Adolescents and Young Women’s Perceived Reasons for the Continued HIV/AIDS Prevalence in Kumba, Cameroon: A Qualitative Study
Elvis Enowbeyang Tarkang1, *, Virginio Pietra2
1School of Public Health, University of Health and Allied Sciences, Ho, Volta Region, Ghana
2Institute of Infectious and Tropical Diseases, Faculty of Medicine, University of Brescia, Brescia, Italy
To cite this article:
Elvis Enowbeyang Tarkang, Virginio Pietra. Adolescents and Young Women’s Perceived Reasons for the Continued HIV/AIDS Prevalence in Kumba, Cameroon: A Qualitative Study. International Journal of HIV/AIDS Prevention, Education and Behavioural Science. Vol. 1, No. 1, 2015, pp. 8-13. doi: 10.11648/j.ijhpebs.20150101.12
Abstract: In Kumba, Cameroon, health education messages apparently succeeded in imparting knowledge but not in changing youths’ risky sexual behaviours. Heterosexual transmission of HIV remains a challenge, especially where female adolescents and young women are not able to negotiate safe sexual practices. The purpose of this study was to examine adolescents and young women’s perceived reasons for the continued HIV/AIDS prevalence in the city of Kumba of the South West region of Cameroon. This region has an HIV/AIDS prevalence of 5.7%, which is above the Cameroon national prevalence of 4.3%. A qualitative research design was adopted, using semi-structured in-depth interviews, conducted with a purposive sample of ten (10) female adolescents and young women, to deliberate on their perceived reasons for the continued spread of HIV/AIDS in Kumba, Cameroon, despite availability of information on the prevention of HIV/AIDS. The participating female adolescents and young women perceived that there is a continued spread of HIV/AIDS in Kumba, Cameroon because of multiple sexual partners and unprotected sexual intercourse, especially among female adolescents, due to poverty; disbelief in the existence of HIV/AIDS and neglect of voluntary counseling and testing (VCT) services. Consequently, health education messages provided knowledge, but did not result in preventive behaviours. Ways should be found for health education messages to result in appropriate actions based on appropriate knowledge. Female adolescents need to be economically empowered and financially independent before they can practice safer sexual intercourse.
Keywords: HIV/AIDS, Unprotected Sexual Intercourse, Multiple Sexual Partners, Poverty, Voluntary Counseling and Testing (VCT), Female Adolescents, Cameroon
Sub-Saharan African (SSA) remains the region most heavily affected by HIV, accounting for 68% of all people living with HIV/AIDS. This region also accounts for 70% of all new HIV infections . In 2013, almost 60% of all new HIV infections among young people aged 15-24 occurred among adolescent girls and young women, and many of them still lack accurate information on how to avoid exposure to the virus. Globally, 15% of all women living with HIV are aged 15-24, of whom 80 % live in SSA .
Cameroon has the highest HIV/AIDS prevalence in the Central and West African sub-region, of 4.3% . Juveniles in Cameroon aged 15-24 comprise 21.5% of the total population and the estimated HIV/AIDS prevalence rate among women in this group is 2.9% . Adolescents in Cameroon are thus at high risk of infection.
Heterosexual transmission of HIV accounts for about 90% of new infections in Cameroon . Hence young people are at risk of getting the disease as soon as they initiate sexual activity. Here too, 61% of people living with HIV (PLHIV) are women , and the prevalence among women of reproductive age is 6.8% [3,6]. These prevalence rates suggest that there is a high likelihood of encountering a sexual partner that is infected with HIV/AIDS because any sexually active person linked in a sexual network will be at high risk. Hence young people are at risk of getting the disease as soon as they initiate sexual activity.
Many Cameroonian youths engage in risky sexual behaviours, such as having sex with casual partners or having unprotected sexual intercourse, which may lead to HIV/AIDS [7,8]. Since there is presently no vaccine or cure for HIV/AIDS, only effective preventive measures can curb this pandemic, especially if these are adopted and sustained by young persons.
