Sex and the girls

An expert view on why Uganda’s HIV/AIDS has a female face

If your daughter is 15 years old, there is a 14% chance that she has already had sex. In fact, if she has had sex, there is a 51% chance that she has had it this month.

Those and more startling details, including that 13.4% girls that age has a sexually transmitted infection (STI) compared to 5.3% boys,  are to be found in the latest Uganda Demographic and Health Survey (UDHS) released in July by the Uganda Bureau of Statistics (UBOS).

The 2011 UDHS is the fifth comprehensive survey conducted in Uganda as part of the worldwide Demographic and Health Surveys project. Its purpose is partly to furnish policymakers and planners with detailed knowledge of trends of HIV/AIDS and other sexually transmitted infections.

Because HIV transmission in Uganda occurs predominantly through sexual intercourse between an infected and a non-infected person, age at first intercourse marks the time at which most individuals first risk exposure to the virus.

Age at first sex is also an important indicator of both exposure to the risk of pregnancy and exposure to STIs. Young people who initiate sex at an early age face a higher risk of becoming pregnant or contracting an STI. Condoms come into play because their consistent use can help in reducing these risks.

The researchers also pay close attention to sex activity among women and girls because, in Uganda use of safe sex interventions is low, and the probability of a woman either becoming pregnant or getting infected with an STI is closely related to the exposure to and frequency of sexual intercourse.

As usual, when UDHS HIV/AIDS figures were released, they made headlines because they are bad. Focus was on findings that most girls have premarital sex by age 15, and that 64% of girls have sex before their eighteenth birthday in spite of the act being a criminal offense for the men involved.

Earlier, the Uganda AIDS Indicator Survey (UAIS) report released in July had showed that HIV/AIDS prevalence was rising from 6.4% in 2005 to 7.3% in 2011.

Significantly, it showed that over 130,000 new HIV infections were recorded in the country, with the prevalence rate higher among women, at 8.3% compared to 6.1% among men.  Since then, many have asked the question why the new infections and why girls?

Dr. Stella Alamo Talisuna, the executive director of  Reach Out Mbuya,  a Catholic NGO providing HIV/AIDS-related care for the urban poor in Kampala, has a wry view about why new infections are going up among women and girls. She uses the anatomy of the female genitalia to make her point.

“HIV has a female face,” she says.

Her smooth, authoritative, and matter-of-fact manner does not change as she heads south; to the genitals.  In a woman, she says, the genitals are wide and can harbor all manner of pathogens or germs. If girls start having sex before their eighteenth birthday, they are more exposed to infection because their genital tract is not well developed.

She points out that STIs thrive among the youth because young people are either ignorant of the symptoms of STIs or are too shy to seek treatment because older people relate the diseases to sex; which is not true for all.

When we met for the interview, this tallish dark skinned woman who sways slightly from side to side when she walks and looks you in the eye with a calm friendly gaze when she talks, spoke with the calm authority of someone who has seen it all.

She has seen girls like the15-year old girl who we shall call Sandra for convenience because we cannot use her real name. Sandra lost both her parents to AIDS in 2004, when she was eight years old, leaving her with the burden of becoming a `child-parent’ for her then two months old sister. T

he situation left Sandra no option but to trade her body for money.  Today, Sandra is a beneficiary of Reach Out’s Operation Child Support project. But many girls in her situation cannot be reached. That is why HIV/AIDS prevention is so critical.

Condom conundrum

Condom use, which is one of the main strategies for combating the spread of HIV, remains controversial.

Although, both men and women report having more than one sexual partner, only a few report consistently using condoms.

Among women who had more than one sexual partner in the past 12 months, nearly 31% reported using a condom during their last sexual act. Only 19% of men with multiple sexual partners over the same period reported using a condom during sex.

The statistics also show that girls aged between 15 and 24 have a higher likelihood than older women of having two or more sexual partners. On average, the young women have two partners, but usually only 45% concurrently. 

By contrast, more men generally have more than one sexual partner but the likelihood is higher among older men than among young men. On average, older men have had six partners, almost 85% concurrently, while the young men have had three.

Dr Alamo says the condom-based prevention strategy is complicated because the campaigns mainly concentrate on distribution and not usage. Even the research into condom use does not query people on whether they used them or not.

“Purchasing a condom or getting a condom from a health centre doesn’t guarantee the persons using it,” she says.

