Despite global declines in new Human Immunodeficiency Virus (HIV) infections, 1.5 million people are newly infected per year [1]. Achieving the UNAID goal of reducing new HIV infections to near-zero by 2030 now seems unlikely. Even if this goal is achieved, HIV will remain an endemic health problem for decades, necessitating the continuation of primary HIV prevention programs [2]. Sub-Saharan Africa, despite having the greatest decline in new infections, remains the region the most heavily affected by HIV. The region reports 860,000 new infections annually and a significant gender gap, with 63% of new infections occurring among women [1, 3]. In countries outside of the region, 94% of new infections occur among key populations (e.g., sex workers, men who have sex with men, injecting drug users, transgender persons and their partners) [1]. In sub-Saharan Africa, 49% of new HIV infections occur in the general population [1], creating the need forrobust community HIV prevention programs for the general population as well as targeted prevention for higher-risk key populations.
This study took place in Malawi, a country in Southern Africa which ranks ninth globally in HIV prevalence [4]. The most recent national survey reported 20,000 annual new adult infections with an incidence rate of 0.21% in 2020-21 [5]. Notably, women experienced twice as many new infections as men. Moreover, the southern region of Malawi, where this study was conducted, had the highest burden of HIV [6].
Despite the introduction of newer strategies such as male circumcision and pre-exposure prophylaxis (PrEP), condom use remains a crucial component of combination HIV prevention [7]. Condoms are highly effective, safe, easy to store and use, and cost-effective for individuals and the health system [8–11]. These advantages make condoms ideal for prevention in the general population [5, 7]. Yet condom use remains low in most of sub-Saharan Africa, including Malawi. Only 18% of all adults 15 and older in Malawi reported using a condom the last time they had sex [12]. Although exceptions exist, such as a recent survey in South Africa where 72% of black youth (ages 18–24) reported using a condom at last sex [13], rates of ondom use in other sub-Saharan African countries also are low. Reanalysis of data for sexually active men only from a nationwide survey in Nigeria found less than 20% used condoms consistently [14], and in Zambia only 41% of urban youth said they used a condom at last sex [15]. Even among university students, whose higher education might be expected to promote condom use, a large meta-analysis found that only 53% used a condom the last time they had sex [16], and two recent surveys in South Africa and Nigeria found fewer than 40% of sexually active youth used condoms consistently [17, 18]. Additionally, complacency about HIV has increased as new HIV infections decline and treatment spreads, leading to a decline in both condom use and funding for condom use and other HIV prevention programs [19–21].
Low rates of condom use across sub-Saharan Africa can be attributed to a variety of contextual factors. Factors include unequal gender norms, concerns about sexual pleasure, negative connotations about trust and commitment, especially within marriage, norms restricting discussion of sexuality among partners and between youth and parents, widespread misconceptions about condoms, poverty and limited educational or job opportunities, lack of privacy for purchasing or obtaining condoms at the clinic, and periodic condom shortages [22–24]. The influence of contextual factors is evident in the personal characteristics that are consistently related to more condom use. National surveys and other studies generally show that condom use is more frequent among men, youth, urban residents, those with more education and/or wealth, and those having sex with non-regular partners (defined as a partner who is not a spouse and/or not cohabiting) [5, 12–14, 26]. Some studies have identified additional factors associated with increased condom use, including peer and parent influences, self-efficacy, HIV status awareness, and access to youth-friendly clinics and condoms [14, 15, 17, 25–28].
Despite barriers to condom use, it is important to recognize that the cultural and socioeconomic context evolves over time, and there is some evidence of changing attitude toward HIV prevention in Malawi and other sub-Saharan African countries. Two of the qualitative studies discussed above also indicated some changes in perspectives, viewing condom use as evidence of commitment and caring for one’s partner by protecting them from HIV infection [22, 23]. Condom use rates may be rising among youth in South Africa [13]. Gender differences may also be shifting; two recent studies among sexually active university students in sub-Saharan Africa found no gender differences in condom use [16, 17],
A substantial body of research has demonstrated that behavior change interventions can effectively reduce risk behaviors associated with HIV transmission and increase condom use, and peer group models have been especially successful [29–36]. However, more recent systematic reviews and meta-analyses yield less consistent evidence regarding effectiveness of behavior change interventions. A meta-analysis focusing on interventions for youth found increased condom use for males only [37]. Another review for young women only in sub-Saharan Africa compared behavioral change interventions, structural change interventions (such as cash transfers for school continuation) and combination interventions. Although at least one study for each type of intervention improved condom use, the only intervention that reduced HIV incidence was a cash transfer program in Malawi [38]. In a systematic review focused on social-cognitive factors, only three of eight studies reported significant effects on condom use [39]. A large systematic review in sub-Saharan Africa found that while cross-sectional studies found a relationship between self-efficacy and condom use among youth, most intervention studies did not find that increased self-efficacy led to increased condom use for youth, and where an intervention effect was found it was often observed among young men only [40]. A three-site study and a large meta-analysis examining multiple constructs of behavioral change models found that these constructs related to greater condom use but explained a relatively small portion of the variation in condom use [41, 42]. Many of these studies recommended that interventions incorporate contextual and environmental factors beyond the individual level, more formative evaluation to tailor the intervention to context, and greater community involvement.
In line with growing emphasis on tailoring, two HIV prevention programs in Malawi incorporated incorporate contextual and environmental factors. The BRIDGES II Program for both men and women, which involved small group discussions, community-based participation, and radio messages, increased AIDS knowledge, self-efficacy and condom use at last sex [43]. The Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe (DREAMS) partnership targeted young women ages 15–24 in 10 sub-Saharan African countries. DREAMS components included “club” meetings for young women, family-strengthening and community awareness programs, and youth-friendly health services [44]. Early results from Kenya, Malawi, and Zambia indicated a reduction in violence against young women, but no effects on condom use [45, 46]. In South Africa and Kenya, the DREAMS program was associated with a decline in HIV incidence, but the decline began before this program was introduced and cannot be attributed to DREAMS. However, in Kenya the program was linked to a reduction in number of lifetime sexual partners and fewer instances of condomless sex [47].
Overall, previous behavior change interventions have yielded mixed results. However, the Mzake ndi Mzake peer group intervention, developed and tested by our team and delivered by trained health workers, has shown consistent efficacy in increasing condom use among rural adults, rural youth, and rural and urban health workers in Malawi [48–51]. Given the broad success of the intervention, the next step was to implement the program more widely, starting in southern Malawi where HIV infections are highest. However, due to health worker shortages and increased demand for HIV testing and treatment [52], delivery of Mzake by health workers is not sustainable. Therefore, in partnership with the community, we decided that trained community volunteers could implement the program, taking responsibility for organizing and implementing Mzake. A previous publication documented that HIV prevention knowledge increased after being in the intervention [53]. The purpose of this analysis is to determine whether the Mzake peer group intervention, when delivered by community volunteers, increased condom use for sexually active community members.