Sexual transmission of HIV can be prevented by using condoms correctly and consistently . Although 67.7% of Cameroon’s females, aged 15-24 years knew that consistent condom use could prevent HIV infection, only 46.5% used condoms during their last sex acts . This indicates a gap between knowledge and practices/behaviours. Condoms are readily available in Cameroon at cheap rates (US $0.18 per packet of three male condoms, and US $0.70 per packet of one female condom), but condoms are not used effectively by many Cameroonians.
In a study by WHO, ten years earlier, only 47% of female youths used condoms at their previous high risk sexual encounters . These percentages are lower than what would be necessary to curb the HIV/AIDS epidemic among young females aged 15-24 in Cameroon. Women in urban Cameroon reported low ability to refuse sex in their relationship with men .
Knowledge about options available to adolescents for the prevention of HIV/AIDS infection, from abstinence to safer sex, is important to empower young people, influencing their choices about sex, and preventing new HIV infection.
The purpose of the current study was to identify female adolescents’ perceived reasons for the continued prevalence of HIV/AIDS in Kumba, Cameroon and recommend ways in which issues raised could be addressed.
The study’s objective was to identify the participating female adolescents’ perceptions about:
• HIV/AIDS as a prevalent disease.
• The reasons for the continued prevalence of HIV/AIDS in Kumba, Cameroon despite available information on its prevention.
Kumba is an urban municipal area in the Southwest region of Cameroon, with a total population of approximately 166,000 inhabitants . The Republic of Cameroon is divided into 10 regions. The North West and South West regions are predominantly English speaking while the other eight regions are predominantly French speaking. The Southwest region where this study was conducted has an HIV/AIDS prevalence of 5.7%, which is above the Cameroon national prevalence of 4.3% .
Information regarding the prevention of HIV/AIDS has been provided by schools, parents, mass media, hospitals, clinics and voluntary organizations. Despite the availability of information, the prevalence of HIV/AIDS is still high.
The impact of HIV/AIDS on young people who provide the greatest hope for turning the tide against this pandemic cannot be understood from quantitative research. However, it can be well appreciated from more in-depth information obtained by conducting individual interviews with adolescents.
The research problem is that knowledge about the prevention of HIV/AIDS and cheap condoms had no impact on reducing the prevalence of HIV/AIDS in Kumba, Cameroon, as evident in the Cameroon DHS 2011 .
The research design used for this study is a qualititative research design, of phenomenological, descriptive and contextual nature. Data collection was carried out during April 2015. Semi-structured in-depth interviews were conducted with 10 female adolescents.
A convenience and purposive sample was drawn from females available at the time of the research in the office of the researcher where data collection took place. Convenience sampling is the selection of the most readily available people as participants in a study. In convenience sampling, participants are included in the study because they happen to be in the right place at the right time . Purposive sampling involves the conscious selection by the researcher of certain participants to include in the study
Ethical clearance for this study was obtained from the research and ethics committee of the faculty of philosophy, religious and social studies of the Cameroon Christian University (CCU). Permission to conduct the current research was obtained from research and ethics committee of the HIV/AIDS Prevention Research Network, Cameroon (HIVPREC) and from the Municipal Authorities of Kumba, Cameroon. Participation was voluntary and informed consent was obtained from each participant, to participate in the study, and that their interviews could be recorded. Human rights, anonymity (names were not used) and confidentiality were maintained throughout the study.
The researcher met the 10 female adolescents in Kumba, and conducted a semi-structured in-depth interview with each adolescent about HIV/AIDS in Kumba.
Two questions were asked to the participants:
1. Is HIV/AIDS a common disease in Kumba?
2. Why is there the continued prevalence of HIV/AIDS in Kumba despite the knowledge on the prevention of the disease that people have?
