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AIDS Care
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The gender ratio imbalance and its relationship to risk of HIV/AIDS among African American women at historically black colleges and universities
Y. Owens Ferguson MPH , S. Crouse Quinn , E. Eng & M. Sandelowski
a b a b a a

University of North Carolina at Chapel Hill University of Pittsburgh

Available online: 18 Jan 2007

To cite this article: Y. Owens Ferguson MPH, S. Crouse Quinn, E. Eng & M. Sandelowski (2006): The gender ratio imbalance and its relationship to risk of HIV/AIDS among African American women at historically black colleges and universities, AIDS Care, 18:4, 323-331 To link to this article: http://dx.doi.org/10.1080/09540120500162122

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AIDS Care, May 2006; 18(4): 323 /331

The gender ratio imbalance and its relationship to risk of HIV/AIDS among African American women at historically black colleges and universities

Y. OWENS FERGUSON1, S. CROUSE QUINN2, E. ENG1, & M. SANDELOWSKI1

1

University of North Carolina at Chapel Hill and 2University of Pittsburgh

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Abstract African American women are at increased risk of HIV transmission through heterosexual contact. HIV/AIDS is the leading cause of death among African American women between 25 to 34 years of age, and many of these women were likely infected while in college. Four focus groups were conducted with African American students attending Historically Black Colleges and Universities (HBCUs) in order to learn about the college dating environment and how it influenced womens risk of HIV infection. We used constant comparison techniques and visual display matrixes to analyse the data. Students identified the gender ratio imbalance of more women to men on campus as a key element of the campus dating environment and described how it places women at an increased risk for HIV infection. Primary consequences of this gender ratio imbalance were men having multiple female sexual partners during the same time period and women complying with mens condom use preferences. HIV preventive intervention programmes at HBCUs must address the gender ratio imbalance and its consequences to reduce womens risk of contracting the infection.

The increase in HIV/AIDS cases among African American women is alarming and the cause of much concern within the African American community (Blocker, 2004; Clark & Robinson, 2004; Wilson, 2004). HIV/AIDS is the leading cause of death among African American women age 25 /34 (Anderson & Smith, 2003). Although both African American men and women are disproportionately represented in HIV/AIDS diagnoses by gender (49% and 72%, respectively) compared to their overall representation in the U.S. population (12.3%) (Centers for Disease Control and Prevention [CDC], 2003), African American women appear to be at increased risk, not only because of their minority status, but also because of gender (Airhihenbuwa et al., 1992; Amaro, 1995; Fullilove et al., 1990; Mays & Cochran, 1988; Quinn, 1993). Many African American women are likely to be infected while in college. But few studies of HIV/ AIDS and African American women have focused on the college student population (Foreman, 2003; Jemmott & Jemmott, 1991; Lewis, et al., 2000; Mays & Cochran, 1988). They have instead focused on low-income, urban, or intravenous drug user populations (Jemmott & Brown, 2003; Mays & Cochran, 1988; Quinn, 1993; Sterk et al., 2003; Wechsberg et al., 2003). Although college students were not

designated as an at risk population (i.e. intravenous drug users, gay males, Haitians) in the early years of the HIV/AIDS epidemic (Sepkowitz, 2001), the sexual behaviours of college students (Lewis et al., 1997) put them at risk for HIV infection. Gayle et al. (1990) reported that 2 in 1000 college students in their multi-state sample of 19 universities tested positive for HIV, with approximately 3 in 1000 HIV positive test results among African American college students. Using a self-report survey, Johnson et al. (1994) found that approximately 13 of the 408 African American college students at a southern university stated that they tested positive for HIV. In North Carolina, researchers reported an HIV outbreak on college campuses (Yee, 2004). A retrospective review of all men aged 18 to 30 years with HIV diagnosed during January 2000 to May 2003 indicated that 49 of the 56 HIV cases were African American college males who had sex with men and women (Leone et al., 2004). Studies investigating HIV/AIDS-related knowledge, attitudes and behaviors among African American college students indicate that most of them had practiced inconsistent condom use and had two or more sexual partners over the past 6 to 12 months (Bazargan et al., 2000; Fennell, 1997; Jemmott & Jemmott, 1991; Johnson et al., 1992b; Johnson et

