Title: Role of condom negotiation on condom use among women of reproductive age in three districts in Tanzania

Transcription

1 Author's response to reviews Title: Role of condom negotiation on condom use among women of reproductive age in three districts in Tanzania Authors: Amon Exavery Almamy M Kante (amk2213@mail.cumc.columbia.edu) Elizabeth Jackson (ej2217@mail.cumc.columbia.edu) John Noronha (jnoronha@ihi.or.tz) Gloria Sikustahili (gsikustahili@ihi.or.tz) Kassimu Tani (ktani@ihi.or.tz) Hildegalda P Mushi (hpmushi@ihi.or.tz) Kate Ramsey (kramsey@ihi.or.tz) Ahmed Hingora (ahingora@ihi.or.tz) James F Phillips (jfp2113@mail.cumc.columbia.edu) Version: 5 Date: 5 December 2012 Author's response to reviews: see over

2 Amon Exavery, Ifakara Health Institute, P.O. Box 78373, Dar es Salaam, Tanzania. 4 th December Executive Editor, Natalie Pafitis, BMC Public Health, Dear Editor, Re: RE-SUBMISSION OF A REVISED MANUSCRIPT (MS: ) The manuscript above, Role of condom negotiation on condom use among women of reproductive age in three districts in Tanzania, has been revised based on two peer reviewers feedback reports received on 14 th November The comments made by the two reviewers, Philip Anglewicz and Adamson Sinjani Muula have been fully addressed and herewith (subsequent pages) we enclose a document detailing our responses. We believe the manuscript in the current form is scientifically in good shape and suits the global scientific community. Our responses are structured in three columns; the first column on the left shows the reviewer s name, the next shows the reviewer s comment and the third column on the right shows authors responses to the comments made by the reviewer. A number that represents a comment in the reviewer s comment column for each reviewer also represents its response in the authors response column. We are very thankful to the reviewers for their time and valuable suggestions that have improved our manuscript. We are also thankful to you, the editor, for handling the peer review processes very well. We are thus happy to re-submit our manuscript for your consideration. The manuscript presents important findings that contribute significantly to the overall efforts in fighting the HIV/AIDS pandemic in Tanzania and elsewhere in the world. We look forward to your response. Sincerely, Exavery A. For the authors Page 1 of 10

3 POINT-BY-POINT RESPONSES TO THE ISSUES REVIEWERS RAISED FOLLOWING THEIR REVIEW OF THE MANUSCRIPT ROLE OF CONDOM NEGOTIATION ON CONDOM USE AMONG WOMEN OF REPRODUCTIVE AGE IN THREE DISTRICTS IN TANZANIA REVIEWER REVIEWER S COMMENT AUTHORS RESPONSE Philip Anglewicz Reviewer's report: 1. Review of Role of condom negotiation on condom use among year-old women in Rufiji, Kilombero and Ulanga districts of Tanzania This paper examines the role of condom negotiation in condom use among women of reproductive ages in Tanzania. The paper finds that prevalence of condom use was relatively low overall, and higher among unmarried than married women. Those who report more confidence in condom use negotiation were more likely to report actual condom use. Overall, this paper addresses an important issue in sub-saharan Africa. Most are aware of the protective effects of condoms against HIV infection, and condoms are now widely available and generally affordable. This issue also has implications for the large number of HIV serodiscordant couples in sub- Saharan Africa, which outnumber HIV concordant positive couples by a fair margin. This paper is also well written and organized. While this paper has some strengths, there are several issues that will likely strengthen the foundation and analysis of this paper. I have listed several of 1. This reviewer, Philip Anglewicz, is greatly appreciated for his very useful and constructive suggestions to improve the manuscript. Our responses to specific issues he raised are detailed in the revised manuscript, and below is how each of the issues has been addressed;- 2. The incompatibility of condom use within marriage is now discussed in the introduction section of the manuscript. 3. Condom use in marriage has been discussed in details. Also condom use in nonmarital relationships, by partner type has also been discussed. Overall, the revised manuscript doesn t portray condom use as a women s empowerment issue. 4. Condom use for HIV prevention purposes was sufficiently discussed, taking marital status into account. 5. All sections of the manuscript in which the level of condom use was regarded as low were revised. Also we do not propose that all individuals, married or not, should be using condoms at every sexual Page 2 of 10

