Inconsistent condom use and associated factors among people living with HIV/AIDS in Selibe-Phikwe, Botswana: A cross-sectional study

Inconsistent condom use and associated factors among people living with HIV/AIDS in Selibe-Phikwe, Botswana: A cross-sectional study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Inconsistent condom use and associated factors among people living with HIV/AIDS in Selibe-Phikwe, Botswana: A cross-sectional study Phenyoyaone Moloko, Billy Tsima, Stephane Tshitenge This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9346303/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Introduction This study aimed to (i) determine the proportion of inconsistent condom use among people living with HIV/AIDS (PLWHA) attending the Selebi-Phikwe Government Hospital Outpatient/Emergency (SPGH-OPD/E) and (ii) identify factors associated with inconsistent use in this population. Methods This was a quantitative, cross-sectional survey conducted among 295 PLWHA attending the SPGH-OPD/E. We used a systematic random sampling technique to select participants who attended the clinic during the study period. The administered-questionnaire covered socio-demographic factors, health-related behaviours, and HIV-specific factors. The dependent variable was consistent/inconsistent condom use over a three-month period. To minimize social desirability bias, the Forced Random Response Technique (RRT) was employed. The aggregate proportion of inconsistent condom use (î) was estimated using Boruch’s forced-response formula. Bivariate and multivariate random-response logistic regression were conducted to assess associations between the dependent and independent variables. Results We enrolled 295 PLWHA in the study, and after adjusting for social desirability bias, the estimated proportion of inconsistent condom use was 8.1%. In the multivariate random-response logistic regression analysis, females had three times higher odds of inconsistent condom use than males (AOR = 2.5, 95% CI: 1.23–4.93, p = 0.011), while non-alcohol users had 53% lower odds of inconsistent condom use than alcohol users (AOR = 0.47, 95% CI: 0.24–0.93, p = 0.039). Participants unaware of their regular partner’s HIV status had twice the odds of inconsistent condom use compared to those who knew their partner’s status (AOR = 1.83, 95% CI: 1.10–3.09, p = 0.019), and those who did not perceive condoms as reducing sexual pleasure were 94% less likely to use condoms inconsistently (AOR = 0.06, 95% CI: 0.03–0.12, p < 0.001). Conclusion There was a low proportion of inconsistent condom use (8.1%) among PLWHA. Factors such as female gender, alcohol consumption, being unaware of partner’s HIV status, and perception of condoms reducing sexual pleasure were significantly associated with inconsistent condom use. HIV prevention interventions should target these factors. Further research using more robust study designs addressing limitations associated with the current study is recommended. Introduction Human immunodeficiency virus (HIV) remains a significant global health challenge, with sub-Saharan Africa bearing the highest burden. Botswana has one of the world’s highest HIV prevalence at 20.8% ( 1 ). The epidemic has hindered progress toward both the Millennium Development Goals (MDGs) and continues to impede efforts to achieve the Sustainable Development Goals (SDGs). Over the past two decades, Botswana has implemented robust measures to combat HIV, yielding notable successes, including the Prevention of Mother-to-Child Transmission (PMTCT), Safe Male Circumcision (SMC), nationwide distribution of free condoms in public institutions, and universal free HIV treatment for citizens and non-citizens—now expanded to all people living with HIV regardless of CD4 count. These efforts align with the United Nations Programme on HIV/AIDS (UNAIDS) "95-95-95" strategy ( 2 ), demonstrating Botswana’s commitment to ending the epidemic. In Botswana, adherence to highly active antiretroviral therapy (HAART) is 82%, with over 95% of adherent patients achieving viral suppression ( 3 ). While this suppression rate exceeds the final target of the WHO 95-95-95 strategy, it represents only ~ 79% of all people living with HIV/AIDS (PLWHA) in the country ( 3 ). Consequently, more than 20% of PLWHA remain unsuppressed, sustaining a reservoir of individuals capable of transmitting the virus. Scientific evidence confirms that people with HIV who maintain an undetectable viral load (typically < 200 copies/mL) cannot sexually transmit HIV (U = U) ( 4 ). However, condoms provide additional protection in cases of treatment interruptions—such as missed doses, drug resistance, or illness leading to viral rebound—and protect against other sexually transmitted infections (STIs), including syphilis, gonorrhoea, chlamydia, herpes, and HPV. Even when HIV transmission is eliminated through viral suppression, condoms remain crucial for preventing other STIs, some of which can have serious health consequences or increase the risk of HIV transmission in others. Some partners (particularly in Sero discordant relationships) may prefer dual protection (condoms + viral suppression) for added peace of mind ( 5 ). The impact of increased HAART access on consistent condom use—a key sexual behaviour—remains debated ( 6 , 7 ). Several studies have assessed this phenomenon. Most research in developed countries indicates that individuals who learn of their HIV-positive status tend to reduce risky sexual behaviours. However, studies in developing countries, including Botswana, have found no significant reduction in such behaviours following an HIV diagnosis ( 7 ). The proportion of inconsistent condom use among PLWHA varies regionally. In the Asia-Pacific region, Deuba et al. ( 8 ) reported rates of 43–46%, with predictors including poor HIV knowledge and the perception that condoms reduce sexual pleasure. In contrast, Reis et al. ( 9 ) documented a lower proportion (28.7%) in Brazil, where alcohol use and female gender were significantly associated with inconsistent condom use. Few recent studies in sub-Saharan Africa have examined this issue among PLWHA. In Uganda, a proportion of 35% was reported ( 10 ), closely mirroring the Asia-Pacific findings. A comparative study by Yalew et al. ( 11 ) in Ethiopia revealed inconsistent condom use proportions of 44.2% pre-HAART and 56% post-HAART, with predictors ranging from stigma to employment status. Notably, all cited studies employed cross-sectional designs, with the Ethiopian study being the only one using a comparative cross-sectional approach. Botswana’s HIV prevention efforts include free condom distribution, with 85% provided at no cost ( 12 ), and an annual supply of 50 condoms per man, exceeding the UNFPA regional benchmark of 30 (2011–2014) ( 13 ). Despite high condom availability in Botswana, usage has declined over time—from 90.2% in 2008 to 81.9% in 2012. Reasons for this decline include misconceptions about HIV transmission and prevention, cultural beliefs, and other behavioural factors ( 14 ). Existing studies on condom-use patterns in Botswana primarily focus on individual, relational, and gender-norm factors influencing use, showing suboptimal consistency among women and highlighting the roles of employment status, cohabitation, and gendered power dynamics ( 15 , 16 ). However, the current body of literature disproportionately examines the general population, leaving a significant gap in understanding condom-use patterns among people living with HIV/AIDS (PLWHA) in Botswana. This gap is critical, as consistent condom use is especially important for PLWHA to prevent reinfection, transmission, and other adverse health outcomes. This study aimed to (i) determine the proportion of inconsistent condom use among PLWHA attending the Selebi-Phikwe Government Hospital Outpatient/Emergency (SPGH-OPD/E) and (ii) identify factors associated with inconsistent use in this population. We hypothesise that there would be no significant association between inconsistent condom use and selected factors, including sociodemographic characteristics, self-perceived health status, the perception that condoms reduce sexual pleasure, and HIV-related factors. Methods Study setting, designs, sample and sampling The study, conducted from May 2020 to June 2020 at the SPGH-OPD/E, employed a quantitative cross-sectional survey design among adult Selibe-Phikwe residents living with HIV/AIDS who were receiving routine HIV care at the facility. SPGH, a district hospital founded in 1970 and initially operating as a clinic in a dwelling house, is located in Selibe-Phikwe, a mining town in Botswana’s Central District with a population of about 49,411 ( 17 ). The town has the highest HIV/AIDS prevalence in Botswana, recorded at 27.5% in 2013—a slight increase from 26.5% in 2008 ( 18 ). As a district hospital, SPGH supports peripheral clinics and provides services including adult medicine, paediatric care, obstetrics and gynaecology, surgery, outpatient care, and infectious disease management, particularly HIV/AIDS care, attending to an average of 2,622 patients monthly in its outpatient department (SPGH-OPD/E). The study population consisted of adult residents diagnosed with HIV/AIDS, with eligibility requiring participants to be aged 18 years or older, residing in Selibe-Phikwe for at least six months, regularly attending SPGH-OPD/E for care, sexually active (with their last sexual activity within the past three months), and excluded those triaged as urgent or emergency cases. The formula for calculating sample size for finite population in cross-sectional studieswas used: \(\:n=\frac{N\:{Z}^{2}P(1-P)}{{d}^{2}\left(N-1\right)+{Z}^{2}P(1-P)}\) ​, where n = sample size with finite population correction, N = population size, Z = statistic for a level of confidence (1.96 for 95% confidence), P = expected proportion (set at 35%, the average of literature-reported inconsistent condom use proportions in PLWHA ranging from 27.9% to 56% ( 10 , 11 , 19 – 21 ) and d = precision (0.05). The population size was derived from 2,622 (monthly attendance) × 2 (months) × 0.27 (HIV prevalence in Selibe-Phikwe), yielding a computed sample size of at least 281, which was inflated by 5% to account for potential declines, resulting in a final sample size of 295 participants. We used a systematic random sampling technique to recruit participants, with the sampling frame consisting of every 5th person living with HIV/AIDS (calculated as 1416/295, where N = estimated population size and n = required sample size) who attended the clinic during the study period. The starting point was determined by randomly selecting a patient number using dice, ensuring an unbiased selection process. Eligible participants were then approached sequentially at every 5th interval until the target sample size of at 295 was achieved. Recruitment of participants and procedure Patient files and outpatient cards were reviewed for HIV status documentation at the SPGH-OPD/E screening point. Eligible individuals were approached for study participation, with male and female participants interviewed separately by same-gender research assistants to reduce bias and improve response rate ( 11 ). Data were collected using an interviewer-guided questionnaire adapted from similar studies by Ayiga (Uganda) ( 10 ) and Yalew (Ethiopia) ( 11 ), selected for their comparable settings. Variables from these studies were merged into a draft questionnaire, which was then reviewed, pre-tested in a pilot study involving 31 participants (10% of the total sample) and approved by two social science experts at a site different from the main study to avoid overlap. The final tool was administered in English and Setswana. The questionnaire covered socio-demographic factors (age, sex, marital status, education, employment), health-related behaviours (circumcision status, substance use, self-perceived health), and HIV-specific factors (duration of status awareness, HAART use, partner status, and fertility desires). The dependent variable was consistent/inconsistent condom use over three months. We defined being sexually active as having engaged in one or more penetrative sexual acts within the last three months prior to data collection, PLWHA as any individual previously diagnosed with HIV and aware of their diagnosis for at least six months before data collection, inconsistent condom use as failing to use a condom in all, some, or a few penetrative sexual encounters within the last three months, and alcohol use as having consumed an alcoholic beverage within the same three-month period. Whereas Parts 1 (socio-demographic factors) and 3 (non-condom health behaviours and HIV-specific factors) required direct answers, Part 2 addressed sensitive condom-use behaviour, which was at risk of socially desirable reporting ( 22 , 23 ). To mitigate this, the Forced Random Response Technique (RRT) was employed: participants flipped a coin, answering "Yes" if it landed heads or truthfully ("Yes/No") if tails. The second stage of RRT involved applying the Boruch-Forced Response Formula to the aggregate "Yes" responses, estimating true proportion while preserving participant anonymity ( 23 ). This method balanced transparency in sensitive questions with statistical rigor, aligning with best practices for reducing bias in behavioural health research. Data analysis The data were summarized as frequencies, means (± standard deviation), or medians (± interquartile range) as appropriate. The aggregate proportion of inconsistent condom use (î) was estimated using the forced-response Boruch formula ( 