“Another reason why these education campaigns are usually ineffective is because Uganda depends wholly on donor funds which sometimes don’t come in time to finance these projects or the funds are insufficient to finance extensive programs which stay forever,” she says.

An official of the Uganda Bureau of Statistics (UBOS) agreed that when condom-related statistics are collected, “there are questions which are considered taboo to ask”.

One taboo question involves asking someone whether they have used condoms before. According to the UBOS official, they circle around the issue by assuming that if a person says they know a place where to buy condoms, it means they are a possible user.

Dr Alamo interprets the resurgence of new infections as a sign of a vicious cycle due to changing lifestyles and prevention campaign focus. 

She says when HIV/AIDS campaigns get busy trying to educate the youth about HIV/AIDS; it becomes prevalent among the married people. When the prevention campaign shifts to married people they realise infections are more prevalent among their age group, they run to the young girls in trans-generational sex relations. 

Then the infection burden shifts back to educating the girls against something for something sex and the cycle continues.

Dr Alamo is, however, optimistic.

Although, the statistics show that girls remain at great risk, the age at first marriage for girls has changed from 14 years to 17 years since 2001.

“Constant awareness campaigns will help the girls and psychosocial programmes will help improve their self-esteem and decision making,” she says.

She focuses on the good news buried below the piles of bad news; including findings that HIV testing has increased dramatically in the past five years to 71% for women and 52 percent for men from 25% and 21% respectively in 2006.

The percentage of women who are getting married by age 15 has also declined from 19% among women currently age 45-49 to 3% among women age 15-19. The median age at marriage for women age 25-49 years is at 17.9 years. But girls in urban areas like Kampala are marrying much later with a median age 20 year compare to rural areas like northern Uganda at 16.7 years. 

That is five years younger than the men at 22.3 years, but it is going down. Educated women and those from wealthier families are marrying later. But Ugandan women are having first sex later; their median age at first sex is about 16 year while men start at 19 years. Combining with the increase in HIV testing and condom acceptance, those figures give the female face of HIV/AIDS, a hopeful look.

The facts and figures

Up to 38% of women aged 15-24 and 40% men have comprehensive knowledge about AIDS from 29.5% and 35.3% respectively in 2001.

87.3% girls and 90.9% boys know HIV can be prevented by limiting sexual intercourse to one uninfected partner. However, this knowledge is not matched with knowledge of ways to avoid the disease. 

Only 69.4% girls and 86.5% boys say they know where to find condoms and have the ability to get them.  

The youths have gone through several awareness stages with various youth based campaigns like Y.E.A.H (Youth Empowered And Healthy) and PIASY (Presidential  Initiative on Aids Strategy and Communication on HIV/AIDS for Youths) which have campaigned that the youths should take up the ABC (Abstinence, being faithful and the use of condoms)  14% young women and 16% young men will have had sexual intercourse before reaching age 15 in the age group 15-24.  In 2005 the figure for young women was 12% for age-group 15-19 and 17% for 20-24 years. 

For young men it was 16.3% for age group 15-19 and

Nearly 58% young women and 47% boys will have had sex before age 18. The percentage of young people age 15-19 who have had sex by age 15 has remained stable for women at 12% but has slightly increased among men since 2006 from 14% to 18%.   

Young boys and girls are starting to have sexual intercourse at about 16 years. Most girls have sex with men who are somewhat older than they are. Eleven percent of women who had sex reported that their first sexual partner was at least 10 years older.

Although the minimum legal age for a woman to get married is 18 years in Uganda, marriage among younger girls is common. But the proportion of women married by age 15 has declined over time, from 19 percent among women currently age 45-49 to 3 percent among women currently age 15-19.

Men tend to marry at much older ages than women. Among men age 25-49, only 9 percent were married by age 18, and 25 percent by age 20. The median age at marriage for men age 25-49 is 22.3 years, four years older than the median age for women. 

The 2007 UDHS prioritised male circumcision. By the 2011 survey, 28.2% of youths were circumcised. Male circumcision is most prevalent among Muslim men (94%) and men living in the East Central region where (42%). Men from the Basoga ethnicity (49%) are circumcised.

Teenage pregnancy remains a major health concern with 24% of teenagers bearing children and only 18% having had a live birth while 6% are carrying their first child.