The researcher conducted the in-depth interviews and took notes, while a research assistant operated the voice-recorder, ensuring that all the discussions were captured. The data recorded during the interviews were verbally transcribed and verified by comparing these statements with the written notes. Coding was initially done independently by the researcher and the research assistant. The researcher then decided on the final presentation of the research results.
During data collection, the researcher probed the participants by encouraging them to explain their perceived reasons for the prevalence of HIV/AIDS in Kumba. Probing is the technique used by interviewers to elicit more useful or detailed information from a participant than was volunteered in the initial reply. The questions were directed at exploring their reasons, and follow-up questions were asked for clarity.
Trustworthiness refers to the ability of the researchers to convince themselves and participants that the findings of the inquiry are trustworthy . A qualitative research is trustworthy when "it accurately represents the experiences of the study participants" . Trustworthiness was enhanced in this study by the following:
• The researcher is an expert in the field of HIV/AIDS
• The researcher understood the language of the participants
• The researcher scrutinized the data and field notes, and also reviewed literature to verify findings. The tape recorded information was also used as supporting information.
• Categorizing data, using codes and summarizing data for analysis.
3.1. Biographic Details
The participants were aged 16-26 years (4 adolescents aged 16-19 and 6 young women aged 20-26), and all were females. All were living with either their parents or guardians, except for two who were living alone.
All were single. The two who were living on their own had two children each and were doing small scale businesses for a living (which is common at their age in Cameroon), while the eight who were living with either their parents or guardians were students. All were Christians, which is the main religion in Kumba.
3.2. Participants’ Perceptions on the Prevalence of HIV/AIDS in Kumba
All the participants in this study perceived HIV/AIDS to be a common disease in Kumba. Their perceptions were based on the fact that they have been hearing about the prevalence statistics from the media (the television and the radio):
"HIV/AIDS is a common disease in Kumba because we have been hearing about the prevalence statistics on a daily basis from the media".
The participants also perceived that HIV/AIDS is a common disease in Kumba because many people had died of the disease, going by the symptoms of the disease they had before their death, even though the patients and their families never disclosed the diagnosis of HIV/AIDS to people.
One participant explained the situation like this:
"I may not necessarily be aware of people’s diagnosis, but from the symptoms, we can determine. If you have HIV and you do not take your treatment, you develop symptoms of AIDS and you can die. I know of many people who have died of AIDS. They become slim; they develop swollen face, cough and rashes on their bodies."
3.3. Participants’ Perceived Reasons for the Continued Prevalence of HIV/AIDS in Kumba
Five categories of responses emerged from the question "Why is there the continued prevalence of HIV/AIDS in Kumba, despite the knowledge on the prevention of the disease that people have?": Poverty, neglect of voluntary counseling and testing (VCT), unprotected sexual intercourse, multiple sexual partners and disbelief in the existence of HIV/AIDS.
3.3.1. Female Poverty
In this study, the participants explained that many adolescents, especially girls, come from poor family backgrounds, and as such they practice unsafe sex such as multiple sexual partners and unprotected sexual intercourse especially with older men for financial gains, since their parents cannot provide for their needs:
"People don’t take preventive measures seriously, even though they have knowledge of risky practices. Most female adolescents are promiscuous. They go out with ‘sugar daddies’ to make ends meet even if they know they are at risk."
Another participant puts it like this:
"A desperate person can do anything for money. One man said to young lady that if he had unprotected sexual intercourse with her he will give her 50 000 XAF (US$ 100.00). The girl accepted because of poverty."
3.3.2. Unprotected Sexual Intercourse
The participants in this study indicated that HIV/AIDS is still prevalent in Kumba because many sexually active adolescents still engage in unprotected sex by not using condoms at all or by not using it consistently.
One participant explained the situation like this:
"Many people say AIDS is not real and they believe condom is a way of preventing sweet sex."
Another participant said:
"I believe condom cannot prevent sexual transmission of HIV because it does not cover the entire length of the penis during sexual intercourse."
