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Côte d'Ivoire Behavioral Surveillance Survey This document presents valuable data about HIV/AIDS-related knowledge, attitudes, and behaviors, based on the behavioral surveillance survey conducted in Côte d'Ivoire in 1998. |
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Introduction to Behavioral Surveillance SurveysFHI's Behavioral Surveillance Surveys (BSS) provide valuable data about HIV/AIDS-related knowledge, attitudes, and behaviors. The BSS methodology is a monitoring and evaluation tool designed to track trends in HIV/AIDS-related knowledge, attitudes, and behaviors in subpopulations at particular risk of HIV infection, such as female sex workers, injection drug users, migrant men, and youth. Based on classic HIV and sexually transmitted disease (STD) serologic surveillance methods, BSS consist of repeated cross-sectional surveys conducted systematically to monitor changes in HIV/STD risk behaviors. A key benefit of the methodology is its standardized approach to questionnaire development, sampling frame construction, and survey implementation and analysis. BSS findings serve many purposes: They yield evidence of project impact, provide indicators of project success and highlight persistent problem areas, identify appropriate intervention priority populations, identify specific behaviors in need of change, function as a policy and advocacy tool, and supply comparative data concerning behavioral risks. BSS have been conducted in more than 20 countries -- primarily in Africa and Asia -- since 1992, and their use in Latin America and the Caribbean is growing. Since 1999 they have been used in cross-border sites in Asia and Africa, where they are proving beneficial for understanding the pandemic from a regional instead of a purely country-specific perspective. In several countries multiple rounds of BSS have been implemented already, with the trend data used to formulate new programs and to adapt existing ones. Introduction to Côte d'Ivoire BSSCôte d'Ivoire is the country hardest hit by the epidemic in West Africa. Of its 15 million inhabitants, nearly 1 million people are living with HIV/AIDS. At least 10 percent of the sexually active population and 70 percent of female sex workers are estimated to be HIV-positive. The National School of Statistics and Applied Economics (ENSEA), in conjunction with FHI/IMPACT, initiated a first wave of BSS in 1998 among four subpopulations in Côte d'Ivoire. This report summarizes the findings of that study. Study Design and MethodologyStudy population Data on high-risk subpopulations provide information on groups having the greatest impact on the HIV and STD epidemics. For this reason, subpopulations for BSS primarily consist of groups, such as female sex workers (FSWs), who are at high risk of becoming infected and passing the infection onto others. Other subpopulations are considered "bridge" groups and consist of individuals who have significant sexual contact with both high- and low-risk groups. Long distance truckers or miners are examples of bridge populations, as they may have contact with non-regular partners and FSWs while away from their regular partners for extended periods of time. Low-risk groups form more broadly defined general populations with varying socio-demographic characteristics, such as workers and students. Table 1 provides a list of the selected subpopulations that participated in BSS: FSWs, truck drivers, male migrant workers ages 15 to 49, and male and female youth ages 15 to 19. Youth were sampled from six regional capitals. FSWs were sampled from five of these six cities. Truck drivers were sampled from three cities along the Abidjan -- Ouagadougou/Bamako/Niamey truck route. Migrant workers were sampled from three large agro-industrial farms located throughout Côte d'Ivoire and came primarily from Côte d'Ivoire (57 percent), Burkina Faso (35 percent), and Mali (3.5 percent). Sample size The number of respondents for each group was determined based on the estimated level of key risk behaviors (such as percentage using condoms with non-regular sex partners) and the degree of confidence required to detect a significant change in behavior over time.