4 these issues below, and also included some citations of literature that the authors may want to at least read, and perhaps consider including in the paper. encounter. Emphasis for consistent condom use has been made to specific groups such as those with multiple partners or unmarried. 2. This article is missing an important component of condom use for its population: the incompatibility of condom use within marriage. Research in sub- Saharan Africa has shown that, in addition to the factors listed by the authors (reduced enjoyment, fertility preferences, discomfort, etc ), condom use within marriage (1) betrays the intimacy that is necessary within the relationship, and (2) that suggesting condom use may be thought of as admitting to infidelity. Articles that describe these issues are cited below. The authors should expand on their discussion of barriers to condom use in the introduction, as they currently omit these important issues. These issues are discussed somewhat at the end, but should appear earlier when the authors are discussing barriers to condom use. 3. A more detailed discussion of condom use in marriage is necessary for this paper, because the current depiction of the factors influencing condom use is somewhat misleading. It is likely that the type of partner dictates condom use among unmarried women (regular partners vs. sugar daddies). But this does not apply to married women- research shows that they are also reluctant 6. Nothing was done to verify the self-reported sexual behaviours due to the nature of the main survey and limited resources. The revised manuscript acknowledges this as one of the limitations of the study. 7. One of our inclusion criteria required that a woman be sexually experienced. This criterion was set because it was not possible to assess condom use among individuals who have never had sex. The manuscript among other things states how a sexually experienced woman was determined. If it was not possible to classify a woman as sexually experienced, then she was dropped. Women who were dropped from the analysis amounted to 0.2% of the total sample. Since the sample was large enough for such a negligible loss, we believe this exerted a negligible effect to the overall results. This is stated in the revised manuscript. 8. Most of the citations suggested especially those that were available online were cited during the revision Page 3 of 10

5 to use condoms within marriage (unless they fear HIV infection), due to the cultural definition of condom use as incompatible with marital intimacy (citations below). So the authors should be careful to avoid describing condom use as predominantly a women s impowerment issue. of the manuscript. 9. Thank you very much! 10. Thanks you very much! 11. Thank you very much! 12. Thank you very much! 4. Furthermore, the authors would benefit from a discussion of the role of HIV infection on condom use negotiation. This again likely differs between married and unmarried women. Unmarried women are more likely to use condoms than married women throughout sub-saharan Africa. For married women, some may be more willing to use condoms if they suspect or know themselves or their spouses to be HIV positive. However, if neither partner is HIV positive (or is afraid that the other partner may be unfaithful and therefore a risk of becoming HIV positive), why should they consider using condoms in marriage- given that they are uncomfortable, reduce pleasure, and inhibit pregnancy? 5. Related to the above, the authors consistently state that condom use among women in their sample is low. What is meant by low? DHS data from various countries in sub-saharan Africa often shows condom use at much lower levels than the 22% in this sample- so how is 22% here low? Also, what is the desired level of condom use? Do the authors propose that all Page 4 of 10

6 individuals, married or not, should be using condoms every sexual encounter- with a spouse or other? Perhaps for non-marital partnerships, but it seems a bit extreme to suggest that condoms should be used for all marital sexual episodes. 6. A large body of research in sub- Saharan Africa very clearly shows that self-reports of sexual behavior are frequently invalid and unreliable. ). This lack of reliability has been established for self-reported condom use specifically, and in a wide range of settings (Allen et al. 2003; Gallo et al. 2006; Rose et al. 2009; Zenilman et al. 1995; Miller, Zulu & Watkins 2001; Taha et al. 1996). What did the authors do to validate these self-reports of condom use? This is an important issue since misreporting condom use could be associated with negotiation, which would lead to biased results in the analysis. 7. Similar measurement issues apply to the don t know or no response responses to condom use. The authors drop these cases from the analysis, explaining because of the difficulty ascertaining whether or not they were sexually experienced. However, it s not clear how reporting either of these categories applies to sexual experience as opposed to condom use. Also, what percentage of respondents reported these responses? Ultimately the authors Page 5 of 10

7 probably have to drop these responses, but (1) they need better justification, and (2) they should discuss the implications of the omission of these response have on their analysis. 8. Citations for condom use in marriage a. Bauni, E. & Jarabi, B.O. (2003) The low acceptability and use of condoms within marriage: evidence from Nakuru District, Kenya. African Population Studies 18(1), b. Chimbiri, A. (2007) The condom is an "intruder" in marriage: Evidence from rural Malawi. Social Science & Medicine 64(5), c. Tavory, I., & Swidler, A. (2009) Condom semiotics: meaning and condom use in Rural Malawi. American Sociological Review 74(April) Citations for self-reports of sexual behavior d. Allen S, Meinzen-Derr J, Kautzman M, et al Sexual behavior of HIV discordant couples after HIV counseling and testing. AIDS;17(5): e. Gallo MF, Behets FM, Steiner MJ, et al Prostate-speci#c antigen to ascertain reliability of self-reported coital exposure to semen. Sexually Transmitted Diseases;33(8): f. Miller, Kate, Susan C. Watkins, and Eliya M. Zulu Husband-Wife Survey Page 6 of 10

