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Perceptions of risk are crucial in explaining why people do or do not make use of HIV-prevention interventions. But considerations of risk need to go beyond the risk of HIV infection to consider the personal, social, emotional, and economic risks associated with using condoms, getting tested or taking other preventative action, researchers argue.

Emily Warren and colleagues at the London School of Hygiene and Tropical Medicine conducted a systematic review of qualitative studies from African countries which examined perceptions of risk associated with HIV and people’s use of HIV prevention interventions. They found that condoms were often seen as symbolic of infidelity and mistrust, and therefore only appropriate in short-term relationships.

“Interventions themselves are replete with risks that may threaten relationship stability, economic security, and may be incompatible with the desire for a committed or loving relationship,” the researchers write.

A simple and effective method of HIV prevention – the male condom – has been available for decades, but uptake has been inconsistent. Several studies of diaphragms, microbicide gels and oral pre-exposure prophylaxis (PrEP) in African countries were hampered by low adherence. A better understanding of the factors that influence people’s use of HIV prevention interventions is therefore vital.

The systematic review included all studies which examined risk perception or uncertainty in the context of a medically regulated HIV prevention intervention (including HIV testing). To be eligible, studies had to use a qualitative method, be based on research with adults in sub-Saharan Africa and have been published in a peer-reviewed journal since 2003.

The 29 studies included were conducted in 12 countries, including several carried out in South Africa, Kenya or Malawi. Most studies examined condom use and around a third looked at various forms of HIV testing, with fewer studies researching the uptake of male circumcision, diaphragms, microbicides or PrEP. Some studies considered more than one prevention option. Seven included research with sex workers; one study was done with men who have sex with men.

A common theme in the studies was that people’s perception of being at risk of HIV decreased when feelings of trust grew in relationships. Condoms were more acceptable in casual relationships that were not characterised by expectations of commitment or fidelity. Abandoning condoms could mark the transition from a casual or transactional relationship to one based on love, trust, and commitment. As condom use was understood to reflect mistrust and suspicions of affairs, it was particularly problematic within marriage.

A Zimbabwean man said to one group of researchers:

“One may use them [condoms] when you have sexual contact with a lover for the first time, but later on people tend to stop using them because of the trust. Love is about trust and if one continues to insist on the use of condoms, then no love exists.”

Some respondents reported on insisting on condom use to ‘punish’ their partner, when they thought the partner was being unfaithful or because they were otherwise dissatisfied. This might be for a short period of time before things went back to normal.

People’s perceptions of HIV risks, especially women’s perceptions, were heavily influenced by their partners’ suspected or actual behaviour. This could make people feel safer or more vulnerable. A Kenyan woman told researchers:

“[HIV] is something I knew was there and I could get it at any time … because I know my status but I don’t know his status. I don’t know his sexual behaviour. I just know my sexual behaviour.”

A number of Ugandan women taking part in a PrEP study felt that trying to protect their health was futile without the support, co-operation, or fidelity of their partner. They felt that surrendering to the inevitability of HIV would be more feasible than sticking with PrEP:

“I began to suspect he is seeing other women… is he sleeping with other women so he can acquire more infection and pass it on to me? [This makes me] so angry that I feel it's useless to keep taking this medicine. Because of that, I decided to leave it.”

A common theme was that a decision to use an HIV prevention intervention is not simply down to the individual. Most interventions are difficult to use covertly. 

Respondents reported male resistance to interventions, limiting their use and leaving women to decide whether to insist on intervention use or risk ending a relationship. It was commonly reported that women would want to use some form of prevention but were discouraged or were not allowed to. Reports of men resisting or sabotaging condoms and refusing HIV testing were common.

A Ghanaian woman said:

“What can you do to prevent your husband from infecting you with AIDS? Are you going to buy the female condom and insert it while sleeping every night?… It is rather the man who can prevent it but if he doesn’t like using condoms, then there is little you can do to prevent yourself from being infected.”

While HIV prevention may be important, other priorities, like preserving a relationship, earning money or being a good parent may be more valued at certain times in a person’s life. In trying to negotiate or insist on condom use, women might risk upsetting or losing their partner. In some instances the certainty of an argument, break up, loss of material support or violence could have a more immediate impact than the more abstract prospect of an infection.

A Zimbabwean woman described the difficult balance between wanting to be safe and wanting to be loved:

“I asked my boyfriend to go for an HIV test together with me, but he is reluctant. He keeps on postponing, which is a sign that he does not want. Now he appears to have lost interest in me because I have said no to sex before being tested. Now, if all men are like that, what do I do?”

More encouragingly, the researchers found that some prevention interventions had positive symbolic meaning in certain contexts, making them more desirable. Voluntary male medical circumcision was seen by some men as a ‘responsible choice’, a ‘symbol of commitment’ and reflected maturity and commitment to future partners, making them more desirable as partners. Its value as an HIV prevention tool was secondary to its perceived hygiene, cleanliness, and sex appeal. One Malawian man said:

“I did not want to be a subject of discussion, so I decided to yank it out [get circumcised]. Now I am happy that I don’t really have to worry about embarrassment [of being uncircumcised].”

Similarly, a supportive relationship motivated some couples to seek HIV testing, despite the potential risks to the relationship of testing positive. Being tested together and receiving negative results could strengthen a couple’s trust and love.

Two specific themes were identified in the studies done with sex workers. Poverty was central to their experience. Many felt that sex work was their only option to provide for themselves or their families and that they were pushed towards less safe but more financially rewarding sexual practices.

A Nigerian woman commented:

“I need to hurry and get as much money before the sickness comes. I have to have the money… it’s very hard. What will happen to my children when I die? If a man will pay big money for sex without condom I will do [it].”

Some sex workers also described complex and fluid relationships with clients, with commercial relationships often transitioning to romantic relationships. When this happened, they would have less income from sex work and be more dependent on the other person. Women could be trapped in cycles of falling in love with clients and losing their power to negotiate condom use.

A Nigerian woman reported her client saying:

“Don’t you love me? I love you and know you’re clean. I believe you don’t have anything in your body. I trust you … don’t you love me … you don’t love me? I’m not your client now I’m your boyfriend … how can we get married if you continue like this?”

“Decision-making around HIV prevention interventions is influenced by multiple factors beyond specific concerns regarding disease prevention,” conclude the authors. “The use of prevention interventions carries personal and symbolic risks, which must be considered.”

The meanings associated with different prevention interventions are crucial, they argue. Whereas condoms are often associated with mistrust and infidelity, in some contexts male circumcision has been represented in terms of responsibility, cleanliness, and increased sexual pleasure.

This has implications for the introduction of PrEP, vaginal rings and other HIV prevention interventions.

“Emerging interventions, whose symbolic meanings are being constructed anew, may be uniquely positioned to infuse their ‘brand’ with associations compatible with love, commitment, responsibility, and sexual pleasure, rather than those associated with disease, danger, and distrust,” they say. “If interventions have positive symbolic meaning and are understood to have fewer risks associated with them, uptake and adherence may improve.”

Warren EA et al. Risk perception and the influence on uptake and use of biomedical prevention interventions for HIV in sub-Saharan Africa: A systematic literature review. PLOS ONE June 2018. (Full text freely available).