Table 1. Subpopulations, Study Sites, and Sample Sizes
Sample design/data collection Due to the different characteristics of each subpopulation, sampling methods varied. A two-stage cluster sampling design was used for FSWs and youth. During the first stage, a list of clusters was established and the number of individuals per cluster was estimated. Locations such as bars and clubs served as clusters for FSWs, and neighborhood blocks served as clusters for youth. Once the list had been developed, clusters were randomly selected for inclusion. During the second stage, individuals in selected clusters were randomly selected to be interviewed from the selected sites until the desired sample sizes were reached. A single-stage sampling design was employed for the trucker survey because the sites were pre-determined. All truckers passing through each selected site were interviewed. A two-stage sampling design was employed for male migrant workers. Company sites were selected based on at pre-determined sites. Systematic random sampling was used in each village until the desired sample sizes were attained. Interviews with respondents were conducted primarily in French, with local languages and English used as needed. ENSEA analyzed the data with technical assistance from FHI/IMPACT. Epi Info and SPSS were used to perform data entry, management, and analysis. Results for Female Sex WorkersSociodemographics The age of the FSWs interviewed ranged from 12 to 60. The majority were between 20 and 30 years old, with a mean age of 26. In most sites approximately 16 percent of FSWs were younger than 20 years of age; however, nearly a quarter of the FSWs in San-Pédro were younger than 20. Overall, it was found that FSWs had little education. On average, 44 percent of FSWs had no schooling and less than one percent had attended high school. One out of four reported attending junior high. FSWs in Korhogo were the least educated: over half (55 percent) had no education, and none of them had attended high school. Forty-four percent of FSWs reported being single at the time of the interview, while only two percent said they were married. One in five reported living with someone to whom they were not married, and more than one-third were separated or divorced. The average age upon entering sex work was 23 years. Knowledge of STDs When asked if they knew male and female symptoms of STDs, 70 percent of FSWs knew at least two female symptoms and over half (55 percent) knew at least two male symptoms (figure 1). Seventeen percent knew no female symptoms and 24 percent knew no male symptoms.
Figure 1. FSW knowledge of STD symptoms
 Knowledge of HIV/AIDS Knowledge of the existence of HIV/AIDS was almost universal (98 percent), and only 11 percent of respondents did not know any correct methods to prevent HIV/AIDS (figure 2). Sixty-seven percent could state one correct method of prevention, while 20 percent reported knew at least two methods.
Figure 2. FSW knowledge of HIV prevention methods
 Eighteen percent of FSWs reported not knowing anyone infected with HIV/AIDS. Only 6.4 percent said they knew a family member or close friend who was living with HIV or had died of AIDS. Behavioral indicators More than half of FSWs surveyed had had sexual intercourse for the first time before age 15, while the majority (87 percent) had had sexual intercourse before the age of 18. The mean age of first sexual relations among the FSWs interviewed was 15 years old. Of FSWs interviewed who were younger than 20 years old, more than three-quarters had their first sexual relations before age 15. In contrast, 23 percent of FSWs older than 40 reported having their first sexual relations before age 15. Most FSWs interviewed had used a condom with their last non-regular and regular clients (84 percent and 82 percent, respectively), but the percentage who had used a condom with regular non-client partners was much lower (figure 3). While 73 percent of FSWs older than 35 reported using a condom with the last non-regular client, 89 percent of those younger than 20 reported using a condom with this type of client. Almost all FSWs (99 percent) interviewed stated they knew where to obtain a condom. Half of the women knew what a female condom was, but only 14 percent knew where to get one.
Figure 3. FSW condom use at last sex
 Results for Male Rural Migrant Workers, Ages 15-49Sociodemographics All rural migrant worker respondents were male and between the ages of 15 and 49 years old. The mean age of respondents did not vary much among study sites (28.6 to 30.5 percent) and was approximately 30 years old for all respondents. The majority (57 percent) of the respondents were from Côte d'Ivoire, followed by those from Burkina Faso (35 percent). The percentage of migrants who were illiterate (no schooling) varied substantially among study sites, ranging from 64 percent at the Agro-Industrial Company of Bettié (SAIBE) and 48 percent at the Rubber Company of Grand Béréby (SOGB) to only 21 percent at Sucrivoire Zuénoula. On average, 39 percent of the migrant workers interviewed had no schooling, 25 percent had a primary school education, and the remaining 36 percent had at least a junior high school education. More than half the migrants interviewed reported being in a union with someone, either married (46 percent) or living with someone (18 percent). The remaining 36 percent reported being single and living alone. Knowledge of STDs Most of the migrant respondents (91 percent) had heard of STDs. Among migrants younger than 20 years old and those with no education, 25 percent and 18 percent, respectively, had never heard of STDs. Well over half (59 percent) of all migrants did not know at least one female STD symptom, while 20 percent did not know at least one male symptom (figure 4). More than half (55 percent) knew at least two male STD symptoms, but only 23 percent knew at least two female symptoms. Just over eight percent of respondents reported that they had never heard of STDs.
Figure 4. Migrant knowledge of STD symptoms
 Knowledge of HIV/AIDS More than 99 percent of migrant workers had heard of AIDS and 55 percent knew at least two correct methods of HIV/AIDS prevention (figure 5). Nine percent could state no correct methods, while 35.5 percent were able to identify one method of prevention. Sixty-eight percent of migrants did not know anyone infected with HIV. However, almost 16 percent reported having a family member or close friend who was living with HIV or had died from AIDS.
