In sub-Saharan Africa, young women ages 15-24 have more than twice the risk of acquiring HIV as their male counterparts. A growing body of epidemiological evidence suggests that the practice of "transactional sex" may contribute to this disparity. Over the last 15 years, the social sciences have contributed significantly to understanding the meaning of and motivations for this practice. The findings from these studies are rich, but varied, rendering lessons difficult to navigate for intervention and further research. We therefore contribute a historically-grounded, comprehensive literature review on the nature and motivations for women's participation in transactional sex in sub-Saharan Africa. Drawing from over 300 studies (through 2014), we distill three prominent paradigms observed in the literature that we review toward presenting a unified conceptualization of the practice. "Sex for basic needs," the first paradigm, positions women as victims in transactional sexual relationships, with implications for interventions that protect girls from exploitation. In contrast, the "sex for improved social status" paradigm positions women as sexual agents who engage in transactional sex toward attaining a middle-class status and lifestyle. Finally, a third paradigm, "sex and material expressions of love," draws attention to the connections between love and money, and the central role of men as providers in relationships. We find important commonalities in the structural factors that shape the three paradigms of transactional sex including gender inequality and processes of economic change. We suggest that there are three continua stretching across these paradigms: deprivation, agency, and instrumentality. This review proposes a definition of transactional sex and discusses implications for research and interventions aiming to reduce young women's risk of HIV through such relationships. We consider the consequences of drawing from too narrow an understanding of the practice, and highlight the benefits of a broader conceptualization.

BackgroundMany programmes on young people and HIV/AIDS prevention have focused on the in-school and channeled sexual and reproductive health messages through schools with limited activities for the young people's families. The assumption has been that parents in African families do not talk about sexual and reproductive health (SRH) with their children. These approach has had limited success because of failure to factor in the young person's family context, and the influence of parents. This paper explores parent-child communication about SRH in families, content, timing and reasons for their communication with their children aged 14-24 years in rural Tanzania.MethodsThis study employed an ethnographic research design. Data collection involved eight weeks of participant observation, 17 focus group discussions and 46 in-depth interviews conducted with young people aged 14-24 years and parents of young people in this age group. Thematic analysis was conducted with the aid of NVIVO 7 software.ResultsParent-child communication about SRH happened in most families. The communication was mainly on same sex basis (mother-daughter and rarely father-son or father-daughter) and took the form of warnings, threats and physical discipline. Communication was triggered by seeing or hearing something a parent perceived negative and would not like their child to experience (such as a death attributable to HIV and unmarried young person's pregnancy). Although most young people were relaxed with their mothers than fathers, there is lack of trust as to what they can tell their parents for fear of punishment. Parents were limited as to what they could communicate about SRH because of lack of appropriate knowledge and cultural norms that restricted interactions between opposite sex.ConclusionsDue to the consequences of the HIV pandemic, parents are making attempts to communicate with their children about SRH. They are however, limited by cultural barriers, and lack of appropriate knowledge. With some skills training on communication and SRH, parents may be a natural avenue for channeling and reinforcing HIV/AIDS prevention messages to their children.

This community-based, qualitative study conducted in rural Kisesa District, Tanzania, explores perceptions and experiences of barriers to accessing the national antiretroviral programme among self-identified HIV-positive persons. Part of wider operations research around local introduction of HIV therapy, the study involved consultation with villagers and documented early referrals' progress through clinical evaluation and, if eligible, further training and drug procurement. Data collection consisted of 16 participatory group discussions with community members and 18 in-depth interviews with treatment-seekers. Although participants welcomed antiretroviral therapy, they feared that transportation and supplementary food costs, the referral hospital's reputation for being unfriendly and confusing, and difficulties in sustaining long-term treatment would limit accessibility. Fear of stigma framed all concerns, posing challenges for contacting referrals who did not want their status disclosed or expressed reluctance to identify a "treatment buddy" as required by the programme. To mitigate logistical barriers, transportation costs were paid and hospital visits facilitated. Participants reported satisfaction with eligibility testing, finding the process easier than anticipated. Most were willing to join a support group and some changed attitudes toward disclosure. However, both experienced and anticipated discrimination continue to hinder widespread antiretroviral therapy (ART) uptake. While simple measures to reduce perceived barriers improved initial access to treatment and helped overcome anxiety among early referrals, pervasive stigma remains the most formidable barrier. Encouraging successful referrals to share their positive experiences and contribute to nascent community mobililzation could start to address this seemingly intractable problem.

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BackgroundMaterial exchange for sex (transactional sex) may be important to sexual relationships and health in certain cultures, yet the motivations for transactional sex, its scale and consequences are still little understood. The aim of this paper is to examine young women's motivations to exchange sex for gifts or money, the way in which they negotiate transactional sex throughout their relationships, and the implications of these negotiations for the HIV epidemic.MethodAn ethnographic research design was used, with information collected primarily using participant observation and in-depth interviews in a rural community in North Western Tanzania. The qualitative approach was complemented by an innovative assisted self-completion questionnaire.FindingsTransactional sex underlay most non-marital relationships and was not, per se, perceived as immoral. However, women's motivations varied, for instance: escaping intense poverty, seeking beauty products or accumulating business capital. There was also strong pressure from peers to engage in transactional sex, in particular to consume like others and avoid ridicule for inadequate remuneration.Macro-level factors shaping transactional sex (e.g. economic, kinship and normative factors) overwhelmingly benefited men, but at a micro-level there were different dimensions of power, stemming from individual attributes and immediate circumstances, some of which benefited women. Young women actively used their sexuality as an economic resource, often entering into relationships primarily for economic gain.ConclusionTransactional sex is likely to increase the risk of HIV by providing a dynamic for partner change, making more affluent, higher risk men more desirable, and creating further barriers to condom use. Behavioural interventions should directly address how embedded transactional sex is in sexual culture.