22 , 23 ): î = [Y − (1 − p)]θ / p, where Y represents the observed fraction of "yes" responses, p is the probability of answering truthfully (set at 0.7 to balance efficiency and validity, given that a lower p value closer to 0.5 maintains methodological integrity), and θ is the expected proportion (set at 0.3 based on regional estimates). A bivariate binary random-response logistic regression was conducted to assess associations between dependent and independent variables, followed by a multivariate analysis incorporating variables with a p-value < 0.1 from the bivariate analysis, using a stepwise elimination approach. Adjusted odds ratios (AOR) with 95% confidence intervals (CI) were reported to quantify associations, and statistical significance was set at p ≤ 0.05. All analyses were performed using STATA version 13.1. Results Out of 300 participants approached, 295 were enrolled in the study. Five individuals were excluded—either due to not being sexually active or refusal to provide consent. The mean age of participants was 37.9 years (males: 39 years; females: 37 years), as detailed in Table 1 . Most participants were single (74.24%), employed (50.85%), and had attained at least a secondary school education (64.75%). Table 1 . Sociodemographic characteristics of PLWHA in Selibe-Phikwe and participating in the study, May to June 2020. Characteristics of Respondents Sex Total n =295 Male n =117 Female n =178 Mean Age in years (s.d.) Marital status n (%) Single Married Employment status n (%) Employed Unemployed Studying Educational level n (%) Primary Secondary Tertiary 39(7.53) 84 (28.47) 33 (11.18) 71 (24.07) 44 (14.92) 2 (0.68) 14 (4.75) 74 (25.08) 29 (9.83) 37(8.46) 135 (45.76) 43 (14.57) 79 (26.78) 91 (30.85) 8 (2.71) 10 (3.39) 117 (39.66) 51 (17.29) 37.9(8.12) 219 (74.23) 76 (25.8) 150 (50.85) 135 (45.76) 10 (3.39) 24 (8.14) 191 (64.75) 80 (27.12) s.d., standard deviation Proportions of inconsistent condom use in adult PLWHA Table 2 presents condom use patterns among PLWHA study participants. Of the 295 participants, 144 (48.8%) reported inconsistent use (males: 18.6%; females: 30.2%). After adjusting for social desirability bias using the specified formula, the estimated proportion of inconsistent condom use was 8.1%. Table 2 Condom use pattern/response among people living with HIV/AIDS in Selibe-Phikwe, May to June 2020. Condom use pattern. Sex Total n (%) Males n (%) Females n (%) Condom use over last 3 months (RRT⁜ step 1 coin flip proportions) Always (consistent) Not always (inconsistent) 62 (21.02) 55 (18.64) 89 (30.17) 89 (30.17) 151 (51.19) 144 (48.81) (RRT⁜ step 2 formula) Not always (inconsistent) \(\:\frac{\left[.488-(1-.7)\right].3}{.7}\) 0.0805 (8.1%) ⁜, random response technique Factors associated with inconsistent condom use in adult PLWHA As shown in Table 3 , the bivariate random-response logistic regression analysis indicated that as participants' age decreased, they were more likely to use condoms inconsistently (OR = 0.95, 95% CI: 0.90–0.99, p = 0.038). The odds of inconsistent use were three times higher in females than in males (OR = 2.7, 95% CI: 1.25–5.68, p = 0.011), and non-alcohol users had 2.4 times lower odds of inconsistent use compared to alcohol users (OR = 0.42, 95% CI: 0.20–0.91, p = 0.027). Participants who reported not knowing their regular sexual partner’s HIV status had six times higher odds of inconsistent condom use compared to those who knew their partner’s status (OR = 5.5, 95% CI: 1.54–19.55, p = 0.009). Conversely, those who did not perceive condom use as reducing sexual pleasure were 17 times less likely to use condoms inconsistently (OR = 0.06, 95% CI: 0.03–0.11, p < 0.001). No significant associations were observed with marital status, employment, circumcision, self-perceived health, desire for children, or duration of HAART. These factors remained statistically significant in the multivariate random-response logistic regression (Table 4 ). Older participants were slightly (4%) but significantly less likely to use condoms inconsistently (AOR = 0.96, 95% CI: 0.92–0.99, p = 0.040). The odds of inconsistent use were three times higher in females than in males (AOR = 2.5, 95% CI: 1.23–4.93, p = 0.011), and non-alcohol users had 2.4 times lower odds of inconsistent use compared to alcohol users (AOR = 0.47, 95% CI: 0.24–0.93, p = 0.039). Participants who did not know their regular partner’s HIV status had two times higher odds of inconsistent condom use compared to those who knew their partner’s status (AOR = 1.83, 95% CI: 1.10–3.09, p = 0.019). Additionally, those who did not perceive condom use as reducing sexual pleasure were 17 times less likely to use condoms inconsistently (AOR = 0.06, 95% CI: 0.03–0.12, p < 0.001). Table 3. Bivariate random response logistic regression for factors associated with inconsistent condom use among people living with HIV/AIDS in Selibe-Phikwe, May to June 2020. Variables OR† 95% CI‡ p value Age 0.95 0.90 – 0.99 0.038* Gender Male Female 1.00 2.66 1.25 – 5.68 0.011* Marital status Single Married 1.00 1.42 0.63 – 3.17 0.398 Employment Employed Unemployed Studying 1.00 1.04 0.45 0.51 – 2.12 0.06 – 3.34 0.909 0.431 Educational level Tertiary Secondary Primary 1.00 0.93 0.30 0.43 – 2.01 0.08 – 1.21 0.860 0.090 Circumcision/circumcised partner No Yes 1.00 1.16 0.61 – 2.21 0.658 Alcohol Use Yes No 1.00 0.42 0.20 – 0.91 0.027* Desire to bear children. Yes No 1.00 0.89 0.40 – 1.96 0.76 Self-perception of health Not good Fair Good 1.00 0.56 0.96 0.04 – 7.34 0.07 – 12.47 0.66 0.98 HIV duration (years) 3 1.00 0.29 0.45 0.02 – 4.88 0.02 – 8.55 0.39 0.60 HAART Duration (years) 2 1.00 5.25 4.93 0.32 – 85.88 0.31 – 78.38 0.25 0.26 HIV status of partner Positive Negative Unknown 1.00 1.31 5.49 0.52 – 3.31 1.54 – 19.55 0.57 0.01* Perception that condom use reduces pleasure. Yes No 1.00 0.05 0.03 – 0.11 0.000* †, odd ratio; ‡, Confidence Interval; *, p value statistically significant (p<0.05) Table 4 . Multivariate random response logistic regression with inconsistent condom use as the dependent variable and independent variable—using stepwise elimination, among people living with HIV/AIDS in Selibe-Phikwe, May–June 2020 Variables AOR† 95% CI ‡ p value Age 0.96 0.92 – 0.99 0.040* Gender (female) 2.46 1.23 – 4.93 0.011* HIV status of partner (unknown) 1.83 1.10 – 3.03 0.019* Alcohol use (No) 0.47 0.24 – 0.93 0.030* Perception that condom use reduces pleasure (No) 0.06 0.03 – 0.12 0.000* †, adjusted odd ratio; ‡, Confidence Interval; *, p value statistically significant (p<0.05) Discussion This study aimed to determine the proportion of inconsistent condom use and its associated factors among PLWHA in Selibe-Phikwe, a high HIV-burden setting with free condom distribution, using the random response technique. The findings revealed an 8.1% prevalence of inconsistent condom use. Older participants were slightly (4%) but significantly less likely to use condoms inconsistently (p = 0.040). Females had three times higher odds of inconsistent use compared to males (p = 0.011), while non-alcohol users had 2.4 times lower odds of inconsistent use compared to alcohol users (p = 0.039). Participants who were unaware of their regular partner’s HIV status had twice the odds of inconsistent condom use compared to those who knew their partner’s status (p = 0.019). Additionally, those who did not perceive condom use as reducing sexual pleasure were 17 times less likely to use condoms inconsistently (p < 0.001). Factors such as self-perceived health status and desire to bear children showed no significant association with inconsistent condom use. A lower proportion (8.1%) of inconsistent condom use was observed in our study compared to previous studies conducted both globally and within the region. For example, Lau et al. reported that among 68 HIV-discordant couples in a rural county in China, 27.9% engaged in inconsistent condom use, with significant associated factors including condom unavailability, suicidal ideation among people living with HIV (PLWH), and misconceptions about HIV transmission ( 21 ). In Uganda, Ayiga et al. found a prevalence of inconsistent condom use of 35% among patients recently initiated on HAART ( 10 ). Yalew et al. reported inconsistent condom use proportions of 56% among HAART-naïve participants and 44.2% among those with HAART experience when asked about condom use behaviour over the preceding three months ( 11 ). The higher prevalence reported by Lau et al. and Ayiga et al. may be partly explained by their broader inclusion criteria, which assessed behaviour over the previous 12 months, compared with the shorter three-month observation period used in our study. Most of these studies also relied on direct questioning (DQ) to obtain information about condom-use behaviour, whereas the present study employed the randomized response technique (RRT). One of the key advantages of RRT over DQ is its ability to reduce social desirability bias, often resulting in higher and potentially more accurate estimates than those obtained through direct questioning. However, Umesh and Peterson have highlighted concerns regarding its limited validity, including its inability to accurately identify individual-level behaviour ( 24 ). Additionally, Lesly et al. noted that respondents may fear that forced “yes” responses could be misinterpreted as admissions of behaviours they did not engage in ( 23 ). Despite these concerns, RRT remains a well-validated and highly effective method for estimating the prevalence of sensitive behaviours at the population level ( 25 , 26 ). Despite these concerns, RRT remains a well-validated and effective method for generating reliable population-level estimates of sensitive behaviours. However, by design, it does not allow for accurate identification of individual behaviour. Several factors could contribute to the lower prevalence of inconsistent condom found in this study. Botswana's condom distribution per capita not only far surpasses the universal recommendation for family planning but also meets nearly 95% of the need for HIV prevention. This national surplus is demonstrated by the estimate of 50 condoms distributed per man per year, a figure significantly higher than the UNFPA's regional benchmark of 30 (2011–2014) ( 14 ). The success of this robust distribution strategy is further illustrated by the case of Selibe-Phikwe. Previously ranked first for HIV prevalence in 2013 ( 18 ), the district was likely a target for intensified HIV campaigns. The observed lower rate of inconsistent condom use there likely reflects the success of these efforts. This is supported by the most recent Botswana AIDS Impact Survey IV (BAIS IV) preliminary report, which shows Selibe-Phikwe has improved its ranking to the top five, with its prevalence rate slightly decreasing from 27.5% in 2013 to 26.7% in 2022 ( 18 ). The high rate of condom availability, targeted campaigns, and subsequent reduction in prevalence are all likely contributors to the low proportion of inconsistent condom use. The present study found that those who did not have this perception were almost 17 times less likely to be inconsistent condom users compared to those who do. Considering other studies, Mehra and colleagues found similar results (AOR 1.78 (95% CI 1.03–3.0)) ( 27 ) as well as Katikiro et al . studied AOR = 8.19; 95% CI 3.98–17.01) ( 28 ). In Nigeria, Ajayi et al . found that the same belief that condom use reduces fun was one of the main reasons why university students did not use condom consistently ( 29 ). Condoms reduce the delivery of stimulation of friction during intimacy, and there is decreased tactile sensation. There is also a sense of interruption of sex. This perception and/or belief that condom use reduces pleasure has the potential to perpetuate the spread of HIV, therefore this highlights the need for HIV prevention messaging to re-focus condom campaigns or marketing strategies. An example would be to emphasize pleasure enhancing aspects of condom use like the ability to prolong sex and therefore reduce sexual tension ( 30 ). Additionally, condom makers could be encouraged to make condoms even thinner or better to increase tactile sensation. In this study, participants who did not know their partners’ HIV status were twice as likely to use condoms inconsistently compared to those who knew their partners were HIV-positive. This finding aligns with the study by Ayiga et al., which observed a negative association between consistent condom use and PLWHA who had partners with a negative status or who were unaware of their partner’s HIV status (AOR: 0.27 and 0.16, respectively) ( 10 ). This behaviour could stem from a sense of invulnerability felt by the uninfected partner, particularly if they remained HIV-negative despite engaging in unprotected sex over a prolonged period. The present study found that females were three times more likely to report inconsistent condom use than males. This aligns with the findings of Yalew et al. and Reis et al., who also identified male gender as a protective factor against inconsistent condom use among PLWHA (OR 0.45; 95% CI 0.21–0.98 and OR 0.36; 95% CI 0.15–0.81, respectively) ( 11 , 19 ). However, these results contrast with a study by Ayiga, which examined predictors of consistent condom use among PLWHA in Uganda. The author’s analysis found that male gender was not a significant predictor of consistent condom use compared to females (OR 0.77; 95% CI 0.45–1.32) ( 10 ). This discrepancy may be attributed to cultural norms in Botswana, where women are traditionally socialized to be submissive to men, potentially limiting their