Yet another participant explained the situation like this:
"People who have been tested HIV positive will not want to use condoms during sexual intercourse because they want to spread the disease to others on the premise that they do not want to die alone."
3.3.3. Voluntary Counselling and Testing
In this study the participants indicated that HIV/AIDS is still prevalent in Kumba because many people do not know their HIV status or that of their partners. As a result, those that are HIV positive continue to spread the disease.
One participant explained the situation like this:
"People do not go for test, and those that go for test and are tested HIV positive, do not disclose their diagnosis to their sexual partners and go about spreading the disease. The most important thing is for couples to do the HIV test and confirm it 3 months later before having unprotected sexual intercourse. The Government must insist that everybody does the HIV test and prevent those who are tested positive from infecting others. The Government should make sure that before you are issued a national identity Card, you must show the result of your HIV test from a recognized centre."
Another one said:
"Some people say they prefer not to know their HIV status because if they find out that they are HIV positive, they will commit suicide."
3.3.4. Multiple Sexual Partners
Participants in this study indicated that young girls in Kumba, Cameroon practise multiple sexual partnerships.
One participant puts it like this:
"I have lost some friends who came from poor family background to HIV/AIDS because they were going out with multiple partners in order to make ends meet."
Another participant said:
"Women, especially adolescents engage in prostitution because of daily bread for themselves and their entire families. When they come home with monies from prostitution, their parents do not even bother to ask them where they were coming from with the monies."
3.3.5. Disbelief in the Existence of HIV/AIDS
Participants in this study indicated that HIV/AIDS is still prevalent study in Kumba, Cameroon. Disbelief in the existence of HIV fuels its spread. They indicated that some people do not still believe that HIV/AIDS really exist, as demonstrated by this excerpt:
"Many people say AIDS is not real and believe it is a way of preventing sweet sex."
Another participant said:
"People do not take preventive measures against the sexual transmission of HIV/AIDS seriously because they do not believe in the existence of HIV/AIDS.
Yet another participant puts it like this:
"Some people do not believe that AIDS exists, so they engage in promiscuous activities. They think HIV/AIDS is a joke. They see people with symptoms of HIV/AIDS but they do not still believe it exists". When they see people with symptoms of AIDS, they say it is witchcraft or poison".
The participants in this study (female adolescents) were aware of the presence of HIV/AIDS in Kumba.
The reasons raised by the participants for the continued prevalence of HIV/AIDS in Kumba, Cameroon were: poverty, unprotected sexual intercourse, neglect of voluntary counselling and testing (VCT), multiple sexual partners and disbelief in the existence of HIV/AIDS.
The introductory sentence of the UNAIDS 2004 Report on the global AIDS epidemic states: "The global AIDS epidemic is one of the greatest challenges facing our generation. AIDS is a new type of global emergency-an unprecedented threat to human development requiring sustained action and commitment over the long term" by Kofi A. Annan, the secretary general of the United Nations . This implies issues beyond the epidemiological aspects of the disease, namely the social and economic dimensions of the pandemic.
Poverty has a clear causal role in the dynamics of the HIV epidemic . Poor female adolescents may find it difficult to initiate and maintain safer sexual practices such as consistent condom use or being faithful to one partner even if their risk perception to HIV/AIDS transmission is high. In this circumstance, poverty will be an important factor working in favour of continued or increased prevalence of HIV/AIDS among adolescent females in Kumba.
Many adolescents come from poverty stricken homes, and poverty is a major setback putting adolescents’ health at stake. For example, parents cannot afford high costs of education and as a result children drop out of education system at the time of their development without proper and adequate preparation about the facts of life.
Despite substantial investment in the promotion of safe sex and marketing of condoms, Cameroon has not succeeded in stemming the epidemic in the general population to lower than the 3% level. Heterosexual HIV transmission accounts for about 90% of new HIV infections in Cameroon. Correct and consistent condom use has been recognized as being very effective in preventing sexual transmission of HIV. Despite such knowledge, many people do not use condoms consistently. HIV infections are more likely to occur within long term multiple concurrent sexual partnerships, as these people are less likely to consistently use condoms within these regular relationships . In Tiko in the Southwest region of Cameroon it was reported that up to 59% of sexually active adolescents had unprotected sex in the last one year prior to the study .
