South African women who seek goods and services from sexual partners more likely to become HIV positive within two years

Young South African women who engage in sex or have relationships partially motivated by economic gain are more likely to become infected with HIV, Rachel Jewkes and colleagues report in the Journal of AIDS & Clinical Research. These data add to previous findings from this cohort showing that women who had a violent partner or who were relatively powerless in a relationship were more likely subsequently to acquire HIV.

The authors therefore argue that HIV prevention programmes need to find ways to help young women to avoid gender inequity, violence and transactional relationships. Moreover, background research they have conducted with men and women sheds light on women’s and men’s expectations in relationships. 

In order to clarify the links between gender issues and HIV infection, Rachel Jewkes of the South African Medical Research Council examined data from the cohort of young women recruited to evaluate the impact of a behavioural intervention known as Stepping Stones. Women from both the intervention and control groups are included in this analysis, as long as they were HIV negative at the beginning of the study, had sex whilst in the cohort and completed follow-up after 12 and 24 months.

The researchers examined the behaviour and experiences that the women reported at the beginning of the study and whether they subsequently acquired HIV. The study design is therefore more robust than a one-off cross-sectional survey, as it can suggest whether a link between one factor and HIV infection is causal or not.  

Included in the analysis are 1077 women aged 15 to 26 years, with an average age of 18 at baseline (the beginning of the study). The majority were very poor, still in school, unmarried and already sexually active. The cohort was recruited in primarily rural parts of the Eastern Cape province.

During the two years of follow-up, 127 women acquired HIV. In other words, the incidence of new infections was extremely high, but not unusual in this setting, at 6.2% a year.

Data from this cohort, published two years ago in The Lancet, showed that women who reported having relatively little power in sexual relationships at baseline (for example, feeling obliged to sleep over when a boyfriend wanted her to) were more likely to subsequently acquire HIV. In women with medium or high relationship power equity, incidence was 5.5% a year; in those with low relationship power equity, it was 8.5% a year.

Similarly, women who reported at baseline that sexual partners had been either physically or sexually violent were also more likely to go on to acquire HIV. Women reporting either one or no incidents of intimate partner violence had an incidence of 5.2% a year, but women reporting two or more incidents had an HIV incidence of 9.6% a year.

Both these differences in incidence were statistically significant after adjustment for confounding factors.

Rachel Jewkes suggests that certain ideals of masculinity which are widely accepted in some South African communities legitimise unequal and often violent relationships. Men are expected to dominate and control women, and violence may be justified to enforce and demonstrate this. This may place women at increased risk of HIV infection by creating psychological distress, encouraging women to be more acquiescent, preventing women from influencing the circumstances of sex (including condom use and the frequency of sex) and allowing men to have multiple and concurrent partners (and therefore more likely to themselves have HIV and sexually transmitted infections).

In their new study, the researchers turn to the issue of ‘transactional’ sex – in other words, when a woman reported that part of her motivation for having a sexual relationship was that she expected her partner to provide cash, food, cosmetics, clothes, transport, a bed for the night or to do some handyman work. These relationships are seen in terms of men fulfilling a traditional provider role, rather than as being akin to prostitution.

Transactional sex was asked about, at the beginning of the study, in relation to different types of partners. A total of 143 women reported it in relation to main partners, 59 women reported it with ongoing and usually secret second partners (known as makhwapheni in the Zulu and Xhosa languages), and seven women reported it with one-off partners.

In relation to main partners, there were no statistically significant differences in HIV incidence between those women reporting and not reporting transactional relationships.

However, when looking at makhwapheni and one-off partners, women who did not report transactional relationships had an HIV incidence of 5.7% a year, but women who did have a transactional relationship had an incidence of 14.5% a year.

The researchers then adjusted their figures for other factors which are known to influence HIV incidence (including condom use, age, herpes infection, relationship inequity and intimate partner violence). They calculated that having transactional relationships with makhwapheni or one-off partners doubled the risk of acquiring HIV (incident rate ratio 2.06, 95% confidence interval 1.22 – 3.48).

Although it could be hypothesised that transactional relationships are risky because male partners are more likely to be older (for example a ‘sugar daddy’) or because they are associated with women having more sexual partners, neither of these factors were associated with statistically significant increases in the risk of HIV infection.

The authors suggest financial and material vulnerabilities may introduce a particular type of vulnerability into sexual relations. “When there is an absence of explicit negotiation and a bolstered sense of male entitlement, men perceive that gifts of cash result in a woman accepting sex on his terms, which are often without condoms and without space to assert preferences for monogamy and so forth.”

In order to better understand young women’s motivations for having transactional relationships – and therefore how HIV prevention programmes might intervene to alter this risk factor – Rachel Jewkes and Robert Morrell have also conducted qualitative interviews with a subset of the Stepping Stones participants.

