Despite numerous efforts made over the last several years to halt HIV/AIDS epidemic through increased access to treatment, educational and policy changes, the burden of HIV/AIDS is enormous especially in sub-Saharan Africa, with >60% of all HIV infections in the world occurring in this region [1] -[4] . In Nigeria, the reported HIV sero-prevalence of 4.1% among ante-natal clinic attendees in 2010 translates to 3.1 million people living with HIV/AIDS (PLWHA) [5] . However despite this high figure, condom use in Nigeria remains alarmingly very low at 25% and 11% for sexually active males and females respectively [6] . To our knowledge, condom use among HIV patients has not been reported in our environment in spite of its peculiar socio demographic characteristics [7] . Despite increased awareness of HIV infection and access to ART, condom use as a preventive measure among HIV patients has not been reported in north eastern Nigeria. Meta analysis of condom use and HAART has been reported to vary with belief about the efficacy of HAART in preventing infection [8] . Initiation of HAART has been reported to be associated with increased sexual risk behaviour [9] . Studies in the developed world suggested that individual’s awareness of their HIV sero-positive status is associated with decrease sexual risk behaviour [8] [10] . On the contrary, a report from developing countries indicated that patients’ awareness of their HIV sero-positive status including access to HAART has not led to significant risky sexual behaviour [11] . However, a subset of PLWHA is still engaged in unprotected intercourse, and hence the potential risk for HIV transmission persists [11] [12] .

To provide effective measures that diminish HIV transmission, it is important to study the knowledge of mechanisms of HIV transmission, sexual behaviour and condom use among heterosexual HIV-positive patients.

With reported high prevalence of HIV infection in Nigeria and the dearth of information on condom use and other preventive measures such as pre-exposure prophylaxis, it becomes expedient to understand the pattern of condom use among HAART naive and experienced patients in North eastern Nigeria with the view of instituting appropriate secondary preventive measures.

There is dearth of reports on condom use and uptake among HIV clients in Nigeria. To our knowledge, this is the first hospital based cross sectional study designed to provide insight into the practice of condom use and associated risk factors among HIV positive clients in north-eastern Nigeria.

Our participants consisted of both HAART naive and experienced, this gave us an opportunity to make comparison and observe the effect of highly active antiretroviral therapy on modifications in their sexual behaviour.

Most of our patients were residents of urban areas (75.3%). A substantial proportion of the HAART naive cohort had secondary education (38.8%), while Tertiary education was the predominant literacy level in HAART experienced cohort (46.6%). Civil servants constituted the majority in HAART experienced, while unemployed cohort constituted one out of every three HAART naive patients (32.8%). This finding suggests literacy level and gainful employment have a positive impact on accessing and continuing HIV care in our setting.

Married participants constituted 42.9% of the participants; they contributed the highest participants in both HAART naive and experienced cohort. At the time of the interview, 53.7% of HAART naive and 39.8% of HAART experienced participants had multiple sexual partners, with most of them in marital union. Condom use was uncommon among study participants even among married couples, almost half of the HAART naive and substantial proportion of HAART experienced never used condom while having sex. The finding of low condom use among the HAART experienced cohort in this study was surprising, considering the fact that regular counselling on adherence and condom use are provided to clients at initial assessment, commencement of HAART and as part of health talk at each clinic visit. Condom provided by the United State Government through the PEPFAR (Presidential Emergency Plan for AIDS Relief in Africa) is available free of charge on demand by clients in our HIV clinic. The low prevalence of condom use in our cohort is however similar to the proportion in HAART naive reported in south-western Nigeria [13] and National HIV/AIDS and Reproductive Health Survey (NARHS) [6] , but unlike report from the southwest, we did not observed association between uptake condom and HAART use. Although reports from developed nations documented that access to HAART to be associated to reduction in risky behaviour including increased condom use [8] [9] [14] , assessment of condom use in 20 countries in sub-Saharan Africa, indicated that levels of condom use are still very low and vary widely [15] .

When they were asked to cite the reasons for not using a condom in the past 3 months, the main reasons given was that their partner did not want to use it because its use decreases sexual satisfaction or desire to have a child. Low condom uptake among HIV clients has a negative impact in HIV/AIDS prevention.

Overall, although risky sexual behaviour was observed among the study participants, there was no difference in the pattern of risky behaviour with respect to gender within a group. When subjects reported having casual partners, in all cases interviewed, they did not know their HIV sero-status. We observed that male participants continue or increase their risky sexual behaviour after knowing their HIV sero-status as significantly more females had multiple sexual partners in the HAART naive and males in the HAART experienced cohort. Female patients among HAART naive group were more prone to high-risk behaviour. This may be a result of poor socioeconomic status and lack of bargaining power of women and those who are not in a stable union. For instance, it may be difficult for a female who provided sex for money to negotiate condom use.

The level of condom use increased with literacy level, our finding is in agreement with similar studies in sub- Saharan Africa, [13] -[18] we found that participants with secondary education or higher were more likely to use condoms with a sex partner. Individuals with more education might have higher levels of HIV/AIDS knowledge and are less likely to have stigma towards HIV/AIDS, thus enabling them to easily change risky sexual behaviour [17] [18] . Additionally, individuals with higher education might be able to seek and accept information that would help protect their partners and themselves from HIV and STI transmission and re-infection [17] .

Our data showed a strong association between disclosure of HIV status and protective patterns of condom use. This finding is consistent with previous studies that found that disclosure was associated with reduced transmission risk behaviours [19] [20] . For instance, a study in Cape Town, South Africa found that people who had not disclosed their HIV status to partners reported more sex partners and more unprotected vaginal and anal intercourse than people who had disclosed [19] . Therefore, interventions targeted to HIV-positive individuals must strengthen preventive altruism, promote HIV-status disclosure and assess issues relating to non disclosure [21] [22] .

In terms of occupation, the highest rate of condom use was found among public/civil servants (68.9%). In this population, it appears that smoking and alcohol do not affect condom use, as reported in other studies conducted in other countries [23] [24] .

Sexual behaviour was self-reported and subject to both recall and social desirability bias. In order to minimize the recall bias, we used 3-month recall period. We also tried to address social desirability bias by assigning male data collectors for male subjects and female data collectors for female subjects. Still we believe that the traditional reluctance to discuss sexual behaviour, especially homosexuality, is regarded as a taboo that may have resulted in underreporting.

We report that condom use is uncommon among HIV clients in our environment. Condom use is significantly influenced by partner notification, occupation as a civil servant and female. This study supports an absence of association between condom uptake and HAART use.

Factors militating against condom use among HIV clients should be individually and confidentially addressed during counselling, with greater emphasis on its positive impact and strengthening condom use negotiation. We recommend interventions directed at increasing condom use among HIV clients in our environment.