IntroductionYoung women aged 15 to 24 years in sub-Saharan Africa continue to be disproportionately affected by HIV. A growing number of studies have suggested that the practice of transactional sex may in part explain women's heightened risk, but evidence on the association between transactional sex and HIV has not yet been synthesized. We set out to systematically review studies that assess the relationship between transactional sex and HIV among men and women in sub-Saharan Africa and to summarize the findings through a meta-analysis.MethodsThe search strategy included 8 databases, hand searches in 10 journals, and searches across 17 websites and portals for organizations as informed by expert colleagues. A systematic review of cross-sectional and longitudinal studies was carried out for studies on women and men who engage in transactional sex published up through 2014. Random effects meta-analysis was used to further examine the relationship between transactional sex and prevalent HIV infection across a subset of studies with the same exposure period. Analyses were conducted separately for men and women.ResultsNineteen papers from 16 studies met our inclusion criteria. Of these 16 studies, 14 provided data on women and 10 on men. We find a significant, positive, unadjusted or adjusted association between transactional sex and HIV in 10 of 14 studies for women, one of which used a longitudinal design (relative risk (RR)=2.06, 95% confidence interval (CI): 1.22 –3.48). Out of 10 studies involving men, only 2 indicate a positive association between HIV and transactional sex in unadjusted or adjusted models. The meta-analysis confirmed general findings from the systematic review (unadjusted meta-analysis findings are significant for women (n=4; pooled odds ratio (OR)=1.54, 95% CI: 1.04–2.28; I2=42.5%, p=0.156), but not for men (n=4; pooled OR=1.47, 95% CI: 0.85–2.56; I2=50.8%, p=0.107).ConclusionsTransactional sex is associated with HIV among women, whereas findings for men were inconclusive. Given that only two studies used a longitudinal approach, there remains a need for better measurement of the practice of transactional sex and additional longitudinal studies to establish the causal pathways between transactional sex and HIV.

Although transactional sex has been linked to undesirable sexual health outcomes, there is a lack of clarity as to the meaning of the practice, which appears to extend beyond behaviors related to women's economic circumstances. This article explored the perspectives of parents and unmarried young people on motivations for, and beliefs about, transactional sex in rural Tanzania using an ethnographic research design. Data collection involved 17 focus groups and 46 in-depth interviews with young people aged 14-24 years and parents/caregivers. Transactional sex was widely accepted by both parents and young people. Male parents equated sexual exchange to buying meat from a butcher and interpreted women's demand for exchange before sex with personal power. Young men referred to transactional sex as the easiest way to get a woman to satisfy their sexual desires while also proving their masculinity. Young women perceived themselves as lucky to be created women as they could exploit their sexuality for pleasure and material gain. They felt men were stupid for paying for "goods" (vagina) they could not take away. Mothers were in agreement with their daughters. Although young women saw exploitation of the female body in positive terms, they were also aware of the health risks but ascribed these to bad luck. Interventions aimed at tackling transactional sex in the interests of women's empowerment and as a strategy for HIV prevention need to understand the cultural beliefs associated with the practice that may make it thrive despite the known risks.

ObjectivesThere are concerns that medical pluralism may delay patients’ progression through the HIV cascade-of-care. However, the pathways of impact through which medical pluralism influence the care of people living with HIV (PLHIV) in African settings remain unclear. We sought to establish the manifestation of medical pluralism among PLHIV, and explore mechanisms through which medical pluralism contributes bottlenecks along the HIV care cascade.MethodsWe conducted a multicountry exploratory qualitative study in seven health and demographic surveillance sites in six eastern and southern African countries: Uganda, Kenya, Tanzania, Malawi, Zimbabwe and South Africa. We interviewed 258 PLHIV at different stages of the HIV cascade-of-care, 48 family members of deceased PLHIV and 53 HIV healthcare workers. Interviews were conducted using shared standardised topic guides, and data managed through NVIVO 8/10/11. We conducted a thematic analysis of healthcare pathways and bottlenecks related to medical pluralism.ResultsMedical pluralism, manifesting across traditional, faith-based and biomedical health-worlds, contributed to the care cascade bottlenecks for PLHIV through three pathways of impact. First, access to HIV treatment was delayed through the nature of health-related beliefs, knowledge and patient journeys. Second, HIV treatment was interrupted by availability of alternative options, perceived failed treatment and exploitation of PLHIV by opportunistic traders and healers. Lastly, the mixing of biomedical healthcare providers and treatment with traditional and faith-based options fuelled tensions driven by fear of drug-to-drug interactions and mistrust between providers operating in different health-worlds.ConclusionMedical pluralism contributes to delays and interruptions of care along the HIV cascade, and mistrust between health providers. Region-wide interventions and policies are urgently needed in sub-Saharan Africa to minimise potential harm and consequences of medical pluralism for PLHIV. The role of sociocultural beliefs in mediating bottlenecks necessitate adoption of culture-sensitive approaches intervention designs and policy reforms appropriate to the context of sub-Saharan Africa.