Figure 5. Migrant knowledge of correct HIV prevention methods
Behavioral indicators Just over six percent of migrant workers reported never having had sexual intercourse. Of the 86 percent who reported having been sexually active in the past 12 months, 69 percent stated that during this period they did not have sexual relations with a non-regular partner. The percentage reporting sex with one non-regular partner was 15.6 percent and with two was 6.1 percent. Only nine percent said that they had had sex with more than two non-regular partners in the past 12 months. Sixty-seven percent of those with non-regular partners also reported using a condom the last time they had sex with a non-regular partner (figure 6). The proportion reporting condom use at last sex with a regular partner was only 21 percent, or approximately one-third the level of condom use at last sex with a non-regular partner.
Figure 6. Migrant condom use at last sex
 Only five percent of the sexually active migrants reported having sex with an FSW in the past 12 months, with only two percent reporting three or more encounters with FSWs. Of the respondents who said they had had commercial sex partners, 82 percent reported using a condom during their last sexual relations with an FSW. Results for Truck Drivers, Ages 15-49Sociodemographics All the truck drivers interviewed were males between the ages of 15 and 48. The mean age of all the truckers was 28 years old, with the majority (38 percent) being 30 years old or older. One-third of the respondents had no schooling, but one-fourth had a secondary school level education or higher. One out of four respondents had a primary school education, and an additional 17 percent had attended a koranic school. More than half the respondents (54 percent) stated they were not married. Over one-third (38 percent) were married, and eight percent said they were not married but were living with someone. The majority of the truckers were from Côte d'Ivoire (35 percent), Mali (36 percent), or Burkina Faso (23 percent). Knowledge of STDs Almost all truckers (95 percent) had heard of STDs, but 70 percent could name no female symptoms and more than one-quarter (27 percent) could name no male symptoms (figure 7). While 41 percent knew at least two male STD symptoms, only eight percent knew at least two female symptoms.
Figure 7. Trucker knowledge of STD symptoms
 Knowledge of HIV/AIDS More than 99 percent of truck drivers had heard of HIV/AIDS. Among all trucker respondents, 87 percent were able to spontaneously name at least one correct method of preventing HIV infection (40 percent cited one correct method and 45 percent gave two or more) (figure 8). There was a direct relationship between the level of education and the number of prevention methods known. While 20 percent of those with no education knew no correct methods of prevention, only six percent with at least a secondary education could name no correct methods.
Figure 8. Trucker knowledge of correct HIV prevention methods
 More than two-thirds (67.5 percent) of respondents stated they knew no one with HIV/AIDS. The remaining respondents knew either a close friend or family member (18.2 percent) or someone else (14.3 percent) who was living with HIV or had died from AIDS. Behavioral indicators Twelve percent of the truckers interviewed said they had not been sexually active in the past 12 months (figure 9). Of those who were sexually active, 63 percent stated that they had not had sex with a non-regular partner in the past 12 months. More than one out of four sexually active truckers reported having one or two non-regular partners; 12 percent had had three or more non-regular partners in the past 12 months. Younger truckers tended to have more non-regular partners than older truckers.
Figure 9. Number of partners in past year among truckers
 Most truck drivers (84 percent) reported they had had no sexual intercourse with FSWs in the past 12 months. Of those who had, eight percent had had one or two encounters with an FSW and an equal percentage had had three or more during the past 12 months. Sexual relations with FSWs over the past 12 months was correlated with age: 24 percent of those under 20 years old had had sexual relations with an FSW at least once, while only 11 percent of those older than 30 had. Of respondents reporting sexual relations with non-regular partners, 60.6 percent said they always used a condom, compared to 77.4 percent who reported always using a condom with FSWs (figure 10). Younger truck drivers were more likely than their elders to always use a condom with both non-regular partners and FSWs.