Correspondence: Y. Owens Ferguson, MPH, Department of Health Behavior and Health Education, CB #7440, UNC School of Public Health, Chapel Hill, North Carolina 27599-7440. Tel: (703) 568-9365. Fax: (703) 991-5935. E-mail: Yvonne_Ferguson@unc.edu ISSN 0954-0121 print/ISSN 1360-0451 online # 2006 Taylor & Francis DOI: 10.1080/09540120500162122

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Y. O Ferguson et al. views with faculty and staff, and focus groups with African American college students who attended two HBCUs. The aim of the primary study was to explore: (a) the social and cultural characteristics of the campus dating environment and how it related to HIV/AIDS-related risk behaviours; (b) African American college students perceptions of their susceptibility to HIV/AIDS; (c) gender differences related to condom negotiations; and (d) students and administrators HIV/AIDS prevention strategies. For this analysis, we used the four focus group interviews to ascertain mens and womens views of the factors within the college dating environment that influence womens risk for HIV infection. Sample A total of 31 African American students from North University and Merrifield State University (pseudonyms) participated in the focus groups. Each focus group consisted of six to nine students. Most were sophomores (n 0/14). Their average age was 20 years across all four groups. Although recruitment efforts targeted both women and men for mixed-sex focus groups, the majority of the participants were women. (The gender imbalance we describe later in this paper may also have contributed to the gender imbalance in the focus groups.) The final sample included three mixed sex groups and one all female group (see Table I). The University of North Carolina at Chapel Hill School of Public Health Institutional Review Board approved this study and each student participating provided written and verbal informed consent. Data collection Focus group interviews were used to capitalize on the knowledge to be gained from group interactions around a predefined topic (Morgan, 1988). We
Table I. Demographics of students (N0/31). Focus Group Group Number of students Gender Male Female Mean Age (yrs.) Year in college Freshman Sophomore Junior Senior Graduate 1* 8 1 7 19.5 2* 8 0 8 20 3** 6 1 5 19.5 3 3 3 3 3 4** 9 2 7 21 Total 31 4 27 20 3 14 6 5 3

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al., 1994; Thomas et al., 1989; Lewis et al., 2000; Whaley & Winfield, 2003). Further, African American male respondents of the CDC National College Risk Behavior Survey of students who attended Historically Black Colleges and Universities (HBCUs) were more likely than women to report having four or more lifetime sexual partners (Fennell, 1997). Studies with only African American female college students have shown that most did not communicate with their male partners about condom use. Communication about condoms depended on various factors including: (a) the anticipated reaction from the male partner; (b) whether the sexual relationship was casual or committed; (c) their attitude toward condom use; and (d) normative condom use behaviour among female friends (Foreman, 2003; Jemmott & Jemmott, 1991; Lewis, et al., 2000; Mays & Cochran, 1988). Historically black colleges and universities as environments of risk Following Green et al. (1990), who stated that environments are key factors in shaping individual and collective behaviour, HIV/AIDS-related risk behaviours of African American college students are shaped by their school environment. Accounting for only 3% of the total number of institutions of higher education in the United States, HBCUs were founded in the 1800s by philanthropic associations, churches, local communities and private donors to provide educational opportunities for African Americans denied government supported education because of slavery laws (Brown & Davis, 2001). Currently, there are 105 public and private HBCUs that differ by size, curriculum, cost and other characteristics, but have a common goal to serve as primary providers of higher education for African Americans (US Department of Education, 2004; Brown & Davis, 2001). Although researchers suggest that HIV/AIDS risk among African American women is best understood by emphasizing HIV/AIDS-related risk behaviours within the larger context of the African American community (Airhihenbuwa et al., 1992; Fullilove et al., 1990), none of the HIV/AIDS studies conducted with samples drawn from HBCUs (Fennell, 1997; Braithwaite, et al., 1998; Taylor, et al., 1997) addressed how this unique campus environment influenced HIV/AIDS-related behaviour or prevention strategies. The purpose of this study was to understand this influence from the perspective of African American students in these schools. Methods The data for this investigation were collected in 1999 as part of a larger study involving individual inter-