8 Responses in Malawi. Studies in Family Planning, 32(2): g. Zenilman, J., C. Weisman, A. Rompalo, N. Ellish, D. Upchurch, E. Hook, and D. Celentano Condom use to prevent STDs: The validity of selfreported condom use. Sexually Transmitted Diseases 22: h. Taha, T.E., J.K. Canner, J.D. Chiphangwi et al Reported condom use is not associated with incidence of sexually transmitted diseases in Malawi. AIDS 10(2): Level of interest: An article whose findings are important to those with closely related research interests. 10. Quality of written English: Acceptable 11. Statistical review: No, the manuscript does not need to be seen by a statistician. 12. Declaration of competing interests: I declare that I have no competing interests Adamson Sinjani Muula Reviewer's report: 1. Thank you for giving me the opportunity to review the manuscript. The following are my comments: 2. The authors refer to data on condom use effectiveness in prevent HIV and pregnancy. 1. We sincerely appreciate the reviewer, Adamson Sinjani Muula, for reviewing our manuscript very constructively. Below is how we responded to the concerns raised;- Page 7 of 10

9 Comment: it may help if the authors specify the context in which such effectiveness is obtained. is it when used correctly and consistently or just routine use? 3. The authors refer to fertility desires as cultural factors. Is this accurate? Below are further statements made within the text and my comments underneath: 4. For example, even though Latin America, Asia and Eastern Europe show gradually growing proportions of women living with HIV due to injecting drug use, unprotected sex or sex with other men, estimates show that in 2007, 26% of adults living with HIV in Eastern Europe were women, whereas that proportion in Asia was 29% [13]. Comment: Is everything in this statement referring to women? 5. In Tanzania, recent findings show that HIV prevalence among antenatal clinic (ANC) attendees in Zanzibar range from 0.7% in Unguja to 1.4% in Pemba [10], whereas in mainland Tanzania in it was 8.7% among women using ANC services, from 9.6% in [23]. The overall prevalence of the HIV in Tanzania among adults aged 15-49, according to the HIV/AIDS and Malaria Indicator Survey (THMIS), was 6% (7% women and 5% men) 2. It is specified in the manuscript that the over 90% condom effectiveness in preventing STIs and pregnancies is achieved only when correctly and consistently used. 3. Corrected. Fertility desires no longer referred to as a cultural factor. 4. No, the statement rather shows how women are affected in the general adult population. It was also intended to show that the proportion of women infected with HIV in sub- Saharan Africa (SSA) is higher than in other regions. However, the statement was revised. 5. Even if the difference in HIV prevalence between men and women in Tanzania and elsewhere in SSA may not be described as heavy as the reviewer pointed out, evidence are clearly showing that more women than men are infected with HIV. Reasons for this happening are discussed in the background section of the manuscript. The statement about ANC attendees was deleted, and the rest of the text was revised. 6. It was meant to be similar with the NBS for the same Page 8 of 10

10 [24]. Comment: The above statements do not effectively support the thesis that women are heavily affected compared to men 6. The proportion of child-bearing aged women observed in the HDSS is similar to that estimated by the National Bureau of statistics (NBS) in the same year [32] [33]. Comment: Similar with the NBS for the same area or for national estimates? 7. In this study, condom negation was derived from the question: For you personally, would it be (a) very easy, (b) easy, (c) difficult, or (d) very difficult to ask your sexual partner to use a condom before having sex? Comment: see underlined word; is this supposed to be negotiation? 8. Since all explanatory variables were categorical, there was no statistical demand giving rise to the use of student s t-test comment: should the statement above be presented? 9. Other independent correlates of condom use at the last sexual intercourse in this population were The odds of condom use at the last sexual intercourse among women ever married (i.e. currently divorced or widowed) was 3.6 times as high as that for women currently married or living with partners as married area. However, in revising the manuscript, this statement about similarity was deleted. Only 24% as the proportion of childbearing aged women in the study area was retained. 7. Yes, it is. Asking especially in sexual relationships is usually not unidirectional; it involves some form of discussions between partners to agree on something, such as whether or not to use a condom. One convinces the other about something. Therefore, unless the reviewer thinks differently, the authors considered asking as carrying the same meaning as negotiation in the context of sexual relationships. 8. The statement was deleted. 9. The statement was completed; this was very unfortunate. 10. AIDS virus was replaced by HIV throughout the manuscript. 11. Thank you very much! 12. Corrections were made throughout the manuscript wherever language problems were detected. 13. Thank you very much! Page 9 of 10

11 (OR=3.64, 95% CI , P<0.001 ). Comment: the statement above sounds incomplete 10. The authors refer several times to the AIDS virus ; would they consider just using HIV 11. Level of interest: An article of importance in its field 12. Quality of written English: Needs some language corrections before being published 13. Statistical review: Yes, and I have assessed the statistics in my report END Page 10 of 10