ability to negotiate safer sexual practices, including condom use. Additionally, male condoms are the most widely available and accepted condom type in Botswana, which may reinforce men’s perceived control over sexual decision-making, further disadvantaging women in such negotiations. In this study, participants who did not consume alcohol were two times less likely to use condoms inconsistently compared to those who consumed alcohol. These findings align with prior research: one study linked alcohol use to an 11-fold increased risk of inconsistent condom use ( 17 ), while Yalew et al. reported that abstaining from alcohol was associated with an 86% reduction in the likelihood of inconsistent use ( 11 ). A meta-analysis by Shuper et al. further reinforced this association, demonstrating that any alcohol consumption, problematic drinking, and alcohol use during sexual activity were all significantly correlated with unprotected sex among PLWHA ( 11 , 31 ). This effect may stem from alcohol’s capacity to impair cognitive function, narrowing focus to immediate cues—a phenomenon observed by Macdonald et al. ( 32 ). To address the link between alcohol/substance use and inconsistent condom use among youth, targeted interventions should include enhanced counselling during routine HIV care and public health campaigns focused on reducing risky sexual behaviours. Counselling strategies for PLWHA should also be strengthened to address alcohol’s impact on sexual health. According to the study, increasing age was protective against inconsistent condom use and this was similar to Yalew et al. who found that age category (> 32 years old) was also protective against inconsistent condom use in both ART naïve and ART experienced compared to younger age group category (< 32 years old) ( 11 ). However, this was contrary to findings by Reis et al. as well as Ayiga and Letamo, who did not find any statistically significant association between age and inconsistent condom use in PLWHA ( 10 , 19 , 33 ). This may be because young people are more likely to engage in alcohol and substance use which had already been shown to be a significant predictor of inconsistent condom use. This calls for more interventions targeting youth in addressing risky sexual behaviours like more counselling during routine HIV care, and more campaigns. More longitudinal research in this field is needed to explore the perspective of the youth about this subject. To enhance HIV prevention, interventions should prioritise gender-sensitive approaches to empower women, alcohol harm reduction, partner status disclosure initiatives, and pleasure-inclusive messaging alongside condom design innovations. Alcohol use was not quantified to distinguish between normal use and abuse, nor was its relationship with inconsistent condom use patterns examined. Other limitations include the cross-sectional design, which cannot assess changes in condom use consistency over time. Additionally, the study focused exclusively on PLWHA in Selibe-Phikwe who attended government hospital settings, excluding those receiving HIV care in other facilities (public or private) and individuals not in routine care but living with HIV. This limits the generalizability of the findings. Conclusion This study found a relatively low rate of inconsistent condom use (8.1%) among PLWHA in Selibe-Phikwe, Botswana, compared to previous studies in similar high-HIV burden settings. Key factors associated with inconsistent use were female gender, alcohol consumption, lack of awareness of a partner’s HIV status, and the perception that condoms reduce sexual pleasure. Older age, conversely, showed a slight but marginally significant protective effect. To enhance HIV prevention, interventions should prioritise gender-sensitive approaches to empower women, alcohol harm reduction, partner status disclosure initiatives, and pleasure-inclusive messaging alongside condom design innovations. Future work should employ more robust methodologies, such as longitudinal studies, the inclusion of non-clinic attendees, and a deeper exploration of the interactions between substance use and sexual behaviour. This will be crucial for strengthening HIV prevention strategies in high-burden settings like Botswana. Abbreviations BAIS IV Botswana AIDS Impact Survey IV HAART Highly Active Antiretroviral Therapy MDGs Millennium Development Goals PLWHA People Living with HIV/AIDS PMTCT Prevention of Mother–to–Child Transmission RRT Randomized Response Technique SDGs Sustainable Development Goals SMC Safe Male Circumcision SPGH Selebi–Phikwe Government Hospital Declarations Ethics approval and consent to participate Ethical approval for the study was obtained from the University of Botswana’s Office of Research and Development (UBR/RES/IRB/BIO/GRAD/111) and the Botswana Ministry of Health & Wellness (HPDME:13/18/1). All study procedures, including consent processes, were conducted in accordance with these approvals. The study was carried out in compliance with the principles of the Helsinki Declaration. Informed consent was obtained from all the participants in the study. They were advised that they may leave at any time without any problems. Everyone who answered agreed to take part on their own. The data was kept safe, and personal identifiers were taken out to protect privacy and anonymity. The data was only available to the research team. Patient consent for publication Not required. Consent for publication Not applicable. Competing Interests The authors have declared that no conflict of interest exists. Clinical trial number: Not applicable. City in the affiliation for author(s): Phenyoyaone Moloko: Letsholathebe II Memorial Hospital, Hospital Road, Disaneng Ward, Maun, Botswana. Billy Tsima and Stephane Tshitenge: Department of Family Medicine and Primary Care, School of Medicine, University of Botswana, Plot 4775 corner Notwane and Mobuto Rd., Gaborone, Botswana Funding declaration: This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors Author Contribution P.M. contributed to the conceptualization of the study, proposal writing, data collection and data analysis, and drafting the original manuscript.B.T. reviewed the research proposal and the manuscript. S.T. reviewed the proposal, data analysis, and compiled the final manuscript. All authors read and approved the final article. Acknowledgements The authors would like to thank the Selebi-Phikwe District Management Team staff for facilitating the data collection. Data Availability The datasets generated and/or analysed during the current study are not publicly available due to ethical and privacy restrictions, as the data contain information that could potentially identify individual participants and relate to sensitive health and sexual behaviour. The study protocol and consent procedures approved by the University of Botswana Office of Research and Development and the Botswana Ministry of Health & Wellness did not include permission for open public data sharing. However, anonymised data supporting the findings of this study are available from the corresponding author upon reasonable request, subject to approval by the relevant ethics committees and in compliance with national data protection regulations. References Botswana AIDS, Impact Survey, V 2021 (BAIS V). Report. [A population-based HIV impact assessment report]. Gaborone: Government of Botswana — National AIDS & Health Promotion Agency; 2023. Report No. 90-90-90. An ambitious treatment target to help end the AIDS epidemic. Geneva, Switzerland: UNAIDS;: Joint United Nations Programme on HIV/AIDS; 2014. UNAIDS Data. 2021. Geneva, Switzerland: UNAIDS; 2021. Report No. Eisinger RW, Dieffenbach CW, Fauci AS. HIV Viral Load and Transmissibility of HIV Infection: Undetectable Equals Untransmittable. JAMA. 2019;321(5):451–2. 10.1001/jama.2018.21167 . Siegfried N, Muller M, Deeks J, Volmink J, Egger M, Low N, et al. HIV and male circumcision–a systematic review with assessment of the quality of studies. Lancet Infect Dis. 2005;5(3):165–73. 10.1016/S1473-3099 . (05)01309-5 PubMed PMID: 15766651. Castilla J, Del Romero J, Hernando V, Marincovich B, García S, Rodríguez C. Effectiveness of highly active antiretroviral therapy in reducing heterosexual transmission of HIV. J Acquir Immune Defic Syndr. 2005;40(1):96–101. 10.1097/01.qai.0000157389.78374.45 . PubMed PMID: 16123689. The impact of HIV treatment on risk behaviour in. developing countries: a systematic review - PubMed [Internet]. [cited 2026 Jan 16]. Available from: https://pubmed.ncbi.nlm.nih.gov/17573590/ Deuba K, Kohlbrenner V, Koirala S, Ekström AM. CAT-S group. Condom use behaviour among people living with HIV: a seven-country community-based participatory research in the Asia-Pacific region - PubMed. Vol. 94. 2018;94(3):200–5. 10.1136/sextrans-2017-053263 PubMed PMID: 29118203. Reis RK, Melo ES, Gir E. Fatores associados ao uso inconsistente do preservativo entre pessoas vivendo com HIV/Aids. Rev Bras Enferm. 2016;69(1):47–53. 10.1590/0034-7167.2016690106i . Ayiga N. Rates and Predictors of Consistent Condom-use by People Living with HIV/AIDS on Antiretroviral Treatment in Uganda. J Health Popul Nutr. 2012;30(3):270–80. 10.3329/jhpn.v30i3.12290 . PubMed PMID: 23082629; PubMed Central PMCID: PMC3489943. Yalew E, Zegeye DT, Meseret S. Patterns of condom use and associated factors among adult HIV positive clients in North Western Ethiopia: a comparative cross sectional study. BMC Public Health. 2012;12:308. 10.1186/1471-2458-12-308 . PubMed PMID: 22537280; PubMed Central PMCID: PMC3426486. Pallin SC, Meekers D, Lupu O, Longfield K, Botswana. A Total Market Approach. PSI/UNFPA Joint Studies on the Total Market for Male Condoms in Six African Countries. [Internet]. 2013. Report No. Available from: Prevention gap report [Internet]. UNDAIDS. 2016. Report No. Available from: Botswana National AIDS Coordinating Agency. Botswana Global AIDS Response. Progress of the national response to 2011 declaration of commitments on HIV and AIDS. 2013. Mlandu C, Machisa M, Christofides N. Consistent condom use among Botswana’s female population and associated factors. Women’s Health. 2024;20:1–8. https://doi.org/10.1177/17455057241266453 . Barchi F, Apps H, Ntshebe O, Ramaphane P. Social and behavioral correlates of adolescent sexual experience and intention to use condoms in northwestern Botswana. Int J Environ Res Public Health. 2021;18(11):5583. https://doi.org/10.3390/ijerph18115583 . Statistics Botswana. Population and housing census 2011 administrative and technical report. 2016. Botswana National AIDS Coordinating Agency. Botswana AIDS impact survey IV: statistical report 2013. Gaborone: Statistics Botswana; 2016. p. 260. Reis RK, Melo ES, Gir E. Factors associated with inconsistent condom use among people living with HIV/Aids. Revista brasileira de enfermagem. 2016. 10.1590/0034-7167.2016690106i . Ngome E, Demographic. Socio-Economic and Psychosocial Determinants of Current and Consistent Condom Use among Adolescents in Botswana. World J AIDS. 2016;6:137–56. 10.4236/wja.2016.64017 . Lau JTF, Yu X, Mak WWS, Cheng Y, Lv Y, Zhang J, et al. Prevalence of Inconsistent Condom Use and Associated Factors Among HIV Discordant Couples in a Rural County in China. AIDS Behav. 2013;17(5):1888–94. 10.1007/s10461-012-0269-z . Pal S, Singh S. A new unrelated question randomized response model. Statistics. 2012;46(1):99–109. 10.1080/02331888.2010.500115 . Lensvelt-Mulders GJLM, Hox JJ, Heijden PGMVD. How to Improve the Efficiency of Randomised Response Designs. Qual Quant. 2005;39(3):253–65. 10.1007/s11135-004-0432-3 . Umesh U, Peterson R. A Critical Evaluation of the Randomized Response Method. Sociol Methods Res. 1991;20(1):104–38. John LK, Loewenstein G, Acquisti A, Vosgerau J. When and why randomized response techniques (fail to) elicit the truth. Organ Behav Hum Decis Process. 2018;148:101–23. 10.1016/j.obhdp.2018.07.004 . Lensvelt-Mulders GJLM, Hox JJ, van der Heijden PGM, Maas CJM. Meta-Analysis of Randomized Response Research: Thirty-Five Years of Validation. Sociol Methods Res. 2005;33(3):319–48. Mehra D, Östergren PO, Ekman B, Agardh A. Inconsistent condom use among Ugandan university students from a gender perspective: a cross-sectional study. Global Health Action. 2014;7(1):22942. 10.3402/gha.v7.22942 . Katikiro E, Njau B. Motivating Factors and Psychosocial Barriers to Condom Use among out-of-School Youths in Dar es Salaam, Tanzania: A Cross Sectional Survey Using the Health Belief Model. ISRN AIDS. 2012;1–8. 10.5402/2012/170739 . Ajayi AI, Ismail KO, Akpan W. Factors associated with consistent condom use: a cross-sectional survey of two Nigerian universities. BMC Public Health. 2019;19(1):1207. 10.1186/s12889-019-7543-1 . Okonta MJ, Ubaka CM, Araukwe NN. Student Demographics and Their Effects on Risky Sexual Behaviors and Poor Condom Use Pattern in Two Departments of a Nigerian University. Am J Public Health Res. 2013;1(3):65–71. 10.12691/ajphr-1-3-2 . Shuper PA, Joharchi N, Irving H, Rehm J. Alcohol as a Correlate of Unprotected Sexual Behavior Among People Living with HIV/AIDS: Review and Meta-Analysis. AIDS Behav. 2009;13(6):1021–36. 10.1007/s10461-009-9589-z . MacDonald TK, MacDonald G, Zanna MP, Fong G. Alcohol, sexual arousal, and intentions to use condoms in young men: Applying alcohol myopia theory to risky sexual behavior. Health Psychol. 2000;19(3):290–8. 10.1037/0278-6133.19.3.290 . Letamo G, Navaneetham K. Levels, trends and reasons for unmet need for family planning among married women in Botswana: a cross-sectional study. BMJ Open. 2015;5(3):e006603. 