6 2

5 1 2

Notes : *North University; **Merrifield University

Gender ratio imbalance worked to ensure that the focus groups were flexible and offered a non-threatening environment in which students could freely share their views on sensitive topics, such as sexuality and HIV/AIDS (Basch, 1987; Krueger, 1998). As threat is often minimized by having moderators of the same race/ethnicity and background as the participants (Jarrett, 1993), the first author, an African American woman who attended an HBCU, moderated all focus groups. The observer for each group also shared the same background. Two one-hour focus groups were held on the grounds of each participating HBCU; two in a residence hall lounge and the other two in a conference room. We used a focus group interview guide to elicit information concerning: (a) the campus dating scene; (b) gender differences on condom negotiations; (c) HIV/AIDS-related behavioural risk factors; and (d) campus-based HIV/ AIDS prevention intervention programmes. To assess the cultural appropriateness and clarity of questions, the focus group interview guide was pretested with a group of students with demographic characteristics similar to the students targeted for this study. Based on the feedback from the pre-test group, we made adjustments to the interview guide to improve the clarity and decrease the amount of questions asked. Analysis All focus group interviews were audio taped and transcribed verbatim to include utterances, pauses, and laughter for context. The transcripts were entered into QRS NVivo 1.0 (QSR International, 1999) for analysis. We used constant comparison strategies, aided by the creation of visual displays (Krueger, 1998; Miles & Huberman, 1994) to analyse students responses. We assessed what topics generated the most discussion, agreement and disagreement, about HIV/AIDS-related risk behaviours and the campus dating environment across all four groups. After noting that all groups discussed the gender ratio imbalance on their campuses, we found that the students responses could be categorized by two primary HIV/AIDS risk factors: (a) multiple sex partners and (b) no condom use during vaginal intercourse (National Institutes of Health [NIH], 1997). Comparing these categories of responses between focus groups and between women and men, we sought to discern how they were linked in the minds of the students. Findings Students consistently identified the gender ratio imbalance /of more women to men on campus /as

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a key element of the campus dating environment that increased womens risk of HIV infection. As they described it, the primary consequences of this gender ratio imbalance were (a) men having multiple female sexual partners and (b) women complying with mens condom use preferences. Although the term dating is used throughout this article, students used various terms, such as messing around, hanging out, socializing, and talking when describing the campus dating environment, which included both social and sexual relationships. Gender ratio imbalance All groups initially described their campus gender ratio as consisting of more women than men. Although the students did not know their universities actual enrolment demographics, their perception of women outnumbering the men on their campus was consistent with the available empirical data at their schools. According to Merrifield State University and North University records, women outnumbered men by at least 1.6 or more to 1 at these and most other HBCU campuses (Anyanwu, 1998; Foston, 2004; Merrifield State University Office of Planning and Evaluation, 2003; Slater, 1994). Researchers have proposed many reasons why African American women outnumber men at the college level (Jordan & Cooper, 2001; Taylor, 1994; Washington & Newman, 1991), with racism (Jones, 2000) emerging as the key social determinant of low male enrolment (Cross & Slater, 2000; Slater, 1994). African American males responses to racism, the absence of African American male role models at school, and the low expectations of teachers of the academic performance of African American males have all contributed to the gender ratio imbalance (Taylor, 1994; Slater, 1994), of which the students were highly aware. Indeed, although these University Admissions Departments reported that the gender ratio was approximately 1.6 women to every one man (Anyanwu, 1998; Merrifield State University Office of Planning and Evaluation, 2003; Slater, 1994), the students perceived the ratio imbalance as even greater. One male student put the ratio at 15 women to 1 man. One female student put it at up to 4 women to 1 man. Making this exaggerated perception more of a reality was the fact that women themselves excluded available men as datable. For example, in one group, the discussion turned to freshmen women wanting to date only upper-class men to gain a higher social status on campus. One woman suggested how the quest for status not only increased the gender imbalance, but also put these women at higher risk for infection. As she observed:

