Re-examining Risk: Condoms, HIV, and Discussions about Sex in Rwanda

About a year ago, I attended a Sexual and Reproductive Health Training in Nyamata, Rwanda as a Global Health Corps (GHC) fellow. Representatives from GHC placement organizations and GHC alumni and fellows were represented. Incredible speakers, including the honorable Minister of Health, the Chief Gender Officer for Rwanda, and the Executive Director of Health Development Initiative (HDI) spoke on interesting and engaging topics around sexual and reproductive health, mainly among adolescents. We debated the age of consent, the strides made towards reducing sexually transmitted infections (STIs) and unwanted pregnancies in Rwanda, and more.

Participants in the convening, June 2018

One of the most heated debates of the day stemmed from a presentation about reducing HIV risk and unplanned pregnancies among youth. We discussed the role of consent, youth testing campaigns, and sexual health education, but it was condom distribution services in schools that generated the fieriest discussion. Throughout the course of this discussion, my eyes were increasingly opened to how important examining and challenging power dynamics is to achieving health equity.

Complexity in culture

At first, I thought the distribution of condoms in schools was a no-brainer. More accessible condoms means safer sex and a decrease in unintended pregnancies, STIs, and of course, HIV. Some conference participants saw condom distribution in schools the same way — as a method of harm reduction. The data indicate that adolescents in Rwanda are having intercourse, so advocating for condom distribution sites that are easily accessible for youth who don’t have a budget for condoms decreases their risk of unintended consequences from sexual activity. Yet many more conference participants argued the exact opposite. Having condoms in school, they said, will increase the number of adolescents engaging in sexual activity.

This infuriated me. Studies across the U.S. have demonstrated that having condoms available in schools does not increase the risk of sexual activity. Those same studies showed that having condom distribution sites in school increased safe sex practices.

To me, condom distribution in school seemed like a simple solution to promote safer sex practices, but at the conference, the idea was met with serious opposition.

As a volunteer with the Boulder County AIDS Project (BCAP) in college, I saw the benefits of harm reduction strategies, especially among people who inject drugs. In 1989, Boulder County Public Health became one of first three syringe exchange programs in the country, and BCAP joined the Works Program in 2013. Ever since, BCAP has served thousands of individuals who are at risk of acquiring HIV and Hepatitis C (HCV) by providing people with syringes, harm reduction strategies, and overdose education. Through my experiences with BCAP, I saw how access programs played an essential role in the reduction of HIV and HCV transmission and overdose. These programs aren’t targeted at stopping drug users, they’re aimed at making a risk less risky.

So what’s the priority: safe sex or no sex? With global studies indicating that abstinence-only education is not sufficient for curbing the HIV epidemic, I’m on the safe sex side. Especially when Sub-Saharan Africa is on the precipice of the second wave of the HIV epidemic, as Dr. Mark Dybul, the former director of The Global Fund to Fight AIDS, Tuberculosis, and Malaria, has pointed out.

“The Tyranny of Averages”

Globally, there have been major improvements in the fight against HIV/AIDS. Between 2000 and 2016, there was a 39% reduction in new HIV infections, and HIV-related mortality decreased by one third because of antiretroviral therapy. Moreover, in Sub-Saharan Africa, between 2010 and 2016, new HIV infections dropped by 29% and AIDS-related deaths dropped 42%. These statistics are incredible and heartening: they are a direct result of the innovation and commitment of all the collaborators working to end HIV. However, it is important to note that these figures are averages — and when we break down the aggregate statistics, a stark and frightening reality becomes more apparent, especially when it comes to youth.

For example, we know that the number of adults aged 15–65 are increasingly aware of their status, connected to treatment, and virally suppressed. But when you look at the population that is 15–24 years old, the percentage of those who know their status is much lower. In Malawi, for instance, approximately 73% of adults know their status, but only about 50% of young people know theirs. These data are consistent across the region and concerning, especially if adolescents are having unprotected intercourse because condoms are not easily accessible to them.

There is massive population growth on the African continent, mainly among young people. It’s estimated that the youth population (those younger than 25-years-old) will more than double from 230 to 450 million by 2050. This means that the fastest growing population is also the most at risk of contracting HIV. As such, Bill Gates projected 4.2 million 15–24-year-olds will be living with HIV in Sub-Saharan Africa if we don’t change our approach.

Projection of HIV prevalence among 15–24 year-olds, living in Sub-Saharan Africa by 2030. Source: Bill Gates, speaking at International AIDS Society Conference, Durban, South Africa, July 2016.

Shifting Gears and Perspectives

With projections like these, it’s clear we, as HIV program implementers and health advocates, need to get creative and try new approaches that target adolescents. But how do we best do this? To me, condom accessibility in schools seemed like a simple solution to promote safer sex practices, but at the conference, the idea was met with serious opposition.

So, when you talk about distributing condoms in schools, you’re openly challenging the cultural and religious notion that sex isn’t/shouldn’t be happening before marriage and especially not among adolescents.

At lunch when I spoke with individuals who had opposed the idea, I learned that it was for several different reasons, but the main reason revolved around religious and cultural norms. In Rwanda, while sex isn’t necessarily a taboo topic, it’s something that is generally seen as an act between married adults. Sex before marriage is not widely accepted and openly talking about sex — as seen regularly in western media, TV shows, and movies — isn’t deemed appropriate. So, when you talk about distributing condoms in schools, you’re openly challenging the cultural and religious notion that sex isn’t/shouldn’t be happening before marriage and especially not among adolescents.

I don’t have the answers, but I think adolescents do — both here, in Rwanda, and around the world.

Regardless, the reality is that wherever you go in the world — no matter the context, culture or country — adolescents are having sex. In my opinion, our job as public health professionals is to keep them safe. Studies around the world indicate that “abstinence only” education isn’t satisfactory in preventing STIs, HIV, and unintended pregnancies. So what then is the culturally and socially appropriate way to tackle this challenge in the Rwandan context?

Adolescent Voices

When the conference reconvened after lunch, it hit me — there were very few adolescents in the room and those who were there were not speaking up. How did they feel about the condom distribution programs in schools? Did it tempt them to have sex? Did it make them uncomfortable? We weren’t asking the key stakeholders how they felt about the situation and if they had any other, more creative ways to address the difficulty adolescents face when trying to access condoms.

I don’t have the answers, but I think adolescents do — both here, in Rwanda, and around the world. In South Africa, at the request of their young adult clients, one organization started a youth club where adolescents could come to pick up their antiretroviral treatment, receive clinical screening services, and initiate family planning services. The Zimele program in South Africa works to educate and empower adolescents so they’re prepared for puberty, sex, and other adult responsibilities. In Zambia, they’ve had success with support groups for adolescents living with HIV.

Grappling with power dynamics across age groups is an important start to improving sexual and reproductive health for all. Engaging adolescents might just be the way of bridging the cultural gap to create programs that are effective in terms of empowerment, education, and bringing about an HIV-free generation.

Grace Lincenberg was a 2017–2018 Global Health Corps fellow in Rwanda.

Global Health Corps (GHC) is a leadership development organization building the next generation of health equity leaders around the world. All GHC fellows, partners, and supporters are united in a common belief: health is a human right. There is a role for everyone in the movement for health equity. To learn more, visit our website and connect with us on Twitter/Instagram/Facebook.