Figure 10. Trucker condom use at last sex
 Condom use at last sex with non-regular partners (71.8 percent) and with FSWs (87.8 percent) was relatively high. In comparison, only 30 percent of respondents had used a condom at last sex with a regular partner. Results for Youth, Ages 15-19 (male and female)Sociodemographics All youth respondents were between 15 and 19 years old. In general, male respondents were evenly distributed across this age range, whereas female respondents tended to be grouped in the younger end of the range. More than twice as many female respondents had no education (29 percent of males compared to 13 percent of females). Male youths were also found to have attended secondary school more often than their female counterparts (60 percent compared to 40 percent). Approximately two percent of the entire sample had attended a koranic school, and less than one-half of one percent had received an education beyond secondary school. Knowledge of STDs Overall, knowledge of STDs among both males and females was poor. Nearly a quarter (23 percent) of female respondents and 12 percent of male respondents had never heard of STDs (figure 11). In addition, over half of both male and female respondents knew no female STD symptoms (66 percent and 54 percent, respectively). Levels of knowledge of male STD symptoms were similar, with 48 percent of males and 59 percent of females not knowing any male symptoms. Knowledge of STD symptoms among males was statistically significant when compared with level of education attained. Data analysis revealed a statistically significant correlation between males' knowledge of STD symptoms and level of education attained.
Figure 11. Knowledge of gender-specific STD symptoms
 Knowledge of HIV/AIDS Almost all respondents (99 percent of males and 98 percent of females) had heard of HIV/AIDS. Just over three-quarters reported that they knew no one with HIV or AIDS. Approximately eight percent reported having a close family member or friend who was living with HIV or had died from AIDS. More than two-thirds of males and over half of the females were found to know at least two correct methods of HIV/AIDS prevention (figure 12). Among males, only eight percent knew no correct means of preventing HIV, while 17 percent of female respondents knew no correct means of prevention.
Figure 12.Knowledge of HIV prevention methods
 Behavioral indicators Out of all youth surveyed, 55.3 percent of males and 53 percent of females reported having had sexual intercourse, and the average age at first sex for both males and females was 15 years old. Over two-thirds (68 percent) of males reported having had a sexual partner in the last year, with 32 percent reporting one partner and 35 percent reporting two or more (figure 13). One-third reported they were unsure as to how many partners they had had in the past year. Among female respondents, 56 percent reported having one partner, and 21 percent reported having two or more partners. 22 percent of females did not know how many sexual partners they had had over the past 12 months. Only about one-third of both sexes reported having used a condom the last time they had sex (35 percent of males and 32 percent of females).
Figure 13. Number of sex partners in last year
 Summary of FindingsKnowledge of gender-specific STD symptoms Of all subpopulations, FSWs were the most knowledgeable regarding STD symptoms. Approximately half of FSWs surveyed knew at least two male STD symptoms, and 65 percent knew at least two female STD symptoms. Among youth, less than one-quarter of both males and females were able to cite at least two gender-specific symptoms. Forty-one percent of truck drivers could site at least two male symptoms, and only eight percent knew two female symptoms. Knowledge of means of HIV prevention Youth were the most knowledgeable of all subpopulations concerning correct methods of HIV prevention, with 67 percent of males and 53 percent of females able to cite at least two correct means of prevention. Less than half (47 percent) of truckers and 55 percent of migrant men were able to site at least two correct prevention methods. The percentage of FSWs who knew at least two correct means of HIV prevention was small (20 percent). Sexual initiation More than half (55 percent) of the youth respondents were sexually active and had started at a young age (15). The majority (51 percent) of FSWs had had their first sexual relations before the age of 15. Non-regular partners The level of sexually active youth with multiple sex partners was relatively high, especially among males (35 percent compared with 14 percent of females). Among migrant workers and truckers, approximately one-third reported having had at least one non-regular sex partner in the past 12 months. Commercial partners Only eight percent of truckers and five percent of migrant workers reported having had at least one sexual encounter with an FSW in the past 12 months. Condom use More migrants reported using a condom during their last encounter with an FSW (82 percent) than with a non-regular partner (67 percent). Truckers reported the inverse: 87.8 percent had used a condom at last sex with an FSW and 71.8 percent had used one at last sex with a non-regular partner. Most FSWs interviewed used a condom with their last non-regular and regular clients, (84 percent and 82 percent, respectively), but FSW condom use at last sex with a regular non-client partner was low (16 percent). Technical Guidelines For more information, see the following technical guidelines: UNAIDS and Family Health International, May 1998. Meeting the Behavioural Data Collection Needs of National HIV/AIDS and STD Programmes.
Family Health International, June 2000. Behavioral Surveillance Surveys (BSS): Guidelines for Repeated Behavioral Surveys in Populations at Risk for HIV.
UNAIDS and WHO, 2000. Guidelines for Second Generation HIV Surveillance.
Acknowledgments The Côte d'Ivoire BSS was executed by:
Administered by:
With technical assistance from:
With administrative and logistical support from:
Funded by:
This executive summary is based on the following report:
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