10.1136/bmjopen-2014-006603 . PubMed PMID: 25829370; PubMed Central PMCID: PMC4386234. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 18 May, 2026 Reviews received at journal 15 May, 2026 Reviewers agreed at journal 13 May, 2026 Reviewers agreed at journal 16 Apr, 2026 Reviewers invited by journal 16 Apr, 2026 Editor invited by journal 14 Apr, 2026 Editor assigned by journal 14 Apr, 2026 Submission checks completed at journal 13 Apr, 2026 First submitted to journal 12 Apr, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9346303","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":626563803,"identity":"81c75b19-7d2c-4739-8def-221c88baeca4","order_by":0,"name":"Phenyoyaone Moloko","email":"","orcid":"","institution":"Ministry of Health","correspondingAuthor":false,"prefix":"","firstName":"Phenyoyaone","middleName":"","lastName":"Moloko","suffix":""},{"id":626563804,"identity":"f78ff9ac-35e3-47a5-8009-ae51e3eaf10c","order_by":1,"name":"Billy Tsima","email":"","orcid":"","institution":"University of Botswana","correspondingAuthor":false,"prefix":"","firstName":"Billy","middleName":"","lastName":"Tsima","suffix":""},{"id":626563805,"identity":"4976ec9f-5294-4675-9ebf-56fd82d0516c","order_by":2,"name":"Stephane Tshitenge","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABFElEQVRIiWNgGAWjYJACZhBhwAzhyIGIAw/wqWcDazEAaoHoMQZrSSBKC8QyhsQGEIlPi/z85mOPCyr+2Juz8x98XPDLJn1+2OGHQFvs5HQbsGsxOMaWbjzjjEHizmZmZuOZfWm5G2+nGQC1JBubHcChhY3HTJq3zSDB4DAzmzRvz+HcjbMTQFoOJG7DoUW+jf8bSIs9UAv7b96e/+mGs9M/4NXCcIyHDaSFcQPQFmaeHwcS5KVz8NticCzN3JjnjHEiUIuxNG9DsuEG6ZyCAwkGuP0i33z42WOeCjl7g/MHH37m+WMnLz87ffOHDxV2cri0MIBjBgYY24D2glUa4FSOpoXhD9DeBryqR8EoGAWjYAQCAAq6XA8wp0pRAAAAAElFTkSuQmCC","orcid":"","institution":"University of Botswana","correspondingAuthor":true,"prefix":"","firstName":"Stephane","middleName":"","lastName":"Tshitenge","suffix":""}],"badges":[],"createdAt":"2026-04-07 14:09:44","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9346303/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9346303/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108006252,"identity":"73b0b26a-3d64-44d8-b973-69d86809db15","added_by":"auto","created_at":"2026-04-28 12:54:55","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":382599,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9346303/v1/de157be7-c9eb-40f5-be2b-d9380949225f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Inconsistent condom use and associated factors among people living with HIV/AIDS in Selibe-Phikwe, Botswana: A cross-sectional study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eHuman immunodeficiency virus (HIV) remains a significant global health challenge, with sub-Saharan Africa bearing the highest burden. Botswana has one of the world\u0026rsquo;s highest HIV prevalence at 20.8% (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). The epidemic has hindered progress toward both the Millennium Development Goals (MDGs) and continues to impede efforts to achieve the Sustainable Development Goals (SDGs). Over the past two decades, Botswana has implemented robust measures to combat HIV, yielding notable successes, including the Prevention of Mother-to-Child Transmission (PMTCT), Safe Male Circumcision (SMC), nationwide distribution of free condoms in public institutions, and universal free HIV treatment for citizens and non-citizens\u0026mdash;now expanded to all people living with HIV regardless of CD4 count. These efforts align with the United Nations Programme on HIV/AIDS (UNAIDS) \"95-95-95\" strategy (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e), demonstrating Botswana\u0026rsquo;s commitment to ending the epidemic.\u003c/p\u003e \u003cp\u003eIn Botswana, adherence to highly active antiretroviral therapy (HAART) is 82%, with over 95% of adherent patients achieving viral suppression (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). While this suppression rate exceeds the final target of the WHO 95-95-95 strategy, it represents only\u0026thinsp;~\u0026thinsp;79% of all people living with HIV/AIDS (PLWHA) in the country (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Consequently, more than 20% of PLWHA remain unsuppressed, sustaining a reservoir of individuals capable of transmitting the virus.\u003c/p\u003e \u003cp\u003eScientific evidence confirms that people with HIV who maintain an undetectable viral load (typically\u0026thinsp;\u0026lt;\u0026thinsp;200 copies/mL) cannot sexually transmit HIV (U\u0026thinsp;=\u0026thinsp;U) (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). However, condoms provide additional protection in cases of treatment interruptions\u0026mdash;such as missed doses, drug resistance, or illness leading to viral rebound\u0026mdash;and protect against other sexually transmitted infections (STIs), including syphilis, gonorrhoea, chlamydia, herpes, and HPV. Even when HIV transmission is eliminated through viral suppression, condoms remain crucial for preventing other STIs, some of which can have serious health consequences or increase the risk of HIV transmission in others. Some partners (particularly in Sero discordant relationships) may prefer dual protection (condoms\u0026thinsp;+\u0026thinsp;viral suppression) for added peace of mind (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe impact of increased HAART access on consistent condom use\u0026mdash;a key sexual behaviour\u0026mdash;remains debated (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Several studies have assessed this phenomenon. Most research in developed countries indicates that individuals who learn of their HIV-positive status tend to reduce risky sexual behaviours. However, studies in developing countries, including Botswana, have found no significant reduction in such behaviours following an HIV diagnosis (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe proportion of inconsistent condom use among PLWHA varies regionally. In the Asia-Pacific region, Deuba et al. (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) reported rates of 43\u0026ndash;46%, with predictors including poor HIV knowledge and the perception that condoms reduce sexual pleasure. In contrast, Reis et al. (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) documented a lower proportion (28.7%) in Brazil, where alcohol use and female gender were significantly associated with inconsistent condom use.\u003c/p\u003e \u003cp\u003eFew recent studies in sub-Saharan Africa have examined this issue among PLWHA. In Uganda, a proportion of 35% was reported (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e), closely mirroring the Asia-Pacific findings. A comparative study by Yalew et al. (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e) in Ethiopia revealed inconsistent condom use proportions of 44.2% pre-HAART and 56% post-HAART, with predictors ranging from stigma to employment status. Notably, all cited studies employed cross-sectional designs, with the Ethiopian study being the only one using a comparative cross-sectional approach.\u003c/p\u003e \u003cp\u003eBotswana\u0026rsquo;s HIV prevention efforts include free condom distribution, with 85% provided at no cost (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e), and an annual supply of 50 condoms per man, exceeding the UNFPA regional benchmark of 30 (2011\u0026ndash;2014) (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Despite high condom availability in Botswana, usage has declined over time\u0026mdash;from 90.2% in 2008 to 81.9% in 2012. Reasons for this decline include misconceptions about HIV transmission and prevention, cultural beliefs, and other behavioural factors (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eExisting studies on condom-use patterns in Botswana primarily focus on individual, relational, and gender-norm factors influencing use, showing suboptimal consistency among women and highlighting the roles of employment status, cohabitation, and gendered power dynamics (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). However, the current body of literature disproportionately examines the general population, leaving a significant gap in understanding condom-use patterns among people living with HIV/AIDS (PLWHA) in Botswana. This gap is critical, as consistent condom use is especially important for PLWHA to prevent reinfection, transmission, and other adverse health outcomes. This study aimed to (i) determine the proportion of inconsistent condom use among PLWHA attending the Selebi-Phikwe Government Hospital Outpatient/Emergency (SPGH-OPD/E) and (ii) identify factors associated with inconsistent use in this population. We hypothesise that there would be no significant association between inconsistent condom use and selected factors, including sociodemographic characteristics, self-perceived health status, the perception that condoms reduce sexual pleasure, and HIV-related factors.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy setting, designs, sample and sampling\u003c/h2\u003e \u003cp\u003eThe study, conducted from May 2020 to June 2020 at the SPGH-OPD/E, employed a quantitative cross-sectional survey design among adult Selibe-Phikwe residents living with HIV/AIDS who were receiving routine HIV care at the facility. SPGH, a district hospital founded in 1970 and initially operating as a clinic in a dwelling house, is located in Selibe-Phikwe, a mining town in Botswana\u0026rsquo;s Central District with a population of about 49,411 (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). The town has the highest HIV/AIDS prevalence in Botswana, recorded at 27.5% in 2013\u0026mdash;a slight increase from 26.5% in 2008 (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). As a district hospital, SPGH supports peripheral clinics and provides services including adult medicine, paediatric care, obstetrics and gynaecology, surgery, outpatient care, and infectious disease management, particularly HIV/AIDS care, attending to an average of 2,622 patients monthly in its outpatient department (SPGH-OPD/E).\u003c/p\u003e \u003cp\u003eThe study population consisted of adult residents diagnosed with HIV/AIDS, with eligibility requiring participants to be aged 18 years or older, residing in Selibe-Phikwe for at least six months, regularly attending SPGH-OPD/E for care, sexually active (with their last sexual activity within the past three months), and excluded those triaged as urgent or emergency cases.\u003c/p\u003e \u003cp\u003eThe formula for calculating sample size for finite population in cross-sectional studieswas used: \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:n=\\frac{N\\:{Z}^{2}P(1-P)}{{d}^{2}\\left(N-1\\right)+{Z}^{2}P(1-P)}\\)\u003c/span\u003e\u003c/span\u003e​, where \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;sample size with finite population correction, \u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;population size, \u003cem\u003eZ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;statistic for a level of confidence (1.96 for 95% confidence), \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;expected proportion (set at 35%, the average of literature-reported inconsistent condom use proportions in PLWHA ranging from 27.9% to 56% (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e) and \u003cem\u003ed\u003c/em\u003e\u0026thinsp;=\u0026thinsp;precision (0.05). The population size was derived from 2,622 (monthly attendance) \u0026times; 2 (months) \u0026times; 0.27 (HIV prevalence in Selibe-Phikwe), yielding a computed sample size of at least 281, which was inflated by 5% to account for potential declines, resulting in a final sample size of 295 participants.\u003c/p\u003e \u003cp\u003e We used a systematic random sampling technique to recruit participants, with the sampling frame consisting of every 5th person living with HIV/AIDS (calculated as 1416/295, where N\u0026thinsp;=\u0026thinsp;estimated population size and n\u0026thinsp;=\u0026thinsp;required sample size) who attended the clinic during the study period. The starting point was determined by randomly selecting a patient number using dice, ensuring an unbiased selection process. Eligible participants were then approached sequentially at every 5th interval until the target sample size of at 295 was achieved.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eRecruitment of participants and procedure\u003c/h3\u003e\n\u003cp\u003ePatient files and outpatient cards were reviewed for HIV status documentation at the SPGH-OPD/E screening point. Eligible individuals were approached for study participation, with male and female participants interviewed separately by same-gender research assistants to reduce bias and improve response rate (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Data were collected using an interviewer-guided questionnaire adapted from similar studies by Ayiga (Uganda) (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) and Yalew (Ethiopia) (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e), selected for their comparable settings. Variables from these studies were merged into a draft questionnaire, which was then reviewed, pre-tested in a pilot study involving 31 participants (10% of the total sample) and approved by two social science experts at a site different from the main study to avoid overlap. The final tool was administered in English and Setswana.