Voluntary counselling and testing (VCT) is an important tool for preventing HIV and for providing care among people living with AIDS the world over. People are encouraged to use VCT services and therefore to take definitive steps to avoid becoming infected (for people who are HIV negative) or to receive the necessary counselling to cope with their status and prolong their lives without infecting others (for people who are HIV positive) .
Haddison et al state that only 27.8% of high school students in Tiko in the Southwest region of Cameroon had used VCT, which was significantly lower than the 80% objective set by the Cameroon government .
People are encouraged to use VCT services and therefore to take definite steps to avoid becoming infected (for people who are HIV negative). Despite advances in technology, testing is still approached with fear, accessing clinics is inconvenient and the experience of HIV testing is often stigmatizing. Stigma and anticipated sigma could be a powerful barrier to testing uptake with a negative impact on programmes such as those designed to eliminate new infections in adolescents.
Multiple current sexual partnerships with low condom use are among the key drivers of HIV infections in Africa. Having multiple sexual partners might promote the rapid transmission of HIV within and across sexual networks, especially in cases of multiple overlapping concurrent partners .
Wealthy HIV positive men in Cameroon tend to have multiple concurrent sexual partners, promoting the spread of HIV/AIDS . Haddison et al report that up to 42.8% of sexually active high school students in Tiko, Cameroon had more than one sexual partner in the last one year prior to their .
Individuals who deny the presence of HIV/AIDS in their communities have perceived invulnerability to the disease and hence might not see the need to adopt preventative behaviours to protect against HIV transmission .
In 1993, an explorative study conducted among students of the University of Douala, Cameroon, revealed that students regarded HIV/AIDS as a fiction, thereby resulting in incredible disbelief of its existence. HIV was perceived as a smokescreen and a clever guise to discourage sexual activity and promiscuity among sexually active groups, including youths . The results of subsequent study in 1998 supported a continued scepticism and disbelief in the existence of AIDS in Cameroon, and in addition revealed that males as well as females were in favour of ‘full contact’ (students’ metaphor for unprotected sex) .
Despite the knowledge of the prevention of HIV/AIDS and the availability of cheap condoms, HIV/AIDS continues to spread in Kumba. The prevalence of HIV in Kumba is unlikely to decrease until condom use becomes acceptable in this area, and until youths, especially female adolescents become empowered economically and morally to insist that men use condoms; and are also given the capacity and enabling environment to put their knowledge on the prevention of HIV/AIDS into practice.
Most adolescents, especially girls are single and consequently depended on their parents and older men for survival. Young girls are trapped in unsafe sexual practices as a means to secure income from their sexual partners. These unsafe sexual practices (unprotected sexual intercourse, multiple sexual partners), non-use of VCT services, disbelief in the existence of HIV/AIDS and poverty expose these female adolescents to the risk of HIV transmission and consequently to the continued prevalence of HIV/AIDS in kumba, Cameroon.
These female adolescents are aware of the risk behaviours that might contribute to the prevalence of HIV/AIDS but could not practice safer sex because of poverty.
The following recommendations were made from this study:
• The Government of Cameroon should shift VCT access to self-testing at home. Information and support could be provided remotely. Most importantly, those who tested positive would need a clear access path to health care, starting with a confirmatory test.
• The Government of Cameroon should pass a legislation against discrimination and stigmatization on the ground of HIV/AIDS.
• The Government of Cameroon should empower female adolescents economically so that they can be independent of men, especially older men for financial support.
EET conceptualised the study, designed the research instrument, interpreted the data and wrote the manuscript; VP critically reviewed the manuscript; both authors approved the final manuscript.