These highlighted the range of qualities women were looking for in a partner. Some women expected to be provided for:

“I wish I would have a relationship with someone who would only be in love with me, he should not drink and smoke, or I want a person who loves me who will always think about me and I will think about him. I don’t like someone who has multiple partners. I wish I should just have a person whom I know that I am in love with, but I wish he should give me money when there is something that I need. I would see that this person does not love me if he gives me nothing, but he sees that I am suffering, no I could see that he does not love me… I wish he should not spend a long time without seeing me and if there is something I need from him knowing that he has it, he should give it to me.”

For many of the participants, obtaining and keeping boyfriends was a central pursuit. Some women were proud of what they had been given, as it reflected their own desirability as well as their boyfriends’ prosperity and status. But many desperately needed the items and money they received, although it was often inadequate for their needs. This teenager was bringing up the child she had had with a married man.

 “He gives me the amount he thinks is good for me, but he never gave me an amount of R200 (US$28). It is usually less than that amount”.

When dating, women had considerable agency and took care in choosing a partner they felt able to submit to. But once relationships were underway, agency was usually lost – most tolerated their partners’ violent and controlling behaviour, and were publicly obedient and respectful. The researchers consider that women often accepted a surrender of power in order to be respected as ‘good’ women and partners.

But there was diversity in women’s views and experiences – some women living in bigger towns presented themselves as being ‘modern’ and in control of their lives, although the researchers comment that this was “part reality, part fantasy”. Others, especially those who had gone through the Stepping Stones intervention, expressed a desire for mutual respect and autonomy, and said they would not accept violence and controlling behaviour.

And what about men’s perspectives? Jewkes reports that a substantial proportion of South African men think that they are expected to provide for their partner and that they wouldn’t be able to have the relationship if they didn’t fulfil that provider role. These social expectations can put a pressure on men which may be resented by those who are unemployed or underpaid.

Data from a household survey conducted with a randomly selected sample of 1645 men in the Eastern Cape and Kwa-Zulu Natal provinces sheds light on the issue. Half the men were under 25 years, nearly half were unemployed, 85% were Black African and a third were married or cohabiting.

Two thirds of men reported relationships where they perceived that their partner had got involved in the expectation of receiving goods and services. This was reported for all types of partners and men tended to give similar items (cash, food, clothes, cosmetics, accommodation, etc.) to main partners, makhwapheni (secret secondary partners) and one-off partners. Prevalence was high across a range of social and demographic groups.

The proportion of men reporting transactional relationships was much higher than in the cohort of Stepping Stones women. This may be because perceptions of what relationships are about can be different or because men want to present themselves as being able to provide.

In contrast to transactional relationships, fewer than one-in-five men reported sex with a prostitute, and there was relatively little overlap between the two. These are seen as very different behaviours and prostitution is stigmatised.

But the same data set showed associations between men’s involvement in transactional relationships and self-report of perpetrating rape, intimate partner violence and various other forms of criminality.

Moreover, participants answered questions about their attitudes to women and relationships, which suggested that men involved in transactional relationships tend to have socially conservative and hostile attitudes towards women as well as an idea of sexual entitlement.

Rachel Jewkes and colleagues conclude with the implications of their research for HIV prevention. “Young women are very vulnerable and much less able to influence their own sexual risk than men of the same age,” they write. “These findings provide support for those who are investigating interventions to enable young women to avoid transactional sex.”

Moreover: “Women need to be supported and brought to a tangible understanding of the possibilities and potential for them to assert control in sexual and relationship domains of their lives. In this respect, both skills building (communication and other skills) and tangible economic empowerment are important.”

Similarly work with men should focus on “reconfiguring how they see themselves as men.”

Jewkes R et al. Transactional Sex and HIV Incidence in a Cohort of Young Women in the Stepping Stones Trial. Journal of AIDS & Clinical Research 3:158, 2012. (Click here for free full text)

Jewkes R et al. Intimate partner violence, relationship power inequity, and incidence of HIV infection in young women in South Africa: a cohort study. The Lancet 376: 41-48, 2010. (Click here for free abstract)

Jewkes R et al. Sexuality and the limits of agency among South African teenage women: theorising femininities and their connections to HIV risk practices. Social Science and Medicine 74:1729-37, 2012. (Click here for free abstract)

Jewkes R et al. Transactional relationships and sex with a woman in prostitution: prevalence and patterns in a representative sample of South African men. BMC Public Health 12:325, 2012. (Click here for free full text)

Jewkes R et al. Men, Prostitution and the Provider Role: Understanding the Intersections of Economic Exchange, Sex, Crime and Violence in South Africa. PLoS ONE 7: e40821, 2012. (Click here for free full text)