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Y. O Ferguson et al. involved with the campus dating scene, she said, Id rather just chill with my girls. Another alternative to being involved in the campus dating scene was to seek partners who were not a part of the university community. For example, one female student observed, A lot of my friends venture away from campus because we dont want anything to do with the men here. Still, some women who chose to engage in the campus dating scene participated even with the knowledge that the men they were dating were also dating other women. One female student described how the gender ratio imbalance provided for a dating environment in which some men communicated directly with their female sexual partners about their sexual relationships with other women and women accepted being one of many other sexual partners. She stated: Well, there are more females than males on this campus. So its like the males think they can have sexual relationships with many women at once. They will say, Im going to be with her at 7, but Ill be by your room at 10. In line with this female students observation, a male student observed: We have a ratio of 15 female students to one male student. And the problem is that females on this campus, not all females, but there are a significant amount of females that are sharing a dude. Mansharing. They think, This guy treats me nice, and they know hes having sex with other women and they dont care. In contrast, because some men were not forthcoming about their sexual relationships with other women, some women were unknowingly participating in man-sharing. Man-sharing was not only present at these HBCUs, but is also present within the greater African American community (Airhihenbuwa et al., 1992; Chapman, 1986). In one study, man-sharing among African American women was described as common as the cold (Johnson et al., 1992a, p. 62). Students observations also reprised comments made by college-educated African American women featured in a recent Newsweek cover story entitled, The Black Gender Gap. In this article, Cose & Samuels (2003) reported that the consequences of the under-representation of African American men on college campuses resulted in African American women: (a) being dateless throughout their college career; (b) finding an African American man who did not attend the university; or (c) knowing that they were dating a man who was also dating other women.

Upper-class men try to get to know you just to have sex with you. The freshmen girls are concerned about who the guys are. Theyll brag to their friends and say, Do you know so and so, girl? Just so their friend will be impressed and say, I know youre not messing with him! Yes girl! He came over to my house last night. Its kind of like, if the guy is well known on campus or has some type of social status, or if hes supposed to be somebody thats untouchable on campus, the freshman girl looks at it as, Well, yeah, at least I got to mess with so and so. So, they look at it as a status mark. A male student from the same group described his dating experiences with upper-class women. He noted that upper-class women took an interest in him only after he bought a car. As he observed: Not only the freshmen girls, but even some of the upper-class women choose what guys they want to talk to. Speaking as a male dealing with females. I got my car senior year and it was a hooptie [old car] (group laughter). And upper-class females who would only speak to me when it was convenient for them, now talk to me and say, Oh, you have a car now? And in the back of my mind I sometimes think, Okay, shes talking to me because I have a car, but at least shes talking to me now (group indicates agreement). So, you may decide to talk to her even though you think she only wants you for your car. It all depends on who youre dealing with and how you think of yourself. African American women outside of the HBCU setting have also been found to apply exclusion criteria that serve to reduce the number of men available to them (Fullilove et al., 1990). They defined marriageable men as heterosexual men who were employed and not incarcerated (Cochran, 1990; Sampson, 1987). Consequences of the gender ratio imbalance Multiple sex partners. Students identified men having multiple female sex partners as a key consequence of the gender ratio imbalance on campus. Women, therefore, had to make decisions about whether to accept this. Some women reportedly chose not to date at all. For example, one female student stated that she had not been on a date with a man for a while. When describing the dating environment and the availability of men on campus she said, Well, theres a drought on campus, and further voiced her frustration with the men on campus who dated multiple women at the same time. Instead of being

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Gender ratio imbalance Students described the gender differences they perceived in emotional attachments. Women discussed sexual relationships in terms of serial monogamy, while men tended to discuss polygamous sexual relationships. For example, one male student said, The point that you said about guys talking to a lot of other girls is true. Guys dont want to put all their eggs in one basket. To better understand why his female classmates preferred serial monogamy over dating several men at one time, another male student asked the women in his group this question: Isnt it possible to love or have feelings for more than one person at a time, or do I have to only have feelings for you right now, and then stop? Then, can I only have feelings for another woman right now then stop again? The following exchange between this male student and a female student further illustrates how men and women in this study differed in terms of their perspectives on emotional attachments. Male: A sexual relationship is not a sexual thing for women. I think its an emotional investment that you [i.e. women] got to kind of hold back. Its just like choosing a bank. You dont go to the first bank and put all your money in that first bank. You shop around. You look at Wachovia, you look at First Union, you look at Mechanics and Farmers and you decide which bank you want to put your money into. But girls want to think Wachovia is the only bank / Female: No! Male: And you put all your money in and Wachovia folds or closes, and then youre upset. Female: No, no, no, no, no. No! (everyone in group laughing) That is not right! We know situations where a guy was dating this girl for 3 years, and this girl is like, okay, he is the one. He is going to be my husband. But hes not even thinking like that. He had this girl strung out [emotionally attached]. Male: Is it the guys fault that the girl got strung? Female: My point is that he got her emotions strung out like that. He got her feelings for him very strong, and he made it seem like his feelings for her were strong too, and thats what men do. You make it seem like, oh yeah, Im [emotionally involved] in this relationship just as much as youre into it. Thats just like Wachovia trying to make it seem like they have a better deal than BB&T, but they dont. (everyone in group laughing).

