School of Public Health

Marielle Goyette

Association between menopause and unprotected sex in high-risk HIV-positive women in Mombasa, Kenya


A growing number of HIV-positive women now live well beyond menopause. There is little information about condom use in postmenopausal women in sub-Saharan Africa. Postmenopausal women are no longer at risk for pregnancy, and some studies suggest that they may choose to use condoms less often than premenopausal women. Our hypothesis was that unprotected sex, defined by the presence of prostate specific antigen (PSA) in vaginal secretions, would be more common at postmenopausal visits compared to premenopausal visits.


Prospective cohort study of HIV-positive women >16 years old, who reported trading sex for cash or in-kind payment in Mombasa, Kenya. Methods: At enrollment and monthly follow-up visits, participants completed a standardized interview. A speculum-assisted pelvic examination with collection of genital samples was performed at enrollment and quarterly visits. Menopause was assessed using a clinical decision tool. The primary outcome of unprotected sex was determined by the presence of PSA in vaginal secretions.


We followed 403 HIV-positive women who contributed 2753 quarterly examination visits. Detection of PSA was less frequent at postmenopausal visits compared to premenopausal visits (55/540,10.2% versus 397/2210, 18.0%; relative risk [RR] 0.57, 95% confidence interval [CI] 0.38-0.86). Adjusting for age diminished the association between menopause and detection of PSA (adjusted RR 0.70, 95%CI 0.45-1.11). Women were more likely to report no sex in the past week at postmenopausal visits compared to premenopausal visits (RR 1.67, 95%CI 1.44-1.95). When sexually active, women reported the same rate of condom use at postmenopausal and premenopausal visits (RR 0.97, 95%CI 0.84-1.12).


Postmenopausal status was associated with a lower risk of unprotected sex compared to being premenopausal in this population of high-risk HIV-positive Kenyan women. The relationship between menopause and unprotected sex is likely to be contextual and may differ with varying risk groups, regions, and levels of exposure to sexual health education.