Gay men and other men who have sex with men (MSM) in Uganda, who had not used a condom the last time they had anal sex with another man, were most likely to say that condoms not being strong enough for anal sex, a lack of suitable lubricant and, in rural areas, a lack of access to condoms were the most common reasons they did not use them.
A number of other reasons were also mentioned, such as pressure from primary or commercial sex partners, false beliefs about the safety of anal sex, lack of pleasure, and ignorance about how to use condoms. Alcohol was also mentioned frequently as a disinhibitor of condomless sex.
While there have been numerous studies among gay and other MSM in high-income, more liberal countries about why they don’t always or ever use condoms, researchers have rarely asked the same questions of MSM in low-income countries, especially ones where male/male sex is criminalised and highly stigmatised. Nonetheless, as the researchers point out, MSM are as disproportionately affected by HIV in such countries as they are elsewhere. HIV prevalence in MSM in sub-Saharan Africa is 25% compared with a continent-wide adult-population prevalence of 9%. In Uganda the figures are 13.5% and 7.3% respectively.
The data come from a qualitative study with 85 self-identified MSM. The men were recruited by the ‘snowball sampling’ method whereby two MSM volunteers were originally recruited in each area and were asked to recruit others. The 85 came from 11 districts in Uganda that had HIV high prevalence, but were also chosen to provide a geographical spread across the country and an urban-rural balance.
Of the 85, 33 (39%) said they had not used a condom the last time they had anal sex with a male partner, and these 35 were selected for the present study. Their views on condoms come from individual 90-minute interviews.
The most common reasons cited for not using condoms involved the practical difficulties of getting hold of quality materials. A lot of the interviewees said that the condom brands available in Uganda were low-quality and unsuitable for anal sex. One said:
“However much I like doing protected sex, they all burst. Anal sex is a bit rough, so we need quality condoms.”
Another said that three condoms had broken in a single sexual encounter and described the experience as “unenjoyable”. Proper sexual lubricants were almost impossible to get in many areas, so the MSM improvised with jellies, oils, spit or soap.
For this reason or others, many interviewees said sex with condoms was more painful and that they had experienced irritation and even bruising:
“The use of a condom is not bad, but the problem is when used for more than a minute, it tends to get dry and starts hurting.”
Some just felt that condomless sex was more pleasurable:
“When I use a condom, I’m not comfortable when having sex. And I don’t feel the person well.”
One commonly-mentioned factor in not using condoms was alcohol use:
“There are times when you drink a lot of alcohol…become very sexually active and may not even think of using a condom.”
One factor that was more common in rural areas was lack of access to condoms. Usually they were simply not available, rather than unaffordable. One participant said he had got genital ulcer disease because condoms had not been available with a partner.
A surprisingly large number of interviewees were completely ignorant of condoms. Some said they knew nothing about them, while one participant mentioned actually having a packet of condoms but being too scared to start using them:
“I even have some condoms I bought recently…I actually want to learn those things but still fear.”
Others were scared that condom use might ‘out’ them as MSM. One fear mentioned by several interviewees was that condoms might get lost up the anus, which would then have to be explained to a healthcare worker:
“I heard of cases where a condom would stick in the anus…such things make me not like condoms and imagine going to a doctor who is not used to such things.”
Some participants – especially in the more rural provinces – did not think anal sex could transmit HIV. One folk theory that was mentioned several times was that HIV could only be transmitted when semen and vaginal fluid were both involved, or even that only women’s vaginal fluid is infectious:
“When having sex with a fellow man…it is only one person releasing the sperms, so you have no chance of getting infected with HIV.”
Other interviewees seem to have taken on board anti-condom messages from conservatives. Some had heard that condoms were only good for preventing pregnancy, not HIV, so did not need to be used with men. Others had heard that condoms actually cause HIV:
“We hear over the radios people saying condoms cause diseases. [We are warned] that we shouldn’t lie to ourselves that we won’t catch HIV when we use condoms…instead we will acquire it.”
Others had decided or been persuaded not to use condoms by partners: “A couple that uses condoms has no faith in each other” said one man. One participant said he and his partner, who had been in a relationship for two and a half years, took an HIV test together and now test quarterly instead of using condoms. Other participants felt persuaded or coerced by partners they did not want to lose:
“I tried to speak about using [a condom] but he was objecting to it; he asked me that 'You no longer trust me nowadays?' and because I love him I have to accept to go without any protection.”
A number of participants were sex workers and gave in to the offer of more money for condomless sex:
“You may find that he tells you I am paying you…a higher price with a condom off…you need the money so you are forced to go for the bigger amount. I have many needs, I have to pay my rent, dress up and eat.”
Conclusions and recommendations
Many of the reasons interviewees cited for choosing condomless sex were similar to those given by gay men in other countries. However some were specific to the Ugandan context. The researchers note that: “In our study, access to lubricants was reported to be extremely difficult” and comment that the irritation and pain interviewees talk about, not to mention some of the condom failure, could be caused by a poor choice of lubricants.
They comment that HIV prevention messaging in African countries urgently needs to include anal sex, suggesting that messaging not obviously directed at gay men might work better in repressive environments.
They add that trained peers within MSM networks represent the best opportunity for increasing access to information, condoms and lubricants within the MSM community. Condom and lubricant distribution and education projects are still one of the most effective and affordable ways of preventing HIV in populations that have had inadequate access to them before, as CAPRISA chief Salim Abdool Karim argued at last year’s International AIDS Conference. African MSM are clearly in need of them.
The authors of the paper – which includes a representative from the Ugandan Ministry of Health – see seeds of hope in the social organisation and networks that MSM have adopted in the face of public condemnation, commenting that “MSM are fairly well organised and several of them participate in social networks that provide an opportunity for mobilisation and delivery of HIV prevention interventions.”
Musinguzi G et al. Barriers to condom use among high risk men who have sex with men in Uganda: a qualitative study. PLoS ONE 10(7): e0132297. doi: 10.1371/journal.pone.0132297. July 2015.