Condom negotiation and use among married couples in Uganda

Background: Condoms have often been stigmatized through their association with extramarital or elicit sex. As marriage becomes a risk factor for HIV infection in high prevalence countries, introducing condom use within stable relationships is an increasing priority for prevention. Methods: In-depth interviews were conducted with both spouses of 40 cohabiting couples in rural and urban sites in Uganda. The qualitative study was nested within a behavioural survey of 400 couples; those reporting ever-use of condoms were purposively selected to reflect diversity in location, education, HIV status, and condom use frequency. Interviews elicited information on perceptions of couple intimacy and communication, fear of HIV infection, and negotiation of condom use. Results: Men and women emphasised that condoms were most frequently used at the start of new relationships to prevent both pregnancy and HIV. As relationships progressed, condom use became sporadic or abandoned to signify “trust” and permit childbearing. Subsequent use was associated with fear and dislike of hormonal contraception; negotiation centred on avoidance or spacing of pregnancy. When both spouses knew they were HIV+ they more easily adopted condom use, citing medical advice, support from treatment programmes, and concerns about re-infection, aggravated health, and HIV+ children. Conclusions: Testing and treatment programs have motivated HIV+ couples to use condoms to avoid re-infection, but general prevention campaigns have not reduced their stigma within committed relationships. Increased interest in contraception, combined with anxiety around hormonal methods may catalyze marital condom use, and could inform acceptable messages with a greater emphasis on family planning.