A reply to Dr. Hemamal Jayawardene:

Safe sexual behaviour and the HIV/AIDS threat

by Dr. A. V. K. V. de Silva

Dr. Jayawardene's article "The need to be open about safe sexual behaviour in the light of the HIV/AIDS threat" published in the Daily News of May 11 has highlighted the need for an active Condom Social Marketing Programme.

In quoting some data from a survey Dr. H J appears to have not only got his terminology mixed up but the quoted data is also incorrect.

This survey was conducted jointly by WHO, National STD/AIDS Control Programme (NSACP) and the Department of Sociology and Anthropology of the Sri Jayawardenepura University in 1997, using UNDP/WHO funds, and implemented according to guidelines provided by WHO, Global Programme on AIDS. The survey was conducted in two non randomly selected districts, namely Colombo (urban) and Matale (rural) and the results represent the findings in these two districts and cannot be applied to other urban or rural areas.

The objective of this survey called the Population Survey/Outlet Visit for measurement of prevention indicators was to obtain data on 5 of the 10 indicators used for evaluating AIDS programmes and compare the results with a repeat survey using the identical methodology, to be carried out five years later i.e. in 2002. The repeat survey has still not been conducted.

Dr. H J states in his article that "condom access" in urban areas was 90% and in rural areas 39%. Unfortunately, "condom access" was not one of the five prevention indicators and cannot be measured in this type of survey. What was measured was "condom availability," which in AIDS programme terminology is completely different to access. The findings for Colombo and Matale are applicable only to these two districts. Dr H J has however extended these findings to all urban and rural areas.

The survey, using the cluster sampling technique, interviewed around 1,800 males and females in the age group 15-49 years in each of the 2 districts i.e. Colombo and Matale. Some of the main findings of this survey were as follows:

(1) In Matale district although the estate sample was only 4.2% of the total, it was quite evident that knowledge on HIV/AIDS of the estate population was quite low (51.3%) compared to 91%-98% in the rural and urban areas in both districts.

(2) Of those individuals who were aware of a disease called HIV/AIDS, only around 50% knew that protection could be obtained by use of condoms. (Colombo-51.2% and Matale-46%)

(3) Only around half the surveyed population in either district knew that HIV/AIDS patients could look healthy and need not always show symptoms.

(4) A condom outlet survey was conducted together with the general population survey to determine "condom availability". Key informants were asked about availability of condoms in 3 types of outlets (a) shops/pharmacies (b) health facilities or health personnel (government or private) (c) bars and hotels. If the cluster (GS Division) had at least one condom outlet with a continuous supply of condoms in the previous 12 months it was assumed that the entire population of that cluster could acquire a condom. If after 3 visits to each of the 3 types of condom outlets (i.e. a total of 9 outlets), no condoms were available continuously, it was assumed that condoms were not available to the population in that cluster. In Matale condoms were available to the urban population but not to the estate population... Condom availability for Matale district was 39%. However, since the Public Health Midwife (PHM) was indicated as the sole outlet for 19%, the actual availability was only 20% since the PHM's role is to provide condoms for contraceptive use. Further, a lot of young people who really require condoms would not approach a PHM in their own area as they may be recognized. Condom availability in Colombo district was 90%. Of this almost 78% was available through shops and pharmacies.

(5) Data from the Population Survey indicated that in Matale 46.2% of males and 28.6% of females knew at least one source from where they could purchase condoms. The corresponding figures for Colombo district were 66.2% and 32.6%.

(6) Of those surveyed only 9.6% in Colombo and 4.7% in Matale had ever used a condom.

(7) Twenty respondents in Matale (19 males and 1 female) and 21 from Colombo (18 males and 3 females) declared having casual partners during the previous 12 months. None of the females reported having used a condom, while 26.3% of males in Matale and 44.4% males in Colombo reported using a condom with the casual partners.

(8) The major reason for not using a condom was that the respondents (all males)" did not like them" (Colombo 70%, Matale 64.3%). Other reasons for not using a condom were "not available" (Matale 21.4%) and "Partner objected (Colombo 20%).

The total number of condoms available in Sri Lanka for distribution in 1997 was 12 million. With an estimated adult population (15-49 years) of approximately 10 million the condom availability at central level was 1.2 condoms per adult per year.

Some of the findings of this survey have been published in UNAIDS/WHO HIV/AIDS Epidemiological Fact Sheets for Sri Lanka.

In December 1993, an external review of the National AIDS Control Programme made the following recommendation: "Widespread availability of condoms through multiple channels should be promoted and provision of condoms through vending machines at selected places should be explored."

In 1994 inquiries were made from several countries in South-East Asia and the West Pacific area about the use of condom vending machines in the AIDS programme. Only one country had used this machine, but had given it up after a short time. It was decided not to take further action on this matter.

As the author of the report on the Population Survey/Outlet visit my objective in writing this article is to place before your readers the actual findings of this survey and to correct the wrong impression one might get after reading Dr. Hemamal Jayawardene's article.

(The writer is Consultant Epidemiologist and Programme Coordinator UNDP/WHO Project on AIDS 1992-97 and Programme Coordinator AIDS - WHO 1998-2001)