\u003c/p\u003e \u003cp\u003eThe questionnaire covered socio-demographic factors (age, sex, marital status, education, employment), health-related behaviours (circumcision status, substance use, self-perceived health), and HIV-specific factors (duration of status awareness, HAART use, partner status, and fertility desires). The dependent variable was consistent/inconsistent condom use over three months. We defined being sexually active as having engaged in one or more penetrative sexual acts within the last three months prior to data collection, PLWHA as any individual previously diagnosed with HIV and aware of their diagnosis for at least six months before data collection, inconsistent condom use as failing to use a condom in all, some, or a few penetrative sexual encounters within the last three months, and alcohol use as having consumed an alcoholic beverage within the same three-month period.\u003c/p\u003e \u003cp\u003eWhereas Parts 1 (socio-demographic factors) and 3 (non-condom health behaviours and HIV-specific factors) required direct answers, Part 2 addressed sensitive condom-use behaviour, which was at risk of socially desirable reporting (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). To mitigate this, the Forced Random Response Technique (RRT) was employed: participants flipped a coin, answering \"Yes\" if it landed heads or truthfully (\"Yes/No\") if tails.\u003c/p\u003e \u003cp\u003eThe second stage of RRT involved applying the Boruch-Forced Response Formula to the aggregate \"Yes\" responses, estimating true proportion while preserving participant anonymity (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). This method balanced transparency in sensitive questions with statistical rigor, aligning with best practices for reducing bias in behavioural health research.\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eThe data were summarized as frequencies, means (\u0026plusmn;\u0026thinsp;standard deviation), or medians (\u0026plusmn;\u0026thinsp;interquartile range) as appropriate. The aggregate proportion of inconsistent condom use (\u0026icirc;) was estimated using the forced-response Boruch formula (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e): \u0026icirc; = [Y \u0026minus; (1\u0026thinsp;\u0026minus;\u0026thinsp;p)]θ / p, where Y represents the observed fraction of \"yes\" responses, p is the probability of answering truthfully (set at 0.7 to balance efficiency and validity, given that a lower p value closer to 0.5 maintains methodological integrity), and θ is the expected proportion (set at 0.3 based on regional estimates). A bivariate binary random-response logistic regression was conducted to assess associations between dependent and independent variables, followed by a multivariate analysis incorporating variables with a p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.1 from the bivariate analysis, using a stepwise elimination approach. Adjusted odds ratios (AOR) with 95% confidence intervals (CI) were reported to quantify associations, and statistical significance was set at p\u0026thinsp;\u0026le;\u0026thinsp;0.05. All analyses were performed using STATA version 13.1.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eOut of 300 participants approached, 295 were enrolled in the study. Five individuals were excluded\u0026mdash;either due to not being sexually active or refusal to provide consent. The mean age of participants was 37.9 years (males: 39 years; females: 37 years), as detailed in Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Most participants were single (74.24%), employed (50.85%), and had attained at least a secondary school education (64.75%).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e. Sociodemographic characteristics of PLWHA in Selibe-Phikwe and participating in the study, May to June 2020.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"621\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 262px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eCharacteristics of Respondents\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003cp\u003e\u003cem\u003en\u003c/em\u003e=295\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003cp\u003e\u003cem\u003en\u003c/em\u003e=117\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003cp\u003e\u003cem\u003en\u003c/em\u003e=178\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 262px;\"\u003e\n \u003cp\u003eMean Age in years (s.d.)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eMarital status \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003cp\u003eMarried\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eEmployment status \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e\n \u003cp\u003eEmployed\u003c/p\u003e\n \u003cp\u003eUnemployed\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eStudying\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eEducational level \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e\n \u003cp\u003ePrimary\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eSecondary\u003c/p\u003e\n \u003cp\u003eTertiary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e39(7.53)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e84 (28.47)\u003c/p\u003e\n \u003cp\u003e33 (11.18)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e71 (24.07)\u003c/p\u003e\n \u003cp\u003e44 (14.92)\u003c/p\u003e\n \u003cp\u003e2 (0.68)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e14 (4.75)\u003c/p\u003e\n \u003cp\u003e74 (25.08)\u003c/p\u003e\n \u003cp\u003e29 (9.83)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e37(8.46)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e135 (45.76)\u003c/p\u003e\n \u003cp\u003e43 (14.57)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e79 (26.78)\u003c/p\u003e\n \u003cp\u003e91 (30.85)\u003c/p\u003e\n \u003cp\u003e8 (2.71)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e10 (3.39)\u003c/p\u003e\n \u003cp\u003e117 (39.66)\u003c/p\u003e\n \u003cp\u003e51 (17.29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e37.9(8.12)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e219 (74.23)\u003c/p\u003e\n \u003cp\u003e76 (25.8)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e150 (50.85)\u003c/p\u003e\n \u003cp\u003e135 (45.76)\u003c/p\u003e\n \u003cp\u003e10 (3.39)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e24 (8.14)\u003c/p\u003e\n \u003cp\u003e191 (64.75)\u003c/p\u003e\n \u003cp\u003e80 (27.12)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003es.d., standard deviation\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n \u003ch2\u003eProportions of inconsistent condom use in adult PLWHA\u003c/h2\u003e\n \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e presents condom use patterns among PLWHA study participants. Of the 295 participants, 144 (48.8%) reported inconsistent use (males: 18.6%; females: 30.2%). After adjusting for social desirability bias using the specified formula, the estimated proportion of inconsistent condom use was 8.1%.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eCondom use pattern/response among people living with HIV/AIDS in Selibe-Phikwe, May to June 2020.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"4\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\n \u003cp\u003eCondom use pattern.\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\n \u003cp\u003eTotal n (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eMales n (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003eFemales n (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eCondom use over last 3 months (RRT⁜ step 1 coin flip proportions)\u003c/p\u003e\n \u003cp\u003eAlways (consistent)\u003c/p\u003e\n \u003cp\u003eNot always (inconsistent)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e62 (21.02)\u003c/p\u003e\n \u003cp\u003e55 (18.64)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e89 (30.17)\u003c/p\u003e\n \u003cp\u003e89 (30.17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e151 (51.19)\u003c/p\u003e\n \u003cp\u003e144 (48.81)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e(RRT⁜ step 2 formula)\u003c/p\u003e\n \u003cp\u003eNot always (inconsistent)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\n \u003cp\u003e\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\frac{\\left[.488-(1-.7)\\right].3}{.7}\\)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e0.0805 (8.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003ch3\u003e⁜, random response technique\u003c/h3\u003e\n\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\n \u003ch2\u003eFactors associated with inconsistent condom use in adult PLWHA\u003c/h2\u003e\n \u003cp\u003eAs shown in Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, the bivariate random-response logistic regression analysis indicated that as participants\u0026apos; age decreased, they were more likely to use condoms inconsistently (OR\u0026thinsp;=\u0026thinsp;0.95, 95% CI: 0.90\u0026ndash;0.99, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.038). The odds of inconsistent use were three times higher in females than in males (OR\u0026thinsp;=\u0026thinsp;2.7, 95% CI: 1.25\u0026ndash;5.68, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.011), and non-alcohol users had 2.4 times lower odds of inconsistent use compared to alcohol users (OR\u0026thinsp;=\u0026thinsp;0.42, 95% CI: 0.20\u0026ndash;0.91, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.027). Participants who reported not knowing their regular sexual partner\u0026rsquo;s HIV status had six times higher odds of inconsistent condom use compared to those who knew their partner\u0026rsquo;s status (OR\u0026thinsp;=\u0026thinsp;5.5, 95% CI: 1.54\u0026ndash;19.55, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.009). Conversely, those who did not perceive condom use as reducing sexual pleasure were 17 times less likely to use condoms inconsistently (OR\u0026thinsp;=\u0026thinsp;0.06, 95% CI: 0.03\u0026ndash;0.11, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). No significant associations were observed with marital status, employment, circumcision, self-perceived health, desire for children, or duration of HAART.\u003c/p\u003e\n \u003cp\u003eThese factors remained statistically significant in the multivariate random-response logistic regression (Table \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Older participants were slightly (4%) but significantly less likely to use condoms inconsistently (AOR\u0026thinsp;=\u0026thinsp;0.96, 95% CI: 0.92\u0026ndash;0.99, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.040). The odds of inconsistent use were three times higher in females than in males (AOR\u0026thinsp;=\u0026thinsp;2.5, 95% CI: 1.23\u0026ndash;4.93, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.011), and non-alcohol users had 2.4 times lower odds of inconsistent use compared to alcohol users (AOR\u0026thinsp;=\u0026thinsp;0.47, 95% CI: 0.24\u0026ndash;0.93, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.039). Participants who did not know their regular partner\u0026rsquo;s HIV status had two times higher odds of inconsistent condom use compared to those who knew their partner\u0026rsquo;s status (AOR\u0026thinsp;=\u0026thinsp;1.83, 95% CI: 1.10\u0026ndash;3.09, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.019). Additionally, those who did not perceive condom use as reducing sexual pleasure were 17 times less likely to use condoms inconsistently (AOR\u0026thinsp;=\u0026thinsp;0.06, 95% CI: 0.03\u0026ndash;0.12, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 3.\u003c/strong\u003e Bivariate random response logistic regression for factors associated with inconsistent condom use among people living with HIV/AIDS in Selibe-Phikwe, May to June 2020.\u003c/p\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"624\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 243px;\"\u003e\n \u003cp\u003eVariables \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eOR\u0026dagger;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e95% CI\u0026Dagger;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e\u003cem\u003ep\u0026nbsp;\u003c/em\u003evalue\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 243px;\"\u003e\n \u003cp\u003eAge\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e0.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e0.90 \u0026ndash; 0.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e0.038*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 243px;\"\u003e\n \u003cp\u003eGender\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eMale\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eFemale\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003cp\u003e2.66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1.25 \u0026ndash; 5.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.011*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 243px;\"\u003e\n \u003cp\u003eMarital status\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eSingle\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eMarried \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003cp\u003e1.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.63 \u0026ndash; 3.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.398\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 243px;\"\u003e\n \u003cp\u003eEmployment\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eEmployed\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eUnemployed\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eStudying\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003cp\u003e1.04\u003c/p\u003e\n \u003cp\u003e0.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.51 \u0026ndash; 2.12\u003c/p\u003e\n \u003cp\u003e0.06 \u0026ndash; 3.