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Later on in this group, the male student re-stated his point by saying: I think theres always going to be a conflict, because guys think of sex differently than girls do. My main point is that girls too much equate sex with love and sex with a relationship, and guys dont necessarily do that. This gender difference in attachment the students described has been reported in research, where college females were found to view sex as a part of love and marriage (Carroll et al., 1985; Houston, 1981; Foreman, 2003) while males were more oriented toward the physical aspects of sex (Houston, 1981). No condom use. Unlike their discussion about multiple sex partners, the students did not identify a direct association between their practice of not using condoms and the gender ratio imbalance on campus. However, their responses suggested an indirect effect of the gender ratio imbalance on condom use practices. Similar to their discussions about multiple sex partners, the students responses regarding condom use indicated gender differences. Students believed that low self-esteem among women compromised womens ability to communicate condom use with their male partners. One female discussed how her friends low self-esteem led to an early pregnancy: As far as the self-esteem thing, I know somebody whos pregnant right now and is young. Their reason why theyre pregnant is because they listened to a man tell them, Come on. Lets make a baby. And they took it like, Oh, he loves me! He wants to make a baby with me! So they dont use the condom and get pregnant. In this example, the man negotiated not using condoms by suggesting to this young woman that he wanted to have a child with her and, according to this student, capitalized on her low self-esteem. The women students suggested that women with low self-esteem had lower perceived control over condom negotiation situations than men. One female student expressed this idea this way: Women are embarrassed /I guess they feel like the guy wont like them if they ask for a condom. So instead of being the woman that they are, theyre just going to let this man take over and have total control of the situation. And thats not good. These students suggested that womens low selfesteem and their willingness to comply with mens

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Y. O Ferguson et al. discussed situations in which women complied with their male partners preference to wear condoms. The students believed that if men suggested condom use, women would agree with the mans suggestion. But, according to the students, men suggesting condom use was not normative behaviour on their campus. One female observed that women would be surprised by a males suggestion to use condoms. She said, I think a lot of females get shocked, like, Oh! I cant believe it! Not saying that you dont want him to use condoms, but its like, Oh, thats good. However, other women in this same group advised women to be suspicious of a mans request to wear condoms. One female student explained: I think women also have to be cautious of men when they first start out saying, Okay, lets use a condom. Lets use a condom. Because sometimes that could be a game to let the female think, Oh hes all about condoms, hes all about safe. And guys are just waiting for the time not to use the condom with her. Another female student from this group added: And I think sometimes women dont look at it like it is a game. They think, Oh, well, he always uses a condom. He cares about me more now. And sometimes its just a game, to just start off [the relationship]. Students responses indicated that for some women, mens suggestions of condom use symbolized care for them. However, because this request was thought to be uncharacteristic of men, female students warned that women should be skeptical if a man suggested condom use. In a study on African American college males and their condom use patterns, Johnson et al. (1992b) used the Condoms Emotional Reaction Scale to measure the intensity of anger experienced in relation to condom use. Men who reported consistent condom use reacted with more intense anger than those who did not practice consistent condom use when their sexual partner insisted on not wearing a condom or joked about the use of condoms (Johnson et al., 1992b). Thus, the female students belief that mens condom use suggestions were a means not to wear condoms in the future with this same sexual partner may not be applicable to men who practice consistent condom use. Indeed, this belief may jeopardize the relationships women desire. However, for men who do practice inconsistent condom use, which is the norm on campus, these womens perceptions about their male counterparts condom use intentions and future practices may be warranted.

