available: <www.unaids.org/html/pub/Publications/IRC-pub06/Epi03_00_en_html.htm>, Accessed Jan. 22, 2004)
6. KIRAGU, K. Youth and HIV/AIDS: Can we avoid catastrophe? Population Reports, Series L, No. 12. Baltimore, Johns Hopkins Bloomberg School of Public Health, Population Information Program, Fall 2001. 39 p. (Available: <http://www.infoforhealth.org/pr/l12edsum.shtml>)
7. MEASURE EVALUATION. A new tool to focus and monitor AIDS prevention efforts: The PLACE method. MEASURE Evaluation Bulletin, No. 4, 2002. p. 46. (Available: <http://www.cpc.unc.edu/measure/publications/pdf/bu-02-04.pdf>, Accessed May 5, 2004)
8. MUINDI, M. and BICEGO, G. AIDS and other sexually transmitted diseases. In: National Council for Population and Development (Ncpd), Central Bureau of Statistics (Cbs), and Macro International. Kenya Demographic and Health Survey, 1998. Calverton, Maryland, NCPD, CBS, Macro International, Apr. 1999. p. 127-159.
9. NNKO, S., BOERMA, J.T., URASSA, M., MWALUKO, G., and ZABA, B. Secretive females or swaggering males? An assessment of the quality of sexual partnership reporting in rural Tanzania. Chapel Hill, North Carolina, MEASURE Evaluation, Sep. 2002. (Working Paper No. 02-57) 28 p. (Available: <http://www.cpc.unc.edu/measure/publications/pdf/wp-02-57.pdf>, Accessed Feb. 6, 2004)
10. PISANI, E., CUCHÍ, P., ZACARÍAS, F., SCHWARTLANDER, B., STANECKI, K., CASTILHO, E., FERNANDEZ-ZINCKE, E., PATZ, D., LAZARI, S., and CALLEJA, T. HIV and AIDS in the Americas: An epidemic with many faces. Rio de Janeiro, Brazil, Latin American and Caribbean Epidemiological Network for HIV/AIDS and Monitoring the AIDS Pandemic Network, Nov. 2000. 50 p. (Provisional Report) (Available: <http://www.paho.org/English/HCP/HCA/Report_Foro_200_HIV-%20AIDS.pdf>, Accessed Aug. 24, 2003)
11. POPULATION HEALTH AND NUTRITION INFORMATION (PHNI) PROJECT. The "ABCs" of HIV prevention: Report of a USAID Technical Meeting on behavior change approaches to primary prevention of HIV/AIDS. Proceedings of the "ABC" Experts Technical Meeting, Washington, D.C., Sep. 17, 2002. PHNI Project, p. 23. (Available: <http://www.usaid.gov/our_work/global_health/aids/TechAreas/prevention/abc.pdf>, Accessed Apr. 8, 2004)
12. PRATA, N., MORRIS, L., STEHR, M., and MAZIVE, E. Does self-perceived risk of contracting HIV change sexual behavior and condom use? The case of Mozambican youth. Proceedings of the International Union for the Scientific Study of Population Seminar on Taking Stock of the Condom in the Era of HIV/AIDS, Gaborone, Botswana, Jul. 13-17, 2003. p. 22. (Draft)
13. SALEM, R. Men's surveys: New findings. Population Reports, Series M, No. 18. Baltimore, Johns Hopkins Bloomberg School of Public Health, the INFO Project, Spring 2004.
14. TIMAEUS, I.M. Impact of the HIV epidemic on mortality in sub-Saharan Africa: Evidence from national surveys and censuses. AIDS 12(Supplement 1): S15-S27. 1998.
15. U.S. AGENCY FOR INTERNATIONAL DEVELOPMENT (USAID). The ABCs of HIV prevention. Washington, D.C., USAID, Jan. 2004. 4 p. (Issue Brief) (Available: <http://www.usaid.gov/our_work/global_health/aids/News/abcjan04.pdf>, Accessed Apr. 8, 2004)
16. UNITED NATIONS (UN). DEPARTMENT OF ECONOMIC AND SOCIAL AFFAIRS. POPULATION DIVISION. HIV/AIDS awareness and behaviour. New York, UN, 2002. 29 p. (ST/ESA/SER.A/209) (Available: <http://www.un.org/esa/population/publications/AIDS_awareness/AIDS_English.pdf>, Accessed Aug. 20, 2003)
17. WORLD HEALTH ORGANIZATION (WHO). The world health report 2002: Reducing risks, Promoting healthy life. Geneva, WHO, 2002. 248 p. (Available: <http://www.who.int/whr/2002/download/en/>, Accessed Aug. 20, 2003)
18. ZLIDAR, V.M., GARDNER, R., RUTSTEIN, S.O., MORRIS, L., GOLDBERG, H., and JOHNSON, K. New survey findings: The reproductive revolution continues. Population Reports, Series M, No. 17. Baltimore, Johns Hopkins Bloomberg School of Public Health, the INFO Project, Spring 2003. 43 p.
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