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.909\u003c/p\u003e\n \u003cp\u003e0.431\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 243px;\"\u003e\n \u003cp\u003eEducational level\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eTertiary\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eSecondary\u003c/p\u003e\n \u003cp\u003ePrimary\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003cp\u003e0.93\u003c/p\u003e\n \u003cp\u003e0.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.43 \u0026ndash; 2.01\u003c/p\u003e\n \u003cp\u003e0.08 \u0026ndash; 1.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.860\u003c/p\u003e\n \u003cp\u003e0.090\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 243px;\"\u003e\n \u003cp\u003eCircumcision/circumcised partner\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eNo\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eYes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003cp\u003e1.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.61 \u0026ndash; 2.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.658\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 243px;\"\u003e\n \u003cp\u003eAlcohol Use\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eYes\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eNo\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003cp\u003e0.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.20 \u0026ndash; 0.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.027*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 243px;\"\u003e\n \u003cp\u003eDesire to bear children.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eYes\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eNo\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003cp\u003e0.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.40 \u0026ndash; 1.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.76\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 243px;\"\u003e\n \u003cp\u003eSelf-perception of health\u003c/p\u003e\n \u003cp\u003eNot good\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eFair\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eGood \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003cp\u003e0.56\u003c/p\u003e\n \u003cp\u003e0.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.04 \u0026ndash; 7.34\u003c/p\u003e\n \u003cp\u003e0.07 \u0026ndash; 12.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.66\u003c/p\u003e\n \u003cp\u003e0.98\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 243px;\"\u003e\n \u003cp\u003eHIV duration (years)\u003c/p\u003e\n \u003cp\u003e\u0026lt; 2\u003c/p\u003e\n \u003cp\u003e2 \u0026ndash; 3\u003c/p\u003e\n \u003cp\u003e\u0026gt;3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003cp\u003e0.29\u003c/p\u003e\n \u003cp\u003e0.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.02 \u0026ndash; 4.88\u003c/p\u003e\n \u003cp\u003e0.02 \u0026ndash; 8.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.39\u003c/p\u003e\n \u003cp\u003e0.60\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 243px;\"\u003e\n \u003cp\u003eHAART Duration (years)\u003c/p\u003e\n \u003cp\u003e\u0026lt; 1\u003c/p\u003e\n \u003cp\u003e1 \u0026ndash; 2\u003c/p\u003e\n \u003cp\u003e\u0026gt;2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003cp\u003e5.25\u003c/p\u003e\n \u003cp\u003e4.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.32 \u0026ndash; 85.88\u003c/p\u003e\n \u003cp\u003e0.31 \u0026ndash; 78.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.25\u003c/p\u003e\n \u003cp\u003e0.26\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 243px;\"\u003e\n \u003cp\u003eHIV status of partner\u0026nbsp;\u003c/p\u003e\n \u003cp\u003ePositive\u003c/p\u003e\n \u003cp\u003eNegative\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eUnknown\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003cp\u003e1.31\u003c/p\u003e\n \u003cp\u003e5.49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.52 \u0026ndash; 3.31\u003c/p\u003e\n \u003cp\u003e1.54 \u0026ndash; 19.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.57\u003c/p\u003e\n \u003cp\u003e0.01*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 243px;\"\u003e\n \u003cp\u003ePerception that condom use reduces pleasure.\u003c/p\u003e\n \u003cp\u003eYes\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eNo\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003cp\u003e0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.03 \u0026ndash; 0.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.000*\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003e\u0026dagger;, odd ratio; \u0026Dagger;, \u003cem\u003eConfidence Interval; *, p value statistically significant (p\u0026lt;0.05)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eTable 4\u003c/strong\u003e. Multivariate random response logistic regression with\u0026nbsp;inconsistent condom use\u0026nbsp;as the dependent variable and independent variable\u0026mdash;using stepwise elimination,\u0026nbsp;among people living with HIV/AIDS in Selibe-Phikwe, May\u0026ndash;June 2020\u003c/p\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"630\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 329px;\"\u003e\n \u003cp\u003eVariables\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eAOR\u0026dagger;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e95% CI \u0026Dagger;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003ep value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 329px;\"\u003e\n \u003cp\u003eAge\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e0.92 \u0026ndash; 0.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.040*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 329px;\"\u003e\n \u003cp\u003eGender (female)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e2.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e1.23 \u0026ndash; 4.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.011*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 329px;\"\u003e\n \u003cp\u003eHIV status of partner (unknown)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e1.10 \u0026ndash; 3.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.019*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 329px;\"\u003e\n \u003cp\u003eAlcohol use (No)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e0.24 \u0026ndash; 0.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.030*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 329px;\"\u003e\n \u003cp\u003ePerception that condom use reduces pleasure (No)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e0.03 \u0026ndash; 0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.000*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003e\u003cem\u003e\u0026dagger;, adjusted odd ratio; \u0026Dagger;, Confidence Interval; *, p value statistically significant (p\u0026lt;0.05)\u003c/em\u003e\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study aimed to determine the proportion of inconsistent condom use and its associated factors among PLWHA in Selibe-Phikwe, a high HIV-burden setting with free condom distribution, using the random response technique. The findings revealed an 8.1% prevalence of inconsistent condom use. Older participants were slightly (4%) but significantly less likely to use condoms inconsistently (p\u0026thinsp;=\u0026thinsp;0.040). Females had three times higher odds of inconsistent use compared to males (p\u0026thinsp;=\u0026thinsp;0.011), while non-alcohol users had 2.4 times lower odds of inconsistent use compared to alcohol users (p\u0026thinsp;=\u0026thinsp;0.039). Participants who were unaware of their regular partner\u0026rsquo;s HIV status had twice the odds of inconsistent condom use compared to those who knew their partner\u0026rsquo;s status (p\u0026thinsp;=\u0026thinsp;0.019). Additionally, those who did not perceive condom use as reducing sexual pleasure were 17 times less likely to use condoms inconsistently (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Factors such as self-perceived health status and desire to bear children showed no significant association with inconsistent condom use.\u003c/p\u003e \u003cp\u003eA lower proportion (8.1%) of inconsistent condom use was observed in our study compared to previous studies conducted both globally and within the region. For example, Lau et al. reported that among 68 HIV-discordant couples in a rural county in China, 27.9% engaged in inconsistent condom use, with significant associated factors including condom unavailability, suicidal ideation among people living with HIV (PLWH), and misconceptions about HIV transmission (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). In Uganda, Ayiga et al. found a prevalence of inconsistent condom use of 35% among patients recently initiated on HAART (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Yalew et al. reported inconsistent condom use proportions of 56% among HAART-na\u0026iuml;ve participants and 44.2% among those with HAART experience when asked about condom use behaviour over the preceding three months (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe higher prevalence reported by Lau et al. and Ayiga et al. may be partly explained by their broader inclusion criteria, which assessed behaviour over the previous 12 months, compared with the shorter three-month observation period used in our study. Most of these studies also relied on direct questioning (DQ) to obtain information about condom-use behaviour, whereas the present study employed the randomized response technique (RRT). One of the key advantages of RRT over DQ is its ability to reduce social desirability bias, often resulting in higher and potentially more accurate estimates than those obtained through direct questioning. However, Umesh and Peterson have highlighted concerns regarding its limited validity, including its inability to accurately identify individual-level behaviour (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Additionally, Lesly et al. noted that respondents may fear that forced \u0026ldquo;yes\u0026rdquo; responses could be misinterpreted as admissions of behaviours they did not engage in (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Despite these concerns, RRT remains a well-validated and highly effective method for estimating the prevalence of sensitive behaviours at the population level (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDespite these concerns, RRT remains a well-validated and effective method for generating reliable population-level estimates of sensitive behaviours. However, by design, it does not allow for accurate identification of individual behaviour.\u003c/p\u003e \u003cp\u003eSeveral factors could contribute to the lower prevalence of inconsistent condom found in this study. Botswana's condom distribution per capita not only far surpasses the universal recommendation for family planning but also meets nearly 95% of the need for HIV prevention. This national surplus is demonstrated by the estimate of 50 condoms distributed per man per year, a figure significantly higher than the UNFPA's regional benchmark of 30 (2011\u0026ndash;2014) (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). The success of this robust distribution strategy is further illustrated by the case of Selibe-Phikwe. Previously ranked first for HIV prevalence in 2013 (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e), the district was likely a target for intensified HIV campaigns. The observed lower rate of inconsistent condom use there likely reflects the success of these efforts. This is supported by the most recent Botswana AIDS Impact Survey IV (BAIS IV) preliminary report, which shows Selibe-Phikwe has improved its ranking to the top five, with its prevalence rate slightly decreasing from 27.5% in 2013 to 26.7% in 2022 (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). The high rate of condom availability, targeted campaigns, and subsequent reduction in prevalence are all likely contributors to the low proportion of inconsistent condom use.\u003c/p\u003e \u003cp\u003eThe present study found that those who did not have this perception were almost 17 times less likely to be inconsistent condom users compared to those who do. Considering other studies, Mehra and colleagues found similar results (AOR 1.78 (95% CI 1.03\u0026ndash;3.0)) (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e) as well as Katikiro \u003cem\u003eet al\u003c/em\u003e. studied AOR\u0026thinsp;=\u0026thinsp;8.19; 95% CI 3.98\u0026ndash;17.01) (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). In Nigeria, Ajayi \u003cem\u003eet al\u003c/em\u003e. found that the same belief that condom use reduces fun was one of the main reasons why university students did not use condom consistently (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Condoms reduce the delivery of stimulation of friction during intimacy, and there is decreased tactile sensation. There is also a sense of interruption of sex. This perception and/or belief that condom use reduces pleasure has the potential to perpetuate the spread of HIV, therefore this highlights the need for HIV prevention messaging to re-focus condom campaigns or marketing strategies. An example would be to emphasize pleasure enhancing aspects of condom use like the ability to prolong sex and therefore reduce sexual tension (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Additionally, condom makers could be encouraged to make condoms even thinner or better to increase tactile sensation.