request not to use condoms were associated with their desire to have a male partner at any cost. While agreeing with the comment above about low selfesteem, another student added: It all goes back to low self-esteem. If they feel theyre not worth protecting themselves then theyre not going to use condoms. Or if they feel like, I need this man in my life, or, Hes caring about me right now. I still want him to be there tomorrow. So, if its going to be a problem with him putting a condom on, then we wont [wear a condom]. These female students described situations in which the negotiation, from a females perspective, was agreeing with their male partners preference to have sex without a condom in exchange for an emotional attachment to the male. Researchers have found that African American womens lack of communication about condom use and decision to comply with mens condom use preferences may also be a consequence of the gender ratio imbalance in the larger African American community (Fullilove et al., 1990). The shortage of available African American men lead some women to accept not using condoms as a means to satisfy their male partner and, thereby, to secure their relationship with him (Fullilove et al., 1990). Students also mentioned that there were differences between how women and men reacted to their partners suggestion of condom use. For example, female students stated that if a woman suggested condom use, the man would associate this request with the woman having a sexually transmitted infection (STI) (versus primary STI prevention for both of them). One female student said, I heard a guy say, a girl told me to put a condom on one time and if a girl says put a condom on, then she must be dirty. Another female student had a similar comment: When a woman says, Oh well, you need to use a condom, men are like, What? You got a disease? (group agrees) The guy automatically will assume that you are trying to protect him from what you have instead of saying, Well, we need to do this [wear a condom] to protect both of us. According to these students responses, women having low self-esteem, a desire for male affective attachment, and fear of being rejected by their male partner for suggesting condom use influenced how they approached the condom negotiation process. These examples show situations where women decided to comply with their male partners preference not to wear condoms. But students also

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Gender ratio imbalance Discussion The students in this study associated the gender ratio imbalance on campus directly with men having multiple sex partners and indirectly with females complying with mens condom use preferences. Inherent in the students discussions and stories was that women had less power than men within sexual relationships on these HBCU campuses and that this imbalance of power resulted in women being exposed to HIV infection. Having a gender ratio on campus where women outnumbered men (approximately 2 to 1) provided for a complex dating environment at these HBCUs. Men had multiple female sex partners and women applied exclusion criteria that further limited their dating options with men on campus. Women had to decide whether to participate in the campus dating scene where man-sharing was a normative behaviour or find alternatives to the campus dating scene. In addition to facilitating a dating environment that limited womens dating options, the gender ratio imbalance on campus also limited womens ability to communicate with their partners about condom use. Students discussions about condom use revealed that inconsistent or no condom use was normative behaviour among students on their campus. Womens ability to communicate with their partners about condom use was compromised by their perception that men had negative attitudes toward condom use and would reject women who suggested condom use. This perception, along with a desire to secure a relationship with an available man on campus, further contributed to women not communicating condom use to their partner, resulting in condoms not being used during sexual intercourse. In short, adversely affecting women was the imbalance in power embodied in the gender ratio imbalance. According to Wingood & DiClemente (2000), the more power men have in heterosexual relationships, the more likely women will experience poor health outcomes. Man-sharing and the ability to control condom use are manifestations of this disparity in power that make women more vulnerable to contracting HIV infection. Wingood & DiClemente (2000) also proposed that the sexual division of affective attachments and social norms dictate appropriate sexual behaviour for women. This division, defined by the emotional and sexual attachments women have with men, is maintained, for example, by the expectations people have concerning how women and men should express their sexuality. According to the students, men tended to view sex as a physical experience, whereas women associated sex with love and commitment. Men assumed women had STIs if they suggested condom use, whereas some women assumed men

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cared for their health and well being if they suggested condom use. Men took advantage of the gender imbalance on campus, while women had to accept it or forego dating. Implications for research and practice Based on these study findings, we suggest that HIV/ AIDS prevention efforts focusing on African American women who attend HBCUs acknowledge how the gender ratio imbalance on these campuses and the subsequent gender power imbalance influence HIV/AIDS-related risk behaviours. This imbalance must become a target of HIV/AIDS prevention programs in African American communities (Johnson et al., 1992). Because current HIV/AIDS prevention programmes tend to target women rather than men, we suggest that these programmes include a focus on men as they play key roles in womens sexual behaviours (Amaro, 1995; Campbell, 1995; Fullilove et al., 1990; Harvey et al., 2002; Wingood & DiClemente, 2000). In conclusion, this is the first study (to our knowledge) addressing the influence of the gender ratio imbalance at HBCUs on HIV/AIDS-related risk behaviours. We encourage public health researchers to explore this topic in more depth. Additional research and intervention programs addressing the dating environment at HBCUs and its influence on the risk of HIV among African American college women could help to slow the spread of the disease and change current sexual behaviours that promote its transmission among this population. References
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