Transactional sex among young women in rural South Africa: prevalence, mediators and association with HIV infection

Abstract

IntroductionYoung adolescent women in sub-Saharan Africa are three to four times more likely to be HIV-positive than boys or men. One of the relationship dynamics that is likely to be associated with young women's increased vulnerability to HIV is transactional sex. There are a range of HIV-related risk behaviours that may drive this vulnerability. However, to date, limited epidemiological data exist on the role of transactional sex in increasing HIV acquisition, especially among young women in sub-Saharan Africa. Our paper presents data on the prevalence of self-reported engagement in transactional sex and explores whether transactional sex is associated with increased risk of HIV infection among a cohort of young, rural, sexually active South African women. We also explore whether this relationship is mediated through certain HIV-related risk behaviours.MethodsWe analyzed baseline data from a phase III trial of conditional cash transfers for HIV prevention of 693 sexually active, school-going young women aged 13–20 years in rural South Africa. We examined the association between young women's engagement in transactional sex and HIV infection. Transactional sex is defined as a non-commercial, non-marital sexual relationship whereby sex is exchanged for money and/or gifts. We explored whether this relationship is mediated by certain HIV-related risk behaviours. We used logistic and multinomial regression and report unadjusted and adjusted odds ratios with 95% CI.ResultsOverall, 14% (n=97) of sexually active young women reported engaging in transactional sex. Engagement in transactional sex was associated with an increased risk of being HIV-positive (aOR: 2.5, CI: 95% 1.19–5.25, p=0.01). The effect size of this association remained nearly unchanged when adjusted for certain other dimensions of HIV risk that might help explain the underlying pathways for this relationship.ConclusionsThis study provides quantitative support demonstrating that transactional sex is associated with HIV infection in young women. Even though the specific variables tested do not mediate the relationship, a potential explanation for this association may be that the men with whom young women are having sex belong to networks of sexually connected individuals who are at a “high risk” for HIV infection. The results highlight the importance of structural intervention approaches that can alter the context of young women's HIV risk.

Transactional sex and risk for HIV infection in sub‐Saharan Africa: a systematic review and meta‐analysis

“…In these studies, transactional sex was included as a predictor, but it was not the focus of the analysis. However, in three studies, the primary objective was to assess the role of transactional sex on HIV [19–21]. Of these three studies, one study used incident measures and was better able to assess the causal role of transactional sex in HIV risk [20].…”

“…Five studies conducted among women [10,17,20,21,26] and four among men [17,22–24] met the inclusion criteria for the meta-analyses.…”

“…Of these, one study with a highly significant unadjusted OR lost significance in the adjusted model [26]. The remaining three studies (including one study not disaggregated by sex) report a significant adjusted OR, indicating that those who had practiced transactional sex had nearly two to more than three times the risk of being HIV positive [10,17,20,21]. One of these studies, using a longitudinal design, reported an increase in HIV incidence resulting from transactional sex for two partner types: casual partners (incidence rate ratio (IRR) 02.06, 95% CI: 1.22Á3.48) and ''one-off'' (one time only) partners (IRR03.29, 95% CI: 1.02Á10.55) [20].…”

“…Exclusion of studies in which the OR was not adjusted for age left us with only two studies: one study showed a large and statistically significant association (OR 02.14, 95% CI: 1.10Á4.60) [21] and the other study showed no association (OR 01.09, 95% CI: 0.73Á1.61) [10].…”

“My partner was not fond of using condoms and I was not on contraception”: understanding adolescent mothers’ perspectives of sexual risk behaviour in KwaZulu-Natal, South Africa

“…A study in Wentworth, South Africa, revealed that both adolescent girls and boys were lured into transactional sex [65]. A qualitative study by Raganathan et al [66] in rural Bushbuckridge in Mpumulanga, South Africa, also found that young women perceived transactional sex as a way of securing financial success. The women from the study in Mpumulanga also viewed money and gifts as a determinant of a woman's value and the commitment of the man to her [66].…”