\u003c/p\u003e \u003cp\u003eIn this study, participants who did not know their partners\u0026rsquo; HIV status were twice as likely to use condoms inconsistently compared to those who knew their partners were HIV-positive. This finding aligns with the study by Ayiga et al., which observed a negative association between consistent condom use and PLWHA who had partners with a negative status or who were unaware of their partner\u0026rsquo;s HIV status (AOR: 0.27 and 0.16, respectively) (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). This behaviour could stem from a sense of invulnerability felt by the uninfected partner, particularly if they remained HIV-negative despite engaging in unprotected sex over a prolonged period.\u003c/p\u003e \u003cp\u003eThe present study found that females were three times more likely to report inconsistent condom use than males. This aligns with the findings of Yalew et al. and Reis et al., who also identified male gender as a protective factor against inconsistent condom use among PLWHA (OR 0.45; 95% CI 0.21\u0026ndash;0.98 and OR 0.36; 95% CI 0.15\u0026ndash;0.81, respectively) (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). However, these results contrast with a study by Ayiga, which examined predictors of consistent condom use among PLWHA in Uganda. The author\u0026rsquo;s analysis found that male gender was not a significant predictor of consistent condom use compared to females (OR 0.77; 95% CI 0.45\u0026ndash;1.32) (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). This discrepancy may be attributed to cultural norms in Botswana, where women are traditionally socialized to be submissive to men, potentially limiting their ability to negotiate safer sexual practices, including condom use. Additionally, male condoms are the most widely available and accepted condom type in Botswana, which may reinforce men\u0026rsquo;s perceived control over sexual decision-making, further disadvantaging women in such negotiations.\u003c/p\u003e \u003cp\u003eIn this study, participants who did not consume alcohol were two times less likely to use condoms inconsistently compared to those who consumed alcohol. These findings align with prior research: one study linked alcohol use to an 11-fold increased risk of inconsistent condom use (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e), while Yalew et al. reported that abstaining from alcohol was associated with an 86% reduction in the likelihood of inconsistent use (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). A meta-analysis by Shuper et al. further reinforced this association, demonstrating that any alcohol consumption, problematic drinking, and alcohol use during sexual activity were all significantly correlated with unprotected sex among PLWHA (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). This effect may stem from alcohol\u0026rsquo;s capacity to impair cognitive function, narrowing focus to immediate cues\u0026mdash;a phenomenon observed by Macdonald et al. (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). To address the link between alcohol/substance use and inconsistent condom use among youth, targeted interventions should include enhanced counselling during routine HIV care and public health campaigns focused on reducing risky sexual behaviours. Counselling strategies for PLWHA should also be strengthened to address alcohol\u0026rsquo;s impact on sexual health.\u003c/p\u003e \u003cp\u003eAccording to the study, increasing age was protective against inconsistent condom use and this was similar to Yalew \u003cem\u003eet al.\u003c/em\u003e who found that age category (\u0026gt;\u0026thinsp;32 years old) was also protective against inconsistent condom use in both ART na\u0026iuml;ve and ART experienced compared to younger age group category (\u0026lt;\u0026thinsp;32 years old) (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). However, this was contrary to findings by Reis \u003cem\u003eet al.\u003c/em\u003e as well as Ayiga and Letamo, who did not find any statistically significant association between age and inconsistent condom use in PLWHA (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). This may be because young people are more likely to engage in alcohol and substance use which had already been shown to be a significant predictor of inconsistent condom use. This calls for more interventions targeting youth in addressing risky sexual behaviours like more counselling during routine HIV care, and more campaigns. More longitudinal research in this field is needed to explore the perspective of the youth about this subject.\u003c/p\u003e \u003cp\u003eTo enhance HIV prevention, interventions should prioritise gender-sensitive approaches to empower women, alcohol harm reduction, partner status disclosure initiatives, and pleasure-inclusive messaging alongside condom design innovations.\u003c/p\u003e \u003cp\u003eAlcohol use was not quantified to distinguish between normal use and abuse, nor was its relationship with inconsistent condom use patterns examined. Other limitations include the cross-sectional design, which cannot assess changes in condom use consistency over time. Additionally, the study focused exclusively on PLWHA in Selibe-Phikwe who attended government hospital settings, excluding those receiving HIV care in other facilities (public or private) and individuals not in routine care but living with HIV. This limits the generalizability of the findings.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study found a relatively low rate of inconsistent condom use (8.1%) among PLWHA in Selibe-Phikwe, Botswana, compared to previous studies in similar high-HIV burden settings. Key factors associated with inconsistent use were female gender, alcohol consumption, lack of awareness of a partner\u0026rsquo;s HIV status, and the perception that condoms reduce sexual pleasure. Older age, conversely, showed a slight but marginally significant protective effect.\u003c/p\u003e \u003cp\u003eTo enhance HIV prevention, interventions should prioritise gender-sensitive approaches to empower women, alcohol harm reduction, partner status disclosure initiatives, and pleasure-inclusive messaging alongside condom design innovations.\u003c/p\u003e \u003cp\u003eFuture work should employ more robust methodologies, such as longitudinal studies, the inclusion of non-clinic attendees, and a deeper exploration of the interactions between substance use and sexual behaviour. This will be crucial for strengthening HIV prevention strategies in high-burden settings like Botswana.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBAIS IV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBotswana AIDS Impact Survey IV\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHAART\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHighly Active Antiretroviral Therapy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMDGs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMillennium Development Goals\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePLWHA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePeople Living with HIV/AIDS\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePMTCT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePrevention of Mother\u0026ndash;to\u0026ndash;Child Transmission\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRRT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eRandomized Response Technique\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSDGs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSustainable Development Goals\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSMC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSafe Male Circumcision\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSPGH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSelebi\u0026ndash;Phikwe Government Hospital\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e \u003cp\u003eEthical approval for the study was obtained from the University of Botswana\u0026rsquo;s Office of Research and Development (UBR/RES/IRB/BIO/GRAD/111) and the Botswana Ministry of Health \u0026amp; Wellness (HPDME:13/18/1). All study procedures, including consent processes, were conducted in accordance with these approvals. The study was carried out in compliance with the principles of the Helsinki Declaration. Informed consent was obtained from all the participants in the study. They were advised that they may leave at any time without any problems. Everyone who answered agreed to take part on their own. The data was kept safe, and personal identifiers were taken out to protect privacy and anonymity. The data was only available to the research team.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003ePatient consent for publication\u003c/h2\u003e \u003cp\u003eNot required.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eConsent for publication\u003c/h2\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCompeting Interests\u003c/h2\u003e \u003cp\u003eThe authors have declared that no conflict of interest exists.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eClinical trial number:\u003c/h2\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCity in the affiliation for author(s):\u003c/h2\u003e \u003cp\u003ePhenyoyaone Moloko: Letsholathebe II Memorial Hospital, Hospital Road, Disaneng Ward, Maun, Botswana.\u003c/p\u003e \u003cp\u003e Billy Tsima and Stephane Tshitenge: Department of Family Medicine and Primary Care, School of Medicine, University of Botswana, Plot 4775 corner Notwane and Mobuto Rd., Gaborone, Botswana\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003edeclaration:\u003c/p\u003e \u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eP.M. contributed to the conceptualization of the study, proposal writing, data collection and data analysis, and drafting the original manuscript.B.T. reviewed the research proposal and the manuscript. S.T. reviewed the proposal, data analysis, and compiled the final manuscript. All authors read and approved the final article.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e \u003cp\u003eThe authors would like to thank the Selebi-Phikwe District Management Team staff for facilitating the data collection.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets generated and/or analysed during the current study are not publicly available due to ethical and privacy restrictions, as the data contain information that could potentially identify individual participants and relate to sensitive health and sexual behaviour. The study protocol and consent procedures approved by the University of Botswana Office of Research and Development and the Botswana Ministry of Health \u0026amp; Wellness did not include permission for open public data sharing. However, anonymised data supporting the findings of this study are available from the corresponding author upon reasonable request, subject to approval by the relevant ethics committees and in compliance with national data protection regulations.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBotswana AIDS, Impact Survey, V 2021 (BAIS V). Report. [A population-based HIV impact assessment report]. Gaborone: Government of Botswana \u0026mdash; National AIDS \u0026amp; Health Promotion Agency; 2023. Report No.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e90-90-90. An ambitious treatment target to help end the AIDS epidemic. Geneva, Switzerland: UNAIDS;: Joint United Nations Programme on HIV/AIDS; 2014.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUNAIDS Data. 2021. Geneva, Switzerland: UNAIDS; 2021. Report No.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEisinger RW, Dieffenbach CW, Fauci AS. HIV Viral Load and Transmissibility of HIV Infection: Undetectable Equals Untransmittable. JAMA. 2019;321(5):451\u0026ndash;2. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1001/jama.2018.21167\u003c/span\u003e\u003cspan address=\"10.1001/jama.2018.21167\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSiegfried N, Muller M, Deeks J, Volmink J, Egger M, Low N, et al. HIV and male circumcision\u0026ndash;a systematic review with assessment of the quality of studies. Lancet Infect Dis. 2005;5(3):165\u0026ndash;73. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/S1473-3099\u003c/span\u003e\u003cspan address=\"10.1016/S1473-3099\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. (05)01309-5 PubMed PMID: 15766651.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCastilla J, Del Romero J, Hernando V, Marincovich B, Garc\u0026iacute;a S, Rodr\u0026iacute;guez C. Effectiveness of highly active antiretroviral therapy in reducing heterosexual transmission of HIV. J Acquir Immune Defic Syndr. 2005;40(1):96\u0026ndash;101. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/01.qai.0000157389.78374.45\u003c/span\u003e\u003cspan address=\"10.1097/01.qai.0000157389.78374.45\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PubMed PMID: 16123689.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThe impact of HIV treatment on risk behaviour in. developing countries: a systematic review - PubMed [Internet]. [cited 2026 Jan 16]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://pubmed.ncbi.nlm.nih.gov/17573590/\u003c/span\u003e\u003cspan address=\"https://pubmed.ncbi.nlm.nih.gov/17573590/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDeuba K, Kohlbrenner V, Koirala S, Ekstr\u0026ouml;m AM. CAT-S group. Condom use behaviour among people living with HIV: a seven-country community-based participatory research in the Asia-Pacific region - PubMed. Vol. 94. 2018;94(3):200\u0026ndash;5. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/sextrans-2017-053263\u003c/span\u003e\u003cspan address=\"10.1136/sextrans-2017-053263\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e PubMed PMID: 29118203.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eReis RK, Melo ES, Gir E. Fatores associados ao uso inconsistente do preservativo entre pessoas vivendo com HIV/Aids. Rev Bras Enferm. 2016;69(1):47\u0026ndash;53. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1590/0034-7167.2016690106i\u003c/span\u003e\u003cspan address=\"10.1590/0034-7167.2016690106i\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAyiga N. Rates and Predictors of Consistent Condom-use by People Living with HIV/AIDS on Antiretroviral Treatment in Uganda. J Health Popul Nutr. 2012;30(3):270\u0026ndash;80. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3329/jhpn.v30i3.12290\u003c/span\u003e\u003cspan address=\"10.3329/jhpn.v30i3.12290\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PubMed PMID: 23082629; PubMed Central PMCID: PMC3489943.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYalew E, Zegeye DT, Meseret S. Patterns of condom use and associated factors among adult HIV positive clients in North Western Ethiopia: a comparative cross sectional study. BMC Public Health. 2012;12:308. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/1471-2458-12-308\u003c/span\u003e\u003cspan address=\"10.1186/1471-2458-12-308\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PubMed PMID: 22537280; PubMed Central PMCID: PMC3426486.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePallin SC, Meekers D, Lupu O, Longfield K, Botswana. A Total Market Approach. PSI/UNFPA Joint Studies on the Total Market for Male Condoms in Six African Countries. [Internet]. 2013. Report No. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e\u003c/span\u003e\u003cspan address=\"http://www.psi.org/total-market-approach\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePrevention gap report [Internet]. UNDAIDS. 2016. Report No. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e\u003c/span\u003e\u003cspan address=\"http://www.unaids.org/sites/default/files/media_asset/2016-prevention-gap-report_en.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBotswana National AIDS Coordinating Agency. Botswana Global AIDS Response. Progress of the national response to 2011 declaration of commitments on HIV and AIDS. 2013.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMlandu C, Machisa M, Christofides N. Consistent condom use among Botswana\u0026rsquo;s female population and associated factors. Women\u0026rsquo;s Health. 2024;20:1\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/17455057241266453\u003c/span\u003e\u003cspan address=\"10.1177/17455057241266453\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBarchi F, Apps H, Ntshebe O, Ramaphane P. Social and behavioral correlates of adolescent sexual experience and intention to use condoms in northwestern Botswana. Int J Environ Res Public Health. 2021;18(11):5583. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3390/ijerph18115583\u003c/span\u003e\u003cspan address=\"10.3390/ijerph18115583\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStatistics Botswana. Population and housing census 2011 administrative and technical report. 2016.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBotswana National AIDS Coordinating Agency. Botswana AIDS impact survey IV: statistical report 2013. Gaborone: Statistics Botswana; 2016. p. 260.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eReis RK, Melo ES, Gir E. Factors associated with inconsistent condom use among people living with HIV/Aids. Revista brasileira de enfermagem. 2016. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1590/0034-7167.2016690106i\u003c/span\u003e\u003cspan address=\"10.1590/0034-7167.2016690106i\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNgome E, Demographic. Socio-Economic and Psychosocial Determinants of Current and Consistent Condom Use among Adolescents in Botswana. World J AIDS. 2016;6:137\u0026ndash;56. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.4236/wja.2016.64017\u003c/span\u003e\u003cspan address=\"10.4236/wja.2016.64017\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLau JTF, Yu X, Mak WWS, Cheng Y, Lv Y, Zhang J, et al. Prevalence of Inconsistent Condom Use and Associated Factors Among HIV Discordant Couples in a Rural County in China. AIDS Behav. 2013;17(5):1888\u0026ndash;94. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s10461-012-0269-z\u003c/span\u003e\u003cspan address=\"10.1007/s10461-012-0269-z\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePal S, Singh S. A new unrelated question randomized response model. Statistics. 2012;46(1):99\u0026ndash;109. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/02331888.2010.500115\u003c/span\u003e\u003cspan address=\"10.1080/02331888.2010.500115\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLensvelt-Mulders GJLM, Hox JJ, Heijden PGMVD. How to Improve the Efficiency of Randomised Response Designs. Qual Quant. 2005;39(3):253\u0026ndash;65. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s11135-004-0432-3\u003c/span\u003e\u003cspan address=\"10.1007/s11135-004-0432-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUmesh U, Peterson R. A Critical Evaluation of the Randomized Response Method. Sociol Methods Res. 1991;20(1):104\u0026ndash;38.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJohn LK, Loewenstein G, Acquisti A, Vosgerau J. When and why randomized response techniques (fail to) elicit the truth. Organ Behav Hum Decis Process. 2018;148:101\u0026ndash;23. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.obhdp.2018.07.004\u003c/span\u003e\u003cspan address=\"10.1016/j.obhdp.2018.07.004\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLensvelt-Mulders GJLM, Hox JJ, van der Heijden PGM, Maas CJM. Meta-Analysis of Randomized Response Research: Thirty-Five Years of Validation. Sociol Methods Res. 2005;33(3):319\u0026ndash;48.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMehra D, \u0026Ouml;stergren PO, Ekman B, Agardh A. Inconsistent condom use among Ugandan university students from a gender perspective: a cross-sectional study. Global Health Action. 2014;7(1):22942. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3402/gha.v7.22942\u003c/span\u003e\u003cspan address=\"10.3402/gha.v7.22942\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKatikiro E, Njau B. Motivating Factors and Psychosocial Barriers to Condom Use among out-of-School Youths in Dar es Salaam, Tanzania: A Cross Sectional Survey Using the Health Belief Model. ISRN AIDS. 2012;1\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.5402/2012/170739\u003c/span\u003e\u003cspan address=\"10.5402/2012/170739\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAjayi AI, Ismail KO, Akpan W. Factors associated with consistent condom use: a cross-sectional survey of two Nigerian universities. BMC Public Health. 2019;19(1):1207. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12889-019-7543-1\u003c/span\u003e\u003cspan address=\"10.1186/s12889-019-7543-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOkonta MJ, Ubaka CM, Araukwe NN. Student Demographics and Their Effects on Risky Sexual Behaviors and Poor Condom Use Pattern in Two Departments of a Nigerian University. Am J Public Health Res. 2013;1(3):65\u0026ndash;71. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.12691/ajphr-1-3-2\u003c/span\u003e\u003cspan address=\"10.12691/ajphr-1-3-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShuper PA, Joharchi N, Irving H, Rehm J. Alcohol as a Correlate of Unprotected Sexual Behavior Among People Living with HIV/AIDS: Review and Meta-Analysis. AIDS Behav. 2009;13(6):1021\u0026ndash;36. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s10461-009-9589-z\u003c/span\u003e\u003cspan address=\"10.1007/s10461-009-9589-z\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMacDonald TK, MacDonald G, Zanna MP, Fong G. Alcohol, sexual arousal, and intentions to use condoms in young men: Applying alcohol myopia theory to risky sexual behavior. Health Psychol. 2000;19(3):290\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1037/0278-6133.19.3.290\u003c/span\u003e\u003cspan address=\"10.1037/0278-6133.19.3.290\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLetamo G, Navaneetham K. Levels, trends and reasons for unmet need for family planning among married women in Botswana: a cross-sectional study. BMJ Open. 2015;5(3):e006603. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/bmjopen-2014-006603\u003c/span\u003e\u003cspan address=\"10.1136/bmjopen-2014-006603\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PubMed PMID: 25829370; PubMed Central PMCID: PMC4386234.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-9346303/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9346303/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction\u003c/h2\u003e \u003cp\u003eThis study aimed to (i) determine the proportion of inconsistent condom use among people living with HIV/AIDS (PLWHA) attending the Selebi-Phikwe Government Hospital Outpatient/Emergency (SPGH-OPD/E) and (ii) identify factors associated with inconsistent use in this population.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis was a quantitative, cross-sectional survey conducted among 295 PLWHA attending the SPGH-OPD/E. We used a systematic random sampling technique to select participants who attended the clinic during the study period. The administered-questionnaire covered socio-demographic factors, health-related behaviours, and HIV-specific factors. The dependent variable was consistent/inconsistent condom use over a three-month period. To minimize social desirability bias, the Forced Random Response Technique (RRT) was employed. The aggregate proportion of inconsistent condom use (\u0026icirc;) was estimated using Boruch\u0026rsquo;s forced-response formula. Bivariate and multivariate random-response logistic regression were conducted to assess associations between the dependent and independent variables.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eWe enrolled 295 PLWHA in the study, and after adjusting for social desirability bias, the estimated proportion of inconsistent condom use was 8.1%. In the multivariate random-response logistic regression analysis, females had three times higher odds of inconsistent condom use than males (AOR\u0026thinsp;=\u0026thinsp;2.5, 95% CI: 1.23\u0026ndash;4.93, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.011), while non-alcohol users had 53% lower odds of inconsistent condom use than alcohol users (AOR\u0026thinsp;=\u0026thinsp;0.47, 95% CI: 0.24\u0026ndash;0.93, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.039). Participants unaware of their regular partner\u0026rsquo;s HIV status had twice the odds of inconsistent condom use compared to those who knew their partner\u0026rsquo;s status (AOR\u0026thinsp;=\u0026thinsp;1.83, 95% CI: 1.10\u0026ndash;3.09, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.019), and those who did not perceive condoms as reducing sexual pleasure were 94% less likely to use condoms inconsistently (AOR\u0026thinsp;=\u0026thinsp;0.06, 95% CI: 0.03\u0026ndash;0.12, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThere was a low proportion of inconsistent condom use (8.1%) among PLWHA. Factors such as female gender, alcohol consumption, being unaware of partner\u0026rsquo;s HIV status, and perception of condoms reducing sexual pleasure were significantly associated with inconsistent condom use. HIV prevention interventions should target these factors. Further research using more robust study designs addressing limitations associated with the current study is recommended.\u003c/p\u003e","manuscriptTitle":"Inconsistent condom use and associated factors among people living with HIV/AIDS in Selibe-Phikwe, Botswana: A cross-sectional study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-24 19:31:01","doi":"10.21203/rs.3.rs-9346303/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"272294448800431821999939129159527059229","date":"2026-05-18T14:28:07+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-15T13:46:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"163511604409679293916545659566471135534","date":"2026-05-13T19:19:00+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"133120188089780356565123453822856265550","date":"2026-04-16T17:00:39+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-16T10:50:35+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-04-14T08:24:56+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-14T08:18:50+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-13T07:14:46+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2026-04-12T21:09:43+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e28f3bfa-b1e4-464a-b065-36f385db9358","owner":[],"postedDate":"April 24th, 2026","published":true,"recentEditorialEvents":[{"type":"reviewerAgreed","content":"272294448800431821999939129159527059229","date":"2026-05-18T14:28:07+00:00","index":65,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-15T13:46:38+00:00","index":64,"fulltext":""},{"type":"reviewerAgreed","content":"163511604409679293916545659566471135534","date":"2026-05-13T19:19:00+00:00","index":62,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-24T19:31:01+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-24 19:31:01","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9346303","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9346303","identity":"rs-9346303","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}