The first survey for six years of attitudes to HIV and sexual risk behaviour among the general public in France has found that young people are less frightened of AIDS than they used to be, are more likely to believe in unlikely routes of HIV transmission, and are strikingly less trustful that condoms will reliably protect them against HIV.
The study finds that almost everyone knows about the most common ways HIV is transmitted, and that condoms as a general anti-HIV and contraceptive strategy are still widely used, far more so than the days before widespread public awareness of HIV.
However, it finds a considerable decline, relative to earlier surveys, in the proportion of people who used condoms the last time they had sex, especially in longer-term relationships.
The French Knowledge, Attitudes, Beliefs and Practice (KABP) survey has been conducted at irregular intervals since 1992 and therefore, with the last data gathered in 2010, represents a unique 18-year longitudinal data set of knowledge and practice about HIV.
In the words of the researchers: “To our knowledge, this is the first time in any country that [KABP] data have been collected over such a long period.”
One advantage of the survey is that the first one, in 1992, was conducted before the first comprehensive HIV awareness campaign was conducted in France and thus provides some measure of baseline awareness and practice. The survey is specifically aimed at the general public rather than high-risk groups such as gay men, injecting drug users and migrants.
The survey, conducted in 1992, 1994, 1998, 2001, 2004 and 2010, was done by random-dialling the home phones of members of the public aged 18-69. For the 2010 survey, to reflect that an increasing proportion of people no longer use a landline, random dialling of all phone numbers including mobiles was used. The acceptance rate for the survey was reasonably consistent, ranging from 63% in 1994 to 81% in 2001. In 2010 it was 67% in landline calls and 65% in mobile calls.
Overall, 26,519 members of the public were interviewed but for this paper only the 6136 aged between 18 and 29 were selected, 54% women and 46% men. The survey did not ask about gender of sexual partners and only 2.5% of men and 1.4% of women volunteered the information that they had had same-sex partners in the previous year. Numbers in this age group interviewed in individual surveys ranged from 187 in 1994 to 398 in 2004, while 3-4 times as many as this – 926 – were interviewed in 2010.
Results: knowledge and beliefs
Knowledge of the major routes of HIV transmission was near-universal: over 99% of people knew you could get HIV from unprotected sexual intercourse in each survey between 1994 and 2010, and over 98.5% knew you could get it from sharing needles in the last three surveys (the questions were not asked in other years).
Beliefs that HIV could be transmitted in unlikely ways, however, have grown. In 1992, 28% of men and 17% of women thought you could get HIV from a mosquito bite and 20% of both sexes thought it could be acquired just from using a public toilet. After a public HIV awareness campaign these proportions were down in 1994 to 12% in both sexes for mosquito bites and 9% in men and 7% in women for transmission in public toilets. By 2010, these had increased to pre-awareness campaign levels: 31% of men and 28% of women in the latest survey thought that mosquitoes transmitted HIV and 21% and 18% respectively thought you could get it from using a public toilet.
Accompanying this was a striking fall in believing that condoms could reliably prevent HIV. Although 93.2% of respondents thought that using a condom reduced the likelihood of HIV transmission, only 54% of men and women thought that condoms offered 100% protection against HIV in 2010, compared with 79% of men and 76% of women in 1994.
When the question was asked another way, by asking people if HIV transmission was possible in sexual intercourse with a condom, 40% of men and 33% of women in 2010 reported this was possible compared with 15.5% of all respondents in 1994.
As the researchers say, these views on condoms could be due to ignorance of their efficacy but could just as well be due to better practical knowledge of the difficulties of using them and their tendency to break or slip.
Personal acquaintance of someone with HIV is now back to 1992 levels: in 1992 and 2010 about 10% of respondents said they knew someone with HIV compared with over 20% in 1998 and 2001, despite HIV prevalence in France having increased by 50% during this time. This is probably both due to treatment reducing symptomatic AIDS and to a reduction in the resultant necessity to disclose.
People have become a lot less scared of the consequences of HIV infection. In 1992, about 20% of respondents were afraid of ‘getting AIDS’. After the HIV awareness campaign this more than doubled to 44% in men and 49% in women in 1994. However, it had already declined to 25% in men and 33% in women in 1998, suggesting that the effect of broad-brush campaigns is relatively transient.
In 2010, 20% of women and 18% of men were afraid of getting AIDS, figures not hugely bigger than their fear of getting other sexually transmitted infections (16 and 14% respectively).
This was accompanied by increasing fatalism about (asymptomatic) HIV infection, though, especially among men. In 2010, 38% of men and 33% of women were afraid they might already have HIV, up from 26 and 28% respectively in 1998, when the question was first asked.
Are changing beliefs about condoms reflected in changes in use? The answer is yes, in some cases. Condom use at first sex has remained steady, at 62% in men and 50% in women in 1994 and almost exactly the same proportions now.
Before the public HIV campaign, a quarter of men and half of women aged 20-29 reported “never” having used a condom. Seven years later, in 1998, this was down to 3.7% of men and 7.4% of women. Since then, figures have wobbled but, even so, in the last survey only 7.5% of men and 11% of women had never used a condom.
When it comes to condom use at last sex, however, this has declined considerably since the 1990s. In 1998, the peak year, 49% of men said they had used as condom last time they had sex while in 2010 it was 36% (a 27% decrease). In women, these proportions were 38% in 1998 and 24% in 2010 (a 37% decrease).
Condom use among higher-risk people – namely those reporting two or more partners in the past year – has held up, standing at 57% in men and 46% in women, with little change since 1994.
Condom use in longer-term relationships, however, has decreased considerably; in relationships lasting more than six months, last-time condom use has gone down from 60% in men and 53% in women to 41 and 33% where the partners do not live together.
Condom use where partners are married or cohabiting has always been low, and indeed women scarcely report condom use at all with cohabiting partners; in men, it has declined from 15 to 9%. Women also reported a decline since 2004, from 71 to 51%, in condom use with partners known for less than six months, though this was not statistically significant and not reflected in the figures for men (75% for 2004 and 72% for 2010).
Declines in condom use are, by and large, not due to people switching to non-barrier contraception methods. While more people are now using the ‘belt and braces’ approach of using both condoms and ‘medical’ methods (hormonal, IUDs etc.), the proportion reporting using no method of contraception has increased from 9.2 to 19% in men (statistically significant) and 7 to 12% in women (not statistically significant).
General-public surveys like this are interesting but do not directly demonstrate a link between knowledge, behaviour and HIV prevalence, as it is possibly the people who would never have been exposed to HIV in the first place who have stopped taking precautions. Certainly the fact that risk behaviour has not increased in people with more partners is relatively encouraging.
The decline in condom use in longer-term relationships and in particular the decline in their image as the most important way to guard against HIV is striking, though: as the researchers comment, young people may now be more concerned about pregnancy than HIV and may perceive HIV as little worse than other sexually transmitted infections, so condom use has slipped downwards in the hierarchy of sexual health measures.
Beltzer N et al. An 18-year follow-up of HIV knowledge, risk perception and practices in young adults living in France. AIDS, early online publication: DOI: 10.1097/QAD.0b013e32835e1583. 2013.